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Spanjers et al.

E-learning at Catharina Hospital

Lessons Learned After 3 Years of E-learning Experience at Catharina Hospital: A Case Study Dr. R. Spanjers Catharina hospital & Tilburg University (The Netherlands) [email protected]

Dr. A.-F. Rutkowski Tilburg University (The Netherlands) Information Systems and Management Department [email protected]

K. de Nobrega Catharina hospital & Tilburg University (The Netherlands) [email protected] ABSTRACT

E-learning and virtual classrooms have proven to be efficient ways to discuss, exchange information and build shared knowledge amongst distributed participants. The paper presents 3 years of experiences gathered and the lesson learned through of an e-learning project conducted at the Catharina hospital. Results show that in such a 24-hour organization, he main advantage, of e-learning is to offer health care professionals the possibilities to engage in learning activities at a convenient time from their working place or from home. It emphasizes particularly on the importance to implement appropriated multimedia technologies. In one hand these new technologies bring a social dimension to the e-learning environment,, and in the other hand are of help to the instructors facing many electronic questions and comments. A classification grid is used to guide the complex and essential steps required deciding upon the use and the development of an electronic course in the healthcare sector. Special attention was given to the implementation of new multimedia technologies based on the expected fit between the learning strategy and the technology. With the support of appropriated multimedia tools , e-learning have been found to improve the quality of education in a cost-effective way, especially for nurses (N=84). The paper concludes that more research pilots have to be conducted in order to narrow down the classification . Keywords: e-learning, hospital, content-dependent classification INTRODUCTION

Catharina hospital is located in Eindhoven (The Netherlands). The hospital (Table 1.) offers education and various professional trainings in cooperation with universities and colleges. Catharina hospital is leading in the use of advanced technology for diagnosis and therapy in the areas of cardiology, cardio-surgery and oncology. Name: Website: Medical staff: Employees: Full time equivalent: Beds: Clinical patients: Ambulant-patients: Total budget:

Catharina hospital www.catharina-ziekenhuis.nl 140 3.000 2.000 700 about 25.000 about 250.000 about 230 million Euro U

Table 1. Description of the Catharina hospital

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E-learning and virtual classrooms have proven to be efficient ways to discuss, exchange information and build shared knowledge amongst distributed participants (Hiltz, 1994; van Genuchten et al, 2005). The e-learning project in Catharina hospital started at the initiative of a group of head nurses who were convinced that elearning would be an effective and efficient mode of education. A breakthrough came when the hospital management team recognized the promise of a cost-effectiveness communication tool to support the hospitals education activities. A budget of 50.000 euro was allocated to develop a set of pilots to evaluate the usefulness of e-learning , especially for nurses. Background research on e-learning in healthcare brought the authors only a few references to previous work that mainly address information technology usage in terms of costs. References mainly link to healthcare organizations that use elearning systems presenting their experiences in internal reports that are rarely accessible (Berk et al, 2003; Herrin, 2001). Most experiences relate to information technology usage by physicians e.g. radiology imaging interpretation courses while there seems to be little interest for the largest population of healthcare professionals: nurses. From a cost-effective perspective this is the most interesting population; more than half of Dutch nurses work in hospitals, about 100.000-150.000 fte (4 billion Euro’s), where there are roughly 10.000-15.000 physicians. Internal reports in the Netherlands indicate that e-learning is principally used as a learning method in large lines of industry such as information technology, financial and transportation. In 2004, 26% of the Dutch hospitals have an organization wide implementation of e-learning infrastructure. Application areas are reserved to nurses and concern basic automation training and life support. Most courses (80%) are developed by or with a third party such as pharmaceutical or medical equipment industry and are usually combined with traditional classroom sessions. Typically, static media such as CD-ROM are for 35% percent synonym of electronic environment. Striking is that the report indicates that most hospitals have no clear policy or budget allocated to e-learning (NVZ B-learningplatform, 2005). In the long term, one of the goals of this research is to develop a practical method to evaluate the effectiveness and efficiency of e-learning in the hospital environment. This paper first presents the steps that lead to the selection of two courses of a long-list of six potential topics. An overview on the general procedure and technologies used to support the new e-learning activities are described. Second, the new multimedia tools that have been developed are introduced and presented relatively to their function: add a social dimension to the e-learning environment and support the instructor(s) and their context of application. A classification grid was build to summarize the complex and essential steps required to decide upon the use and the development of an electronic course in the healthcare sector. Such technology/task fit classification has been evaluated by the management team to be an interesting tool to decide upon the right e-learning course to implement and the best technology to use to support the learning strategy of the participants. PILOT RESEARCH: CASE STUDY

