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Information and Communication Technologies and Continuing Health Professional Education in Canada: A Survey of Providers

Health and the Information Highway Division, Health Canada 2003

Final Report. March 2003

Table of Contents

Acknowledgments

Information and Communication Technologies and Continuing Health Professional Education in Canada is the result of a collaborative effort of a national group of partners. We would like to acknowledge the support and assistance of these individuals and groups:

Partners and Members of the Project Team

The project has been managed by a day-to-day project management team composed of individuals from the Office of Professional Development and the Finance Office at Memorial University, as well as by a Research Management Team, which allowed for national consultation with individuals who have expertise in distance education and continuing health professional education. These individuals have devoted many hours over the past year to the development of Information and Communication Technologies and Continuing Health Professional Education in Canada. We would like to thank them for their time, energy, and expertise.

National Research Project Team

University of Calgary, Faculty of Medicine, Office of Continuing Medical Education

  • Dr. John Toews
  • Dr. Jocelyn Lockyer

Memorial University of Newfoundland, Faculty of Medicine

  • Ms. Fran Kirby, Office of Professional Development
  • Dr. Vernon Curran, Centre for Collaborative Health Professional Education
  • Dr. Bill Bavington, Division of Community Health

University of Ottawa, Faculty of Medicine, Office of Continuing Medical Education

  • Dr. Craig Campbell, past Director of CME and current Director of Professional Education, The Royal College of Physicians and Surgeons of Canada

The Royal College of Physicians and Surgeons of Canada

  • Dr. John Parboosingh, past Director of Professional Education, Royal College of Physicians and Surgeons of Canada, and currently a Consultant to the CEO - Professional Development, The Royal College of Physicians and Surgeons of Canada

ZeddComm

  • Ms. Bonnie Miller
  • Mr. Stephen Lenser
  • Mr. Jude Hall

Office of Professional Development Team

Thank you to the Office of Professional Development team for all their dedication and hard work. These individuals include: Ms. Fran Kirby (Manager, Office of Professional Development Team), Ms. Lisa Wells and Ms. Michelle Pidgeon (Research Assistants), David Adams (Project Accountant), and Diane Stuckless (Administrative Assistant).

In addition, thank you to Mr. Gary Pedigrew (Manager of Finance and Administration) and Ms. Sheila Courish (Administrative Assistant) of our Finance Office within the Faculty of Medicine, from whom we received advice and guidance on financial matters.

Centre for Collaborative Health Professional Education

A special thank you to Dr. Vernon Curran and Ms. Lisa Wells of the Centre for Collaborative Health Professional Education, who diligently worked with the Office of Professional Development, the research project partners, to direct the collaborative research and writing of the final report.

University of Calgary, Faculty of Medicine, CME

Thank you to Ms. Dale E. Wright and Ms. Herta Fidler for writing and preparing the appended document Facilitator's Guide to Online Conferencing, which will be used as a model for other continuing education providers.

ZeddComm

Thank you to Mr. Stephen Lenser and Ms. Wynn-ann Wells for writing and preparing the appended Best Practices Document in Distance Education, which will also be used as a model for other continuing education providers.

Funding Partner

Thank you to Health Canada, Office of Health and the Information Highway, for their funding and for their invaluable grant support in the amount of $100,000 for the research and development of Information and Communication Technologies and Continuing Health Professional Education in Canada.

Executive Summary

One of the distinguishing characteristics of a profession is the commitment by its members to lifelong learning. In order to provide high-quality health care services, health professionals require access to effective ongoing professional development and continuing education programs. With the rapid advances that are occurring in the health sciences, it is becoming increasingly challenging for health care professionals to stay abreast of the latest health research information. Knowledge in the health sciences is constantly expanding as new information is published, disseminated, and quickly updated or revised. In this context, the health care practitioner is placed in the unenviable position of having to provide the best health care to the public while trying to use and apply a rapidly changing body of knowledge.

The provision of an equitable and sustainable level of health care in rural communities is challenged, because of problems in recruiting and retaining rural health care providers. Rural health care delivery is a demanding and challenging form of practice, regardless of the profession. For example, the rural physician or nurse practitioner frequently practices in an isolated environment, with inadequate resources and limited or distant specialist back-up resources. This isolation necessitates a level of clinical competence beyond that of his / her urban health care peers. It has been reported that rural health care providers perceive their opportunities for participation in traditional continuing health professional education as inadequate. The sense of professional isolation that results from a lack of continuing education opportunities also influences feelings of job dissatisfaction with rural practice.

In Canada, the trend appears to be towards greater use of information and communication technologies (ICTs) in the health care system and in the continuing education of health professionals. ICTs have an important role to play in addressing recruitment and retention challenges, facilitating the maintenance of competencies among rural health care providers, and enhancing the quality of care provided to rural and remote communities. The objectives of the study described in this report were twofold. Firstly, we were interested in identifying the extent and level of ICT usage among Canadian continuing health professional education (CHPE) providers. Secondly, we were interested in assessing the type of ICT-related training and educational programming that is being provided by Canadian CHPE providers. A greater understanding of the efforts to educate health professionals in the integration and usage of ICTs in health care practices, and of how Canadian CHPE providers are utilizing ICTs to deliver continuing professional education will contribute to effective decision and policy making that impacts the health and health care of all Canadians.

A national questionnaire-survey of Canadian CHPE providers was conducted in order to meet the project goals. The survey was designed by the research team and validated by an advisory committee. The questionnaire-survey items were developed from a review of relevant and available literature. The survey was designed to collect information concerning: the technologies being used to deliver distance education programs; factors that influence decisions to offer technology-based distance education; source(s) of support and available resources for technology-based distance education programs; and the type(s) of CHPE programs being offered in the areas of ICT-related training and education.

A total of 3,044 (N = 3,044) surveys were distributed between September and December 2002. The target CHPE provider audience included schools of medicine (N = 16), schools of nursing (N = 135), and schools of pharmacy (N = 9). It also included national / provincial health professional associations and non-profit health advocacy organizations (N =101), the pharmaceutical industry (N = 56), and hospital / health care authority organizations (N = 2,727). Six hundred and seventy-seven (N = 677) surveys were returned. School of medicine and school of pharmacy organizational respondents provided the highest response rates of 62.5% and 55.6%, respectively. Fifty-eight (N = 58) of 135 school of nursing questionnaire-surveys were returned, a response rate of 43%. Forty-seven (N = 47) of 101 surveys were completed by national / provincial health professional associations, a response rate of 46.5%. The response rates for the pharmaceutical industry and the hospital / health care management board organizational categories were less than expected. Only 15 of 56 pharmaceutical industry organizational respondents completed and returned surveys, a response rate of 26.8%. The lowest response rate (19.9%) was received from hospital / health care management board organizational respondents.

The main findings of the survey included:

  1. Canadian schools of medicine and nursing are responsible for a significant number of the technology-based distance education programs offered as CHPE to health professionals.
  2. Canadian schools of medicine and nursing report the highest level of experience in technology-based distance education programs offered as CHPE to health professionals.
  3. Existing educational technology resources and expertise (human, technical, and infrastructure) within an organization are important factors influencing the likelihood of a CHPE organizational unit being a provider of technology-based distance education programs.
  4. Factors related to 'financial gain' do not influence an academic CHPE organizational unit's decision to provide technology-based distance education. Academic CHPE providers are more likely to provide technology-based distance education as a means of addressing needs of rural / remote health professionals; to increase opportunities for flexible CHPE access; and to fulfill an organization's mission.
  5. Hospital / health care management boards favor technology-based distance education as a more 'cost-effective' means of addressing mandatory CHPE needs of health professionals.
  6. Schools of medicine report a high level of dependency on 'industry' funding as a means of supporting technology-based distance education program development and delivery.
  7. Partnering (with other organizations and institutions or with other internal departments) appears to be a significant characteristic of technology-based distance education program development and delivery by Canadian CHPE providers.
  8. Schools of medicine reported a lower level of importance of partnerships with other internal departments in the parent institution, when compared to other academic organizations.
  9. Partnerships with provincial and federal government organizations and community-based agencies were not identified as significant partnership types.
  10. Internet-based technologies (e.g., e-mail and the World Wide Web) and videoconferencing are the most common educational technologies used by CHPE providers in technology-based distance education programming.
  11. Technology-based Canadian CHPE providers are mostly targeting 'regional' and 'provincial' audiences, not international ones.
  12. Participants in technology-based CHPE programs are varied, and include experienced health professionals.
  13. School of medicine and hospital / health care management board respondents are addressing the needs of a predominantly rural practitioner audience. Schools of nursing are addressing the needs of both urban and rural practitioners through their technology-based CHPE programs.
  14. The most common ICT-related CHPE topics being provided to Canadian health professionals include: using computers; e-mail applications; using the Internet; presentation software; and hospital computer systems.
  15. Providers of technology-based CHPE distance education programs are more likely to report a positive perception of: supportive organizational factors; technological infrastructure, access to equipment and Internet services; and levels of computer experience, enthusiasm, and commitment among their distance education programming target audience.

The main recommendations that stem from the study findings include:

  1. ICTs play a significant role in the delivery of CHPE programming, which addresses the mandatory continuing professional education and lifelong learning needs of rural, remote, and northern health professionals. These technologies are essential in facilitating the effective distance education programming that maintains the competencies of these practitioners and reduces the level of professional isolation they experience. Access to and use of ICTs in CHPE delivery are vital components of any effective strategy to enhance retention and recruitment of rural health care providers.
  2. Academic institutions are responsible for providing the majority of CHPE programming via technology-based distance education. Academic institutions view this programming as an important part of their mission and commitment to addressing and supporting the lifelong learning needs of health professionals, particularly of those practicing in rural and remote regions of Canada.
  3. The Internet and videoconferencing are the main educational technologies being used by Canadian CHPE providers in the delivery of technology-based continuing professional education.
  4. Organizational support is a critical factor in the development and expansion of resources for the successful and sustainable delivery of technology-based distance education to rural and remote health professionals.
  5. The use of ICTs in the delivery of CHPE places unique and special demands on instructors and subject matter experts (SMEs) who are unfamiliar with these technologies in training and educational delivery. Faculty and instructional development support are key services in assisting instructors and trainers in the effective use of ICTs in continuing professional education.
  6. Health professionals require a fundamental understanding of ICTs, in order to be able to utilize these technologies in pursuing lifelong and continuing professional education opportunities. Appropriate stakeholders need to ensure that optimal efforts are made to provide CHPE opportunities, so that health care practitioners are able to develop the skills needed for optimal use of ICT systems.
  7. Technology-based CHPE development and delivery costs are generally higher than those associated with face-to-face CHPE delivery. Many organizations undertake these programs as a means of addressing the mission of their institution or the mandatory CHPE requirements of rural, remote, and northern health professionals. External funding to support such initiatives is essential, in order to offset those costs that are normally not covered in institutional operating budgets.
  8. Partnerships involve the combining of expertise and resources. Partnerships are essential in the development and delivery of technology-based CHPE. Partnering avoids duplication and allows organizations to share limited resources, equipment, and infrastructure. CHPE providers need to partner with other organizations and communities in the development and delivery of technology-based CHPE programs, in order to ensure program sustainability and acceptance. Municipal, provincial, and federal levels of government have a role to play in encouraging, facilitating, and supporting such partnerships.
  9. Governments have an important role to play in stimulating efforts for the development and delivery of technology-based CHPE. Apart from funding to support the development and delivery of technology-based CHPE and appropriate technological infrastructure networks, governments have a role to play in facilitating partnerships between institutions and organizations.
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Introduction

The provision of an equitable and sustainable level of health care in rural communities has been a challenge to the Canadian health care system for some time (Tepper & Rourke, 1999; Rourke, 1997; Hutten-Czapski, 1998). Rural communities have suffered from a shortage of primary care physicians and other health care providers for many years, and they have felt the chronic shortage longer and more severely than urban areas (Ramsey, Coombs, Hunt, Marshall, & Wenrich, 2001). There are many obstacles with regard to recruiting and sustaining an adequate supply of rural health care providers. Common deterrents are usually related to a lack of time for family and leisure, lack of work and educational opportunities for family members, professional isolation, lack of professional development opportunities, low salaries, poor locum support, underfunded hospital services, and over-scheduling (Rourke, 1993; Rourke, 1994). Each rural setting has its own special challenges. In the smallest, most remote communities, help is far away, both in terms of distance and time. This places an immense strain on limited local resources and on the health care provider, particularly when emergencies occur.

