After carefully reading and analyzing the selected publications, we found that e-learning studies on medical education significantly outnumbered (N=15/36) those in other areas. We therefore arrived at some conclusions firstly regarding medical education, followed by other areas, which will be presented according to the sequence of proposed research questions.
Main research themes
We obtained 1885 results in Science Citation Index, Social Science Citations Index, and Arts & Humanities Citation Index, using e-learning as the title, ranging from 1980 to 2020. Via VOSviewer concurrence analysis, we obtained nine clusters, i.e. main research themes (Figure 1).
Cluster 1 includes 81 items, e.g. Accuracy, acquisition, adolescents, blended learning, competence, computers, continuing education, curriculum, and education, etc. Cluster 2 includes 78 items, e.g. adaptation, adaptive e-learning, anxiety, collaboration, cluster analysis, courseware, data mining, e-learning environment and educational data mining, etc. Cluster 3 includes 69 items, e.g. acceptance, adoption, antecedents, continuance intention, e-learning system, ease, gender, intention, perceived ease, social cognitive theory, and workplace, etc. Cluster 4 includes 43 items, e.g. active learning, cloud computing, communication, computer-assisted instruction, games, higher education, innovation, m-learning, online learning, social presence, support, virtual-reality, and web 2.0, etc.
Cluster 5 includes 41 items, e.g. achievement, classroom, distance education, effectiveness, engagement, formative assessment, experiences, motivation, quality assurance, self-regulated learning, student satisfaction, training, and trends, etc. Cluster 6 includes 34 items, e.g. accessibility, adult learning, distributed learning, engineering education, human-computer interaction, improving classroom teaching, teaching/learning strategies, and technologies, etc. Cluster 7 includes 18 items, e.g. barriers, beliefs, efficacy, knowledge management, self-determination theory, and tools, etc. Cluster 8 includes 5 items, i.e. knowledge sharing, management, participation, virtual communities and work. Cluster 9 includes 3 items, i.e. authoring tools, experience, and integration.
Information technology literacy
Information technology literacy was strongly correlated with use of information technology devices, exploitation of online databases and exploration of online information. It is thus important for universities to recruit professional with high information technology literacy in order to train digital talents and maintain digital programs. Students’ digital exposure could encourage but not force them to improve digital literacy and skills (Rafi, Zheng, & Ahmad, 2019).
Although it has been demonstrated by numerous studies that e-learning is effective in education, there are still numerous factors that may influence its effectiveness. Effects of e-learning on nursing education are under great influence of differences in information technology literacy of both students and teachers. High literacy of information technology may facilitate the achievements of e-learning in nursing education (Button et al., 2014). Lower literacy of information technology may, however, weaken its effectiveness.
It is thus necessary to connect the educational institute to the society and to develop the digital literacy of teachers and students by enhancing collaborative learning and teaching, as well as mutual cooperation and communication. Digital literacy could not develop without control over digital ethics in educational practice (Domingo-Coscollola, Bosco, Segovia, & Valero, 2020). eHealth literacy was closely related to use of Internet. Use of Internet was closely related to age, ethnicity, education, economic status, computer characteristics, marital status, health literacy, medical decision making, and health information sources, rather than health status (Arcury et al., 2020).
E-learning acceptance and effectiveness
In the information age, innovation of knowledge is leading to the acceptance of e-learning, breaking the limitations of time and space. Most English learners consider e-learning significantly more convenient and helpful than the traditional learning (Tan, 2015). In general, most studies supported e-learning education since they revealed significantly higher acceptance and effectiveness compared with traditional learning. Many studies have recently discussed acceptance and effectiveness of e-learning in many fields. E-learning has become increasingly popular in nursing and healthy profession. Since the transformation of hospital training to e-training, e-learning has emerged as the most significant change in nursing education (Button, 2014). It was also demonstrated that e-learning, which met certain quality criteria, could achieve cognitive, affective and psychomotor learning goals as effectively as the traditional learning approach (Koch, 2014). E-learning has also been widely used and accepted in children’s care training work.
