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  1. 1. I S S U E S A N D IN N O V A T I O N S I N N U R S I N G E D U C A T I O NFeasibility of combining e-health for patients with e-learning forstudents using synchronous technologiesRay Jones PhD FFPHProfessor of Health Informatics, School of Nursing and Community Studies, Faculty of Health and Social Work, University ofPlymouth, Plymouth, UKHeather Skirton PhD RNReader in Applied Health Genetics and Communication, School of Nursing and Community Studies, Faculty of Health andSocial Work, University of Plymouth, Taunton, UKMiriam McMullan MSc SRCHLecturer in Podiatry, School of Health Professions, Faculty of Health and Social Work, University of Plymouth, Plymouth, UKAccepted for publication 18 April 2006Correspondence: JONES R., SKIRTON H. & MCMULLAN M. (2006) Journal of Advanced NursingRay Jones, 56(1), 99–109Professor of Health Informatics, Feasibility of combining e-health for patients with e-learning for students usingSchool of Nursing and Community Studies, synchronous technologiesFaculty of Health and Social Work, Aim. This paper is a report of a project to introduce and evaluate methods for usingUniversity of Plymouth,Drake Circus, information and communication technologies to involve academic staff, students,Plymouth PL4 8AA, and patients in a common synchronous e-learning environment.UK. Background. Although there is no strong evidence for this, there may be benefits inE-mail: ‘efficiency’ and for patients and students from shared e-learning. Asynchronous e- learning methods in nursing education are well-established, but synchronousdoi: 10.1111/j.1365-2648.2006.03984.x methods have received less attention. However, if feasible, because they are more akin to face-to-face contact, they may be more suitable for patients and may provide a quicker development path for e-learning. Method. We evaluated three synchronous technologies: (1) non-commercial satellite interactive television (TV); (2) Internet videoconferencing; and (3) webcasting, through feasibility studies of ‘TV-style’ panel discussions on health topics and seminars with interaction with viewers by e-mail, inter-site research meetings with face-to-face interaction, user surveys and literature reviews. Results. Interactive satellite TV required the booking of rooms with specialized receiving equipment. This limited accessibility contributed to the high cost per participant. Videoconferencing proved acceptable for cross-site research meetings and is proposed for joint meetings for doctoral students with overseas centres but has the same access issues as interactive satellite TV. Webcasting is accessible to most users with Internet access and provides a feasible means of delivery of synchronous interactive material. Reported live webcasts have had audiences of thousands. Presentation formats: panel discussions with mixed patient–profes- sional membership and mixed patient–professional audiences were acceptable to participants but engaging academic staff and students was problematic. This may be overcome with webcasting but there may still be barriers such as time- tabling and students’ concerns about learning in the same ‘live’ environment as patients.Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 99
  2. 2. R. Jones et al. Conclusions. Limitations in accessibility have been demonstrated for both satel- lite broadcasts and videoconferencing. Webcasting proved the most acceptable way of supporting a common synchronous environment. Having identified a feasible synchronous method we can now investigate hypothesized benefits for staff, students, and patients of combined e-health e-learning. Keywords: e-health, e-learning, feasibility study, nursing, synchronous methods the 1970s with the work of Hannah (Hannah 1978) which hasBackground been described by Richards (2006). Claims for the benefit of aE-learning is being used increasingly in nursing and other computer-assisted approach have been made over the years,health professions’ education. Patient education and health but only in recent years (with the availability of the Internet)promotion are important elements of any health service and have these developments started to have a major and routinethe use of information and communication technologies impact on the way nursing education is delivered. Many(ICT) to support e-health is increasing. Both e-learning for schools of nursing, as other disciplines in higher education, arestudents and e-health for patients has tended to be through now developing e-learning (Adams 2004) which may comprisethe use of web pages and interactive materials used by not only web pages but also e-mail based discussion groups,students in their own time (asynchronously). Although there videoconferencing, synchronous chat, satellite broadcasts andis no strong evidence as yet, there may be benefits in webcasting. Others have described some of the benefits and‘efficiency’, and for patients and students, from shared difficulties of e-learning (Cravener 1999). Five potentiale-learning. Schools of nursing have adopted different strat- benefits of e-learning for schools of nursing can be identified as:egies to improve teaching and learning activity as well as • Providing, as a blend of different methods, a more flexibleenhancing their research capability. Exploration of shared and effective learning environment for students.e-learning may also be a useful strategy for increasing • Providing the opportunity for collaboration betweenresearch activity of teaching staff. institutions and therefore a more efficient delivery of nurse More evidence is required on the benefits or otherwise for education. Most United Kingdom (UK) nursing curriculapatients and students of combining developments in are similar and some aspects of content will occur one-learning and e-health, but first feasible methods must be numerous occasions, although at different levels, buildingdeveloped. Asynchronous