Rural health care delivery is a demanding and challenging form of practice, regardless of the profession. As an example, the rural physician or nurse practitioner frequently practices in an isolated environment, with inadequate resources and limited or distant specialist back-up resources. This isolation necessitates a level of clinical competence beyond that of his / her urban health care peers. The rural physician, in particular, is often expected to perform a generalist role in every aspect of clinical practice. Because of this, he / she must develop and maintain a special base of knowledge and technical skill in a variety of clinical areas, particularly in those related to rural medicine; e.g., emergency medicine, obstetrics, and anesthesia (Rourke, 1988; Woolf, 1991; Kamien & Buttfield, 1990; Gill & Game, 1994).

Several studies have confirmed the existence of unique continuing medical education needs among rural physicians (Rourke, 1988; Woolf, 1991; Kamien & Buttfield, 1990; Gill & Game, 1994). Some studies have also found significant differences between the continuing medical education needs of rural and urban medical practitioners (Lott, 1995; Rosenthal & Miller, 1982; Woolf, 1991). A number of authors have suggested that rural physicians perceive their opportunities for participation in traditional continuing medical education as inadequate (Lott, 1995; Gill & Game, 1994; Rosenthal & Miller, 1982; Woolf, 1991). As well, Bhatara et al. (1996) have suggested that rural physicians' sense of professional isolation, due to a lack of continuing education opportunities, influences feelings of job dissatisfaction with rural practice.

Nurses in rural communities encounter several barriers to participation in professional development and continuing nursing education programs. Some of these barriers include being far removed from library resources, and the long travel distances to meetings of their professional associations. According to Treloar (1985), for many nurses it is very difficult and costly to travel to high-quality continuing education programs. This is particularly true in areas where travel may be seasonally restricted because of climatic conditions, or where educational resources are sparse / poorly distributed. Rural nurses often find it difficult to travel to distant sites to attend continuing education offerings, because staffing and financial constraints restrict the number of nurses that health care agencies can send to outside courses (Clark & Cleveland, 1984).

Pharmacists practicing in rural areas also find that continuing education opportunities are few and far between. DeMuth (1996) has reported that the major barriers to pharmacists' participation in continuing professional education were related to time constraints, job constraints (such as lack of relief staff), the scheduling and location of group learning, and family commitments. One of the greatest barriers for rural pharmacists was the centralized location of most face-to-face continuing education programs. This was a major problem for practising pharmacists, because they are required to travel long distances from their community in order to participate in them.

Continuing Health Professional Education (CHPE) & Information and Communication Technologies (ICTs)

One of the distinguishing characteristics of a profession is the commitment by its members to the promotion of continued study and lifelong learning (Buchholz, 1979). This commitment is vital to the health professional. Due to the constant acceleration of change in health sciences information, no amount of formal education -- no matter how complete or excellent -- can totally prepare for a lifetime of learning (Herman & Buerki, 1977). Health professionals, regardless of their practice location, require access to effective professional development and continuing education programs.

With the rapid advances that are occurring in the health sciences, it is becoming increasingly challenging for health care professionals to stay abreast of the latest health research information (Whitten, Ford, Davis, Speicher & Collins, 1998). In the health sciences, knowledge is constantly expanding as new information is published, disseminated, and quickly updated or revised. In this context, the health care practitioner is placed in the unenviable position of having to provide the best health care to the public while trying to use and apply a rapidly changing body of knowledge (Lorenzi, Kues, & Anthony, 1984). For the rural health care provider, gaining access to this timely information is an even greater challenge, because of isolation and distance from the larger tertiary care and teaching hospitals where this information exists.

ICTs have been used for supporting the delivery of educational and clinical support to health and medical professionals (Walker et al., 1998). Historically, audio teleconferencing, videoconferencing, slow scan imaging, and video tape programs have been used to deliver continuing health professional education at a distance (Black & Dunikowski, 1985; Dunn et al., 1980; Lindsay et al., 1987; McDowell et al., 1987; Oeffinger et al., 1992; Moore & Hartman, 1992). In recent years, Internet-based technologies have been adopted as a means of delivering information that can be linked to patient care issues in a timely and interactive fashion (Peterson et al., 1999). The use of ICTs in this manner -- to bridge the distance of geography and professional isolation -- is referred to as 'distance education'.

Distance education occurs when an instructor and adult learner(s) are separated by geography and time, and instruction is mediated through either print, information, and / or communication technologies. Distance education delivery modes are distinguished according to the technologies and medium used to carry the learning materials and / or to facilitate the two-way communication between participants and instructors. The four main categories of distance learning technologies are audio, video, computer (data), and print. Dating back to the late 1800s and early 1900s, correspondence study appears as the first format used for providing educational programming to adult learners residing and studying at a distance from an educational institution or an instructor. Beginning in the 1920s, the means of communication slowly shifted from the medium of print to the mass medium of radio. The 1940s and 50s saw another shift in distance education to educational television and the resulting 'one-to-many' patterns of communication offered by the broadcast technologies.

The next technological breakthrough occurred around 1970, with the advent of two-way audio systems. Interaction between instructor and the adult learner was now possible. Later, satellite courses, implemented in educational settings during the mid 1970s, which use one-way video and two-way audio, allowed for interaction at a verbal level and, to some extent, at a visual level. In the mid 1980s, the advent of two-way audio and video systems (also known as two-way interactive video systems) revolutionized distance learning, and allowed instructors and learners at distant sites to communicate with one another on both visual and verbal levels.

In the 1990s, the landscape of the distance education field was transformed yet again. Significant advances in ICTs have enabled the rapid movement of information to almost anywhere in the world. Computer capacities and speed have advanced to levels previously unimaginable, and present day innovations in multimedia and data compression capabilities are enabling the integration of voice, data, and images over computer networks. Delivery systems that use fiber optics or regular telephone lines are also making use of advanced telecommunication technologies (e.g., Integrated Services Digital Network), and these are revolutionizing the technologies used for delivering distance education programming.

Information and Communication Technologies (ICTs) & the Health Professions

The increased capacities of these ICTs have contributed to a movement away from traditional continuing health professional education (Moore et al., 1994). In Canada, the trend appears to be towards greater use of information and communication technologies in the health care system and in the continuing education of health professionals. ICTs are useful tools for health professionals, because they can provide greater access to clinical and health information, continuing health professional education, and the enormous range of online resources that normally would not be available to them. The availability of these resources is believed to strengthen the communication and networking capabilities of health professionals (Miller et al., 1997; Robinson et al., 1998; Manske et al., 2000). Robinson et al. (1998) report that the advantages of using ICTs include: improved opportunities to find information that meets the specific needs of individuals; improved capabilities to combine various media to meet the learning styles of users; increased access to information and support on demand; and the ability for widespread information dissemination.

Internet and e-mail use have been reported as high among health professionals (Kaczorowski, 2000; Pereira, 2001; Manske et al., 2000). Eighty percent (80%) of health professionals have reported using e-mail (Pereira, 2001; Manske et al., 2000). The Canadian Medical Association (CMA) indicates that in 2001, 83.6% of physicians were using the Internet, and 80.6% were using e-mail (CMA, 2001). At least 67% of physicians use the Internet for MEDLINE searching, and 23% of physicians (21% rural, 24% urban) use the Internet to participate in online CME courses (CMA, 2001). Yung, Foy, and MacCara (2001) surveyed all licensed pharmacists (N = 1,637) within the three Maritime provinces. The majority of respondents (56.2%) used e-mail daily. Some respondents also indicated weekly collection of disease information (18.8%), therapeutic / treatment information (17.6%), information for patients (17%), and information on new drugs (17%).

While these data suggest that a large number of health professionals are using the Internet, they do not indicate whether the technologies are being used in an appropriate and efficient manner. According to Buckeridge and Goel (2001), the use of informatics or ICTs by Canadian health professionals, and the promotion of their use by institutions are limited. After conducting interviews with 26 leading Canadian health informatics researchers and practitioners, Buckeridge and Goel concluded that health informatics education in Canada is not being integrated into the curriculum as quickly as it is in other G-7 countries. An awareness and understanding of the benefits of using health informatics is one of the major issues challenging the development of health informatics in Canada.

Barriers to Information and Communication Technology (ICT) Adoption and Use

A number of barriers to the use and adoption of ICTs among health professionals and health institutions have been attributed to concerns about security, reliability, and confidentiality of information (Bigsby & Moehr, 1995; Robinson et al., 1998; Leeseberg Stamler et al., 1999; Lacher et al., 2000; Ferguson et al., 2000; Delaney, 2001). Ferguson et al. (2000), for example, report that general practitioners are wary of e-mail for receiving patient discharge summaries or drug information. Also reported as barriers are lack of the necessary time to learn how to use these technologies and lack of time to use them, as well as the difficulty in locating relevant and useful information on the Internet (Bigsby & Moehr, 1995; Rowe et al., 1995; Lacher et al., 2000; Lawton et al., 2001). Inadequate funding has been reported as another major barrier to the use of ICTs in the health professions (Rowe et al., 1995; Cameron, 1998; Hebert, 2000; Jerant & Lloyd, 2000). Forty nine percent (49%) of respondents in the Rowe et al. study identified the high cost of computers as a major barrier.

Lack of access to new technologies, rather than a lack of preference for them, has also been identified as a primary barrier in discouraging their use (Mamary & Charles, 2000). Royle et al. (1997) conducted a survey of nursing administrators in hospitals in central and northwest Ontario, and found that the larger the hospital, the more likely it was that electronic databases and other information resources were available. Of the 32 respondents who worked in hospitals with less than 100 beds, 90.6% had access to a library but only 6.2% had access to MEDLINE, and 3.1% had access to CINAHL. Manske et al. (2000) also report that a higher percentage of health units serving large (versus small) populations have greater access to ICT resources such as e-mail (91% vs. 69%) and the Internet (72% vs. 43%). Health units in smaller regions were less likely to have the infrastructure in place to use the technology (Manske et al., 2000).

The levels of comfort, experience, and skill that health professionals have with ICTs are also important factors influencing adoption and usage. Rowe et al. (1995) surveyed first-year family medicine residents from Canadian university-affiliated programs, and found that only 13% reported being very or extremely comfortable with computers, while 29% reported being somewhat comfortable and 24% not at all comfortable. They also found that 30% of Canadian family medicine residents felt they were not exposed to enough computer training during their education. Five years later, Jerant and Lloyd (2000) again identified lack of suitable training as a barrier to computer use.

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Enhancing Information and Communication Technology (ICT) Adoption and Use

It is believed that the benefits of adoption and usage of ICTs have not been realized, because individuals and organizations are unable to use these resources to their full capabilities (Hebert, 2000). According to Moehr and Grant (2000), Canadian health professionals and students need a basic knowledge of the capabilities and limitations of information systems. Saranto and Leino-Kilpi (1997) report that nurses need to know how to access and use hospital / management information systems, including those that address clinical and patient care. Staggers, Gassert, and Curran (2001) have identified competencies for both the beginner and the experienced nurse. Beginner nurses should possess basic information management and computer technology skills, while experienced nurses should be highly skilled in these areas.

Many family physicians now identify 'improving computer skills' as a core CME area more frequently than most clinical areas (McClaran et al., 2000). Cameron (1998) has suggested that the informatics skills required by Canadian physicians should include an ability to use various word processing and presentation software, Internet and e-mail, Internet databases, and office management systems. Other medical informatics areas include: knowledge of computer-based information sources for patient care; knowledge of electronic medical records (EMR); office-based and hospital-based management systems; and an increased knowledge of computer-based continuing medical education, telecommunications, and telemedicine (Lacher et al., 2000; Candy, 2000).