In the first year of the project, a large survey research (N=1.558) was conducted amongst the health care professionals in order to gain insight in the attitude towards e-learning at the Catharina hospital. The results of the survey indicated that elearning is overall perceived positively. However, the lack of social contact is seen as one the dark side of the electronic learning. In parallel a first pilot research was developed for nurses in ER, CCU and ICU. The conclusions of this pilot stressed that a socially structured e-learning environment was essential to a successful implementation (see Spanjers et al, 2005). The overall positive attitude toward e-learning inside and the practical success of the first research pilot opened the door to a more general interest for e-learning. It gave the opportunity to conduct new pilots research on two different courses content, electro-cardiogram interpretation and wound care.

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Table 2 presents an overview on the experimental steps taken during the 3 years of the project . Survey hospital employees (N=1.558) Spanjers, R.; Rutkowski, A.-F.; Martens, R. (2005) Pilot Electro-cardiogram advanced interpretation (N=28) Spanjers, R.; Rutkowski, A.-F.; Martens, R. (2005) Selection matrix based on (Zigurs and Buckland (1998) fit technology and task: procedural versus declarative. Pilot based on Technology Acceptance Model (TAM) (Davis, 1989). Animated tutorial T(N=84) 1.

Electro-cardiogram (advanced and refresh) interpretation (N=24)

2.

Wound care (N=60) Table 2. Overview research process

When constraints become success factors

Zigurs and Buckland (1998) emphasize the importance of the fit between the technology and the task. Research has demonstrated that the nature of the task plays a major role in the group interaction and performance (Poole et al., 1985). In the frame of the case study, the learning task was of different nature: procedural versus declarative. Anderson (1983) described procedural knowledge as, knowing how; knowledge that is applied automatically and is difficult to report verbally. In addition, declarative knowledge is described as knowing that; knowledge that can be reported and is not tied to a specific application. In practice, both level of knowledge are highly interdependent and the acquisition of procedural knowledge is based on the level of declarative knowledge. Procedural and declarative knowledge acquisitions are both relying on the individual cognitive abilities. In order of not adding procedural level of complexity link to the technology, it is central to reflect on the technologies that will best fit the learning process. In the case study, fit was defined as mediation. The technology was used as a mediation tool to support the best learning strategy in order to favorize individual performance to the final learning test. The procedural versus declarative axe of classification was used to examine each of courses separately. The technologies that seem the most adapted to mediate the learning strategy to the nature of the task that was chosen and tested during the pilot research. The course was also thought in terms of population and potential number of participants. The selection of two new pilots started with a long-list of six potential topics suggested by the health care professionals. A. Medical terminology B. Electro-cardiogram interpretation C. Wound care D. Infusion technique E. Basic life support F. Völkerbed (operating an electrically adjustable bed)

Ad) A. Medical terminology consists of learning or refreshing knowledge based of Latin terminology that are very specific to healthcare professionals. Such course gives little room for discussion and/or difference in interpretation . It can be classified as a declarative-based knowledge. This course has a large potential of participants. Static media like a CD-Rom sounded like one the most adapted medium. Ad) B The electro-cardiogram (ECG) interpretation course has a limited potential in term of number of participants: nurses from ER, CCU and ICU. This group of professional is usually working in shifts in an ad hoc type of process and therefore are not the easiest group to plan for a course. The results of the first pilot (see Spanjers et al, 2005) show that this problem can partially be alleviated using e-learning. E-learning provides the participants the benefits to follow a large part of the course at their own pace and from different locations. In addition, the interactive multimedia facilities did greatly enhance the possibility to teach a difficult topic, this combining procedural and declarative knowledge. Ad) C Wound care is a topic with a large potential of participants. Since the level of wound care has room for improvement wound care has became a topic of interest at the Catharina hospital (Bours, et al, 2003). When only for one patient wound