e-learning methods in nursing upon previous knowledge and skills. Widespread use ofeducation and e-health are well established and would form e-learning that facilitates use of re-usable learning objectspart of blended solutions to combined e-learning e-health. appears an obvious development. The Royal College ofSynchronous methods have received less attention but, if Nursing with City, Leicester, and Ulster Universities, havefeasible, because they are more akin to face-to-face contact, developed modules that are taught totally online (UKthey may be more suitable in an environment in which both Healthcare Education Partnership Ltd 2005). The firstacademic staff and students are relative ‘computer novices’. phase of modules ran in 2005 and included e-tutors from Synchronous methods for e-learning e-health are worthy of all over the UK and living abroad. In theory, and perhapsfurther exploration. This paper is a report of the development in the longer term, delivering such modules should be cost-and evaluation of three different synchronous methods of efficient and this consortium might grow into a nationalstudent and patient education. network. Although the new National Health Service (NHS) training organization called NHSU (supposedly NHS University but not officially named as such) has beenE-learning for nurses abandoned in its initial format (NHS 2002), the idea of aThere is currently considerable interest in developing national nursing curriculum delivered by e-learning withe-learning in nursing. An international survey of six universi- local face-to-face tutorials still seems possible.ties ranked nursing and health related subjects fourth out of 11 • Reducing travel time for students and staff. Many universitydiscipline areas in terms of current level of e-learning activity schools of nursing are on multiple campuses and both stu-[Organization for Economic Co-operation and Development dents and staff may have to travel considerable distances.(OECD) 2005]. Apart from very early work (Bitzer 1963), • Reducing costs for universities. Potential cost-savings can becomputer-assisted learning amongst nurses dates mainly from illustrated at our university. As the school of nursing is100 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
  3. 3. Issues and innovations in nursing education E-health and e-learning using synchronous technologies spread over four main sites many academic staff tradition- • meeting patients’ information needs leading to greater ally travelled to different sites to provide classes. If one psychological well-being and satisfaction with care; lecture can be given by e-learning methods to 100 students • helping improve patients’ knowledge, skills, and ability to rather than a lecturer from the main site giving the lecture to carry out self-care. 50 students there then travelling to a peripheral site to give the same seminar to another 50 students, then the saving Combining e-learning and e-health would be 2 hours travel there, 2 hours travel back, 2 hours set up and delivery. Assuming a lecturer cost (with on-costs, Patients may be experts in their own conditions. They have a i.e. administrative costs) of £30/hour, the ‘extra’ peripheral role to play in educating nurses, other health professionals, lecture costs approaching £200. If it is assumed that five and other patients, about the impact and effects of the such lectures a week can be saved, the university saves condition (Jones et al. 2000). Their expertise has been under- £1000/week or £30 000 in 30 weeks teaching time to be set utilized, but there is insufficient evidence about the costs and against the new costs of developing and delivering effectiveness of service user involvement in e-learning and e-learning. Students would also save in travel cost and time. whether it is beneficial to try to inform and educate patients• Helping to improve the information and IT literacy of and staff in the same learning environment. It is not clear nurses to participate in e-health developments in the NHS. whether students of the health professions and patients will Digital technology is playing an increasingly important be comfortable learning with each other, nor whether the role in the NHS. The NHS is investing £2Æ3 billion over information needs of patients and professionals are too 3 years in information technology and has initiatives such disparate to make shared learning possible. There is certainly as electronic patient records, electronic prescribing, and evidence that nursing students may use information aimed at the development of interoperable systems in primary and patients to help with coursework (Wilson 1995) while many secondary care (Department of Health 2002). The patients access ‘professional’ literature (Budtz & Witt 2002), National Electronic Library for Health is delivering high indicating that it may be possible to share some materials or quality information to professionals to support their ‘events’ even though each group might require other sources practice and continuing professional development of information more specific to their needs. (Department of Health 2000), but nurses may not always fully participate through lack of IT literacy (Stokes 2004). The study Health professionals need to become proficient in infor- matics during their training (NHS Information Authority Aim 1999), and using IT for e-learning could contribute to this (Kenny 2002). The overall aim of the work reported here was to introduce and evaluate methods for using information and communi- cation technologies to involve academic staff, students, andE-health for patients patients in a common synchronous e-learning environment.Access to credible information on health and enhancement of This evaluation was required to inform an e-learning strategyhealth literacy is an important aspect of patient care (Coiera that had demonstrable benefits for (a) patients and students,1996). Consumer