Like other health professionals, pharmacists do not need to become informatics specialists, but they do need to understand how informatics works (Felkey & Barker, 1995). Balen, Miller, and Malyuk (2000) suggest that the informatics skills for pharmacists need to include the use of computers to collect, store, retrieve, and send drug and patient-related data for both administrative and clinical purposes. Pharmacists also require knowledge of personal and network computing; hospital information systems; personal digital assistants; the Internet; word processing; and presentation, statistical analysis, and database management software. However, Balen et al. (2000) believe that students are not necessarily receiving the instruction they require, as pharmacy has not taken the lead in developing informatics that meet the profession's needs.

The literature identifies a number of strategies and methodologies that can be used to introduce ICTs into health professional education. Carty and Rosenfeld (1998) have identified a number of criteria related to how nursing education programs could achieve technological excellence. Their criteria include providing students and faculty with adequate access to computers, making informatics courses available, and providing the necessary infrastructure (i.e., technical support, computer labs, Internet and e-mail access, allocation of financial and personnel resources, etc.). Other authors discuss the development of specific programs or workshops designed to improve the ICT skills of health professionals. From 1996 to 1997, three rural northwest Ohio hospitals, along with the state's medical college co-sponsored sessions that addressed the medical application of computers for rural physicians (Hartmann, 1998). Program topics included medical databases, medical CD-ROMS, the Internet, and e-mail. Allan et al. (2000) discuss a series of physicians' workshops related to computer basics, introduction to computers in medicine, introduction to the Internet, and computer-aided learning (CAL) and information retrieval. Through follow-up surveys they discovered that more physicians reported increased use of computers as a result of participation in the workshops (Allan et al., 2000).

Patel & Arocha (2000) describe a meeting of a group of scholars from the fields of cognitive science, medicine, ethics, medical technologies, and intelligent tutoring systems, which was held in order to explore issues relevant to the education of the health professions in an information age. One of the research agendas suggested for future development was information technology-related research (Patel & Arocha, 2000). According to this agenda, there were a number of important questions that needed to be examined: Who uses information technologies in health care settings and how? Are such technologies integrated into clinical practice? Are they being used successfully? According to the scholars participating in this meeting, there was a need for improved studies of how best to educate health professionals for the challenging practice environment of the future (Patel & Arocha, 2000).

In 1999, a Health Canada report entitled Canada Health Infoway: Paths to Better Health was prepared by the Advisory Council on Health Infostructure for the Office of Health and the Information Highway. According to the Council's report, health care was an information and communication-intensive activity, and as a result, most health care professionals needed training in how to use these new ICTs. A number of recommendations concerning the need for health professional training to adopt and apply information systems in their work were suggested:

Recommendation 3.2
Federal, provincial, and territorial governments, in collaboration with associations representing health care professionals and providers should provide funding for:
(a) professional education and development opportunities for health care professionals and providers across the spectrum of health care, to acquire the skills needed for optimal use of health information and communications systems.
Recommendation 3.7 (d)
Support training for health care professionals and providers, so that they can fully exploit the potential of telehealth (Health Canada, 1999).

The report proceeded to suggest that governments, in collaboration with associations of health care professionals should also fund training to help these groups acquire the necessary digital skills, as well as participate in developing, piloting, and evaluating tools to support clinical decision making. In the Council's view, it was also prudent to put in place a labour force strategy, to address the impact of these changes upon health care professionals, providers, and workers, and to make sure that the necessary skills and knowledge were in place.

Study Purpose

The purpose of this study was twofold. To begin with, the project team was interested in identifying the extent and level of ICT usage among Canadian CHPE providers. Secondly, the team was interested in assessing the type and nature of ICT training and educational programming currently being offered by Canadian CHPE providers. CHPE was defined as "continuing health professional educational courses and / or programs that are directed to a health practitioner audience." For the purposes of this project, these programs may or may not be approved for the continuing education credit required by a licensure board, professional organization or the workplace to maintain competence, retain licensure, certification, and / or employment.

A national questionnaire-survey of CHPE providers was conducted in order to identify the type of ICTs being used to deliver CHPE; to identify 'best practices' pertaining to the planning, development, delivery, and evaluation of distance learning programs for CHPE; and to identify programs and / or services that have been established to provide CHPE for the use, adoption, integration, and application of ICTs among health professional groups. The CHPE provider audience included academic respondents (schools of medicine, nursing and pharmacy), national / provincial health professional associations and non-governmental organizations, pharmaceutical industry, and hospital / health care authority organizational respondents.

In Canada, there is a trend towards greater usage of ICTs in the health care system and in the continuing education of health professionals. Canada faces unique difficulties in delivering health care, particularly among its many rural and remote communities. Telehealth applications have been shown to be effective in enabling teleconsultations, supporting rural and remote health professionals in the provision of care, decreasing the costs of health care delivery, and providing greater access to health care services for geographically isolated populations. Some of the main barriers to the adoption, integration, and usage of these applications among health professionals have included negative attitudes, lack of awareness and understanding of the technologies and particular applications, and lack of knowledge and skills in ICT usage. ICTs have been used for many years to provide CHPE to rural and remote health professionals, and as a result they have addressed recruitment and retention challenges, allowed for the maintenance of competencies among rural health care providers, and enhanced the quality of care provided to rural and remote communities. A greater understanding of the efforts to educate health professionals in the integration and usage of ICTs in their practices, as well as a better understanding of how Canadian CHPE providers are applying best practices in their use of ICTs to deliver continuing education will contribute to effective decision-making and policy-making that will affect the health and health care of all Canadians.

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Methodology

The research team designed a questionnaire-survey to collect data on the extent to which information and communication technologies (ICTs) have been adopted by continuing health professional education (CHPE) providers in Canada. Survey respondents were also asked to provide information about existing programming initiatives to enhance the knowledge, skills, and attitudes of health professionals towards the adoption and use of ICTs in their professional work. The survey was validated by an advisory committee consisting of national experts in the field of continuing professional education and information and communication technology usage. These experts were consulted on the composition of the respondent population for the study, and they were given several drafts of the questionnaire-survey for review. A draft of the questionnaire-survey was piloted with several health professional educators who were asked to critically review the survey and provide feedback on the readability and clarity of the questionnaire items. Lastly, two epidemiologists reviewed the formatting aspects of the survey and survey items. A final version of the survey and accompanying cover letters were submitted to the Human Investigation Committee, Faculty of Medicine, Memorial University. Full ethical approval was received in August 2002.

A total of three thousand and forty-four (N = 3,044) surveys were distributed to a variety of CHPE providers in Canada between September and December 2002. In cases where the names of the appropriate contacts were known, surveys were directed towards specific individuals (i.e., Dean, Director, Manager) or departments (i.e., CME, Professional Development, Human Resources). Six hundred and seventy-seven (N = 677) surveys were returned (the return and response rates per CHPE provider category are presented in the Results section). The following CHPE providers were included in the survey population:

  • One hundred and thirty five (N = 135) school of nursing respondents were forwarded the questionnaire-survey for completion. This organizational respondent category encompassed all accredited schools of nursing in Canada. The address list was compiled from an Internet search and the Next link will take you to another Web site Canadian Schools of Nursing (CAN) web site. It was compared and validated against the nursing education programs listed on the Next link will take you to another Web site Canadian Nurses Association (CNA) web site.
  • Sixteen (N = 16) school of medicine respondents (including CME Deans, Associate Deans or Directors) were forwarded the survey. This group included all accredited school of medicine respondents in Canada. The list was compiled and validated from the Next link will take you to another Web site Association of Canadian Medical Colleges (ACMC) web site.
  • Nine (N = 9) school of pharmacy respondents were forwarded the questionnaire-survey. This group included all accredited school of pharmacy respondents in Canada. The address list was compiled from an Internet search, and was compared and validated against the programs listed on the Next link will take you to another Web site Canadian Pharmacists Association (CPhA) web site.
  • One hundred and one (N = 101) national / provincial health professional sssociations were forwarded the questionnaire-survey. This organizational respondent category included national and provincial professional associations for nursing, medicine, and pharmacy practitioners, as well as professional societies representing medical specialities. This category also included non-profit health organizations such as the Canadian Diabetes Association and the Canadian Mental Health Association, which address the diverse health issues of the Canadian population. The list of respondents for this organizational category was compiled from an Internet search and through a mailing address list prepared by the Next link will take you to another Web site Canadian Healthcare Association (CHA).
  • Fifty-six (N = 56) pharmaceutical industry organizational respondents (Directors) were forwarded the survey. This group was compiled from the listing of Next link will take you to another Web site Canada's research-based pharmaceutical companies (Rx&D) on the Rx&D web site.
  • Hospital / health care management boards comprised the final organizational category included in the survey respondent population. This organizational category consisted of two thousand seven-hundred and twenty-seven (N = 2727) potential respondents, and included hospitals, regional district health authorities and boards, retirement, nursing, and long-term care facilities, and various health centres (e.g., rehabilitation, children's, mental health, etc.). Whenever possible, surveys were directed towards each organization's CEO / Director or a specific department, such as Human Resources, Communications, Staff Development or Information Services / Technology. The address list for this category was compiled through the Canadian Healthcare Association.
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A number of methods were used in an attempt to increase the survey response rate. To begin with, a cover letter that detailed the study's purpose and deadline for submission was included with each survey. A second copy of the survey was mailed to non-respondents after the first submission deadline had passed. Included with this survey was a follow-up letter and a new submission deadline. After the second deadline had passed, reminder letters -- but not copies of the survey -- were sent to a stratified sample of non-respondents (N = 965). The stratified sample included non-respondents from each province and territory, as well as each CHPE provider category. In most cases, there was a period of three to four weeks between respondents' receipt of the survey / reminder letter and the submission deadline. The survey was also made available for download in .pdf file format from the Office of Professional Development's web site (http://www.med.mun.ca/pdmed).

The questionnaire survey items were developed from a review of available relevant literature. A number of survey items were adapted and modified, with permission, from the American Association of Colleges of Nursing (AACN) Technology Survey (AACN, 1999). The questionnaire-survey included items that were designed to collect information in the following areas:

  • the type of organization to which respondents belonged;
  • the organization's commitment to the provision of continuing professional education by technology-based distance education programming;
  • experience in technology-based distance education delivery to health professionals;
  • factors influencing decision to offer technology-based distance education;
  • source(s) of support for technology-based distance education program delivery, and access to internal resources to support distance education program development and delivery;
  • type(s) and nature of partnerships formed for the purpose of sharing resources for technology-based distance education program development and delivery;
  • type(s) of technologies used in delivering distance education programs to health professionals;
  • type(s) of faculty development provided to support instructors and faculty in distance education program development and delivery;
  • composition of target audience / participants in distance education programs;
  • factors influencing likelihood of use of information and communication technologies for technology-based continuing professional education;
  • types of continuing professional education programs offered in the areas of information and communication technologies.

The questions concerning 'factors' influencing the likelihood of ICT usage in CHPE delivery were adopted and modified from the work of Collis, Peters, and Pals (2000). According to Collis et al. (2000), telematics applications are not being used regularly as instructional tools in educational settings. Collis and colleagues developed a model for predicting an individual's likelihood of using a telematics application in teaching practices. According to this model, or the '4-E Model' hypothesis, the likelihood of using a telematics application in teaching practices can be expressed as the sum of four factors: 'environmental aspects' in the institution in which one works; 'educational effectiveness' or perceived educational payoff; 'ease of use' or level of difficulty in making use of the application; and 'personal engagement' or subjective personal interest in the application. According to the 4-E Model, only when the sum of these factors approaches a certain threshold is usage likely to occur.

Items comprising the three scales of 'organizational influences', 'professional influences', and 'strengths and resources' were adopted and modified from the Collis et al. (2000) 4-E Model questionnaire. Table 1 lists the items included within each of these scales. The organizational influences scale encompasses items that are intended to measure the influence of organizational factors on the likelihood of information and communication technology adoption in continuing professional education delivery. Each item (N = 7) is responded to via a five-point scale; the most negative option is coded as having a value '1', and the most positive option is coded as having a value '5'. The professional influences scale consists of items (N = 6) that are intended to measure the influence of professional factors. These include items such as: 'My peers and colleagues believe that the Internet is an important tool'; 'In the professional field in which I work, many people are Internet users'; 'In the professional field in which I work, most people think that technology-based distance education is important'; 'Soon everyone will be using the Internet'; 'Distance learning is likely to contribute to the solution of learning-related problems relevant to the professional field in which I work'; and 'It is my personal opinion that technology-based distance education will improve teaching and learning'. Response possibilities range from 'Strongly Disagree' = 1; 'Disagree' = 2; 'I can't say' = 3; 'Agree' = 4; to 'Strongly Agree' = 5.

