There was marked heterogeneity of study approach and results in the reviews, making broad interpretation inconclusive [19–24]. Collectively the reviews and their cited papers applied communities of practice or more commonly various learning management systems (LMS such as Blackboard, Moodle) over highly varied lengths of programme time (e.g., 20 min to 6 h, once or over a 3–8 week period) to examine: different groups of healthcare workers (e.g., allied health professionals, nurses, physicians), from different country types (developed versus developing), and from different geographic regions (e.g., North America, Europe, Australasia). They used different modes of delivery (e.g., face to face, blended learning, fully online), addressed various topics (e.g., biostatistics, research ethics, evidence-based healthcare, pharmacology, dementia management, AIDS/HIV, patient safety), leveraged various tools (e.g., multimedia, multiple techniques, multiple exposures, animation, simulation, virtual reality, hyperlinks), and used various means of assessment (e.g., quizzes, pre-test / post-test, surveys) to gauge different comparisons between healthcare worker groups and modes of delivery using a variety of outcome measures (e.g., satisfaction, knowledge gain, change in practice).
Overall the selected reviews showed that technology use is no longer novel [19] and that many different approaches and tools have been applied to provide tertiary and professional education [19–24]. Many learner characteristics (e.g., age, gender, practice setting, experience, speciality, country of training, practice) and external factors (e.g., funding, available infrastructure and infostructure, licensing, accreditation) were noted to influence which tool and approach is best in any given setting. The utility and impact of more recent tools (e.g., smartphones for mobile distance education) did not figure highly in these reviews, but the swift pace of change in technology was noted.
All forms of distance education provided a benefit over no education, with online learning being effective across different learners, learning contexts, clinical topics and learning outcomes. Overall there appears to be little or no distinction to be made between online learning and traditional onsite or face-to-face education, with both being comparable or at least as effective as one another for improving participant knowledge gain, skills and practice decisions, as well as patient outcomes [19]. Despite these generally positive findings there remains uncertainty regarding specific conclusions about which tool and or approach is best for which form of education, for which topic, and for which type of learner. Essentially, there is no ‘one size fits all’ and as a consequence application of blended and / or online learning requires careful planning.
In practical terms, distance education allows a ‘one-to-many’ (synchronous) or ‘none-to-many’ (pre-recorded asynchronous) delivery, allowing efficient access by large numbers of health practitioners and others over geographically wide areas. Synchronous versus asynchronous delivery each have benefit. For example, the former allows real-time interaction with instructors and other participants for debate and clarification, while the latter permits ‘any time’ access. Of note was that face-to-face, or at least blended learning, may still be necessary for educational activities that require a change in learners’ values or beliefs in order to permit in-depth debate, or for activities where the practice of new skills is beneficial[19]. Cost and viable connectivity can still be barriers [23].
Less positive aspects were also noted. Whilst distance education avoids the cost and inconvenience of travel and time away from a remote, often single practitioner ‘time poor’ setting, there is still inconvenience and difficulty in making time available when pursuing education ‘at home’ [21]. Dedicated time and space for elearning is not available, potentially requiring use of ‘off work site locations’ [19]. Other issues noted were: bugs in programmes, lag time, need to refresh the Internet connection and limited access to necessary equipment [19]. In addition, participant fatigue was reported when attending protracted activities (e.g., a day-long videoconference activity) indicating shorter periods would be of benefit (e.g., learning sessions of 20–30 min or less), or an ability to save progress and pick up later [19, 23]. The need for consideration of the characteristics of targeted adult learners was also noted, in particular, their differing technological expertise and online access capability [21].
Of particular note was the absence of identifying educational needs before implementing programmes [21, 23].This is related to other generic e-readiness and needs assessment issues beyond elearning, which is of importance in a country like Rwanda that has seized upon the broad use of ICTs as a key national strategy. Studies have shown that the more ‘ready’ a setting is to adopt solutions facilitated by ICT, the more likely implementation is to succeed. Similarly, any ICT solution (including elearning programmes) must be ‘needed’ [21], [23], responding to an evidence-based issue rather than a perceived issue. As a consequence, readiness assessment and needs assessment prior to any elearning implementation will enhance the probability of successful implementation, scaling, and ultimate integration and sustained routine use.
Also of concern is experience in the development of, or conversion to, online formats. Experience of the authors and reports in the literature have shown it is not effective to simply ‘e’ an existing face-to-face module or programme. Indeed, Seymour-Walsh et al. [10] state simply “The strategies used in a face-to-face lecture cannot be directly transferred into the online environment.” For example, for asynchronous delivery (absence of a live facilitator) incorporating interactive experiences can be time consuming, and for synchronous delivery (presence of a live facilitator) logistical and audience management difficulties arise when handling a mixed cohort of online and on-campus students.
Based upon the study and author experience, the following recommendations are proffered.
• Identify clear and prioritised health-related CPD educational needs (needs assessment).
• Identify and apply the simplest TEET solutions (mode of delivery, technological approach) to address the identified educational needs.
• Ensure the readiness of the national, facility, and local settings:
- Ensure national infrastructure and infostructure can support the chosen TEET solutions and are feasible and affordable for the given context.
- Ensure the technological literacy of all planned learners.
- Ensure all planned learners have affordable access to programmes, required equipment, and required connectivity.
• Ensure all education interventions are based on sound educational theories or conceptual frameworks, and that appropriate andragogy is used during design and implementation.
- Implement training programmes for educators in the design and provision of TEET for CPD to adult learners.
• Engage national professional societies to design, instigate, and maintain mandatory, incentivised, and regulated CPD programmes.
• Ensure all CPD programmes are evaluated, monitored for ongoing performance, and reviewed and revised periodically (every 3–5 years) to maintain currency and relevance.