health informatics (Eysenbach 2000) and (b) the learning and research environment of a school ofentails using ICT for patient information and education. nursing.E-health is used in this paper as ‘shorthand’ for this particularuse of ICT. There are >16 million regular users of the Study settingInternet in the UK and accessing health information is one ofthe commonest reasons for going online. Developments such The first author, with a background in e-health research, wasas interactive digital television (TV) and increasing access to appointed as Director of Research for the Institute of Healthbroadband will further increase the numbers of health Studies (IHS) at the University of Plymouth, UK, in 2002.consumers using online health information, virtual commu- Like most UK university schools of nursing, IHS was still atnities, e-consultations and Internet pharmacies (Jones et al. an early stage of developing the research environment. It was2005, Pagliari et al. 2005). While there are concerns about characterized by a large proportion of staff without doctor-inequalities for those excluded from e-developments (Jones ates, who were not research active, who were unlikely to2003), providing information for patients on the Internet has develop into lead researchers, but who were good teachersthe potential benefits (Bessell et al. 2002) of and mentors who could contribute to a developing researchÓ 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 101
  4. 4. R. Jones et al.culture through innovations in their teaching and improve • Staff said that teaching loads were high. Developing tra-support for evidence based practice in the health professions. ditional e-learning materials requires new skills that staffIn general, both academic staff and students were relative have little time to learn.ICT novices. • Students had a wide range of backgrounds; some were The university had a unique resource, a link from their mature students with little previous experience of usingTV studio to the TDS4b satellite uplink, on loan from the computers.European Space Agency (ESA). The ESA satellite has a‘footprint’ of the whole of Europe and can provide high Designquality delivery with ready access to sites where equivalentquality access to learners via terrestrial networks is restricted, The project was not designed as a single research study, butfor example, because of the non-availability of high band- as a series of pilot studies, exploratory surveys, literature andwidth terrestrial links. Our university therefore had a facility Internet reviews to explore ways of delivering synchronousto explore the use of satellite TV for health programmes in e-learning for students combined with e-health forthe community at reasonable cost without major involvement patients. These are described grouped according to the threeof commercial satellite providers. The IHS had used the main technologies investigated: (a) satellite TV (Box 1);interactive satellite TV between 1998 and 2002 for ‘satellite (b) videoconferencing (Box 2); and (c) webcasting (Box 3).seminars’, i.e. academic seminars aimed at IHS staff. Each ofthe four sites had a receiving dish with TVs wired in one or Technology 1. Satellite TVtwo rooms. Interaction with the studio was by live telephoneto the presenter and discussants. Audiences were typically Aim of the strategy20–25 academic staff. Broadcast costs included TV studio The aim of the strategy was to widen the appeal of the sat-time and satellite connect time with a total cost typically of ellite broadcasts to patients and students, to increase the£600 per 1 hour programme. This seemed a very poor use of audience size, to collaborate with other centres, and toa facility that, in theory, could broadcast to any number of improve interaction with the studio and the availability of thereceivers across Europe. In practice only 40 receivers were broadcasts.known to be installed in the UK and Ireland as a result of useof the facility in training for surgeons (Kingsnorth et al. Methods and results1999, 2000). The experience with satellite TV emphasized Methods of evaluation and results are presented together.the need to be able to deliver education via the Internet. • Staff survey: a postal self-completed questionnaire surveyResources to develop webcasting at our university were of 143 IHS staff was undertaken to discover why partici-limited, but eventually a live webcasting facility was made pation rates in satellite broadcasts were low and whatavailable in March 2005. could be done to improve uptake. Responses were received High quality videoconferencing facilities have been avail- from 67 people (response rate of 47%). Of these, 42% hadable in some universities for some time. For example, fourmetropolitan area networks have been used for videoconfer-encing between Scottish universities since 1996 (Lloyd 2000, Box 1 Interactive TVCoventry 2002). Videoconferencing has also been used in What is interactive TV via satellite and how does it work?nursing education (Waddell et al. 1999). In 2001, our Although millions of people have satellite TV via commercialuniversity had only poor videoconferencing facilities which broadcasters their charges for academic uses are prohibitive. Ourwere rarely used by the IHS, despite it being distributed university had equipment to uplift programmes to a Europeanacross four sites with approximately 150 mi between its most Space Agency Satellite. These programmes could then be receiveddistant points. freely by anyone in Europe who had a satellite dish pointing in the right direction. TV quality programmes could therefore be A strategy to develop combined e-health e-learning seemed broadcast to millions of people across Europe if satellite receiversa logical approach to help develop both e-learning and the were in place. In practice the capital costs for installing a receivingresearch environment. However, there were numerous bar- dish were around £600–800. There were about 40 hospitals,riers to development that are common to many university universities and other sites in the UK and Ireland with receivers.schools of nursing, including: The rooftop receiving dishes normally had cables to one or two rooms within the building. TV programmes could therefore be• Despite its multiple sites and use of the satellite, there was seen in those rooms. Costs of transmission comprised TV studio no major use of e-learning. Like other universities, many costs and satellite uplift costs. staff were not confident ICT users.102 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