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Table 1 Survey Scales for Factors Influencing ICT Adoption & Usage
Organizational Influences
  • The vision within my organization for technology-based distance education is...
  • The support from the leaders in my organization for technology-based distance education is...
  • The readiness to change among the people in my organization when it comes to the use of technology-based distance education is...
  • The adequacy of my organization's technical infrastructure for technology-based distance education is...
  • The day-to-day support of technology-based distance education in my organization is...
  • The funding and incentives for technology-based distance education that are available in my organization are...
  • The experiences in the past that my organization has had with technology-based distance education have been...
Professional Influences
  • My peers and colleagues believe the Internet is an important tool.
  • In the professional field in which I work, many people are Internet users.
  • In the professional field in which I work, most people think that technology-based distance education is important.
  • Soon everyone will be using the Internet.
  • Distance learning is likely to contribute to the solution of learning-related problems relevant to the professional field in which I work.
  • It is my personal opinion that technology-based distance education will improve teaching and learning
Strengths & Resources
  • A priority of my unit.
  • A priority of my organization.
  • Administration supportive of the idea.
  • Sufficient administrative / clerical support staff.
  • Specialized staff to design the courses.
  • Experience in technology-based distance education.
  • Adequate budget for technology-based distance education programs.
  • Telecommunication costs are reasonable.
  • Adequate telecommunication infrastructure (e.g., bandwidth availability).
  • Adequate facilities / equipment for supporting distance education development and delivery.
  • Adequate faculty / subject matter expert support.
  • Convenient personal Internet access among target audience.
  • Convenient personal computer access among target audience.
  • Adequate level of computer experience among target audience.
  • Enthusiasm among target audience.
  • Organizational support from employers of target audience.
  • Sufficient time commitment for participation among target audience.

The range of sum scores (minimum to maximum) that respondents could receive for each scale was as follows: organizational influences, range of 7 - 35; professional influences, range of 6 - 30; and strengths and resources, range of 17 - 85. According to Collis et al. (2000), each factor's sum (i.e., vector sum) can be either positive or negative. When the positive vector is large enough to approach a threshold level described as a 'likelihood-of-use' line, an individual is likely to use a telematics application in his / her teaching and learning (Collis et al., 2000). Therefore, using the 4-E Model as a template, an analysis of the sums of respondents' scores for the scales of organizational influences, professional influences, and strengths and resources was hypothesized as being indicative of the point at which information and communication technology adoption and usage is likely to occur.

Surveys were coded and analyzed using the Statistical Package for the Social Science (SPSS 11.0 for Windows). Methods of analysis included cross-tabulation analysis to determine and compare the responses of organizational category respondents to individual survey items, and Mann-Whitney and Kruskal-Wallis tests to analyze the differences in and the relationships between organizational, professional, and strengths and resources factors and the actual reported usage, by the organizational respondents, of information and communication technologies.

This project report provides a large amount of survey data and information; a large portion of these are presented in table format. To facilitate the reading of the report, discussion of the findings is found in the text accompanying the tables. A discussion of the major findings and the conclusions follow the presentation of results. The results of this survey provide a national overview of the use of ICTs for CHPE delivery. The results also provide a national summary of the CHPE programs being offered by CHPE providers to develop the ICT-related knowledge, skills, and attitudes of health professionals, as well as important information for future policy and decision-making related to the effective use of ICTs in CHPE delivery. The findings also contribute to a better understanding of the type and nature of CHPE programs being offered to enhance ICT-related skills among the health professions.

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Results

Table 2 and Figure 1 present the results pertaining to the response rate for each CHPE provider category. School of medicine and school of pharmacy organizational respondents provided the highest response rates of 62.5% and 55.6%, respectively; surveys were received from ten of the sixteen schools of medicine and from five of the nine schools of pharmacy. Fifty-eight (N = 58) of the 135 school of nursing questionnaire-surveys were returned, for a response rate of 43.0%. Forty-seven (N = 47) of the 101 surveys were completed by organizations comprising the national / provincial health professional associations category, for a response rate of 46.5%. The response rates for the pharmaceutical industry and the hospital / health care management board organizational categories were less than expected. Only 15 of the 56 pharmaceutical industry organizational respondents completed and returned the survey, for a response rate of 26.8%. Hospital / health care management board organizational respondents had the lowest response rate (19.9%); only 542 of the 2,727 potential respondents completed and returned the survey.

Table 2 Summary of Potential / Actual Respondents and Response Rate
Type of Organization # of Potential Respondents # of Actual Respondents Response Rate
School of Nursing 135 58 43.0%
School of Medicine 16 10 62.5%
School of Pharmacy 9 5 55.6%
National / Provincial Health Professional Association 101 47 46.5%
Pharmaceutical Industry 56 15 26.8%
Hospital / Health Care Management Board 2727 542 19.9%
Total 3044 677

Response Rate By Organization

Table 3 presents the results pertaining to the provision of technology-based distance education programming among the survey respondents. The majority of school of nursing (55.2%) and school of medicine (70.0%) organizational respondents reported that they provide technology-based distance education programming to health professionals. The majority of school of pharmacy respondents (80.0%) reported that they were not providing distance CHPE programming. As well, the majority of national / provincial health professional associations (65.2%), pharmaceutical industry respondents (73.3%), and hspital / health care management boards (78.9%) indicated that they were not providing distance CHPE programming. Overall, 74.2% of survey respondents indicated that they were not providing technology-based distance education programming to address the continuing professional education needs of health care practitioners. Figures 2 through 6 present pie charts representing the organizational respondent categories and their reports of technology-based distance education program delivery.

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Table 3 Summary of Providers of Technology-Based Distance Education Programming to Health Professionals
Type of Organization Yes No TOTAL
N % N %
School of Nursing 32 55.2% 26 44.8% 58
School of Medicine 7 70.0% 3 30.0% 10
School of Pharmacy 1 20.0% 4 80.0% 5
National / Provincial Health Professional Association 16 34.8% 30 65.2% 46
Pharmaceutical Industry 4 26.7% 11 73.3% 15
Hospital / Health Care Management Board 114 21.1% 426 78.9% 540
Total 174 500 674

Figure 1
School of Nursing
Figure 2

School of Medicine
Figure 3

School of Pharmacy
Figure 4

Pharmaceutical Industry
Figure 5

Hospital/Health Care Management Board
Figure 6

Table 4 provides the results pertaining to the number of years that respondents have been offering CHPE programming via technology-based distance education. These results only reflect the responses of those organizations that had indicated that they were providing technology-based distance education programming to health professionals. The results indicate that schools of nursing and schools of medicine reported the greatest level of experience in the delivery of continuing professional education programming by technology-based distance education. The majority of school of nursing respondents (59.4%) reported that they had been offering distance education programs for six years or more. Forty-three percent (42.9%) of school of medicine respondents indicated that they had been offering continuing professional education programs by distance education for six years or more. Thirty-one percent (31.3%) of national / provincial associations reported offering continuing professional education programming by technology-based distance education for six years or more, and 19.3% of hospital / health care management organizational respondents indicated that they had been offering programs by distance education for six years or more. The pharmaceutical industry respondents reported the least experience in CHPE delivery by technology-based distance education. Only two (N = 2) respondents reported between one and five years of experience. The majority of hospital / health care management board respondents (58.8%) indicated that they had been offering CHPE programming by technology-based distance education for between one and five years.

Table 5 presents the results pertaining to respondents' reports of factors that had influenced organizational decision-making in the area of technology-based distance education program delivery. These results only reflect the responses of those organizations that had indicated that they were providing technology-based distance education programming to health professionals. The results show a consistent level of responses across the organizational respondent categories. The majority of school of nursing respondents reported that the factors that had the greatest influence on their decision to offer technology-based distance education included: 'addressing CHPE needs of rural / remote health professionals' (78.8%), 'increasing opportunities for flexible CHPE access' (70.6%), and fulfilling a 'part of the organization's mission' (53.1%). The majority of school of medicine respondents also indicated similar factors, including 'addressing CHPE needs of rural / remote health professionals' (85.7%), 'increasing opportunities for flexible CHPE access' (71.4%), and fulfilling 'part of the organization's mission' (57.1%).

Interestingly, only a minority of respondents across the organizational categories indicated that 'increasing revenue' was a factor that influenced the decision to offer technology-based distance education. In addition, only a minority of the academic organizational respondents indicated that 'less expensive delivery modality' was a significant factor that had influenced their decision to offer technology-based distance education. Only 15.6% of school of nursing respondents and 14.3% of school of medicine respondents reported that this factor had influenced their decision to offer distance education. However, a majority of hospital / health care management board organizational respondents indicated that 'less expensive delivery modality' was a significant factor that had influenced their decision to offer continuing professional education by technology-based distance education (60.5%). Hospital / health care management board respondents also reported that 'addressing mandatory CE needs of health professionals' was an important factor (43.0%). This result was considerably higher than other scores. Respondents were also provided with an option to identify 'other' factors that may have influenced their organization's decision to offer technology-based distance education. The 'availability of funding' (N = 5) and 'being able to research the effectiveness of the technology' (N = 1) were factors identified by the respondents.

Table 4 Summary of Years of Experience in Offering Technology-Based Distance Education Programming
Number of Years of Experience
Type of Organization < 1 1 - 5 years 6 - 10 years 11 - 15 years 16 - 20 years > 20 years TOTAL
N % N % N % N % N % N %
School of Nursing 2 6.3% 11 34.4% 5 15.6% 5 15.6% 6 18.8% 3 9.4% 32
School of Medicine 2 28.6% 2 28.6% 1 14.3% 1 14.3% 0 0.0% 1 14.3% 7
School of Pharmacy 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1 100% 1
National / Provincial Health Professional Association 4 25.0% 7 43.8% 3 18.8% 1 6.3% 0 0.0% 1 6.3% 16
Pharmaceutical Industry 2 50.0% 2 50.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 4
Hospital / Health Care Management Board 25 21.9% 67 58.8% 13 11.4% 4 3.5% 4 3.5% 1 0.9% 114
Total 35 89 22 11 10 7 174
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Table 5 Factors Influencing Organizational Decision to Offer Technology-Based Distance Education Programming
Organizations Part of Organization Mission Increase Revenue Address CHPE Needs of Rural / Remote Health Profession'ls Increase Opportunity for CHPE Access Address Mandatory CE Needs Less Expensive CHPE Modality Don't Know
N % N % N % N % N % N % N %
School of Nursing Yes 17 53.1% 7 21.2% 26 78.8% 24 70.6% 5 15.6% 5 15.6%
No 15 46.9% 26 78.8% 7 21.2% 10 29.4% 27 8.4% 27 8.4% 32 100%
School of Medicine Yes 4 57.1% 1 14.3% 6 85.7% 5 71.4% 2 28.6% 1 14.3% 0 0.0%
No 3 42.9% 6 85.7% 1 14.3% 2 28.6% 5 71.4% 6 85.7% 7 100%
School of Pharmacy Yes 0 0.0% 0 0.0% 1 100% 1 100% 1 100% 0 0.0% 0 0.0%
No 1 100% 1 100% 0 0.0% 0 0.0% 0 0.0% 1 100% 1 100%
Nat. / Prov. Health Professional Association Yes 5 31.3% 1 6.3% 14 87.5% 16 94.1% 5 31.3% 8 50.0% 0 0.0%
No 11 68.8% 15 93.8% 2 12.5% 1 5.9% 11 68.8% 8 50.0% 16 100%
Pharm. Industry Yes 2 50.0% 0 0.0% 2 50.0% 4 100% 1 25.0% 2 50.0% 0 0.0%
No 2 50.0% 4
8		 100% 2 50.0% 0 0.0% 3 75.0% 2 50.0% 4 100%
Hospital / Health Care Manage't Board Yes 49 43.0% 6 5.3% 70 61.4% 66 57.4% 49 43.0% 69 60.5% 3 2.6%
No 65 57.0% 10
8		 94.7% 44 38.6% 49 42.6% 65 57.0% 45 39.5% 11
1		 97.4%
Total 174 175 175 178 174 174 174

Table 6 presents the results pertaining to respondents' reports of sources of support for continuing professional education by technology-based distance education programming. These results only reflect the responses of those organizations that had indicated that they were providing technology-based distance education programming to health professionals. The majority of school of nursing respondents reported that 'tuition / registration fees' (78.1%) and 'provincial government grants' (50.0%) were main sources of support for their distance education programming. Seventy one percent (71.4%) of school of medicine respondents reported that ' industry educational grants' were a main source of support for their distance education programs, while 57.1% also indicated that 'tuition / registration fees' were a source of support. National / provincial health professional association respondents indicated that the main sources of support for their distance education program offerings were from 'provincial government grants' (37.5%), 'industry educational grants' (37.5%), and 'tuition / registration fees' (37.5%). Forty-five percent (45.0%) of hospital / health care management board organizational respondents reported that a main source of support for their distance education programming was from a 'parent institution grant / subsidy', while 31.6% reported support from 'provincial government grants', and 24.6% indicated support from 'tuition / registration fees'. Respondents were also provided with an option to identify any other sources of support for continuing professional education by technology-based distance education programming. 'Bursary programs' (N =1), 'membership of a telehealth organization or network' (N =2), and 'research funding support' (N = 1) were identified as other sources of support.

