A feasibility study on the adoption of e-learning for public health nurse continuing education in Taiwan

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A feasibility study on the adoption of e-learning

for public health nurse continuing education in


Shu Yu


, I-Ju Chen


, Kuei-Feng Yang


, Tze-Fang Wang


,Lee-Lan Yen



School of Nursing, National Yang-Ming University, No.155, Section 2, Li-Nong Street, Taipei 112, Taiwan, ROC


Institute of Health Policy and Management, National Taiwan University, Room 623 , No.17, Hsu-Chow Road, Taipei 100, Taiwan, ROC

Accepted 23 October 2006


Public health nurses; Continuing education; Web-based learning; E-learning

Summary The purpose of this study is to investigate the feasibility of developing e-learning and to examine reasons for adopting or rejecting e-e-learning as an alterna-tive way to conduct continuing education (CE) for public health nurses (PHNs). A nationwide-based cross-sectional study was conducted with a randomly selected sample of 233 PHNs in Taiwan. A structured questionnaire was used to collect data by mailing methods. The majority of PHNs (88.84%, n = 207) showed an affirmative intention towards adopting e-learning as their one way of CE. Reasons for adopting e-learning included achieving life learning, fulfilling personal interests, time-saving, based on job needs, information diversity, flexible in time and space, self-regula-tory learning, cost-effectiveness, less impact on family duties and life. Twenty-six PHNs (11.16%) who rejected e-learning as their way of CE indicated main reasons including poor computer competence, lack of personal computer and without inter-net access, heavy work load, heavy family duties, conflict with personal preference, heavy economic burden, lack of motivation, and low self-control. This study reveals a high feasibility of developing e-learning that coexists with other CE models (e.g. traditional instruction). Reasons analyses provide directions for decreasing barriers for developing a learning model of this new medium for nurses’ CE.

c 2006 Elsevier Ltd. All rights reserved.

Introduction and literature review

With rapid changes occurring in health care envi-ronments, it is critical for health care professionals to keep pace with updated information. The

0260-6917/$ - see front matter

c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.10.016

* Corresponding author. Tel.: +886 2 33228062; fax: +886 2 2391778.

E-mail address:lan@ha.mc.ntu.edu.tw(L.-L. Yen).






e-learning program (or web-based learning) in-volves learning activities, either on-line or off-line, which is carried out with digital tools and access to teaching materials through wired and wireless net-works. Public health nurses (PHNs) are expected to play the gatekeepers of public health and, as such, constantly need to update their professional knowl-edge and skills to ensure the quality of health care (Gebbie, 1999). Similarly, in Taiwan, PHNs working in public health centers play major roles in commu-nity health care (Yu and Chin, 1996).

In an era of knowledge economy, the Internet, a relatively new medium, is expected to play an important part in providing continuing education (CE) for health professionals, i.e., PHNs in this study. The use of computers is widespread and increasing, especially with the advancement of software and hardware platforms. PHNs who need continuing edu-cation can now select the most suitable learning style for themselves (Billings et al., 2001; Wills and Stommel, 2002; Frith and Kee, 2003). E-learning, as a diverse learning style, has been widely recog-nized in several countries. E-learning has become a valuable and legitimate learning method for health care professionals in the 21st century (Cook et al., 2004; Leasure et al., 2000; Kearns et al., 2004; Ful-lerton and Ingle, 2003; Bernhardt et al., 2003; DiMa-ria-Ghalili et al., 2005). However, research in the application of web-based learning in providing CE for health professionals is still in its early stage. Although most nurses reveal a positive attitude to-wards e-learning (Yu and Yang, 2006), whether and why nurses, PHNs in this study, adopt or reject e-learning as their new way of CE still needs to be con-firmed, because e-learning does not suit every lear-ner (Atack, 2003). Therefore, the main purposes of this study are to investigate the feasibility of e-learning for establishing PHNs’ continuing education and to further examine the reasons for adopting or rejecting e-learning as their alternative way of continuing education. Through analyses of reasons, we expect to increase the success of and reduce the barriers in developing e-learning.



This study employed a cross-sectional research design.


