Nursing Informatic

C O N T I N U I N G

E D U C A T I O N

The Design, Marketing, and Implementation of Online Continuing Education About Computers and Nursing Informatics

NANCY M. SWEENEY, DNSc, RN

LEMBI SAARMANN, EdD, RN

ROBERT SEIDMAN, PhD

JOAN FLAGG, PhD, RN

As long ago as 1995, an American Nurses Association position statement supported the ‘‘computerization of health information,’’ including computerized patient records and the simultaneous collection of aggregate patient care and outcome data.1 The Institute of Medi- cine (IOM)2 brought the need for computerization to the forefront when it reported on preventable medical errors in 1999, errors that cost the nation between $17 and $29 billion and contributed to between 44 000 and 98 000 patient deaths annually. Noting that many of the errors could have been prevented by automated medication systems, a later IOM report called for the implementation of a healthcare information infrastruc- ture including automated patient records and drug ordering systems.3

While healthcare systems are not yet fully automated, nurses need to use computers and software to function in their jobs. However, most working nurses gradu- ated before computers and nursing informatics were integrated into curricula and many did not return for additional formal education that might have taught them about those subjects. The latest National Sam- ple Survey of Registered Nurses (2000) showed the average age of nurses working in nursing to be 43.3 years, with 68% of the nurses older than 40 years.

Only 19% of survey respondents reported continuing their formal nursing education after initial licensure, with the most commonly achieved degree being the baccalaureate.4 Thus, the job of educating nurses to work with computers and computerized patient records falls to employers and the purveyors of con- tinuing education. This article describes a university- based community project offering asynchronous online

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Asynchronous online tutorials using PowerPoint slides with accompanying audio to teach prac-

ticing nurses about computers and nursing informatics were designed for this project, which awarded free continuing education units

to completers. Participants had control over the advancement of slides, with the ability to repeat when desired. Graphics were kept to a mini-

mum; thus, the program ran smoothly on com- puters using dial-up modems. The tutorials were marketed in live meetings and through e-mail messages on nursing listservs. Findings

include that the enrollment process must be automated and instantaneous, the program must work from every type of computer and

Internet connection, marketing should be live and electronic, and workshops should be offered to familiarize nurses with the online

learning system.

K E Y W O R D S

Attitude to computers & Computer-assisted instruction &

Distance education & Distance learning &

Nursing informatics

CECE

From the School of Nursing (Dr Sweeney, Dr Saarmann, and Dr Flagg); and the Graduate School of Public Health (Dr Seidman), San Diego State University, San Diego, CA.

The project was funded by Health Resources and Services Administration Grant Number D11HP00284.

Parts of this manuscript were previously presented at the Elearning Conference in Phoenix, AZ, Fall 2003, as ‘‘Web Based Informatics For Practicing Nurses’’ and at the Association for the Advancement of Computing in Education, World Conference on Educational Multimedia, Hypermedia, & Telecommunications, June 21 to 26, 2004, Lugano, Switzerland, as ‘‘Final Report: Web Based Training in Nursing Informatics For Practicing Nurses.’’

Corresponding author: Nancy M. Sweeney, DNSc, RN, School of Nursing, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-4158 (e-mail: [email protected]).

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tutorials about computers and nursing informatics, which awarded continuing education credit at no cost to practicing nurses.

BACKGROUND

The Internet is a rich source of education programs,5

yet few nurses report using it for continuing education. Findings from a survey of advanced practice nurses about the sources of their continuing education units (CEUs) indicated that 5% of these nurses took online education programs and 3% of them took computer- based programs.6 While 45% of oncology nurses re- sponding to a survey said they liked computer-assisted continuing education programs, only 10% of the re- spondents reported using the Internet for education.7

Studies report that the nurses most likely to use online education are those who see themselves as self-directed and disciplined,8 used computers more hours each week, and had more computer experience and experi- ence navigating the Internet.9

Despite individual nurse hesitance toward computer- based and online modalities, employers instituted them as an efficient way to educate employees. Franck and Langenkamp10 report working with information systems personnel to design and implement PowerPoint-based modules for staff on computers throughout the organi- zation. Staff were very satisfied with the computer-based education and demonstrated excellent knowledge reten- tion over time. Nurses completing computer-based learning at another institution gave more positive ratings than did those in the instructor-led environment and expressed significantly more interest in future classes.11

A later study at the same facility showed significantly higher satisfaction with the learning experience among the computer-based nurses than the instructor-led group.12 Schmitt et al13 describe an online continuing education program offered through a university that nurses were not completing because of a lack of con- fidence in their computer skills or computer literacy, a lack of Internet access at home, and images requiring long download times. The university had to create an alternate, paper-copy version of the course so that nurses could complete it in a timely fashion. Nurses attempting an online college course experienced myriad problems, including the need for significant technical assistance, the desire for more instructor contact, the need for self- discipline, and finding a quiet place to work at home, yet 79% of the nurses completed the course, stating that they enjoyed the flexibility of online learning.14 Leasure and colleagues8 report that undergraduate nursing stu- dents who identified themselves as self-directed, disci- plined, and not procrastinators chose an online rather than the traditional section of a research course.