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complications can be avoided by a well educated healthcare professional the entire cost of the e-learning course (10.000 Euro) development and infrastructure is regained. Beside the quality of life improvement for the patient. Blended e-learning mixing face-to-face meetings and forum/chat discussion could support interesting discussion amongst the participants when it concerns, for example, the type of wounds. The participants can also exercise the different wound care procedures. The course combines procedural and declarative knowledge. Ad) D Infusion technique offers to health care professionals a course presenting the different sets of technologies, views and procedures used when inserting and removing the infusion on a patient. This course combines procedural and declarative knowledge. Forum of discussion can be open to many topics. Ad) E Basic Life Support (BLS) is a skill that needs to be certified annually for all healthcare professionals. Therefore, the course has a large potential of participants ranging from physician, nurses to administration. Arranging face-to-face meetings for a course on BLS is very time consuming. This problem could partially be alleviated using e-learning. This course combines procedural and declarative knowledge. Ad) F. The Völkerbed; consists in learning the basic level of instruction required to operate an electrically adjustable bed. Although this course has a large potential of participants, mostly nurses, the content is procedural-based knowledge and can easily be instructed during the working process. All beds have a written manual attached and clear operating signs.

Table 3. Classification grid

Following the discussion previously summarized in the text, the course on wound care and a second pilot on the ECG interpretation course were chosen to test the implementation of new multimedia technologies based on expected fit between the learning strategy and the technology (Table 3). To support and facilitate the learning process a classroom-based learning environment was developed on both courses. Both pilots were based on the concept of socially structured electronic environments, mixing face-to-face and traditional education to e-learning. Socially well-structured e-learning environment, supporting a balance in synchronous and asynchronous modes of communication, reinforced by face-to-face social contacts amongst social peer and with their instructors, has proven to efficiently support the learning process (See Spanjers et al, 2005).Crucial, it is necessary to respect and not to enforce elearning technology on potential users. Therefore and core to our research before to incorporate new multimedia tools as a part of the e-learning environment, video lecture and flash animation have been tested using the Technology Acceptance Model (TAM) (Davis, 1989). The TAM is a widely accepted theory (Venkatesh, 2003) that explains information technology usage behavior using the construct of perceived usefulness and perceived ease of use. The first construct concerns the degree to which a person believes that using a particular system would enhance his or her job performance. Perceived ease of use

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concerns the degree to which a person believes that using a particular system would be free of effort (Davis, 1989). The Technology acceptance model of Davis was chosen amongst other acceptation models. In this research, the technology is used as a mediation tool that should not overload the participants.. The construct of perceived ease of use was particularly relevant to the case study. The TAM scales (see appendix A) will allow to measure the perceived usefulness and ease off use of flash animation and the video lecture that have been build to support the socially structured e-learning environment. The interest of the scale is to provide us with indication concerning the appropriativeness of each technology as the best mediation tool that can support the best learning strategy.