Assisted with the International Children's Palliative Care Network, most (>80%) e-learning participants reported that e-learning courses were clearly presented, easily understood, highly rated and particularly beneficial. Some (75%) learners reported that e-learning could enhance knowledge, improve skills and cultivate positive attitudes although only 61% learners reported a significant change in learning practice. This e-learning network is an innovative approach of knowledge acquisition, by which learning contents are easily accessible and available to learners (Daniels & Downing, 2018). Use of e-learning in medical education could facilitate adult learning theory, where educators would improve learning effectiveness (Ruiz et al., 2006).
The integration of e-learning into traditional learning proves acceptable and effective. After adaptation to e-learning contexts, e-learning integrated into pedagogical approaches and teaching strategies is beneficial to nurses who are in need of continuous education, which equips nurses with continuous learning skills and safe evidence based care (Button et al., 2014). Although e-learning has received great positive comments, it can hardly replace the traditional approach completely. Situated e-learning could effectively improve nursing education although the cognitive ability was not significantly enhanced under the e-learning model compared with traditional learning. E-learning can therefore be considered an effective aid to traditional learning in nursing education (Feng et al., 2013). Nevertheless, there has been no enough evidence demonstrating that e-learning can completely substitute the traditional pedagogical approach.
The similar effect of e-learning was revealed on health education. Similar to traditional learning, e-learning can achieve success in health professional training. E-learning may provide special training, practices and self-management support for patients, which may not be realized through traditional learning alone. The effect of e-learning on self-management support is a relatively new field with sparse studies exploring characteristics of e-learning support for self-management (Lawn et al., 2017). The effect of e-learning on self-management is, therefore, in need of further explorations.
E-learning tools have been used in so many fields that they are of great significance to education and training. E-learning is able to provide indisputable benefits for learners in terms of evaluation and knowledge delivery. The different effectiveness of e-learning was mainly due to choice of appropriate e-learning platform, learning contents, and e-learning user friendliness. A multilingual medium is an important feature for an e-learning platform to deliver the learning contents to a wide range of learners.
E-learning could improve learning outcomes, e.g. self-regulation, learner satisfaction, flexible and speedy learning. It could also meet various learning needs, facilitate cooperation among learners, save time and costs, reach multiple learners, stimulate mutual learning and teaching, obtain instant feedback, access plentiful resources, and lessen environmental pollution. Generally, e-learning approach could exert a positive influence on education on the basis of necessary grounds (Somayeh et al., 2016).
In language education, e-learning also received positive feedback. Commercial e-learning courseware has been immensely accepted in Japan, which could be used to improve students’ English proficiency. The courseware could be used to evaluate learning progress and enhance students’ concentration on learning. The usefulness of courseware is closely related with students’ previous learning experiences (Hirata, 2018). Those who have experienced e-learning performed significantly better than those who have not.
The blended English language e-learning approach produced positive learning outcomes in Islamic higher education. Combination of face-to-face with online e-learning could enhance motivation and collaboration of learners although no significant differences were found in test results (Yauri et al., 2016). E-learning could improve English learners’ academic achievements, enhance their self-regulation, and create a relaxing learning environment to reduce learners’ anxiety and stress (Shahi, 2016). E-learning strategies could improve language course management, better learning outcomes, and enhance learner self-regulation (Milliner & Cote, 2016).
Regulated e-learning situation could lead to positive learning outcomes. Regulation plays an important role in the e-learning context. Highly regulated e-learning model could lead to significantly better learning outcomes and academic achievements than the non-regulated (Goda et al., 2015). The e-learning model, which requires strong regulation, has been widely accepted in both academic and business areas due to its easy accessibility, reasonable price and resourceful contents (Laisi et al., 2011). Although the new decade has been witnessing various advantages of e-learning, we cannot ignore its barriers.
Interactions in the e-learning context
Interactions may be negatively influenced in the e-learning situation in many fields. The self-regulated and asynchronous nature of e-learning may decrease the interactions between learners, peers and teachers (Koch, 2014). The decrease in the interactions may cause ineffectiveness in e-learning, which should be considered in learning and teaching designs.