  5. 5. Issues and innovations in nursing education E-health and e-learning using synchronous technologiesBox 2 Videoconferencing identify individuals in those institutions with a willingness to participate. Sixty-four sites with receiving equipment What is videoconferencing and how does it work? Although many were identified and attempts were made to contact some- people now have desktop webcams allowing desktop videoconf- erencing for reasonable quality of picture and sound, it requires a one who would know about the use of the satellite recei- camera and device to pass the video/sound to another place by ver. Seventeen receivers at sites in our region were being wire. Most universities will have one or more videoconference used to watch the programmes, while viewers at five sites rooms set up with equipment. There are at least three forms of outside the region had watched at least some of the transmission: (a) telephone (ISDN), (b) Internet (IP), (c) private programmes. Twenty sites were not currently watching: lines. Videoconferencing can be point to point (two sites), or multipoint (many sites) although with >10–15 sites participating, reasons included ‘no interest’ and difficulty with rooms. control of a meeting would become difficult. The quality of the Despite several attempts to identify someone who would picture and sound depend on the cameras, projection equipment, have responsibility, there was no reply from 22 (34%) of and transmission speeds. Running costs mainly comprise the the sites. capital costs plus some technician time. There are no connection charges if using Internet. Actions following evaluation Availability was improved by making recorded programmes available on a videostreamer on the Internet. These recordedBox 3 Webcasting programmes remain available to all on the university website. A collaborative relationship was formed with the local What is webcasting and how does it work? A webcast delivers Primary Care Trust (PCT): (a) to persuade other PCTs in the synchronous broadcasting over the Internet and is analogous to broadcast television. Webcasts happen in real time and viewers region to buy and install receiving equipment and (b) in watch the event as it happens. The viewers cannot skip ahead or making a series of programmes on National Institute for otherwise control the pace. However, webcasts can be archived Clinical Excellence (NICE) Guidelines (http://www.nice. allowing viewers to watch later at their own convenience, but PCTS in our region installed 10 more receivers. without the interactivity. Webcasts are always streamed from A new style of programme was piloted to make better use specialized streaming servers. Potentially, webcasting can be used, of TV with video clips, panel discussion and use of e-mail for example, by a teacher to teach a live class to students who are sitting at their personal computers. Students log on to a webpage for audience contact instead of telephone. Programmes were and can see and hear the lecturer and view any audiovisual aimed at patients, students and staff, potentially having a material. Any questions or comments are either sent by e-mail or wider appeal and fitting with the agreed e-health e-learning typed into a ‘chat room’. However, as the live video streaming strategy. The first pilot programme on prostate cancer was may be up to 1–2 minutes behind the broadcast, lecturers need to broadcast in May 2003. A series of six programmes was allow a pause for questions. The need for pauses has been rein- forced by studies showing that students find it difficult to view, advertized in collaboration with the local PCT (epilepsy, and compose and type questions at the same time. hypertension, access to health information, diabetic foot ulcers, head injury and multiple sclerosis) and was broadcast to mixed audiences of students, staff, and members of the watched at least one programme since October 2002 public from October 2003. Programmes were broadcast (range 7–15 people for each of seven seminars in this ‘live’ and lasted 1 hour. They comprised a studio panel period). Two main reasons for not watching were ‘always discussion interspersed with video clips of other patients teaching’ and ‘too busy’. E-mail was thought better than talking taken from the DIPEX website (http://www. the telephone as a means of communication with the studio A typical studio panel included about six as it avoided ‘queuing’ to make a comment. Only 58% of people, such as a patient, nurse, hospital doctor, family the respondents knew of the recorded programmes avail- doctor, information provider, pharmacist. Faculty staff able on the Internet. Many of the suggestions for contacted and recruited panel members and chaired the improvement related to the day or time but there was no studio discussion. Interaction between viewers and TV consistent ‘solution’. Some described how timetables are studio was mostly by e-mail direct to the studio with a set many months in advance and satellite programmes, few calls to a secretary who then e-mailed the studio. arranged at short notice, were likely to clash. Some Recorded programmes were made available on the Internet respondents suggested embedding the programmes in about 1 week after the live programme. We tried to get teaching modules. local TV interest but failed. For this series of broadcasts we• Site survey: Attempts were made to contact each site in the had collaboration only from our region and no more than UK and Ireland thought to have a receiving dish and to six sites for any one programme.Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 103