Multimedia to support instruction and lecture

Research has shown that e-learning is as efficient for learners as traditional face-to-face education (Harasim et al., 1995; Lockyer et al., 2001). Instructional implementations (Willis, 1994, 1993) reinforce a successful implementation of e-learning (Webster and Hackley, 1997). Indeed, in an e-learning environment where the teacher is typically not present “face-to-face” to answer the participants’question, guidelines and their electronic implementation should be clear (Govindasamy, 2002; Storck and Sproull, 1995). Blackboard was selected amongst other e-learning systems as a main tool to support the e-learning project. The system was hosted externally by a professional provider on a pay-per-student base and provided a low cost and low investment solution. From a research perspective the Blackboard system allows to record different set of data such as a number of hits per participants or the most used areas of the e-learning system. The system is a course delivery system with group support capabilities that enables participants or group of participants to enter information simultaneously in a structured manner, using a variety of specially designed tools such as chat, forum, email, and file attachment including guidelines. It allows combining synchronous activities such as chat sessions as well as asynchronous activities such as discussion forum. A significant number of participants was involved in the course (N=84). Supporting the instructor when the number of participants extend and the level of interaction overload his/her time to provide feedback is a bottleneck. Multimedia clips were introduced as a teaching support to bring a social dimension to the e-environment. Participants of the first pilot have declared lacking of social support and lacked contact with the instructor. Learning is a collaborative and interactive process. A participant from the first year project declared, “With E-learning it is important to still have the opportunity for personal contact with the teacher.”(Spanjers et al, 2005). Animated instruction and video lectures were the technologies chosen to be tested. Participants have another representation of the virtual presence of the instructor and require imminent feedback as in face-toface traditional classroom environment: “With E-learning it is important to get a quick response from the teacher.”A paradox is that because they often assume that social contact could lack and generate failure, they become more exigent toward the instructor. In order to support the instructor and fulfill the need of the participants, video lectures and video cases were built and tested. The authors assume that multimedia tools would be also of help to reduce the overload of work and questions raised.

Instructional implementations The animated instruction and video lecture were embedded in the Blackboard system. An animated tutorial was developed to introduce basic navigation skills of Blackboard to the participants and support the explanation of the instructors. The animation provides help for the participants when alone outside the classroom. Flash animation was developed to assure a low barrier enter to the blackboard system (Figure 1.)

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Figure 1. Animated tutorial

The animation was developed with Macromedia Flash MX®. This software supports animated content for websites. It was placed outside the system on a link of the hospital www.cze.nl/teleleren. It was necessary to be logged on to Blackboard to access the introduction. The participants were asked to fill in a short questionnaire after they first used the animation. The questionnaire is built using the TAM construct that has been developed to measure the perceived usefulness and perceived ease off use of the user towards a specific information technology: Flash animation and video lecture. The original constructs of ease off use and usefulness as build by Davis (see Appendix A) were adapted to the two technologies put into test and the population (N=177). The items where translated in Dutch language and two items had to be removed from the scale for both constructs: USE2 and EASE2 that both addresses performances. In order to validate the new instruments of measure we used Cronbach’s (1950) alpha coefficient as an index of internal consistency. The computation of the coefficient range from .748 to .954 for the group of nurses (n=84). Overall, the computed value of the coefficient based the all population exceeded the threshold of .6 given by Nunally (1978). The mean and standard deviation obtained from aggregating the scores of the 84 participants revealed that the Flash animation was as useful as easy to use. Overall, the tool was evaluated as helpful (Table 4.).

Description The Flash animation helped me to access Blackboard more quickly (scale 1-7) Using the Flash animation helped me to understand the Blackboard log-in sequence better (scale 1-7) The Flash animation allowed me to use the Blackboard more productively (scale 1-7) The Flash animation allowed me to use the Blackboard more efficiently (scale 1-7) Overall, I found the Flash animation useful for learning how Blackboard works (scale 1-7) The Flash animation was easy to use (scale 1-7) The Flash animation was clear and understandable (scale 1-7) I found it cumbersome to use the Flash animation (scale 1-7)* Overall, I found the Flash animation facilitate my understanding of Blackboard functions (scale 1-7) Learning to operate the Blackboard was made easy because of the Flash animation (scale 1-7) αUSE=.966, αEASE=.896

Mean and standard deviation M = 5.68, StD. = 1.221 M = 5.69, StD. = 1.252 M = 5.67, StD. = 1.212 M = 5.59, StD. = 1.245 M = 5.80, StD. = 1.294 M = 6.08, StD. = 1.239 M = 6.12, StD. = 1.241 M = 3.27, StD. = 2.220 M = 5.68, StD. = 1.286 M = 5.76, StD. = 1.261

Table 4. Statistics on Flash animation *Reversed score that explains that the means values differ and indicate congruency in the overall scoring.

