Asynchronous e-learning with technology-enabled and enhanced training for continuing education of nurses: a scoping review | BMC Medical Education

Characteristics of selected studies

Between 2011 and 2023, 11 studies were published in 2020, 10 in 2017, and seven in 2015; 39 of the 60 studies were published in 2017 or later (Fig. 2). Data on country of publication are shown in Fig. 3. The most common continents of publication were Asia (25 articles: China, three [27, 32, 40]; Japan, 11 [29, 34, 56, 61, 63, 64, 68, 70, 71, 75, 76]; South Korea, six [26, 30, 44, 47, 65, 69]; Singapore, two [12, 67]; Turkey, one [38]; Israel, one [66]]; Iran, one [25]), followed by North America (21 articles: US, 18 [11, 21, 24, 31, 39, 43, 46, 48,49,50, 52, 54, 55, 58, 60, 62, 72, 73]; Canada, three [9, 23, 57]), Europe (eight articles: UK, two [35, 45]; Spain, one [36]; Italy, one [59]; Switzerland, one [74]; Netherlands, one [77]; Sweden, one [37]; Finland, one [51]) and Australia (six articles [22, 28, 33, 41, 42, 53]). Of the 60 studies, three were systematic review articles (Table 3) [9, 12, 41], while the remaining 57 were intervention studies. The study population in the 37 articles included only nurses, two included only midwives [34, 63], and 21 included health personnel, such as physicians and therapists. The total number of healthcare professionals included in the intervention studies examined in this study was 26,273. Of the study designs, the most common was pretest–posttest (n = 34), followed by quasi-experimental design (n = 8) and randomized controlled trial (n = 8), and systematic review (n = 3).

Technologies used (TEET options)

Table 4 shows the classifications of technological approaches based on the two categories mentioned by Ngenzi et al. (2021) [14]. The most commonly used technologies among enabling technologies were interactive online modules (25 articles) [11, 21,22,23,24, 28, 29, 31, 33, 35, 37, 42, 43, 45, 48,49,50, 53, 54, 56, 57, 62, 65, 66, 72] and videos (25 articles) [11, 24, 26, 30,31,32, 34, 35, 38, 42, 44, 50, 52, 57, 61, 65, 68, 70,71,72,73,74,75,76,77]. The next most commonly used technologies were slides or PowerPoint (11 articles) [11, 34, 39, 46, 47, 58, 59, 63, 69, 73, 77] and online discussions (seven articles) [11, 26, 28, 31, 54, 57, 72]. The most commonly used enhancing technology category was scenario-based learning (nine articles) [31, 32, 42, 51, 53, 54, 59, 62, 76], followed by resource access (eight articles) [24, 26, 28, 33, 35, 53, 59, 60] and narrated PowerPoint (eight articles) [23, 27, 46, 57, 60, 64, 71, 75], computer simulation or virtual reality (three articles) [31, 49, 62], and gamification (three articles) [11, 50, 67]. Five studies used multiple enhancing technology options [31, 53, 59, 60, 62]. Overall, there was a marked trend toward using various TEET options after 2017.

Modes of delivery

According to Ngenzi et al. (2021) [14], delivery modes can be classified into three categories: face-to-face or on-campus delivery, blended delivery, and pure online delivery. Blended delivery is “a mode of study that encompasses both online and face-to-face learning”, and pure online delivery “encompasses online learning.” Of the 57 studies, 46 used purely online learning, and 11 used blended learning [37, 43, 44, 48, 51, 54, 63, 66, 68, 70, 77].

Outcomes

As shown in Table 4, all of the included papers reported some outcomes. Knowledge acquisition was the most frequently reported outcome (41 articles), followed by behavior (14 articles) [11, 24, 32, 33, 35, 39, 42, 45, 47, 49, 52, 59, 64, 76], attitude (12 articles) [11, 30, 32, 35, 40, 44, 45, 49, 52, 53, 59, 66], satisfaction (nine articles) [22, 24, 30, 34, 36, 38, 57, 59, 71], and skills (nine articles) [43, 50, 61, 62, 67, 68, 70, 72, 77].

The studies did not use a common method for assessing the outcomes. The following scales and tools were used in the studies: the knowledge, confidence, and attitudes scale [53]; self-efficacy toward helping scale [45]; professional comfort and capability instrument [55]; sexual healthcare practice scale [26]; attitudes regarding the use of restraints scale [44]; and other existing scales as well as independently developed tests, scales, and questionnaires such as comprehension, awareness, and confidence [28, 29, 33, 34, 47,48,49, 63, 65, 69, 72]. Attitude and behavioral outcome items were previously the main assessment items, but recent years have shown a trend toward assessing skills. In addition, among the enhancing technologies that have been used since 2017, those using computer simulation or virtual reality, scenario-based learning, and gamification were effective in improving knowledge acquisition and actual behavior-related outcomes such as skills, behavior, performance, and attitude [11, 49, 50, 53, 62, 67].

Benefits of asynchronous e-learning

The benefits of asynchronous e-learning were as follows: cost-effective [25, 30, 32, 39, 47, 57, 70], time-saving and efficient [9, 25, 32, 47, 52, 68, 69, 75, 76], immediate feedback [11, 47, 68], self-paced learning [9, 11, 25, 47, 53, 57, 70, 76], flexibility [50, 70, 72, 75], ease of participation despite location and time limitations [26, 32, 50, 52, 53, 57, 63, 72], ease of participation [30, 35, 51,52,53, 57, 68], and repeated learning [53].

In addition, the following description of the benefits of the onboard features was provided: the simulation of interactive materials allows for a proxy experience on the screen. The proxy experience enhances self-efficacy, provides motivation, and leads to continued motivation to learn [29]. No one dropped out because the interactive materials kept them engaged [29]; the variety of interactive, multimedia, and hands-on elements helped maintain the nurses’ curiosity and interest [43]; fun quiz formats could be used [26]; and innovative and interactive features retained the participants’ interest [35]. Regarding motivation, the authors stated that adding incentives increased extrinsic motivation [11], and the connection of learning content to clinical experience increased intrinsic motivation [71]. Creating an active learning experience that promotes a sense of accomplishment among learners to increase motivation is necessary [30].

Issues related to asynchronous e-learning

The challenges related to asynchronous e-learning were as follows: the need for communication between learners and educators [57, 58]; lack of real-time feedback [71]; the influence of module and evaluation design on learning effectiveness [58]; possible failure to complete the entire module by some participants [58]; lack of time to study lengthy content [26, 51, 62]; lack of computer skills [33, 37, 51]; internet connection problems [9, 33]; lack of follow-up to prevent dropping out [56]; and lack of incentives to stay motivated [26]. Consequently, the need to provide opportunities to observe actual situations [71] has been highlighted, as asynchronous e-learning was considered insufficient for improving confidence [47] and practical skills [22, 71].

The onboard features in gamification present some risks; for instance, in situations involving differences or discontinuities in spatial position and timing of movements between practice with web-based game scenarios and real-life scenarios, game users might negatively modify their performance, and an inappropriate transfer of skills may occur. Moreover, a negative transfer may occur when game users find that the skills they see in the game differ from those needed in real life [67]. It was also stated that research designs to measure the educational effectiveness of e-learning are insufficient because there is a lack of good-quality RCTs to compare the effects of purely digital education [12]. In particular, few studies have measured outcomes on the impact of gamification, and those that have identified educational or clinical outcomes have low power and little clear evidence [67].