  6. 6. R. Jones et al. Greater involvement of patient groups was explored by viewers and has some structure to ensure programmemailing the Guild of Community Groups in our city to offer coherence was achieved in some cases but health professionalthe facility for them to make a programme with our support. feedback for some programmes indicated a desire for moreThe local Endometriosis Society took up the challenge and structure.produced a programme with participation from both localclinicians and National Endometriosis Society representation. Technology 2. Videoconferencing Although the attempt to get participation from a numberof sites (see ‘site survey’ above) had little success, it did lead Aim of the strategyto collaboration with the University of Southampton in the The aim of the strategy was to get greater use of videoconf-UK. A series of videoconferenced meetings were held to erencing amongst colleagues, to improve communicationdiscuss working together and subsequently one programme between sites while reducing travel, and to extend its use towas produced on organ donation. A further series is planned students.using webcasting rather than satellite TV. ImplementationDiscussion The IHS started to use the services and (morally) supportedSome, but not all, of the strategies were successful. It was colleagues centrally who installed new Internet videocon-possible to recruit a TV panel from various health profes- ference equipment in 2002. Our university reorganized itssions, patients, carers and charities to take part (with no faculties in August 2003 and IHS was incorporated into acharge to the university) in the programmes. Programmes new Faculty of Health and Social Work (FHSW) with fourwere well received by viewers and we achieved mixed audi- schools. We appointed research coordinators at each of theences of patients, carers, students and staff. Interaction be- four main sites (and later at a fifth site) who were encour-tween studio and audience was variable, mainly dependent on aged to organize monthly research meetings, including someaudience size. In those programmes which achieved a good multi-site meetings using videoconferencing. Videoconfer-level of audience participation, the studio received around 15 encing has been promoted at faculty management meetingse-mails during the hour-long programme. There was anec- and through personal contacts. It was used with patients asdotal evidence of interaction and discussion between mem- part of a stakeholder consultation on e-health (Jones et al.bers of the audience at receiving sites. It was possible, but not 2005).easy, to achieve programme content relevant to patients,students, and staff. The recorded programmes provide a Methods and resultscontinuing resource for re-useable learning objects on the The use of videoconference facilities was monitored fromweb, although we have no evidence that they have been used. 2002 and trend in usage recorded. Joint research meetings There were problems that, in the end, persuaded us to between four of the five FHSW sites have been regular anddiscontinue this method. The main problem was audience successful, with 16 such videoconferenced meetings in 2004.size. Advertizing the events was time-consuming and we Use of videoconferencing is now used for multi-site schoolfailed to get much TV, radio or newspaper coverage of the business meetings and for supervision, when students andevents to generate audiences amongst patients. The estimated supervisors are based on different sites. In 2004, via one ofmaximum audience was only 70 people. Limited audience our personal links (HS) we started ad hoc videoconferencedsize was, we think, mainly due to problems of access. There meetings with the University of Iowa, initially to discussare only limited access points in the UK. In addition, ensuring possible areas of collaboration in teaching and research andthat rooms equipped to receive the TV broadcast were subsequently on topics of mutual interest. In 2005, we suc-booked and that someone was available to provide directions cessfully used videoconferencing to ‘bring in’ overseasfor patients and other viewers to each room was time- speakers to a 2-day conference (University of Plymouthconsuming. Providing e-mail or telephone access at each site 2005). We also planned for postgraduate research studentsand having someone to provide technical assistance in the between FHSW and the University of Iowa to meet monthlycase of problems was sometimes difficult. If we had achieved by videoconference to present and discuss their research.participation from (say) 50 sites with (say) 10 peoplewatching at each site the cost per viewer would be only £3 Discussionbut, with the small audiences that we achieved, the cost of Videoconferencing can make a useful but limited contribu-each broadcast was prohibitive. Maintaining a balance tion to e-learning, having the same drawback as satellite TVbetween a programme which follows the questions of the in that special rooms have to be booked.104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