A closer look at the design of computer-based and online education programs demonstrates that authors used Web-CT13,15–17 or PowerPoint slides10–12 as their basic modality, adding options as needed. Nurse au- thors describing experiences with designing online learning for nurses report that care must be taken to communicate clearly16 and often18 and to give adequate support.16 Nurse educators recommend and describe active learning strategies suitable for adult students of all learning styles18 and detail interactive teaching methods suitable for Web-based courses19 to promote optimal learning. Curran-Smith and Best15 describe an online course using Web-CT designed at a hospital needing to update staff on emergency department procedures. It included content provided in text format and six scenarios used in a discussion on the bulletin board. While participation rates were excellent, evalua- tion of outcomes stimulated the hospital to develop ongoing programs to enhance staff computer skills. At a large children’s hospital, Web-based self-study mod- ules incorporating hypertext links, learner control, and interactivity/feedback were created for staff develop- ment.9 Users gained knowledge and left with a strong positive perception of online learning. Educators at Sinclair Community College described the process of searching for the right template for their Web-CT– based courses so that the text was used easily by all students, including those with disabilities.17 Cragg et al20

created a ‘‘toolbox’’ of technical supports that included live computer orientation sessions, a support person available by telephone, a CD-ROM starter kit, online directions and FAQs, chat sessions, and a Readiness Self- Test for their nurse practitioner students taking online courses. Almost all (91%) of their students who re- sponded to a survey reported being online within 1 to 2 weeks, with 88% of the students feeling comfortable in 4 weeks or less.

Nurse educators’ experiences with designing success- ful online education programs suggest that the pro- grams must be carefully tailored to the learners, with consideration of their computer skills, experience with the Internet, type of connectivity, and the amount of time they can allocate to any one session. While nurses do not initially seek computer-based or online educa- tion programs, they can be recruited to these modalities and, at completion, leave with a positive perception.

THE PLANNING PHASE

A proposal was submitted for a federal grant to fund a project to deliver asynchronous online tutorials that would provide knowledge about computers and nurs- ing informatics to practicing nurses. The project staff included university faculty and their community

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partners gathered together in a community partnership called the Nursing Informatics Community (NIC). Mem- bers of the NIC were nurses involved in information systems at their employing organizations, which in- cluded the local healthcare systems, school districts, and the public health department. The target audience was nurses living or working in the two southernmost counties in California, San Diego and Imperial. The tutorials would award CEUs at no cost to participants. To demonstrate the need for the project, two local sur- veys were completed: one of practicing nurses and the other of their employers.

The survey of the practicing nurses asked about their use of computers at work and at home, their computer training, and their perceived computer com- petency. Completed surveys were received from 192 nurses working at four healthcare systems and one school district participating in the NIC. Details of the responses are found in Table 1. Fewer than a quarter (23%) of the respondents stated that they were ‘‘very satisfied’’ with their computer skills; another 49% of the respondents reported being ‘‘somewhat satisfied.’’ A majority of respondents (83%) stated that they were interested in taking classes to improve their computer skills, and 87% of the respondents were interested in

computer education offered in an asynchronous online format that would award CEUs. When asked if they would need a live workshop to learn how to use the Web to participate in the online learning, 78% of the respondents answered ‘‘maybe’’ or ‘‘definitely.’’

The employer survey asked how computers were used at each facility. Five healthcare systems, two local health departments, two districts of the Indian Health Service, one hospice, and 44 school districts responded to the survey. One hospital had full electronic charting for nursing data, while the remainder of the respond- ing hospitals had minimal, if any, electronic systems to document nursing care. Some hospitals had electronic physician order entry, and all hospitals had some form of computerized pharmacy and laboratory systems. They also had some form of management information systems and provided nurses with Internet access and e-mail. The school districts had information systems that had fields in which school nurses entered and tracked information such as immunizations, individual student health problems, insurance coverage, and health histo- ries. The health departments and the Indian Health Service districts either had word-processing functions or were in the process of implementing them. None had electronic patient charting for nurses but did provide the nurses with Internet access for professional infor- mation. All responding organizations were planning to upgrade their information systems in the near future, which would demand that nurses be able to understand and possibly use multiple systems (most had legacy systems that did not interact). They wanted their nurses to have baseline knowledge of computer systems, including capabilities and strengths and weaknesses, to which they would add in-service education on the use of specific software programs.