A cluster random-sampling method was used to select sample. In this sampling method, first, all

health centers were stratified into four strata: metropolitan city, county, township, and village. Then, health centers in each stratum were pro-portionally selected by a cluster random sam-pling; PHNs working at the selected health centers comprised the study sample. After the list of selected health centers was confirmed and oral approval obtained by municipal or county health bureaus and relevant health centers via tele-phone, we filed the official letter with the rele-vant centers for administrative recognition and support. Data were collected by mailing the ques-tionnaire. Prior contact, continued follow up (weekly, three times), and provision of reward were used to increase the response rate in this study. Finally, of 280 recipients, 233 returned completed questionnaires, with a return rate of 83.2%. Using a v2 test, no significant differences were seen in PHN proportion in four levels be-tween the sample and the population (X2= 2.14, P > 0.05); i.e., the sample was representative of the population (Table 1).


A self-administered questionnaire was used to col-lect data in this study. It included two main parts: 1. Independent variables: this category included age, education level, marital status, job posi-tion, types of health centers, and previous expe-rience in web-based learning.

2. Dependent variables: this category included two parts, the feasibility of adopting e-learning as an alternative way of continuing education, and reasons for adopting or rejecting e-learning. (1) Feasibility of adopting e-learning.

In this part, a four-point question was used to examine PHNs’ perceived likelihood of adopting e-learning as their continuing education method in the future. ‘‘Definitely possible’’, ‘‘possible’’, ‘‘not possible’’, ‘‘definitely not possible’’ corresponded to points 4, 3, 2, and 1, respectively. Scores greater than and equal to 3 meant affirmative possibility of adopting web-based learning; conversely, scores less than and equal to 2 meant negative possibility (i.e., rejection) of adopting e-learning. (2) Reasons for adopting or rejecting e-learning.

A structured questionnaire, called Reasons for Adopting or Rejecting E-learning Scale, was used to examine the reasons why PHNs adopt or reject e-learning. This scale was a 20-item self-reporting scale. It included two separate dimensions: the reasons for adopting e-learning


(11 items) and the reasons for rejecting e-learning (9 items). For single items (i.e., rea-sons), a yes/no question was used to collect data; one point was given to ‘‘yes’’ answers, and zero points were given for ‘‘no’’ answers. Moreover, an open-ended question in each dimension was designed to collect extra rea-sons that were not listed in the questionnaire. To evaluate questionnaire validity and reliability, six experts in the areas of distance education, health information, informational technology, nurs-ing education, and community health nursnurs-ing estab-lished the questionnaire’s content validity. Three PHNs completed the face validity test. Regarding reliability of this study, the agreement of behav-ioural intention toward e-learning (a four-point question) was 90%; an rkr21coefficient was used to

examine internal consistency. For the Reason of Adopting or Rejecting E-learning Scale, an rkr21

coefficient was 0.89 in pilot test with 30 PHNs indi-cating good reliability in internal consistency. For two dimensions of the Reason of Adopting or Reject-ing E-learnReject-ing Scale, ‘‘reasons for adoptReject-ing e-learn-ing’’ and ‘‘reasons for rejecting e-learne-learn-ing’’, rkr21

coefficients were 0.88 and 0.78, respectively.

Ethical considerations

This study was supported by the Taiwan govern-ment. Human rights and privacy of participants were protected. All subjects participated in this study based upon confidential and voluntary participa-tion. Informed consents have been obtained from all participants in this study. Moreover, the study protocol, informed consent form, and questionnaire were reviewed and approved by the Institutional Review Board, Taipei Veterans General Hospital, to guarantee the subjects’ rights and interests.

Data analysis

SPSS 10.0 (SPSS Inc., Chicago) for Windows was used to analyze data. Frequency and percentage

were used to describe subjects’ backgrounds as well as to investigate the feasibility of developing e-learning and to examine the reasons for adopting or rejecting e-learning for PHNs. v2 test was used to examine the distribution differences of urbani-zation between the sample and population.


Basic data of the subjects

The mean age of the participating subjects was 39.37 years (SD = 8.29). Over one half (58.37%) had graduated from junior college; only 14.59% had a bachelors degree. Most subjects were mar-ried (81.97%). About three-fourth (72.10%) worked as registered nurses (RNs), 20.60% (n = 43) worked as registered professional nurses (RPNs). Over one-half (51.50%, n = 120) of the subjects worked in village health centers. Participants’ locations in metropolitan city, county, and township type were 18.03%, 15.45%, and 15.02%, respectively. Only 9.87% of the subjects had ever participated in an e-learning program (Tables 1 and 2).