  7. 7. Issues and innovations in nursing education E-health and e-learning using synchronous technologies broadcast interviews [e.g. with politicians on health policyTechnology 3. Webcasting (Kaiser Family Foundation 2005)] or panel discussions.Aims of the strategy Webcasting has been used in nursing education. West Vir-The aim of the strategy was to see how others were using ginia University School of Nursing United States of Americawebcasting, to test the feasibility of using webcasting, to (USA) (DiMaria-Ghalili et al. 2005, Ostrow & DiMaria-explore staff attitudes to further development of e-learning Ghalili 2005) now use webcasting, having previously triedusing this or other methods, and to explore student views on satellite and videoconferencing methods.e-health e-learning via webcasting. Webcast streams are subject to delay depending on the speed of the server and users’ connections to the Internet (Scott &Methods and results Quick 2002, Locatis et al. 2003). This has consequences forMethods and results are presented together. the organization of the programme. Scott and Quick trans-• We conducted a literature review on webcasting: searching mitted a series of five webcasts at Kettering General Hospi- PubMed, British Nursing Index, CINAHL, Ovid and tal, UK, suitable for nursing staff with interaction via a chat AHMED using the term ‘ webcast*’, limited to the English interface. They reported that viewers found it distracting to language and the years 1985–2005, led to respectively 6, 1, compose and type in questions while listening and presenters 7, 4 and 0 records with a final number, after duplications found it difficult to scan and answer questions while still were discarded, of 11 records. Five of these discussed web- broadcasting. After introducing an intermission of a few casting for conferences, two for use in distance education for minutes, feedback from nursing staff was positive. They graduate health professionals, and four technical aspects. enjoyed being able to ask questions anonymously and not Searching Google and Google Scholar with the exact phrase having to travel and leave the clinical area. ‘Live Webcast’ and the word Health returned 113,000 pages • To explore how webcasting might be used together with on Google and 56 on Google Scholar. The first 30 from face-to-face seminars for students and patients, a webcast Google and all from Google Scholar were reviewed manu- and discussion with students from a module on Specialist ally and examples of live webcasts extracted. Cancer Care was held in June 2005. Seven students and A number of centres (including University of Kentucky, their lecturer participated from a computer laboratory in Thomas Jefferson Hospital, Hartford Hospital Connecticut, one of the peripheral sites with the principal author web- and Brigham and Women’s Hospital – all USA) have used casting from the main site. The presentation described how live webcasting for students, staff in continuing education, videoconferencing and webcasting work and students and or for patients (Table 1). These webcasts included live sur- lecturer were asked for their views on the advantages and gery broadcasts (Gandsas et al. 2002, Botvin 2004) achiev- disadvantages of each. Views were sought on a possible ing large audiences. For example, a live webcast of coronary module reorganization in which patients participated. brachytherapy for re-stenosis in March 2002 was watched Students and lecturer were generally positive about the use by 7384 individuals, with 125 e-mails submitted during the of webcasting. Comments in favour included: ‘This would session (American Journal of Nursing 2002). Others have meet a huge need for cancer education and save lots ofTable 1 Examples of live webcastingReference Organization Types of webcastGandsas et al. (2002) University of Kentucky Live surgeryRankin et al. (2004) University of Toronto Various, using ePresence softwareSan Diego County San Diego County Medical Society Bioterrorism preparedness Medical Society (2003) training 1 day course (2003)Botvin (2004) Hartford Hospital Live surgeryUniversity Health Systems University Health Systems of East Carolina; Robot assisted live of East Carolina (2005) surgeryGood Samaritan Good Samaritan Hospital; Live surgery Hospital (2004) of University of Pittsburgh; Memorial lecture Pittsburgh (2005)Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 105
  8. 8. R. Jones et al. duplication by individual work areas’ and ‘Good if you Internet videoconferencing unsuitable as methods for possible have missed a lecture. You can catch up’. Concerns synchronous e-learning e-health. Webcasting appears a feas- included students’ ability with the technology (Difficulties ible method (Table 2). for people who are not IT literate or who do not have access to a computer) and concerns about sharing learning What are the limitations of the study? with patients (‘I think there are huge issues regards confi- dentiality with patients participating. It might also silence The evaluations were not planned as a programme of some ethical debate that can arise in group discussion’ and research. Rather, the opportunities that presented for such ‘the things we have experienced in the work area we talk evaluation were taken. Further study using a series of about. Would we be able to talk so freely with patients interventions and the same methods of assessment for each there?’ and ‘It could end up with the nurses supporting the strategy would be helpful. Perhaps inevitably for such a patients re their experiences’). practical study, some of the negative outcomes have resulted from the number of staff available, for example, to directDiscussion attendees or act as technicians, and from the limited numberThe literature review showed that webcasts can be used to of rooms equipped with appropriate technical equipment.gain very large audiences with good interaction. The experi- However, these practical limitations also reflect the realence of West Virginia University which moved from satellite world in higher videoconferencing to webcasting (DiMaria-Ghalili et al.2005) confirms our own view that webcasting is a technology Can webcasting play a role in tailoring asynchronouswhich will allow us to implement synchronous methods as web-based information?part of a strategy of e-health e-learning. West Virginia University covers a large rural geographical The sharing of asynchronous web pages between patients,area. To help cut travel time they initially used a satellite