Interactions of factors such as sense of community, learner satisfaction, and perceived cognition could also significantly influence the effectiveness of e-learning. In the e-learning settings, sense of community is closely correlated with learner satisfaction and the latter is also strongly correlated with learner perceived cognitive learning. The perceived cognitive learning is strongly correlated with the interaction between learners and learning contents, while weakly correlated with the interaction between learners and instructors and moderately correlated with the interaction between learners. It is indispensable to deal with the interactions in the e-learning contexts so that the e-learning effectiveness may be augmented (Baturay, 2011).
Adaptation to e-learning
It is very important to obtain cooperation from both students and teachers. Due to the technological innovation and human curiosity, students may be ready to adapt to a new pedagogical approach, while teachers, who have been teaching for many years based on a stereotypical method, may refuse any change because the new teaching method will cost them more efforts than the traditional one. Academic staff tend to resist adapting to the unfamiliar e-learning strategies (Black, Beck, Dawson, Jinks & DiPietro, 2007), because it is most likely that they would like to spend more efforts engaging academic research instead of a new trial of e-learning. They would prefer the familiar effort-saving traditional pedagogy to the unfamiliar effort-consuming e-style. It is thus meaningful for e-learning technology designers to carefully take into account how to save teachers’ efforts to accept the new pedagogy.
In addition, it is too early to conclude that all the teachers and learners are skillful in technology use. Thus, merely ongoing e-learning training may be insufficient and completely replacing teachers with e-learning technologies may prove unrealistic. Technology adaptation and social context should be considered in order to familiarize students and teachers with use of e-learning technologies. A scaffolding approach may be helpful to the development of e-learning expertise. The minimum entrance requirements for e-learning may be necessary to include (Bharuthram & Kies, 2013). It is also important for designers to make the e-learning technology playful, useful and easy in the learning and teaching process. In this way, those who are unfamiliar with the technology will possibly spend some time trying it.
As a new learning approach, e-learning is also confronted with many cultural challenges (Laisi et al., 2011), which is hard for learners and teachers to adapt to. In a culture where educational technology is not supported, it may be hard to implement e-learning device assisted learning and teaching. On the other hand, in a culture where information technology is encouraged and immensely popular, e-learning would most likely be accepted and developed, coupled with its higher effectiveness. On condition that the educational institute has a strong academic culture, the e-learning atmosphere will be more easily cultivated than the one without a strong academic culture.
Motivation and enjoyment
The form of e-learning alone without help of teachers or instructors may discourage students from learning, due to which students’ motivation may be dampened. The perceived teacher online and offline support exerted a direct and mediated effect on learners’ e-learning motivation. Effort beliefs consistently predicted task value and ability beliefs, and ability beliefs predicted e-learning task fulfillment (Fryer & Bovee, 2016). Briefly, the perceived teacher online and offline support, effort beliefs, task value and ability belief are all considered influencing factors, which should be taken into account when e-learning is included in teaching and learning design.
Vocabulary learning is an important element in language acquisition. The vocabulary acquisition was positively influenced by educational game-assisted e-learning enjoyment, which could motivate learners to continue the long-term learning process. Enjoyment of the educational game might be an important factor that could determine the effectiveness of vocabulary e-learning (Ebrahimzadeh & Alavi, 2016). It is therefore indispensable that educational games involve the element of enjoyment when designed.
Numerous e-learning devices have been developed and applied to education, among which those used in language acquisition were huge in number. Below are merely recent e-learning devices retrieved from a limited number of databases, coupled with their specifically demonstrated effectiveness in education.
Educational Broadcasting Service. It is noteworthy that numerous e-learning devices were developed to assist language acquisition and obtained significantly better learning outcomes than traditional pedagogy. Learners felt satisfied with the blended e-learning model, via which they showed positive continuance intention to learn English (Lin et al., 2016). Consistent use of video-based e-learning (i.e. Educational Broadcasting Service: EBS) led to changes in high school students’ English proficiency mediated by behavior control strategies, which precluded the decrease of English proficiency possibly due to the time management function of EBS (Chae, 2018). Another e-learning medium, i.e. Moodle platform, has been demonstrated able to improve German communicative competence of students majoring in tourism management. Integrated with modern pedagogical conceptions and second language teaching strategies, this e-learning platform could effectively complete innovative and professional tasks (Bihych & Okopna, 2018).