THE IMPLEMENTATION PHASE

Web Site Design

Once funding was secured, Web site design began. During that process, project staff realized that while they were designing and testing graphics and other characteristics from high-end computers with broad- band connections, learners would be using computers with varying capabilities and Internet connectivities, including dial-up modems. As a result, the Web site and tutorials were designed using a minimal amount of graphics to convey content in a reasonable period of time for users with dial-up connections. Also, the sponsoring university’s colors (red and black) were found to be too harsh for the long-term viewing necessitated by these tutorials, so pleasing shades of blue and white were selected for the NIC Web site and

T a b l e 1

Survey of Practicing Nurses (N = 192)

Issue No. (%)

Use computers at work Daily or almost daily 164 (85) Every few days, weekly, or less 25 (13)

Do not use computers at work 3 (2) Work use of computers

E-mail 135 (74)

Patient records 134 (70) World Wide Web (WWW) 127 (66) Create documents 125 (65)

Web access

At home 161 (84) At work 169 (88) No access 10 (5)

Home Internet connection Dial-up 81 (42) Broadband 61 (32)

None 50 (26) Home use of computers

E-mail 154 (80)

WWW for personal information 152 (79) WWW for professional information 144 (75)

Computer classes completed At work 100 (52)

In school 48 (25) Other 36 (19) No classes taken 52 (27)

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modules. Figure 1 shows the NIC homepage. The logo was designed by a graphic artist to include the NIC name along with an EKG pattern formed by a computer mouse. The photos selected represent both the target audience and content. While under design, everything was viewed from various off-site locations to assure ease of loading and viewing.

To award CEUs and track data required by the funding organization, the enrollment process included establish- ing a user account and completing a questionnaire. For the user account, nurses provided names and RN license numbers and then selected a personal username. These were submitted to the project coordinator, who sent back a password (as seen in Figure 1). The nurse then com- pleted the demographic questionnaire. Items on the questionnaire satisfied the data-reporting requirements of the funding agency, with project staff adding items to describe the participants in more detail. Once both these processes were completed, the RN could begin taking the tutorials. It is important to note that nurses’ names, license numbers, passwords, and user names were never associated with their demographic data; each user was given a unique identification number. The information from the demographic questionnaire was imported into an Excel spreadsheet along with a user ID number. As users completed the tutorials, that information was also added to their ‘‘account.’’

Establishing a user account was originally a two-step process, as described above, that involved the project coordinator and prohibited the participant from enroll- ing and completing a tutorial on the initial visit to the NIC site. Many participants failed to return to the Web site after the initial enrollment session. Project staff changed the process to instant registration by allowing

participants to create both a personal username and password. After completing the demographic survey, they could begin viewing tutorials immediately. This proved successful in encouraging nurses to participate in the online continuing education modules.

The Tutorial Delivery Process

The basic template for the tutorials was PowerPoint slides (Microsoft, Redmond, WA) with accompanying audio. The original plan was to use RealPlayer (Real- Networks, Seattle, WA) streaming media to deliver the tutorials that most participants would access through computers at each workplace. Members of the NIC agreed with that plan, believing that their healthcare systems would allow nurses to download the RealPlayer plug-ins that were required. However, the healthcare systems’ information technology personnel, who were not NIC members, were unaware of this need, and the downloads were blocked by server firewalls. This left participants unable to view tutorials at the workplace; the majority completed them at home. Meanwhile, project staff redesigned the tutorials as audio with HTML files, a simpler format that could be accessed by the local healthcare systems’ networks or at the participants’ homes. Redesign of the tutorials occurred approximately halfway through the project.

The streaming process required another set of deci- sions: would the slides and audio stream continuously through each tutorial or would the learner be able to control the process? Project staff recognized that the participants would be of all levels of computer expertise, and many might have English as a second language; it was thus decided that participants needed some control.

FIGURE 1. NIC Homepage.