Feasibility of e-learning in PHNs’ continuing


A total of 233 PHNs participated in this study. Most of the subjects (88.84%, n = 207) replied that it was ‘‘highly possible’’ or ‘‘possible’’ for them to take continuing education programs via e-learning in the future. However, twenty-six subjects (11.16%) rejected e-learning as their alternative way of continuing education.

Reasons for adopting or rejecting e-learning

for PHNs

Firstly, data were analysed as a whole. Among a total of 233 PHNs, more than one-half of subjects expressed that e-learning was beneficial for achieving lifelong learning (54.08%),especially

Table 1 Distribution of PHNs in different types of public health centers between population and sample

Types of health centers Population Sample X2

N % N % Metropolitan city 335 13.54 42 18.03 2.14 County 434 17.54 36 15.45 (df = 3) Townships 337 13.62 35 15.02 Village 1368 55.30 120 51.50 Total 2474 100.00 233 100.00


because of allowing nurses to choose curriculum and content based on personal learning needs (52.79%) (Table 3).

Then, according to the response of PHNs on fea-sibility, we divided participants into two groups: ‘‘adopting group’’ and ‘‘rejecting group’’.

In the adopting group (n = 207), who tended to adopt e-learning as the alternative way of contin-uing education, more than one-half of subjects ex-pressed that e-learning was beneficial for them to

achieve lifelong learning (60.87%). Except achieving lifelong learning, the other five main reasons given for adopting e-learning as their alternative way of continuing education included: allowing them to se-lect curriculum and content based on personal learning needs (59.42%), broadening one’s horizon and/or learning the newest knowledge (55.7%), time-savings (55.07%), based on job needs (50.72%), and information diversity (50.24%) (Table 3).

In contrast, the rejecting group (n = 26) indi-cated that poor computer competence (84.62%), lack of adequate computer facilities (76.92%), con-flict or unmatching interests existing between job and education content (69.23%), time limits (69.23%), and heavy family duties and burdens (65.38%) were the five main reasons PHNs rejected e-learning as their alternative way of continuing education (Table 4).

Discussion and recommendation

The feasibility of e-learning in PHNs’

continuing education

Among a total of 233 subjects participating in this study, only 23 had ever previously enrolled in dis-tance learning. Nearly nine-tenths (88.84%) of sub-jects tended to adopt e-learning as their way of continuing education. This finding confirmed that e-learning (via the Internet) is a highly feasible way and worthy of development as a means of PHN continuing education. This finding is similar to those ofChapman (2000), and Kooker et al. (2000), which indicated that health professionals agree to the va-lue of e-learning and tend to adopt e-learning as their way of continuing education, helping them to achieve the goal of lifelong learning.

Table 2 Basic data of the subjects (n = 233)

Variables n %

Personal factors

Age (Mean ± SD = 39.37 ± 8.29; range: 23–63 years old)

20–29 28 12.02

30–39 83 35.62

40–49 91 39.06

50 and above 31 13.30

Educational level

Vocational senior high school 63 27.04

Junior college 136 58.37

University and above 34 14.59

Marital status Not married 42 18.03 Married 191 81.97 Job position Registered nurse (RN) 168 72.10 Registered professional nurse (RPN) 48 20.60 Head nurse 17 7.30 Previous experience in web-based learning Yes 23 9.87 No 210 90.13

Table 3 Main reasons for PHNs adopting e-learning programs

Rank Reasons for adoption n % of the acceptors

(n = 207)

% of the total (N = 233)

1 Achieving lifelong learning 126 60.87 54.08

2 Based on personal demand and interests 123 59.42 52.79

3 Broaden one’s horizon and/or learn the newest knowledge 114 55.07 48.93 3 Time-saving in traffic for attending continuing education class 114 55.07 48.93