MyEVA and EED. An e-learning tool, MyEVA, was made of three modes: MyEVA in preference mode, MyEVA in basic mode, an Internet dictionary and a traditional acquisition mode. It could greatly improve vocabulary learning and prolong the retention of second language vocabulary on the basis of mixed modes (Yang & Wu, 2015). In online e-learning English for Educational Development (EED) course, both advantages and disadvantage of e-learning were explored. The technology assisted e-learning was flexible and the integrated discussion forum was useful for practitioners who were to join or joined the e-learning model (Bharuthram & Kies, 2013).
WebCT and IPHRAS. An e-learning platform, WebCT, was designed by two European universities: the London School of Economics (United Kingdom) and the University of Valencia (Spain) to improve language learning and information exchange between both universities. It was reported that the student participation in the platform was strongly correlated with the final qualifications, and the e-learning platform positively contributed to learning and teaching in both English and Spanish languages (Cuadrado et al., 2009). An innovative e-learning platform--IPHRAS: Interphraseologie for Studien-und Berufsmobile was developed to incorporate theme-based words in multilingual forms including Greek, Turkish, Romanian, and Bulgarian into more popularly used languages such as English and German. More importantly, this platform contained idiomatic expression, carried cultural concepts, and included endangered languages (Teodora et al., 2017).
An on-line bulletin board and GBWI. It was also demonstrated that e-learning devices could improve English writing skills. An e-learning tool, actually an on-line bulletin board, was demonstrated more beneficial to academic writing compared with traditional face-to-face communication (Ferriman, 2013). An e-learning tool--Genre-based Writing Instructions (GBWI) was developed to cultivate learners’ English academic writing skills, which proved useful and helpful to learners. Learners’ skills in handling e-learning tools were also improved during the process of using GBWI (Lin et al., 2017). In an e-learning technology assisted course, students achieved significantly more success in English rhetoric use in academic writing, and reached a significantly higher level of performance than those without e-learning support. The e-learning platform could also help students to analyze culturally different rhetorical styles and the e-learning platform assisted interactions could also improve international students’ academic writing skills (Xing et al., 2008).
An e-learning module. Besides those used in language acquisition, a large number of e-learning devices in medical education were also developed. An e-learning module was designed to interpret the medical interview between medical students and patients, which enhanced students’ self-efficacy during the professional interpretation and produced a significantly higher gain on knowledge for students. This e-learning tool might help medical professionals to overcome language barriers and thus improve healthcare services for patients who have difficulty in linguistic communication (Ikram et al., 2015).
An e-learning course and platform. An e-learning course was designed to train medical postgraduate students in English, Spanish, German and Hungarian across five countries in Europe, where a significant gain in knowledge scores was found in acquisition, appraisal, application and implementation. Learners felt confident that through the e-learning platform, they could easily assess research evidence and that the clinical effectiveness of the healthcare system should be evaluated. E-learning could effectively assist learning and teaching in different languages, educational environments and clinical specialties (Kulier et al., 2008).
eGender Platform. An e-learning platform, i.e. eGender Platform, was designed for learners to acquire the knowledge of Sex and Gender Medicine. The most frequently visited module was "Gender Medicine-Basics", where the discussion forum was the most attractive section. This e-learning platform proved a flexible and user-friendly knowledge sharing medium, which provided highly qualified learning contents for learners and met the requirements of higher education especially in the pursuit of accredited Master of Public Health at Charite-Berlin (Seeland et al., 2016).
The FAO/INFOODS e-Learning Course. The FAO/INFOODS e-Learning Course on Food Composition Data was designed to deliver food composition knowledge to food professionals, which included fundamental knowledge of food composition, and provided comprehensive and interactive knowledge for learners. Learners held positive attitudes to this cost-effective and widely accepted e-learning platform (Charrondiere et al., 2016).