Table 7 presents the results pertaining to the relationship, in terms of distance education, between the responding organizational unit and its parent institution. As an example, within academic institutions, the responsibility for the organization and management of continuing professional education programs may be based within a unit that is separate and distinct from a distance education unit responsible for the development and delivery of undergraduate and graduate-level distance education courses. The responses to this item only reflect those organizations that had reported that they were providing technology-based distance education programming to health professionals. A majority of the academic organizational respondents (nursing and medicine) reported that their parent organization offered distance education courses, and that they had access to distance education resources within the parent institution. Seventy-eight percent (78.0%) of school of nursing and 100% of school of medicine respondents indicated that their parent institution offered distance education courses. Seventy-eight percent (78.1%) of school of nursing and 71.4% of school of medicine respondents also reported that they had access to distance education resources within their parent institution.

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Table 6 Sources of Support for Technology-Based Distance Education Programming
Org. Foundation Grant Federal Grant Pro. Grant Prof. Ass. Grant Subsidy Industry Edu.
Grant		 Parent Insti. Grant Subsidy Tuition Reg. Fees Alumni Donation
N % N % N % N % N % N % N % N %
School of Nursing Yes 1 3.1% 1 3.1% 16 50.0% 1 3.1% 1 3.1% 11 32.4% 25 78.1%
No 31 96.9% 31 96.9% 16 50.0% 31 96.9% 31 96.9% 23 67.6% 7 21.9% 32 97.0%
School Med. Yes 0 0.0% 1 14.3% 1 14.3% 2 28.6% 5 71.4% 1 14.3% 4 57.1% 2 28.6%
No 7 100% 6 85.7% 6 85.7% 5 71.4% 2 28.6% 6 85.7% 3 42.9% 5 71.4%
School Pharm. Yes 0 0.0% 0 0.0% 0 0.0% 1 100% 1 100% 0 0.0% 1 100% 0 0.0%
No 1 100% 1 100% 1 100% 0 0.0% 0 0.0% 1 100% 0 0.0% 1 100%
Health Prof. Yes 1 6.3% 1 6.3% 6 37.5% 3 18.8% 6 37.5% 4 23.5% 6 37.5% 0 0.0%
No 15 93.8% 15 93.8% 10 62.5% 13 81.3% 10 62.5% 13 76.5% 10 62.5% 16 100%
Pharm. Ind. Yes 0 0.0% 0 0.0% 2 66.7% 0 0.0% 0 0.0% 0 0.0% 2 66.7% 0 0.0%
No 3 100% 3 100% 1 33.3% 3 100% 3 100% 3 100% 1 33.3% 3 100%
Hosp. Health Care Man.'t Board Yes 7 6.1% 11 9.6% 36 31.6% 9 7.9% 5 4.4% 68 45.0% 28 24.6% 1 0.9%
No 107 93.9% 103 90.4% 78 68.4% 105 92.1% 109 95.6% 83 55.0% 86 75.4% 113 99.1%
Total 173 173 173 173 173 213 173 174
Table 7 Summary of Relationship Between Organizational Respondent and Parent Institution
Type of Organization Parent Institution Offers Distance Education Courses Total Access to Distance Education Resources Total
Yes No N/A Yes No N/A
N % N % N % N % N % N %
School of Nursing 25 78.0% 1 3.1% 6 18.8% 32 25 78.1% 3 9.4% 4 12.5% 32
School of Medicine 7 100% 0 0.0% 0 0.0% 7 5 71.4% 2 28.6% 0 0.0% 7
School of Pharmacy 1 100% 0 0.0% 0 0.0% 1 1 100% 0 0.0% 0 0.0% 1
National/Provincial Health Professional Association 3 20.0% 4 26.7% 8 53.3% 15 1 6.7% 8 53.3% 6 40.0% 15
Pharmaceutical Industry 4 100% 0 0.0% 0 0.0% 4 4 100% 0 0.0% 0 0.0% 4
Hospital/Health Care Management Board 41 38.0% 33 30.6% 34 31.5% 108 41 37.3% 34 30.9% 35 31.8% 110
Total 81 38 48 167 77 47 45 169

Table 8 presents the results pertaining to respondents' reports of partnerships. These results only reflect the responses of those organizations that had indicated that they were providing technology-based distance education programming to health professionals. The majority of respondents from the organizational categories of schools of nursing, schools of medicine and hospital / health care management boards reported that they had formed partnerships for the purpose of sharing financial, human, and / or technical resources. Sixty-two percent (62.5%) of school of nursing respondents, 85.7% of school of medicine respondents, and 67.9% of hospital / health care management board respondents indicated that they had formed partnerships.

Table 8 Summary of Partnering Relationships
Type of Organization Yes No Total
N % N %
School of Nursing 20 62.5% 12
School of Medicine 6 85.7% 1 14.3% 7
School of Pharmacy 1 100% 0 0.0% 1
National / Provincial Health Professional Association 6 42.9% 8 57.1% 14
Pharmaceutical Industry 3 75.0% 1 25.0% 4
Hospital / Health Care Management Board 74 67.9% 35 32.1% 109
Total 110 57 167

Table 9 provides the results pertaining to the types of partnerships which organizational respondents reported having formed. The responses to this item only reflect those organizations that had reported that they were providing technology-based distance education programming to health professionals. Across organizational categories, the most significant type of partnership was that which was formed with other educational institutions. Fifty-nine percent (59.1%) of school of nursing respondents, 66.7% of school of medicine respondents, 66.7% of health professional association respondents, and 67.1% of hospital / health care management board respondents indicated that a partnership with other educational institutions was a major type of partnership. A partnerships with other departments in the parent institution was also a major type of partnership across organizational categories; sixty-three percent (63.6%) of schools of nursing and 75.0% of pharmaceutical industry respondents indicated that a partnership with other departments in their parent institution was a major type of partnership. However, only 33.3% of schools of medicine indicated this type of partnership. A majority of health professional association respondents reported that partnerships with business / industry (83.3%) and professional associations / societies (50.0%) were also important. Partnerships with provincial and federal government organizations and community-based agencies were not identified as significant partnership types by the majority of respondents, nor were they identified across the organizational respondent categories. Respondents were also invited to identify any 'other' partnership types. Partnerships with health regions / authorities (N = 5) and telehealth networks / projects (N = 2) were reported.

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Table 9 Types of Partnerships Formed by Organizational Respondents
Organizations Other Dept.(s) in Parent Institution Other Educational Instit.(s) With Business Industry With Prof. Ass. Societies With Prov. Gov. With Fed. Gov. With Community
based Agencies
N % N % N % N % N % N % N %
School of Nursing Yes 14 63.6% 13 59.1% 5 22.7% 4 18.2% 5 22.7% 0 0.0%
No 8 36.4% 9 40.9% 17 77.3% 18 81.8% 17 77.3% 22 100% 21 95.5%
School of Medicine Yes 2 33.3% 4 66.7% 2 33.3% 2 33.3% 1 16.7% 1 16.7% 0 0.0%
No 4 66.7% 2 33.3% 4 66.7% 4 66.7% 5 83.3% 5 83.3% 6 100%
School of Pharmacy Yes 1 100% 0 0.0% 0 0.0% 1 100% 0 0.0% 0 0.0% 0 0.0%
No 0 0.0% 1 100% 1 100% 0 0.0% 1 100% 1 100% 1 100%
Health Professional Association Yes 3 50.0% 4 66.7% 5 83.3% 3 50.0% 2 33.3% 0 0.0% 3 50.0%
No 3 50.0% 2 33.3% 1 16.7% 3 50.0% 4 66.7% 6 100% 3 50.0%
Pharmaceutical Industry Yes 3 75.0% 1 25.0% 0 0.0% 2 50.0% 1 25.0% 0 0.0% 0 0.0%
No 1 25.0% 3 75.0% 4 100% 2 50.0% 3 75.0% 4 100% 4 100%
Hospital / Health Care Management Board Yes 25 31.3% 51 67.1% 14 18.2% 32 41.6% 30 39.0% 6 7.8% 24 31.2%
No 55 68.8% 26 32.9% 63 81.8% 45 58.4% 47 61.0% 71 92.2% 53 68.8%
Total 119 116 116 116 116 116 116

Table 10 provides the results relating to the types of technologies used in distance education delivery by all organizational survey respondents. The results have been rank-ordered and only reflect the responses of those respondents who had indicated that they were providing technology-based distance education programming to health professionals. The majority of respondents reported that the following technologies were used in the delivery of continuing health professional education by distance education: electronic mail (61.4%); web-based education (59.9%); videoconferencing (59.2%); correspondence materials (57.2%); video tapes (52.0%); and audio teleconferencing (51.5%).

Table 11 presents the results pertaining to accreditation of CHPE programs delivered by technology-based distance education methods. This item asked respondents to indicate whether the distance education programs they offered were accredited by a professional body. These results only reflect the responses of those organizations that had indicated that they were providing technology-based distance education programming to health professionals. Eighty-five percent (85.7%) of school of medicine respondents and 58.1% of schools of nursing respondents reported that their programs were accredited. Thirty-six percent (36.6%) of hospital / health care management board respondents indicated that their distance education CPE programs were accredited.

Table 12 presents the results pertaining to respondents' reports of formal training and support services offered to faculty or instructors who teach in the continuing professional education programs offered by technology-based distance education. The responses to this item only reflect those organizations that had reported that they were providing technology-based distance education programming to health professionals. The majority of school of nursing and school of medicine respondents indicated that they were providing training and support to faculty and instructors who taught in their distance education programs. Eighty-seven percent (87.5%) of schools of nursing and 71.4% of schools of medicine reported that they were providing this type of support. Forty-three percent (43.9%) of hospital / health care management boards respondents reported that they provided formal training and / or support services to instructors who taught in their distance education programs.