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Video lecture versus video case Case 1: Electro-cardiogram video lecture

The course topic was on electro-cardiogram (ECG) interpretation. ECG interpretation is a required skill for nurses and physicians working in ER, CCU and ICU. The topic of the course was particularly suitable to test the e-learning environment due to the possibilities to present and discuss ECG read-outs on the screen. The course material consist of theory (Figure 2.) related to interpretation of the ECG, including practice in the interpretation of 12-lead ECG. The course focuses on ECG changes, which for instance occur with myocardial infraction, axis deviation, artificial pacemaker, defibrillation, cardio version or the premature ventricular complex, medication et cetera. An ECG content expert, a didactical expert, a content ECG intermediary as well as technical staff and editor supported the development, authorization (an important factor in the healthcare environment) and implementation of the learning material. Blackboard also allows the instructors to post announcements, email and guidelines about the course and to generate a grade book. Tools are also available to evaluate by means of quiz and survey the progress or difficulties of the participants and to provide adequate feedback.

Figure 2. Example of the ECG course content

Multimedia clips displaying the actual teacher answering frequently asked questions enhances the socially structured environment (Figure 3.). The clips were captured and edited. These footages were loaded in Microsoft Producer®. This software allows with the use of streaming media to synchronize with PowerPoint slides resulting in an animated video lecture with the instructor. Dynamic slides are synchronized with the lecture. In the Catharina hospital, these videos could be viewed on all clients that were running a Windows XP platform. The usage of the multimedia clips was 21% of all the hits on the content area (303).

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Figure 3. Example video lecture

The instructor explained,”The video lectures helped to decrease the load of questions that I had to answer in comparison with the first year pilot. It gave me more time to interact with the students on the forum. The overload has become less and the time save was useful to increase my active participation in the e-environment.”The instructor added “it is great to see the students stimulating each other using the interactive tools that we provide them thanks to the e-learning environment. For me as a teacher, I see my role as monitoring and fuelling these discussions, this beside my role as teaching individual students.” Description The animated tutorial was sufficient to understand the functioning of the Blackboard system (scale 1-5) The animations embedded in the course material were useful to my understanding of wound care (scale 1-5) The Video lecture enabled me to get the answers to my questions more quickly (scale 1-7) Using the video lecture improves my learning performance (scale 1-7) Using the video lecture for learning increases my productivity (scale 1-7) The video lectures presented enhances my effectiveness in learning (scale 1-7) Using the video lectures makes learning easier (scale 1-7) Overall, I find the video lectures useful for learning (scale 1-7) Learning to operate the video lectures was easy for me (scale 1-7) Usage of the video lectures is clear and understandable (scale 1-7) I find it cumbersome to use the video lecture technology (scale 1-7)* Overall, I find the video lecture technology easy to use (scale 1-7) αUSE=.954, αEASE=.748

Mean and standard deviation M = 3.8 StD. = 0.788 M = 3.6 StD. = 0.568 M = 4.3 StD. = 1.174 M = 5 StD. = 1.490 M = 4.1 StD. = 1.197 M = 4.4 StD. = 1.26 M = 5.1 StD = 1.449 M = 5 StD. = 1.414 M = 5.4 StD. = 1.776 M = 5.5 StD. = 0.971 M = 1.8 StD. = 1.032 M = 5.4 StD. = 1.349

Table 5. Statistics on multimedia clips * Reversed score that explains that the means values differ and indicate congruency in the overall scoring.