Commonwealth of Learning. The branch of e-learning platform of the Commonwealth of Learning's (COL), i.e. International Organisations (eLIO) section, was demonstrated to have successfully constructed a distance learning approach, which satisfied most participants. Specifically, more than 2000 learners showed their satisfaction with this e-learning platform, cooperating with 8 globalized institutes, reaching a high female participation rate (62%) and graduation rate (75%) in the online courses (McGreal, 2009).
Personalized Learning Course Planner. An e-learning platform, named a Personalized Learning Course Planner (PLCP) allowed learners to select learning contents on their own, which resulted in satisfactory learning outcomes based on the data collected from test scores after the study. The platform also improved learning effectiveness and enhanced learner satisfaction (Jeong et al., 2012).
Other e-learning tools and platforms. The e-learning tools such as Master's Binary Schema (Master 1988, 2003), explicit instruction, chunking, and direct feedback were significantly more effective than traditional pedagogical techniques in English learning and teaching of articles and grammatical structures (Gillian & Lew, 2018). Learners assisted with the e-learning platform, i.e. an Adaptive Learning in Teaching English as a Second Language performed significantly better than those who learned without the aid of e-learning platform in second language acquisition (Wang & Liao, 2011). Additionally, learners’ attitudes were explored towards an e-learning platform named Learn English Pathways. The e-learning platform could not only positively influence learners’ global attitudes toward English language learning but also improve their English language proficiency and enhance their self-regulation (Aladl, 2016).
Barriers to e-learning
Despite that the blended e-learning approach could enhance learners’ perceptions of and confidence in End of Life Care, there were still numerous barriers to e-learning implementation such as passive participation, lack of new insights dissemination, knowledge within homes and other organizational and inter-professional resistance (Farrington, 2014). Overcoming these barriers would possibly play a positive role in improving learning effectiveness. Barriers to face-to-face interactions between patients and medical workers are also an important element to negatively influence e-learning effectiveness.
E-learning could possibly lead to barriers to face-to-face interactions between patients and medical workers. Traditional didactic nursing education limited learner-patient interaction to physical situation, while e-learning could enhance knowledge acquisition and skill improvements through extending interaction to online activities. Healthcare providers who interact with virtual patients in designed situations may avoid unnecessary risks and encounters with real patients. However, the effectiveness of situated e-learning is inconsistent (Feng et al., 2013) in that patient and nurses could not implement face-to-face interaction and communication, which could cause many misunderstandings. As for care and assurance, this physical interaction and communication is superior to virtual situation. In this case, it may be reasonable to integrate e-learning into traditional learning in medical education.
Ineffectiveness of e-learning alone
E-learning alone might not be effective enough to achieve success in the training of nursing. Combination of e-learning with traditional learning was strongly suggested because very few e-learning models could independently achieve success in high interactivity, reflection, practice and application to practice for health professionals who learned how to deliver SMS effectively. This indicates that there is still much room to understand about how best to deliver e-learning for SMS skills development. It was also suggested that the way to implement health professional training regarding SMS delivery was important for the patients under chronic conditions in order to provide partnership, and human-oriented care (Lawn et al., 2017). It may be too hasty to draw a conclusion that e-learning is effective in all aspects in medical education.
Despite the fact that e-learning is a flexible approach, face-to-face patient simulation is superior to e-learning alone, which is especially true when nursing evaluation is not scalar. Although e-learning may bring positive results to nursing education, combination with other forms of approaches may be a wise decision to augment the e-learning effectiveness in teaching and learning. Integration of e-learning into traditional pedagogical approach will most likely prove a really effective and highly efficient learning approach (McDonald et al., 2018). In e-learning contexts, there were no significantly correlations between visual learning style, auditory learning style, kinesthetic learning style, read/write learning style and students' English achievement among Moroccan university students, although the e-learning style could improve students’ academic achievements of English language (Azize, 2017).