Table 13 provides the results pertaining to respondents' reports of the types of formal training and support that are provided to faculty and instructors in their distance education programs. These results only reflect responses of those organizations that had indicated that they were providing technology-based distance education programming to health professionals, as well as faculty development support activities. 'Faculty development seminars / workshops', 'instructional development support materials', 'mentoring by experienced instructors', and 'one-on-one consultation with an educational specialist' were the main types of faculty development activities reported by the majority of respondents across the organizational categories. Eighty-nine percent (89.7%) of school of nursing respondents, 80.0% of school of medicine respondents, and 51.9% of hospital / health care management board respondents indicated that they used 'faculty development seminars and workshops' for providing support services. Sixty-five percent (65.5%) of school of nursing respondents, 80.0% of school of medicine respondents, and 57.4% of hospital / health care management board respondents indicated the use of 'instructional development support materials' for supporting faculty and instructors. Sixty-two percent (62.1%) of school of nursing respondents indicated that 'mentoring' by experienced instructors was a strategy they provided to instructors. Sixty-nine percent (69.0%) of schools of nursing and 80.0% of schools of medicine also reported the use of 'one-on-one consultation with educational specialists' as means of supporting faculty and instructors teaching through distance education technologies. Other types of support identified by respondents included 'videoconferencing / network training' (N = 4), 'guest presenters / distance modules purchased from outside suppliers' (N = 2), and 'support programs / costs of instructor covered by parent institution' (N = 2).

Table 10 Types of Technologies Used in Distance Education
Technologies Used N % Total
Electronic Mail 105 61.4% 171
Web-based Education 103 59.9% 172
Videoconferencing 103 59.2% 174
Correspondence Materials 99 57.2% 173
Video Tapes 89 52.0% 171
Audio Teleconferencing 88 51.5% 171
Interactive Multimedia CD-ROMS 59 34.1% 173
Fax 55 32.2% 171
Computer Conferencing 44 25.7% 171
Audio Cassette 36 21.1% 171
Web Broadcasts 34 19.9% 171
E-mail List Servs 25 14.6% 171
Interactive Video Discs 17 9.9% 171
Cable / Broadcast TV 10 5.7% 174
Audiographic Teleconferencing 7 4.1% 171
Radio 2 1.2% 172
Total 876
Table 11 Organizations Reporting Accredited Distance Education Programs
Type of Organization Yes No Total
N % N %
School of Nursing 18 58.1% 13
School of Medicine 6 85.7% 1 14.3% 7
School of Pharmacy 1 100% 0 0.0% 1
National / Provincial Health Professional Association 6 40.0% 9 60.0% 15
Pharmaceutical Industry 4 100% 0 0.0% 4
Hospital / Health Care Management Board 37 36.6% 64 63.4% 101
Total 72 87 159
Table 12 Training / Support Offered to Faculty / Instructors
Type of Organization Yes No Total
N % N %
School of Nursing 28 87.5% 4
School of Medicine 5 71.4% 2 28.6% 7
School of Pharmacy 1 100% 0 0.0% 1
National / Provincial Health Professional Association 6 40.0% 9 60.0% 15
Pharmaceutical Industry 2 50.0% 2 50.0% 4
Hospital / Health Care Management Board 47 43.9% 60 56.1% 107
Total 89 77 166
Table 13 Types of Formal Training / Support Offered
Organi/
zations		 Faculty Dev. Seminars / Workshops Inst. Dev. Support Materials Inst. Dev. Web Site Mentoring by Exp. Inst. One-on-one Consult. with Ed. Specialist Fellow/
ships		 Bursaries Teaching Award/other Recognition
N % N % N % N % N % N % N % N %
School Nurs. Yes 26 89.7% 19 65.5% 8 27.6% 18 62.1% 20 69.0% 1 3.4% 3 10.3%
No 3 10.3% 10 34.5% 21 72.4% 11 37.9% 9 31.0% 28 96.6% 26 89.7% 26 89.7%
School Med. Yes 4 80.0% 4 80.0% 2 40.0% 0 0.0% 4 80.0% 0 0.0% 1 20.0% 2 40.0%
No 1 20.0% 1 20.0% 3 60.0% 5 100% 1 20.0% 5 100% 4 80.0% 3 60.0%
School Pharm. Yes 1 100% 0 0.0% 0 0.0% 1 100% 1 100% 0 0.0% 0 0.0% 0 0.0%
No 0 0.0% 1 100% 1 100% 0 0.0% 0 0.0% 1 100% 1 100% 1 100%
Nat. / Prov. Health Prof. Ass. Yes 1 12.5% 3 37.5% 0 0.0% 3 37.5% 2 25.0% 0 0.0% 1 12.5% 0 0.0%
No 7 87.5% 5 62.5% 8 100% 5 62.5% 6 75.0% 8 100% 7 87.5% 8 100%
Pharm. Ind. Yes 0 0.0% 2 100% 1 50.0% 1 50.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%
No 2 100% 0 0.0% 1 50.0% 1 50.0% 2 100% 2 100% 2 100% 2 100%
Hosp. Health Care Board Yes 28 51.9% 31 57.4% 6 11.1% 25 46.3% 22 40.7% 1 1.9% 7 13.0% 4 7.4%
No 26 48.1% 23 42.6% 48 88.9% 29 53.7% 32 59.3% 53 98.1% 47 87.0% 50 92.6%
Total 99 99 99 99 99 99 99 99

Table 14 provides the results pertaining to respondents' reports of the location of the audience to whom their distance education programs are provided. The responses to this item only reflect those organizations that had reported that they were providing technology-based distance education programming to health professionals. The main audiences identified across the organizational categories were 'regional' and 'provincial'. Thirty-one percent (31.2%) of school of nursing respondents reported that their audience was 'provincial', while 32.5% indicated a 'regional' audience. Forty-three percent (43.8%) of school of medicine respondents indicated that their target audience was 'provincial' in scope, while 18.8% indicated a 'regional' target audience. Twenty percent (20.8%) of school of nursing respondents also reported a 'national' audience, while 25.0% of school of medicine respondents also reported a 'national' audience. Sixty-one percent (61.2%) of hospital / health care management board respondents indicated a 'regional' audience, while 28.4% reported a 'provincial' audience. An 'international' audience was identified by 15.6% of schools of nursing and by 12.5% of schools of medicine.

Forty-eight (48.0%) of school of nursing respondents reported that at least 1 - 25% of participants in their distance education programs during the past 12 months were of a 'national' audience. Forty-two percent (42.9%) of schools of medicine reported that 1 - 25% of their participant audience were of a national scope. The majority of health professional association respondents (58.3%) and hospital / health care management board respondents (59.8%) indicated that they had no participants from a national audience in their distance education programs. Forty-seven percent (47.4%) of schools of nursing and 50.0% of schools of medicine indicated that 1 - 25% of their participant audience during the past 12 months were of an international scope. Fifty-two percent (52.6%) of school of nursing respondents and 50.0% of school of medicine respondents indicated that there were no international participants in their programs. Ninety-one percent (91.8%) of hospital / health care management board respondents indicated that there were no international participants in the distance education program offerings of their organization.

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Table 14 Location of Distance Education Audience
Type of Organization Location of Audience
Regional Provincial National International Total
N % N % N % N %
School of Nursing 25 32.5% 24 31.2% 16 20.8% 12
School of Medicine 3 18.8% 7 43.8% 4 25.0% 2 12.5% 16
School of Pharmacy 0 0.0% 1 50.0% 1 50.0% 0 0.0%
National / Provincial Health Professional Association 3 15.0% 11 55.0% 6 30.0% 0 0.0% 20
Pharmaceutical Industry 1 25.0% 2 50.0% 1 25.0% 0 0.0% 4
Hospital / Health Care Management Board 82 61.2% 38 28.4% 10 7.5% 4 3.0% 134
Total 114 83 38 18 253

Table 15 shows the results of the general characteristics of health professionals who participate in the distance learning programs reported by respondents. The majority of respondents across all organizational categories reported that participants in their distance learning programs were not predominantly recent university graduates. Ninety-three percent (93.1%) of school of nursing respondents, 100% of school of medicine respondents, 90.9% of health professional associations, and 77.1% of hospital / health care management board respondents indicated that the participants in their distance learning programming were not predominantly recent university graduates. Sixty-six percent (66.7%) of school of medicine respondents and 51.0% of hospital / health care management board respondents indicated that the participants in their distance learning programs were predominantly rural practitioners, while 25.0% of school of nursing organizational respondents indicated that participants in these programs were predominantly rural practitioners. Twenty-one percent (21.4%) of school of nursing respondents and 32.3% of hospital / health care management board respondents reported that participants in their programs were predominantly urban practitioners. Fifty-five percent (55.2%) of school of nursing respondents indicated that their audience encompassed an even mix of rural and urban practitioners. As well, 72.7% of health professional association organizational respondents reported that participants in their distance learning programs comprised an even mix of rural and urban practitioners. Eighty-five percent (85.7%) of school of nursing respondents, 72.2% of health professional association respondents, and 64.2% of hospital / health care management board respondents indicated that their participants did not require CHPE credit to maintain licensure, whereas 50.0% of school of medicine respondents reported that their participants required CHPE credit.

Table 15 Characteristics of Distance Education Program Participants
Organizations Predominantly Recent University Graduates (<5 yrs) Predominantly Rural Practitioners (population <10,000) Predominantly Urban Practitioners (population >10,000) Even Mix of Both Rural and Urban Require CHPE Credit to Maintain Licensure
N % N % N % N % N %
School of Nursing Yes 2 6.9% 7 25.0% 6 21.4% 16 55.2%
No 27 93.1% 21 75.0% 22 78.6% 13 44.8% 24 85.7%
School of Medicine Yes 0 0.0% 4 66.7% 0 0.0% 2 33.3% 3 50.0%
No 6 100% 2 33.3% 6 100% 4 66.7% 3 50.0%
School of Pharmacy Yes 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1 100%
No 1 100% 0 0.0% 0 0.0% 0 0.0% 0 0.0%
Health Professional Association Yes 1 9.1% 4 36.4% 0 0.0% 8 72.7% 3 27.3%
No 10 90.9% 7 63.6% 11 100% 3 27.3% 8 72.7%
Pharmaceutical Industry Yes 1 50.0% 2 100% 0 0.0% 0 0.0% 0 0.0%
No 1 50.0% 0 0.0% 2 100% 2 100% 2 100%
Hospital / Health Care Board Yes 22 22.9% 49 51.0% 31 32.3% 26 27.4% 34 35.8%
No 74 77.1% 47 49.0% 65 67.7% 69 72.6% 61 64.2%
Total 145 143 143 143 143

Table 16 presents the results related to respondents' reports of the nature of the topics provided through their CPE programs. This question item was intended to identify the type and extent of programming that is being delivered to enhance capabilities in the use and application of information and communication technologies among health care practitioners. The results are rank-ordered according to the frequency of responses, and represent the responses of respondents from all organizational categories. Thirty-two percent (32.4%) of all organizational respondents indicated that 'using computers' was a common continuing professional education program offered to health care practitioners. Respondents also reported that 'e-mail applications' (29.9%), 'using the Internet' (25.8%), 'presentation software' (24.2%), and 'hospital computer systems' (19.1%) were common information and communication technology-related topics covered in continuing professional education programming. Respondents were also provided with an opportunity to identify 'other' continuing professional education topics provided to health professionals. The topic areas that were identified included 'word processing software' (N = 4), 'MDS / RUGS' software (N = 5), 'medicare software' (N = 1), and 'general health care software' (N = 2).

Table 17 presents the results of the Kruskal-Wallis Analysis of Variance of Ranks used to determine the existence of relationships between the 'organizational respondent category' and the organizational influences, professional influences, and strengths and resources scales. A sum score was calculated for each scale by totalling the individual item ratings. No significant relationship was found between the organizational category and the sum score on the organizational influence scale (p = 0.190) at the < .05 probability level. School of pharmacy respondents reported the highest mean score on the organizational influence scale (24.4), followed by schools of medicine (23.2) and schools of nursing (22.3). National / provincial health professional associations reported the lowest mean score on organizational influences (19).