students and staff already occurs. Some web-based resourcesnetwork providing a one-way video, two-way audio system are being developed which could have multiple uses forwith a telephone bridge to each of six to eight receiving sites. professionals, patients and their families. For example,However, it still involved travelling for the students and ‘DIPEX’ ( is aimed not only attelephone lines and satellite time was expensive. Subsequently, patients, their carers, family and friends but as a teachingthey tried videoconferencing which was less expensive because resource for health professionals. The costs of maintaining anof the use of dedicated telephone lines but was still costly in evidence-based web site are considerable. Use of the sametravel to one of the eight sites for students. After personal knowledge base, web sites, TV programmes by a wide rangecomputers became more widely available web-based courses of health professionals and patients may help to maximize thewere developed. Students liked the convenience of time and impact of the investment, but staff found it hard to design the course for maximum Many studies of patient education conclude that informa-interactivity. Webcasting greatly improved the flexibility and tion needs to be tailored to the individual (e.g. Maguire &interactivity, but the disadvantage noted was that reception Pitceathly 2003). The ‘traditional’ response has been toquality and speed varied according to the student computer’s develop separate resources, as witnessed by the millions ofbandwidth connection. The pilot webcast and discussion with web sites, or different books. Yet, if we knew more about howstudents from one module showed that students were still people (whether patient, student, nurse or doctor) constructednervous of the technology and some had concerns about knowledge, and how their information and learning needsincluding patients in their learning environment. varied, we could develop user models and meta-knowledge which would allow dynamic systems to produce information tailored to the needs of individuals (Abram et al. 1999, BentalOverall discussion et al. 1999). Research into human–computer interaction on ‘traditional’ e-learning web sites will give information on howWhat does this paper add? to tailor the sites, but research on human–human interaction isIn this paper, we have drawn together the experiences and also needed. At the moment, the way professionals tailorevaluative strategies used to try to determine whether any of information to patients, or teachers tailor information tothe three synchronous technologies are feasible to deliver students, is often not explicit. Analysis of webcasts and howeducation to a wide spread of students, staff and patients. presenters adapt explanations could provide one method forIssues of accessibility made interactive satellite TV and carrying out such research.106 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
  9. 9. Issues and innovations in nursing education E-health and e-learning using synchronous technologiesTable 2 Comparison of technologies Non-commercial satellite TV Internet videoconferencing WebcastingLocations with access Available at centres in Europe that Available on any high speed Available on any reasonable have installed a satellite receiver Internet connection in the World specification Internet connected with Internet videoconferencing computer equipmentCosts Viewing centre: receiver satellite Dedicated VC room c. £6000 Receiving PC: no additional cost dish c. £600 Transmission: currently no Transmission capital cost: Transmission: £800/hour marginal costs (Internet) c. £6000 (TV þ uplift cost)Logistical requirements Only available in certain rooms in Although some centres may have Computer needs reasonably for viewing those centres. Rooms need to be mobile videoconferencing modern software and sound card. booked and equipment (satellite equipment, most have certain User may not have support to reception, Internet connection for rooms in which it is set up. check these requirements e-mail) set up. In most locations Rooms need to be booked rooms are multi-purpose and heavily booked.Interaction Needs separate Internet connection Interaction is by talking. Viewers Viewers can use the computer on for e-mail. Presenters can respond see the presenters, and the which the webcast is playing to by talking or by e-mail. Viewers presenters see the viewers in ‘real send e-mail. Presenters can see the presentation in ‘real time’. time’ respond by talking or by e-mail. Presenters will not know who is Viewers see the presentation up watching unless those viewers to 1 minute later. Some e-mail the TV studio difficulties to date, but should be possible to know who is watchingUser participation Staff survey showed relatively low Participation in staff meetings Audience from weblog of 60–70. participation even with rooms quite high (from monitored use) Literature reviews show booked and equipment but rooms booked and equipment audiences of over 7000 organized. Maximum audience organized. Maximum number in size from programme inter-site meetings 30–40 surveys ¼ 60–70Patient involvement Panel discussions of topics. Only attempted in the context of a One panel discussion webcast Questionnaires at sites and study (video-conferenced focus which potentially included e-mails showed patient groups) patients but no logging or survey participation was carried out for that programme expensive and webcasting with e-mail and webpage responsesWhat role can webcasting play within the range of could achieve the same result in an e-learning environment.e-learning in nursing education? Many nursing students (particularly from non-traditionalWe were concerned to identify a synchronous technology for entry) as well as academic staff in schools of nursing are notfurther exploration of combined e-learning e-health. How- highly computer literate. It is very important to build