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The streaming tutorials were designed so that the par- ticipant advanced each slide by clicking on an arrow at the bottom of the screen. The participant could hear and watch the same slide multiple times, revert to an earlier slide, or move forward. Also, using the navigation bar that appeared on each slide, the participant could move freely among the subsections of each tutorial.

Tutorial Design

While the Web site was under construction, the NIC convened repeatedly to help the project staff delineate content for each of the tutorials proposed in the grant application. The community partners saw the tutorials as a means to convey basic knowledge about comput- ers, hardware, software, e-mail, nursing informatics, and patient privacy that would serve as background knowledge for their nurses who would be taught more specific information at each of the local institutions, none of which used the same software for their com- puterized systems. A list of the tutorials designed is found in Table 2. Each tutorial contained content that could be completed in a minimum of 30 minutes if the participant did not repeat any slides. At the end of each tutorial, there was a printable reference list, in- cluding articles, books, and Web sites; a printable out- line of the content; a quiz with feedback about the answers; and a CEU certificate printable upon comple- tion of the quiz. Recognizing the need for repetition of

slides and audio, exploration of the reference list, and completion of the quiz, each tutorial awarded two contact hours. One CEU was awarded for each 10 contact hours; thus, participants earned one CEU for every five completed tutorials.

Once the content of each tutorial was outlined, the details of the slide design were discussed by project staff. Once again, the fact that some nurses would use dial-up Internet connections had to be considered; thus, the tutorials could not include as many graphics as originally planned. The final template included a navigation bar, which displayed the NIC logo, the name of the various tutorial subsections, the quiz (Questions), and a Close button, along the left side of each slide (Figure 2). The remaining three quarters of each screen comprised the PowerPoint slide, with a bar along the bottom showing the progress of the audio and providing the control for moving forward or backward among the slides. The slides had a white background, with bullet points, underlining, and three variations in font color (blue, green, and red) to emphasize conent. Graphics were incorporated when appropriate, with arrows pointing to specific aspects. As seen in Figure 2, the description of a central processing unit (CPU) included a graphic of the back of a CPU and one slide for each part discussed in the tutorial, with an arrow pointing to the exact part. As the audio described a specific part, such as the USB port, only the label for the USB port and a red arrow pointing to its location appear. The words on each slide were kept to a minimum, while the audio supplied additional information.

Initial Evaluation of the Tutorials

The first two tutorials were previewed by the NIC members, who approved the design, content, and the decision to empower the participant to advance or repeat slides. Because of NIC member time constraints, their reviews were limited in scope. The project staff, as faculty members at a university, turned to students for detailed feedback.

Thirty-five graduate nursing students enrolled in a nursing informatics course taught by a member of the project staff were asked to critique the tutorials as a course assignment for which they received credit. The university’s Institutional Review Board approved the tool used to critique the tutorials along with the survey of practicing nurses and employers as a research study, with permission to analyze data and publish the findings. The graduate students ranged in computer competence from novice to experienced user. A Likert scale was used to rate the Web site and its ease of use, the tutorials’ ease of use, and the content of each tutorial. Table 3 lists the graduate student responses to some of the evaluation items about the Web site and

T a b l e 2

Tutorials

Informatics Introduction to nursing informatics Brief history of computers in healthcare

Informatics applications to nursing Nursing informatics competencies

Basic computing

A short history of the computer Hardware and peripheral devices Input/output devices

Working with software and files Overview and history of the Internet

Maintaining personal computers Basic user skills

Preventive care for the computer Triaging computer problems Troubleshooting windows-based systems

Electronic communication How electronic communication works Working with e-mail

Organizational and professional e-mail Patient privacy

Privacy and confidentiality HIPAA

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tutorials, and Table 4 lists the strengths and weaknesses of specific tutorials. It must be remembered that these evaluators were graduate nursing students enrolled in a nursing informatics course that included a weekly computer laboratory, which may explain the few problems they experienced with connecting, navigating the Web site, and running the tutorials. Almost all (92%) of the evaluators said they would recommend these online tutorials to other nurses.

Project staff reviewed the student evaluations, made revisions to the Web site, and improved the process of tutorial design. The importance of a smooth, fast initial enrollment phase became apparent. The comments of the graduate nursing students contributed to the revision of the enrollment process from a two- step to an instantaneous process. Users reported satis- faction with the fonts, colors, and graphics yet were less satisfied with information about the projected comple- tion time for each tutorial and the number of contact hours associated with each. As a result, more detailed information about the project, tutorials, and contact hours was provided on the Web site. Review of the feedback about the quality of the content of specific tutorials alerted project staff to the importance of collegial review of the rough draft of each tutorial. Thereafter, the staff more carefully scrutinized each other’s work for adherence to the slide template, use of similar vocabulary words, provision of too much or too little detail, and the logical sequence of content.