5 Based on job needs: task-oriented 104 50.72 45.06

6 Various information available (information diversity) 103 50.24 44.64

7 Flexibility in time and space 95 45.89 40.77

8 Self-regulatory learning 93 44.93 39.91

9 Cost-effective 83 40.10 35.62

10 Opportunity to increase interaction with children: accompanying with children learning from the internet

72 34.78 32.67


The reasons of adopting or rejecting

e-learning for PHNs

Most PHNs believe e-learning could fulfil their per-sonal learning needs and job demands. How to inte-grate PHNs’ personal needs and job demands is important, especially with the high challenge of designing curriculum and content. Soon et al. (2000) has proposed seven steps for developing e-learning courses; the first step is analysis of the learning needs of learners. Learning needs assess-ment is critical before developing an e-learning course that is capable of fulfilling personal needs and job demands simultaneously. However, provid-ing diverse learnprovid-ing programs might be more feasi-ble for fulfilling various needs and demands. Content diversity, for example, has been one essential characteristic of e-learning (Yu and Yang, 2006). According to this finding, we emphasize three principles (diversity, individualization, and task-orientation) that should be considered in e-learning curriculum development and content de-sign. It is also necessary to increase search infor-mation ability and to provide clear e-learning information in order to help PHNs acquire desirable and effective e-learning programs.

PHNs in the adopting group believed that an e-learning model could overcome the barriers of tra-ditional face-to-face instruction models especially in addressing time and space barriers. This finding is similar to that ofCragg (1994), which indicates that an asynchronous e-learning style is more suit-able than a synchronous e-learning style. However, in the rejecting group, 38.46% of the subjects were used to traditional face-to-face instruction. Thus, multi-channel learning patterns are still considered for PHN continuing education. Nearly one-half (44%) of subjects in the adopting group (39.9% of to-tal subjects) believed e-learning to be a

self-regula-tory learning style; 11.54% of subjects in the rejecting group expressed that low self-control is a barrier to adopting e-learning. These findings im-ply that for some PHNs, self-controlling ability might be one consideration for adopting or reject-ing e-learnreject-ing. For example, PHNs with high self-control ability might tend to adopt e-learning; on the contrary, PHNs with low self-control ability then tend to reject e-learning. For individuals with less self-control, it is highly important to establish auser-friendly learning environment on the Internet in the beginning stages of development. Then, strategies of behaviour modification such as keep-ing learners’ interest and attention, and increaskeep-ing learners’ achievement, could increase learners’ confidence and self-controllability, thereby main-taining their participation and improving their learning effect.

The current study revealed that personal factors play important roles in either adopting or rejecting e-learning. In particular, poor computer comptence was the main overall reason for rejecting e-learning. Our finding is similar to those of Atack and Rankin (2002); Cragg (1994); Garland (1993); Kenny (2000); Leasure et al. (2000); and Yellen (1998). Although all public health centers in Taiwan are computerized (Department of Health, 2000), and PHNs regularly use specific work computer software (i.e., PHIS, Public Health Informatics System), these facts do not guarantee that PHNs have adequate computer competence for participating in e-learning programs. Basic computer competence improve-ment for PHNs is crucial for developing e-learning, because learners’ adequate computer competence makes e-learning more acceptable and successful. Moreover, constructing a highly user-friendly platform and learning environments that reduce learners’ fears would be useful in spreading the implementation of this new learning medium model.

Table 4 Main reasons for PHNs rejecting e-learning programs

Rank Reasons for rejection n % of the rejectors

(n = 26)

% of the total (N = 233)

1 Poor computer competence 20 84.62 9.44

2 No personal computer and internet access at home 20 76.92 8.58

3 Conflict or unmatching interests existed between job and education content

18 69.23 7.73

4 Time limits 18 69.23 7.73

5 Heavy family duties and burden; e.g., play caregiver role in taking care of children and parents

17 65.38 7.30

6 Preference for face-to-face instruction 10 38.46 4.29

7 Heavy economic burden 8 30.77 3.43

8 Lack of motivation 4 15.38 1.72

9 Heavy work burden and stress 3 11.54 1.29


Regarding computer and internet access in households, the percentage of households owning a home computer in Taiwan in 2005 was 63.1%; the percentage of households with an internet con-nection was 55.7% (Directorate-General of Budget, R.O.C., 2006). Prevalence of personal computers and internet access at home in Taiwan are similar to developed countries. For example, the percent-ages of households owning a home computer in Uni-ted States (United States Department of Labor, Bureau of Labor Statistics, 2005), United Kingdom (The Office for National Statistics, UK., 2005), Sin-gapore (Infocomm Development Authority of Singa-pore, 2006), and Hong Kong-China (Census and Statistics Department, Hong Kong-China, 2004) were reported to be 54.7%, 62.0%, 74.0%, 71.1%, respectively. The percentage of households with an internet connection in United States (United States Department of Labor, Bureau of Labor Sta-tistics, 2005), United Kingdom (The Office for Na-tional Statistics, UK., 2005), Singapore (Infocomm Development Authority of Singapore, 2006), and Hong Kong-China (Census and Statistics Depart-ment, Hong Kong-China, 2004) were reported to be 61.8%, 53.0%, 66.0%, 64.9%, respectively. Com-pared to developing countries, the percentages of households owning a home computer and with an internet connection are obviously higher than most developing countries (The World Bank, 2006).