As indicated in Table 5, the participants were overall satisfied with the video lecture proposed in the ECG course (n=25). Congruently, they declared, “The course material and exercise material are excellent learning methods”. Participants liked to meet the instructors face-to-face or use the multimedia clips. Case 2: Wound video case

The second course pilot was on wound care. The publication of national prevalence figures of decubitus (Bours et al. 2003) led the need to improve the quality of care. This course did not exist in the Catharina hospital before this pilot. The management team evaluated the cost of developing the content against buying it. The content was bought from the Academic Hospital of Groningen and could be embedded in the Blackboard with minor changes. The course material consisted of theory of skin, pathology, anatomy and prevention of wounds. In addition, bondage techniques, material and protocol used at the Catharina hospital were discussed.

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This course was suitable to an electronic-learning environment because it mainly allowed health care professionals to discuss the types of wound care and treatments as applied within various departments. New treatments and experiments were also discussed. The forum was chosen as a tool to discuss the comments of the participants. Examples of forum topics were: general wound and decubitus care, tests and feedback, websites and articles and use of computer and electronic environment. The course material was enriched with video cases, describing the way certain particular wounds could be efficiently treated. Examples are cases that presented the treatment of wounds with vacuum assisted closure therapy, and cellular regeneration of wounds (Figure 4.).

Figure 4. Example of the wound care course content

Overall, the use of the video was evaluated to enriched the participants’knowledge of the material (n= 60) (M = 3.193 StD. = 0.98). CONCLUSION, LIMITATION AND FUTURE RESEARCH

E-learning cannot be perceived as a substitute of a traditional face-to-face education, which can be used widely. Many factors play a key role to a successful implementation. Each new project is a new challenge. Through the 3 years of the project we learned that when the e-learning environment is socially well structured, its content well defined and applicable to the new technologies, e-learning becomes an efficient support to education and particularly well adapted to the different time/same place context encountered by the health care professionals in most hospital. The research reported in this paper is limited. The complexity of the natural environment is itself a limitation. First, the relative small size of classroom did not provide us with information concerning the efficient of the e-learning system when larger group will be addressed. Second, the different level of knowledge of the technology and the acceptance was not taken as dependent variables. Further test should be conduct to investigate in more details the fit between the technologies we used to support the learning strategy. Worthwhile will be to explore differences in benefit from e-learning between nurses and physicians. Overall, the results of the case study demonstrate that healthcare professionals need an education environment with communication tools that are accessible 24 hours a day in- and outside the hospital. This relief from the time and place constraint meant that healthcare professionals could follow a large part of the education in off-hours or quiet hours during an evening shift. Not having to interrupt the healthcare professional shifts around typical classroom sessions with fixed dates was a big relief for the planning process of departments. Both factors provide efficiency in the use of (scarce) healthcare professional and provide a clear cost-benefit. From a cost perspective, e-learning seems to be cheaper than traditional method. We also stress that technologies should not be enforce on the users. The context, material and possibilities have to be studied. To assure the success of each project, a socially structured e-learning environment has to be carefully thought of and build. Elearning is a useful tool when applied in courses that combine procedural-based and declarative-based knowledge When implementation of e-learning fails in such a context, the reasons are mainly human or motivational (Rutkowski et al., 2002).

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REFERENCES

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Wendy J. Berke, RN, BSN, MHA, and Tina L. Wiseman (2003) The e-learning answer; Secure this education solution by setting a vision for its usage and building a sound business plan for its purchase, Nursing management 34, pp. 26-29

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Bours, G. J. J. W., Halfens, R. J. G., Wansink, S. W. (2003). Landelijk Prevalentie Onderzoek Decubitus: Resultaten vijfde jaarlijkse meting 2002. Maastricht: Universiteit Maastricht, Sectie Verplegingswetenschap, Stuurgroep Decubitus.

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Conway, M.A., Cohen, G.M., and Stanhope, N. (1992). Very Long Term Memory for Knowledge Acquired at School and University, Applied Cognitive Psychology, 6, pp. 169-189.

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Cronbach, L. J. (1950) Coefficient Alpha and the Internal Structure of Tests,”Psychometrika, 16, pp. 297-334.

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Davis, FD (1989) Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13, 3, 319-340.