Marketing

The NIC convened repeatedly to discuss the market- ing plan for the tutorials; each community member

was to oversee marketing to his or her staff. Members from the healthcare systems informed staff of the avail- ability of the tutorials through organizational e-mail

FIGURE 2. Sample Slide.

T a b l e 3

Evaluation of Tutorials by Graduate Nursing Students (N = 35)

Issue No. (%)

Connection and loading Used a dial-up modem 11 (31) Used a broadband connection 16 (46)

Was able to open Web site easily 25 (71) Liked the look of the Web site 31 (91) Found the Web site engaging and friendly 31 (91)

Found the Web site font easy to read 33 (94) Navigating the Web site

Was able to find information on the Web site easily

24 (68)

Completed the demographic survey without difficulty

30 (86)

Knew where they were and where they

should go next

29 (83)

Knew in advance how long each tutorial would take to complete

19 (57)

Knew in advance how many CEUs were associated with each tutorial

23 (66)

The tutorials

Rated the tutorials as running smoothly 20 (58) Stated that the best aspect was the concise,

easy-to-understand information 14 (41)

Rated the tutorials as somewhat or very

helpful to their practice

23 (66)

Reported a significant increase in their knowledge of the subject

11 (33)

Would recommend these online streaming tutorials 32 (92)

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and live staff meetings. School nurse leaders invited project staff to a mandatory school nurse meeting of one large school district, where a short presentation was given followed by the distribution of flyers that included the URL of the NIC Web site and directions for enrolling. To reach school nurses employed by smaller districts, one project staff member identified listserv managers for each of those districts who sent e-mail messages about the project to all of their nurses. Community health nurses were informed during their regularly scheduled staff meetings, at which they too received flyers.

Enrollment was heavy at first, with school nurses who had received a live presentation about the tutorials responding in the highest numbers. Potential partici- pants notified by their employer but without contact with project staff or by e-mail responded in much lower numbers. Early users often encountered problems. The

enrollment process did not always work well. Some nurses using computers at work were blocked by firewalls; others could not download RealPlayer, which prevented streaming tutorials. Project staff responded to each problem as quickly as possible and sent e-mails to the users with instructions on how to proceed. The enrollment problems were resolved quickly, but the conversion from RealPlayer to HTML took longer. During this time, potential students were lost. Even after work-associated problems were solved, most participants worked from home computers, on which learners experienced fewer problems and could spend as much uninterrupted time as needed.

Project staff sent out e-mail messages to all users who were enrolled as problems connecting to the streaming tutorials were fixed and as new tutorials were made available. Further attempts at local marketing were done via e-mail. In a final effort to bolster enrollment

T a b l e 4

Critique of Individual Tutorials

No. (%) Most frequently completed tutorials

Introduction to nursing informatics 20 (57) A short history of the computer 19 (54) Hardware and peripheral devices 18 (51)

Brief history of computers in healthcare 17 (49) Informatics applications to nursing, input/output devices, and working with software and files 16 (46) Nursing informatics competencies, basic user skills 15 (43)

n*(n =35) No.y (%) Tutorials with the highest ratings

Best in organization and at meeting objectives

Organizational e-mail 13 7 (64) Working with e-mail 11 8 (62)

Best in breadth

Input/Output devices 16 13 (81) Most helpful

Working with e-mail 11 7 (54)

Increased participant knowledge the most Nursing informatics competencies 15 7 (47) Working with e-mail 11 6 (46)

Informatics applications to nursing 16 7 (44) Working with software and files 16 7 (44)

Tutorials with the lowest ratings Worst in organization and meeting objectives

Privacy and confidentiality 6 2 (33) Least helpful

Overview of the Internet 11 2 (18)

Too complex Working with e-mail 11 2 (15)

Increased participant knowledge the least

Organizational e-mail 13 1 (9) Overview of the Internet 11 1 (9)

*Number of students out of the 35 graduate students who completed the corresponding tutorial and could have evaluated it. y Number of students who evaluated the tutorial to fit the strength/weakness mentioned.

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figures, project staff marketed the tutorials to nurses throughout California using e-mail.

By the end of the funded period, 474 practicing RNs enrolled in the NIC project, with 52% (246) of them completing at least one tutorial. Of this sub- set, 42% (68) of school nurses, 30% (58) of commu- nity health nurses, and 2.6% (107) of hospital nurses from the original target audience of 8210 practicing RNs employed in the two counties participated in the program.