Table 16 Continuing Professional Education Topics
Topics Provided Yes Total
N %
Using Computers 217
E-mail Applications 200 29.9% 670
Using the Internet 173 25.8% 670
Presentation Software 162 24.2% 669
Hospital Computer Systems 129 19.1% 675
Telemedicine / Telehealth 123 18.4% 669
Spreadsheet / Database Software 123 18.3% 671
Literature Databases 122 18.2% 669
Using Search Engines 92 13.8% 669
Literature Search Strategies 89 13.3% 669
Electronic Health Records 85 12.7% 670
Using Web Browsers 83 12.4% 669
Keyboarding Skills 74 11.1% 669
E-journals / Text Books 70 10.5% 669
Electronic Drug Databases 53 7.9% 669
Patient Education Software 38 5.6% 673
Statistics Software 23 3.4% 669
Practice Management Programs 18 2.7% 669
Evaluating Quality of Web Pages for Patient Information Referrals 16 2.4% 669
Total 1767
Table 17 Kruskal-Wallis Test of Organizational Respondent Categories, by Factors of Usage Scales

 

 Types of Organizations N Mean SD Mean Rank Sig.
Organizational Influences School of Nursing 58 22.3 6.3 381.5 0.19
School of Medicine 10 23.2 5.1 395
School of Pharmacy 5 24.4 5.5 448.8
Health Professional Assoc 47 19 8.1 310
Pharmaceutical Industry 15 22.2 4.1 385.1
Hospital / Health Care Board 542 20.5 6 333.7
Total 677 20.6 6.1
Professional Influences School of Nursing 58 24.7 2.9 360.2
School of Medicine 10 24.3 3.9 350.8
School of Pharmacy 5 22.8 2.7 223.3
Health Professional Assoc 47 23.2 6 319.7
Pharmaceutical Industry 15 23.1 2.4 252.3
Hospital / Health Care Board 542 24 4.7 341.7
Total 677 24 4.6
Strengths & Resources School of Nursing 58 57 17.8 393.2
School of Medicine 10 56 11.2 375
School of Pharmacy 5 51.4 6.8 312
Health Professional Assoc 47 41.9 26.1 268.9
Pharmaceutical Industry 15 53.5 11.2 333.2
Hospital / Health Care Board 542 52.8 16.6 339
Total 677 52.4 17.5
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No significant difference was found between the type of organizational respondent and the corresponding sum score on the professional influence scale (p = 0.302). Schools of nursing reported the highest mean score on the professional influences scale (24.7), followed by schools of medicine (24.3) and hospital / health care management boards (24). No significant relationship was found between the type of organizational respondent and the corresponding mean score on the organizational strengths and resources scale (p = 0.053) at the < .05 probability level. Medical and nursing schools did report a higher rating than other organizational respondents on their perceptions of organizational strengths and resources as they pertained to distance education program development and delivery. Schools of nursing (57) and schools of medicine (56) reported a higher mean score on the strengths and resources scale than national / provincial health professional associations (41.9), hospital / health care management boards (52.8), and other organizational respondents. The individual items within the strengths and resources scale were also examined using the Kruskal-Wallis Analysis of Variance of Ranks, in order to determine the existence of relationships between organizational respondent category and individual strengths and resources items. There were significant differences between organizational categories and the items 'priority of my unit' (p = 0.001) and 'adequate faculty / subject matter expert support' (p = 0.014). These differences were significant at the < .05 level of probability. Schools of medicine reported the highest mean score (4.2) as it pertained to the item 'a priority of my unit'; school of pharmacy (2.4) and pharmaceutical industry (2.7) respondents reported the lowest mean scores. Schools of pharmacy also reported the lowest mean score on the item 'adequate faculty / subject matter expert support' (2.4), while schools of medicine reported the highest mean score (3.8). Schools of medicine also reported the highest mean score on 'enthusiasm among the target audience' (3.8).

Table 18 presents the results of the Mann-Whitney analysis pertaining to an organization's provision of technology-based distance education and the corresponding perception of organizational and professional influences, and the existence of strengths and resources within the organization for the delivery of distance education. A sum score was calculated for each scale by totalling the individual item ratings. The mean score for respondents reporting that their organization provided distance education programs was 22.9 on the organizational influence scale, while the mean score of respondents reporting that their organization did not provide distance education programs was 19.9. The Mann-Whitney analysis revealed a significant difference between the mean ranks of these scores at the < .05 level of probability (p = 0.000). Organizational respondents who indicated that they were providing distance education programs reported a higher score on the organizational factors scale.

The mean score of respondents reporting that their organization provided distance education programs was 24.2 on the professional influence scale, while the mean score of respondents reporting that their organization did not provide distance education programs was 24. The Mann-Whitney analysis revealed that there was not a significant difference between the mean ranks of these scores at the < .05 probability level (p = 0.796). No difference was found between organizations on their rating of professional factors, and whether they did or did not provide distance education programs.

The mean score of respondents reporting that their organization provided distance education programs was 55.8 on the strengths and resources scale, while the mean score of respondents reporting that their organization did not provide distance education programs was 51.5. A significant difference was found between the mean ranks of these scores at the < .05 level of probability (p = 0.000). Organizational respondents who indicated that they were providing distance education programs reported a higher score on the strengths and resources scale.

Table 19 presents the results of the Mann-Whitney analysis pertaining to an organization's provision of technology-based distance education and the corresponding perception of individual strengths and resources within the organization for the delivery of distance education. Significant differences were found on a number of the strengths and resources items between organizations reporting that they did provide distance education programs and those that did not. On the items 'a priority of my unit' (p = 0.000), 'a priority of organization' (p = 0.000), 'administration supportive of the idea' (p = 0.001), and 'sufficient administrative / clerical support staff' (p = 0.020), providers of distance education reported significantly higher mean scores than the non-providers at the < .05 probability level. All of these items were related to organizational support factors. On the items 'adequate telecommunication infrastructure' (p = 0.048), 'adequate facilities / equipment for supporting distance education development and delivery' (p = 0.001), 'convenient personal Internet access among target audience' (p = 0.022), and 'convenient personal computer access among target audience' (p = 0.042), providers of distance education also reported mean scores that were significantly higher than non-providers' at the < .05 probability level. Perception of infrastructure and access to equipment and Internet services were more positive among organizations providing technology-based distance education. Providers of distance education also reported higher mean scores on items related to experience, enthusiasm, and sufficient time commitment among target audience at the < .05 level of probability. Organizational respondents who were providing distance education reported that their target audience had high levels of computer knowledge, enthusiasm about technology-based CHPE, and sufficient time to commit to participation in CHPE.

Table 20 presents the results of the Kruskal-Wallis Analysis of Variance of Ranks used to determine the existence of relationships between the level of experience (length of time offering distance education programs) and the corresponding perceptions of organizational and professional influences, and the existence of strengths and resources within an organization for the delivery of distance education. A sum score was calculated for each scale by totalling the individual item ratings. No significant relationship was found between the years of experience in offering distance education programs and the rating of organizational influences (p = 0.092) at the < .05 probability level. Organizational respondents reporting > 20 years of experiences did report the highest mean score on the organizational influence scale (24.6), followed by organizations reporting 16 - 20 years of experiences (24.6). However, the differences between the mean ranks of these scores was not significant.

No significant difference was found between years of experience in offering distance education programs and the rating of professional influences (p = 0.455). Organizations reporting > 20 years of experience in distance education program delivery reported the highest mean score on professional influences (26.3), followed by organizations with 1 - 5 years of experience (24.5) and organizations with 16 - 20 years of experiences (24.4). Scores on the strengths and resources scale revealed a similar result. No significant relationship was found between the years of experience in offering distance education programs and the rating of organizational strengths and resources (p = 0.360) at the < .05 probability level. Respondents reporting 16 - 20 years of experience reported the highest mean score (61.8), followed by organizations with > 20 years of experience (58.3) and organizations with 1 - 5 years of experiences (57). The individual items within the strengths and resources scale were also examined using the Kruskal-Wallis Analysis of Variance of Ranks, in order to determine the existence of relationships between the level of experience (length of time offering distance education programs) and individual strengths and resources items. There were significant differences between the level of an organization's experience and the items: 'priority of my unit' (p = 0.021); 'experience in technology-based distance education' (p = 0.004); and 'sufficient time commitment for participation among target audience' (p = 0.021). These differences were significant at the < .05 level of probability. Organizations reporting less than 1 year of experience reported the lowest mean score (3.5) on the item 'a priority of my unit', while organizations reporting 'more than 20 years experience' reported the highest mean score (4.7). Organizations reporting less than 1 year of experience also reported the lowest mean score (2.7) on the item 'experience in technology-based distance education'.

Table 18 Mann-Whitney Tests of Organizational Respondents Providing Distance Education Programming, by Factors of Usage Scales
Does your organizational unit provide technology-based distance education programming to health professionals?
N Mean SD Mean
Rank		 Sum of
Ranks		 Z Sig.
Organizational Influences Yes 174 22.9 6.4 421.7 73368.5 -6.63 0
No 500 19.9 5.8 308.2 154106.5
Total 674 20.6 6.1
Professional Influences Yes 174 24.2 4.4 340.8 59295 -0.26 0.796
No 500 24 4.6 336.4 168179.99
Total 674 24 4.6
Strengths & Resources Yes 174 55.8 17.3 383.2 66684 -3.6 0
No 500 51.5 17.2 321.6 160791
Total 674 52.4 17.5
Table 19 Mann-Whitney Tests of Organizational Respondents Providing Distance Education Programming, by Strengths and Resources Factors
Does your organizational unit provide technology-based distance education programming to health professionals?
N Mean SD Mean
Rank		 Sum of
Ranks		 Z Sig.
A priority of my unit. Yes 164 3.7 0.9 407.6 66853.5 -7.21 0
No 478 3 1 291.9 139549.5
A priority of organization. Yes 164 3.6 1 382.8 62778 -5.05 0
No 479 3.1 1.1 301.2 144268
Administration supportive of the idea. Yes 165 3.9 0.9 361 59560.5 -3.38 0
No 479 3.6 0.9 309.3 148129.5
Sufficient administrative / clerical support staff. Yes 166 3.1 1.2 351 58260.5 -2.33 0.02
No 479 2.8 1.1 313.3 150074.5
Specialized staff to design the courses. Yes 165 3 1.3 342.2 56462.5 -1.75 0.08
No 476 2.8 1.3 313.7 149298.5
Experience in technology-based distance education. Yes 166 3.4 1.1 366 60760.5 -3.87 0
No 473 2.9 1.2 303.9 143719.5
Adequate budget for technology-based distance education programs. Yes 166 3 1.4 342.2 56812 -1.67 0.1
No 477 2.8 1.4 315 150234
Telecommunication costs are reasonable. Yes 166 3.4 1 331.7 55060 -0.65 0.518
No 481 3.3 1 321.4 154568
Adequate telecommunication infrastructure. Yes 165 3.5 1.1 346.4 57156 -1.98 0.05
No 479 3.3 1.1 314.3 150534
Adequate facilities / equipment for supporting distance education development and delivery. Yes 166 3.5 1.1 363.1 60276.5 -3.27 0
No 480 3.1 1.3 309.8 148704.5
Adequate faculty / subject matter expert support. Yes 165 3.5 1.1 375.3 61924.5 -4.46 0
No 477 3.1 1.2 302.9 144478.5
Convenient personal Internet access among target audience. Yes 166 3.6 1 352 58428 -2.3 0.02
No 482 3.3 1.2 315 151848
Convenient personal computer access among target audience. Yes 166 3.6 1 344.3 57158 -2.03 0.04
No 474 3.4 1.2 312.2 147962
Adequate level of computer experience among target audience. Yes 166 3.4 1 342 56777.5 -1.77 0.08
No 475 3.2 1.1 313.7 148983.5
Enthusiasm among target audience. Yes 166 3.7 0.9 346.7 57556.5 -2.12 0.03
No 477 3.5 0.9 313.4 149489.5
Organizational support from employers of target audience. Yes 165 3.7 0.9 349.5 57671 -2.51 0.01
No 474 3.5 1.1 309.7 146809
Sufficient time commitment for participation among target audience. Yes 166 3.2 1.1 330.4 54842 -0.82 0.41
No 474 3.1 1.2 317 150278
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Table 20 Kruskal-Wallis Test of Distance Education Programming Experience, by Factors of Usage Scales
How long have distance education programs been offered by your organizational unit?
N Mean SD Mean
Rank		 Sig.
Organizational Influences < 1 year 35 22.8 4.3 82.3 0.092
 
1-5 years 89 22.9 6 86.7
 
6-10 years 22 23.7 7.8 96.8
 
11-15 years 11 18.9 7.5 56.1
 
16-20 years 10 24.6 6.6 104.1
 
> 20 years 7 24.6 11.2 120
Total 174 20.6 6.1
Professional Influences < 1 year 35 23.9 3.4 76.7 0.455
 
1-5 years 89 24.5 3.9 90.1
 
6-10 years 22 23.7 6.4 90.1
 
11-15 years 11 22.2 7.7 77.9
 
16-20 years 10 24.4 2.8 86.4
 
> 20 years 7 26.3 2.9 116.5
Total 174 24 4.6
Strengths & Resources < 1 year 35 51.5 16.7 71.1 0.36
 
1-5 years 89 57 16.7 90.6
 
6-10 years 22 53.9 20.2 87.2
 
11-15 years 11 56.8 23.1 98.8
 
16-20 years 10 61.8 14.5 101
 
> 20 years 7 58.3 11.5 94.8
Total 174 52.4 17.5

Table 21 presents the results of the Mann-Whitney analysis pertaining to respondents' reported access to organizational resources and the corresponding perceptions of organizational and professional influences, and the existence of strengths and resources within an organization for the delivery of distance education. A sum score was calculated for each scale by totalling the individual item ratings. The mean score for respondents reporting access to the resources of a distance education division was 23.8 on the organizational influence scale, while the mean score of respondents reporting that their organizational unit did not have access to the resources of a distance education division was 21.3. There was a significant difference between the mean ranks of these scores at the < .05 level of probability (p = 0.020). Organizational units that stated that they had access to the resources of a distance education division reported a higher score on the organizational factor scale.