bothever, does our experience help those considering the use of student and staff confidence in new technologies (Eklund et al.ICT in nursing education? The use of other technologies 2003). Webcasting is similar to other activities such asaiming to improve teaching and learning has been explored. watching television, and may therefore prove an easier methodVoting systems have been used for a variety of disciplines to adopt than asynchronous methods, such as the development(Draper & Brown 2004) including nursing (Stuart et al. of web pages. Some patients may also find synchronous2004). Draper and Brown found that voting systems used methods preferable. So far as we can see from the literature,across the University of Glasgow in traditional face-to-face however, there are no trials comparing ‘head-on’ e-learninglectures were effective, particularly to support ‘contingent based on synchronous methods such as webcasting with moreteaching’ in which lectures focus on using diagnostic ques- ‘traditional’ e-learning. Given the large amount of time andtions on the points that the particular audience most needs on money spent by schools of nursing on moving towards greaterthat occasion. However, these technologies are relatively e-learning, that would be a study worth doing.Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 107
  10. 10. R. Jones et al. Higher Education Funding Council for England (HEFCE) What is already known about this topic Capability fund. • E-learning is increasingly utilized to deliver course materials in higher education. E-health is a term used to Author contributions describe the use of information technology to deliver health education to patients. RJ, HS and MM were responsible for the study conception • Students of health professions utilize information de- and design and drafting of the manuscript. RJ, HS and MM signed for patients, and patients access student materi- performed the data collection and data analysis. RJ and MM als to learn about their own conditions. obtained funding and provided administrative support. RJ • The literature suggests that students and staff can provided statistical expertise. RJ, HS and MM made critical sometimes learn from patients. revisions to the paper. RJ and SS supervised the study. What this paper adds References • Interactive TV using non-commercial satellite failed be- Abram D.B., Mills S. & Bulger D. (1999) Challenges and future cause it required access to rooms with appropriate con- directions for tailored communications research. Annals of Beha- vioural Medicine 21(4), 299–306. nections, and was expensive for small numbers of users. Adams A.M. (2004) Pedagogical underpinnings of computer-based • Videoconferencing using dedicated equipment has a role learning. Journal of Advanced Nursing 46(1), 5–12. in between-site meetings but also has access problems American Journal of Nursing (2002) News report on http:// for e-health e-learning in which many users may wish to–0003.asp. A record- participate from unscheduled locations. ing of the webcast is available at: webcast or at the Continuing Medical Education Website jeff- • Webcasting is an appropriate technology for exploring accessed on 16 August 2005. possible joint e-health (for patients) and e-learning (for Bental D.S., Cawsey A.J. & Jones R. (1999) Patient information students). systems that tailor to the individual. Patient Education and Counseling 36, 171–180. Bessell T.L., McDonald S., Silagy C.A., Andersen J.N., Hiller J.E. &Conclusion Sansom L.N. (2002) Do Internet interventions for consumers causeWebcasting has proved a suitable method for supporting more harm than good? A systematic review. Health Expectations 5(1), 28–37.academic staff, students and patients in a common synchron- Bitzer M.D. (1963) Self-directed inquiry in clinical nursing interac-ous e-learning environment. Now that a feasible method for tions by means of the PLATO Simulation Laboraory. Reporte-health e-learning has been identified, further study is needed R-184, University of Illinois, Urbana, investigate the hypothesized benefits for students, patients Botvin J.D. (2004) Hartford Hospital surgeons share publicityand the research environment of the university. If shared with robot ‘assistants’. Profiles in Healthcare Marketing 20(4), 1, 3–9.learning proves to have benefit it could radically alter nursing Budtz S. & Witt K. (2002) Consulting the Internet before visit toeducation, with the sharing of the learning environment general practice. Patients’use of the Internet and other sources ofacross professional and patient boundaries and across the health information. Scandinavian Journal of Primary Health Careworld. 20(3), 174–176. Coiera E. (1996) The Internet’s challenge to health care provision (editorial). British Medical Journal 312, 3–4.Acknowledgements Coventry L. (2002) Video Conferencing in Higher Education. Report. Support Initiative for Multimedia Applications. Part of the JISCWe thank all those who have helped in developing the e-health New Technologies Initiative. Retrieved from http://www.e-learning approach using synchronous technologies including on 14 SeptemberAndy Dickens, Dave Hurrell, Ros Jowett, Susan Lea, Jane 2005.Morgan, Zoe Portman, Morag Prowse, Phil Richards, Debbie Cravener P.A. (1999) Faculty experiences with providing online courses. Thorns among the roses. Computing in Nursing 17(1),Shrubb, Liz Stenhouse, Adrian Vranch and Gail Wilson. 42–47. Department of Health (2000) The NHS Plan. A Plan for Investment.Funding A Plan for Reform. The Stationery Office, London. Department of Health (2002) Delivering 21st Century IT Support forThere was no external funding for this work other than the the NHS: National Strategic Programme. Department of Healthe-health e-learning facilitator post being funded via the Information Policy Unit, London.108 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
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