For some PHNs, not having a home computer and being without an internet access are their stated barriers to adopting e-learning. For these PHNs, economic burden might impede them from having personal computers and internet access at home. Otherwise, on the whole, the percentages of pene-tration and usage of information technology in gov-ernment offices and public enterprises in Taiwan is 100.0%. As stated above, all public health centers in Taiwan are computerized (Directorate-General of Budget, R.O.C., 2006) and only a few PHNs did not have internet access at their worksite. Thus, there is a continuing need for government support to enable more people to access the internet. For example, government strategies for training PHNs in basic computer competence, will help ensure internet access at worksites, promising PHNs continuing education via e-learning and increasing incentives for learning (e.g., an official or aca-demic certification). These steps will make devel-opment of e-learning as continuing education for PHNs both feasible and successful.

Administrative support is also critical in devel-oping e-learning programs and in building support-ive environments that motivate PHNs’ participation in e-learning programs. However, for countries with lower percentages of computer use, such as

certain developing countries (The World Bank, 2006), we still propose that the availability of com-puters and internet access is the basic element in developing effective e-learning programs.

Apart from computer hardware and software reasons, heavy workload, job stress and family du-ties all might impede PHNs’ adoption of e-learning. These findings are similar to those of Atack and Rankin (2002), andChapman (2000), which all indi-cate that time constraints due to work and family load still play important roles and make a negative impact on PHN continuing education. Therefore, in the future, education policy makers should con-sider how to increase PHNs’ motivation and to im-prove PHNs’ time-management skills so that they may be able to participate in e-learning and achieve improved educational outcomes.

PHNs’ previous e-learning experience

One important statistic presented in this study is that only 9.87% of subjects had ever before partic-ipated in an e-learning program. Studies are lacking for comparison but we have compared this impor-tant data with percentages of personal computers and internet access in Taiwan. This obviously low rate of previous e-learning experience by PHNs par-ticipating in this study might imply that fewer PHNs have used the internet for professional develop-ment in past two decades, even though e-learning has been applied to nursing education (Yu and Yang, 2006).Reinert and Fryback (1997) surveyed 353 schools of the American Nursing School Alli-ance and found that web-based courses have in-creased more than five-fold in the past 5 years. In the future, it is believed that the rate of e-learning will be maintained incrementally. Therefore, in or-der to produce a significant educational impact, it is important to conduct more studies to determine barriers to e-learning for nurses.


E-learning is a feasible and valuable learning model that is worth making generally available to PHNs, and indeed, to all health care professionals. From our reasons analyses findings, we have confirmed that asynchronous e-learning programs are a suitable method for PHN continuing education, especially for individuals with high self-control that allows PHNs to learn at remote locations according to their own needs and pace. Needs assessment is strongly recom-mended in the program preparation stage. Only by fulfilling PHNs’ individual needs (personal and job), reducing learning barriers (time, space, computer


competence, family and work load, etc.), increasing their motivation and self-controlling ability, can this new learning style be successful. Multi-channel learning patterns are still considered for inclusion in PHN continuing education because not all PHNs are accustomed to e-learning. Furthermore, regard-ing the effectiveness of e-learnregard-ing programs, we suggest that further studies are required.


We acknowledge the National Science Council of Taiwan for funding this project (Project number: NSC 91-2314-B-010-065).


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Table 2 Basic data of the subjects (n = 233)

Table 2

Basic data of the subjects (n = 233) p.4
Table 3 Main reasons for PHNs adopting e-learning programs

Table 3

Main reasons for PHNs adopting e-learning programs p.4
Table 4 Main reasons for PHNs rejecting e-learning programs

Table 4

Main reasons for PHNs rejecting e-learning programs p.5