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Genuchten, M. (2005) Genuchten, M.; Vogel, D.; Rutkowski, A. and Saunders, C. HKNET: Instilling Realism into the Study of Emerging Trends, Communications of AIS, 15, 2005, pp. 357-370.

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Govindasamy, T. (2002). Successful Implementation of E-Learning, Pedagogical Considerations Internet and Higher Education, 4, pp. 287-299.

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Harasim, L., Hiltz, S. R., Teles, L., and Turoff, M. (1995). Learning networks: A field guide to teaching and learning online. Cambridge, MA: The MIT Press.

10. Herrin D.M. (2001). E-learning: directions for nurses in executive practice. Journal of Nursing administration pp.5-6 11. Hiltz, S.R. (1994). The Virtual Classroom: Learning without Limits via Computer Networks”. Ablex, Noorwood, NJ. 12. Lockyer, L., Patterson, J. and Harper B. (2001), ICT in Higher Education: Evaluating Outcomes For Health Education, Journal of Computer Assisted Learning,17, pp.275-283 13. Nunnaly, J. (1978) Psychometric Theory, New York: McGraw-Hill, 1978. 14. NVZ B-learning platform (2005) B-learning in de zorg (B-learning in Dutch Hospitals), Nederlandse Vereniging van Ziekenhuizen, Utrecht 15. Ramsden, P. (1997). The Context of Learning in Academic Departments. In F. Marton, D. Hounsell, and N.J. Entwistle (Eds.), The Experience of Learning: Implications for Teaching and Studying in Higher Education, pp.198-216, Edinburgh, Scottish Academic Press. 16. Poole, M.S., Siebold, D.R., and McPhee, R.D.(1985). “Group decision-making as a structurational process”, Quaterly Journal of Speech, 71:1, 74-102. 17. Rutkowski, A.; Vogel, D.; Genuchten, M.; Bemelmans, T. and Favier, M. (2002) E-Collaboration: The Reality of Virtuality, IEEE Transactions on Professional Communication, 45(4), pp. 219-230. 18. Rosenberg, M. (2001). Learning: Strategies for Delivering Knowledge in the Digital Age. McGraw-Hill, New York 19. Spanjers, R.; Rutkowski, A.-F.; Martens, R. (2005) Implementation and Acceptation of E-learning in a Hospital Environment, International Journal of Health Technology Management 20. Storck, J. and L. Sproull (1995). Through a Glass Darkedly: What Do People Learn in Videoconferencing, Human Communication Research, 22, pp.197-219. 21. Venkatesh (2003) User Acceptance of Information Technology: Toward a Unified View" MISQ, Vol 27 No 3. 22. Willis, B. (1993). Distance education: A practical guide. Englewood Cliffs, NJ: Educational Technology Publications. 23. Willis, B. (Ed.). (1994). Distance education strategies and tools. Englewood Cliffs, NJ: Educational Technology Publications. 24. Webster, J. and Hackley, P. (1997). The Teaching Effectiveness in Technology-Mediated Distance Learning, Academy of Management Journal, 40, pp.1282 –1309. 25. Zigurs, I. and Buckland, B.K. (1998). A Theory of Task/Technology Fit and Group Support Systems Effectiveness, MIS Quarterly, September pp. 313-334.

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APPENDIX A. ORIGINAL CONSTRUCTS OF EASE OFF USE AND USEFULNESS AS BUILD BY DAVIS

Perceived Usefulness

USE1

(… ) enables me to accomplish tasks more quickly.

USE2

Using (… ) improves my job performance.

USE3

Using (… ) increases my productivity.

USE4 Using (… ) enhances my effectiveness on the job. USE5

Using (… ) makes it easier to do my job.

USE6

Overall, I find (… ) useful in my job.

Perceived ease of use

EASE1 Learning to operate the (...) is easy for me. EASE2 I find it easy to get the (… ) to do what I want it to do. EASE3 Usage of the (… ) is clear and understandable. EASE4 I find it cumbersome to use the (… ). EASE5 It is easy for me to remember how to perform tasks using (… ). EASE6 Overall, I find the (… ) easy to use.

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