EVALUATION OF THE PROJECT

From the survey of practicing nurses conducted during the planning phase, project staff learned that 83% of the 192 responding nurses were interested in taking classes to improve their computer skills and 87% were open to an asynchronous online format. Thus, from a base of 8210 nurses employed locally, the staff expected more than 474 enrollees for these tutorials awarding free CEUs. School nurses who were reached through a combination of live and electronic marketing strategies had the highest participation rates. Project staff and NIC members concluded that a combination of mar- keting strategies was appropriate, especially for a new program.

In the same survey, 78% of the respondents indicated that they wanted a live workshop to learn how to use the Internet to participate in the online learning. However, the project never implemented a live intro- ductory workshop to help participants navigate the tutorials. This, along with enrollment and RealPlayer problems, undoubtedly contributed to the disappointing rate of tutorial completion by enrollees. Project staff and NIC members agreed that there was generally only one opportunity to reach the prospective participants. All aspects of the online education program, from enrollment to streaming of tutorials and printable certificates, had to work flawlessly, or prospective par- ticipants would not return to complete the tutorials. Because there were few complaints about downloading graphics once the initial technical problems were resolved, the staff felt that the time and effort spent planning slides with a minimum of graphics and testing tutorials from remote computers using dial-up modems had been well spent.

When the number of completed tutorials was cate- gorized, the participation rates were the following: none, 48% (226); one to six tutorials, 31% (147); seven to 12 tutorials, 9% (40); and 13 to 18 tutorials, 13% (59). Nurses of all ages, years of work experience, ethnicity, practice settings, and computer capability completed the online tutorials. Those aged 20 to 29 years (18%), those with 15 to 20 years of work ex-

perience (16%), Hispanic nurses (22%), school nurses (16%), those working part-time (18%), and nurses with or studying for a master’s degree (17%) were the most likely to complete between 13 and 18 tutorials. However, significant differences in the number of tuto- rials completed among groups were not found, indicat- ing that nurses were similarly disposed to participate in online education regardless of their demographic or employment characteristics.

While the tutorial content ranged from the simple (how a computer works) to the complex (nursing informatics), some of the most popular tutorials were the more complex ones. The graduate student evalua- tors most often completed one of the nursing infor- matics tutorials, and when participants rated tutorials from which they had learned the most, two of the informatics tutorials were on the list. Asynchronous online tutorials were an appropriate modality for con- veying some rather high-level knowledge in addition to more basic information about computers.

CONCLUSION

Asynchronous online tutorials that include carefully crafted slides accompanied by audio is a very effective way to teach nurses online, yet the creation of stream- ing tutorials is a complex task that includes technical considerations and adult learning strategies. The NIC nursing members, although involved in the computer- ization of their healthcare systems, were unaware of the technical barriers that their system intranets of- fered. Information technology personnel from each participating organization should have been involved in the design process from its inception.

Each aspect of tutorial creation involves a different set of skills. It is important to assemble a team with members fluent in various aspects of the process, such as content expertise and technical expertise, including knowing how to save and stream tutorials, capture screen shots, insert annotations, record and edit audio, and synchronize audio with PowerPoint slides. Recent innovations in software applications that automate these technical functions will make it easier to create online tutorials in the future.

Project staff and NIC members agreed that there was one initial opportunity to attract nurses to online learning; if the program did not operate smoothly or if the nurses encountered any barrier, generally they did not return to give it a second chance. During users’ first contact with the program, they must become invested in completing some online tutorials. The enrollment process must be automated and instantaneous, allowing learners to enroll and start the first tutorial during the initial computer session. The tutorials must be viewable

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from every type of computer and Internet connection before they are made available to learners.

Marketing should be live and electronic, and work- shops should be offered to familiarize nurses with the online learning system. Technical assistance must be avail- able to help learners overcome problems as they arise.

Once participants mastered this online learning sys- tem, they completed the tutorials covering content that ranged from simple to complex. Tutorials containing more complex content were favored by the learners. Most participants reported gaining knowledge that they could apply in the practice setting. Project staff concluded that nurses need initial technical support to use the online learning modality, but once they mas- tered the technique, they were willing to use it.

Acknowledgment

This project would not have been possible without the significant contributions of Barbara Lefkarites and Kanako Sturgis. The authors also thank all of the mem- bers of the Nursing Informatics Community, who gave so generously of their time and expertise.

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