The mean score of respondents reporting that they had access to the resources of a distance education division was 24.6 on the professional influence scale, while the mean score of respondents reporting that their organizational unit did not have access to the resources of a distance education division was 23.8. No significant difference was found between the mean ranks of these scores at the < .05 probability level (p = 0.294). No difference was found between organizational units on whether they had access to the resources of a distance education division and their perception of professional factors.

The mean score of respondents reporting that they had access to the resources of a distance education division was 57.4 on the strengths and resources scale, while the mean score of respondents reporting that their organizational unit did not have access to the resources of a distance education division was 53.7. No significant difference was found between the mean ranks of these scores at the < .05 level of probability (p = 0.084). No difference was found between organizational units on whether they had access to the resources of a distance education division and their perceptions of organizational strengths and resources.

Table 22 provides the results of the Mann-Whitney analysis pertaining to respondents' reports of 'partnering' and corresponding perception of organizational and professional influences, and the existence of strengths and resources within an organization for the delivery of distance education. A sum score was calculated for each scale by totalling the individual item ratings. The mean score of respondents reporting that they had formed partnerships with other organizations was 23.8 on the organizational influence scale, while the mean score of respondents reporting that their organizational unit had not formed partnerships was 20.7. There was a significant difference between the mean ranks of these scores at the < .05 level of probability (p = 0.005). Organizational units reporting that they had formed partnerships for the purposes of technology-based distance education development and delivery reported a higher score on the organizational factor scale. The mean score of respondents reporting that they had formed partnerships with other organizations was 24.6 on the professional influence scale, while the mean score of respondents reporting that they had not formed partnerships with other organizations was 23.4. No significant difference was found between the mean ranks of these scores at the < .05 probability level (p = 0.179). No difference was found between organizations on whether they had formed partnerships with other organizations and their perception of professional factor influences. The mean score of respondents reporting that they had formed partnerships with other organizations was 57.8 on the strengths and resources scale, while the mean score of respondents reporting that they had not formed partnerships was 52.1. There was a significant difference between the mean ranks of these scores at the < .05 level of probability (p = 0.037). Organizations reporting the formation of partnerships reported a higher score on the strengths and resources scale.

The individual items within the strengths and resources scale were also compared to respondents' reports of 'partnering'. The scores on these items were examined using the Mann-Whitney analysis. There were significant differences between organizations reporting partnering and the items: 'a priority of my unit' (p = 0.004); 'administration supportive of the idea' (p = 0.047); and 'experience in technology-based distance education' (p = 0.003). These differences were significant at the < .05 level of probability. Organizations indicating partnerships reported a mean score of 3.9, while those organizations that did not indicate partnerships reported a mean score of 3.4 on the item 'a priority of my unit'. Organizations indicating partnerships also had a higher mean score on items 'administration supportive of the idea' (4) and 'experience in technology-based distance education' (3.5).

Table 21 Mann-Whitney Tests of Respondents' Access to Organizational Resources, by Factors of Usage Scales
Does your organizational unit have access to the resources of a distance education division within your parent institution?
N Mean SD Mean
Rank		 Sum of
Rank		 Z Sig.
Organizational Influences Yes 77 23.8 6.3 68.3 5261.5 -2 0.02
No 47 21.3 6.2 53 2488.5
Total 124 20.6 6.1
Professional Influences Yes 77 24.6 4 65.1 5015 -1 0.294
No 47 23.8 5.1 58.2 2735
Total 124 24 4.6
Strengths & Resources Yes 77 57.4 16.5 66.9 5148 -2 0.08
No 47 53.7 17.4 55.4 2602
Total 124 52.4 17.5
Table 22 Mann-Whitney Tests of Respondents' Report of Partnering, by Factors of Usage Scales
Has your organizational unit formed partnerships with other departments, schools, businesses or organizations for the purposes of sharing financial, human, and / or technical resources for CHPE development and delivery?
N Mean SD Mean
Rank		 Sum of
Rank		 Z Sig.
Organizational Influences Yes 110 23.8 5.7 91.5 100063.5 -3 0
No 57 20.7 7.2 69.6 3964.5
Total 167 20.6 6.1
Professional Influences Yes 110 24.6 4 87.6 9636.5 -1 0.179
No 57 23.4 5.3 77 4391.5
Total 167 24 4.6
Strengths & Resources Yes 110 57.8 15.2 89.6 9857 -2 0.04
No 57 52.1 19.3 73.2 4171
Total 167 52.4 17.5
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Table 23 provides the results of the Mann-Whitney analysis pertaining to respondents' reports of whether the organization's parent institution offered distance education courses and the corresponding perceptions of organizational and professional influences, and the strengths and resources within an organization for the delivery of distance education. A sum score was calculated for each scale by totalling the individual item ratings. The mean score of respondents reporting that their parent institution offered distance education was 23.7 on the organizational influence scale, while the mean score of respondents reporting that their parent institution did not offer distance education courses was 20.4. There was a significant difference between the mean ranks of these scores at the < .05 level of probability (p = 0.024). Organizations reporting that their parent institution offered distance education courses reported a higher organizational influence score.

The mean score of respondents reporting that their parent institution offered distance education was 24.7 on the professional influence scale, while the mean score of respondents reporting that their parent institution did not offer distance education courses was 23.2. No significant difference was found between the mean ranks of these scores at the < .05 probability level (p = 0.888). No difference was found between organizations as to whether their parent institution offered distance education courses and their perception of the influence of professional factors. The mean score of respondents reporting that their parent institution offered distance education was 57.7 on the strengths and resources scale, while the mean score of respondents reporting that their parent institution did not offer distance education courses was 51.9. No significant difference was found between organizations as to whether their parent institution offered distance education courses and their perception of organizational strengths and resources.

The individual items within the strengths and resources scale were also compared to the respondents' reports of whether the organization's parent institution offered distance education courses. The scores on these items were examined using the Mann-Whitney analysis. There were significant differences between organizations reporting that their parent institution offered distance education courses and the items 'experience in technology-based distance education' (p = 0.042) and 'adequate facilities / equipment for supporting distance education development and delivery' (p = 0.034). These differences were significant at the < .05 level of probability. Organizations reporting that their parent institution offered distance education courses reported a mean score of 3.4, while those respondents reporting that their organizations did not offer distance education courses scored 2.94 on the item 'experience in technology-based distance education'. As well, organizations reporting that their parent institution offered distance education courses reported a mean score of 3.6, while those respondents reporting that their organizations did not offer distance education courses scored 3.1 on the item 'adequate facilities / equipment for supporting distance education development and delivery'.

Table 23 Mann-Whitney Tests of Respondents' Report of Institutional Experience, by Factors of Usage Scales
Does your parent institution offer distance education courses?
N Mean SD Mean
Rank		 Sum of
Rank		 Z Sig.
Organizational Influences Yes 81 23.7 5.9 64.9 5255 -2.3 0.024
No 38 20.4 7.6 49.6 1885
Total 119 20.6 6.1
Professional Influences Yes 81 24.7 3 59.7 4835.5 -0.1 0.888
No 38 23.2 7.5 60.6 2304.5
Total 119 24 4.6
Strengths & Resources Yes 81 57.7 15.3 63.1 5109 -1.4 0.156
No 38 51.9 20 53.5 2031
Total 119 52.4 17.5

Discussion of Major Findings and Conclusions

The response rate to questionnaire-survey studies is always a concern for researchers. Traditionally, questionnaire-survey research methods have resulted in lower response rates than other research methodologies. In this study, a number of strategies were used to increase the survey response rate. Firstly, a cover letter detailing the study's purpose and the submission deadline was included with each survey. After the first submission deadline had passed, a second copy of the survey was mailed to non-respondents. Included with this survey was a follow-up letter and a new submission deadline. After the second deadline had passed, reminder letters were sent to a stratified sample of non-respondents. The highest response rates were received from school of medicine, school of pharmacy, and school of nursing organizational respondents. This was not surprising, given that these organizational respondent categories represented academic institutions with a mission to develop and deliver higher educational programming. The lowest response rates were for the pharmaceutical industry and hospital / health care management board organizations. These organizations do not typically have a mandate to lead the development and delivery of continuing education and training programs, and this may have influenced respondents' decision to participate in the survey study.

Physicians and nurses comprise the largest health professional groups in the country, as well as in rural and remote regions of Canada. The majority of schools of nursing and schools of medicine reported that they provide technology-based distance education programming to health professionals. The majority of schools of pharmacy, national / provincial health professional associations, pharmaceutical industry, and hospital /health care management board respondents reported that they were not providing distance continuing professional education programming. The results indicate that schools of nursing and schools of medicine reported the greatest level of experience in the delivery of continuing professional education programming by technology-based distance education. The majority of the nursing and medical schools that indicated involvement in technology-based continuing professional education delivery also reported that their parent organization offered distance education courses, and that they had access to distance education resources within the parent institution. Institutional experience may also be an important characteristic of those organizational units involved in technology-based distance education delivery.

The majority of school of nursing and school of medicine respondents reported that the factors that had the greatest influence on their decision to offer technology-based distance education included:

  • addressing CHPE needs of rural / remote health professionals;
  • increasing opportunities for flexible CHPE access;
  • part of the organization's mission.

An interesting finding pertained to the factor 'less expensive delivery modality'. A majority of hospital / health care management board organizational respondents indicated that 'less expensive delivery modality' was a significant factor that influenced their decision to offer continuing professional education by technology-based distance education. However, medical and nursing schools indicated that this factor was not significant in their decision to offer technology-based distance education. The main reason for this difference between organizational respondents may be related to the significant costs associated with the training of rural and remote health care practitioners. Hospitals and health care organizations often have to incur travel and accommodation costs, as well as replacement staff salaries to provide workplace-related training and education to health professionals. Technology-based distance education enables these employers to reduce such costs by providing training and educational programs at the health professional's work location. This reduces the need for travel and accommodations, and in some instances may reduce replacement salary costs. Hospital / health care management board respondents also reported that 'addressing mandatory CE needs of health professionals' was an important factor. This finding suggests the importance of employer-related responsibilities in ensuring that health professionals have access to accredited programming to maintain professional and clinical competencies.

The costs associated with technology-based distance education are often higher during the program development stages. Usually, there are costs associated with instructional material and media development, and a need for more specialized human resources. These costs are normally higher than those that would be associated with the delivery of traditional face-to-face training or instruction. However, technology-based distance education programs normally result in lower delivery costs over the long-term, when compared to costs associated with face-to-face teaching on campus or at workplace sites. In this study, the majority of school of nursing respondents reported that 'tuition / registration fees' and 'provincial government grants' were the main sources of support for their distance education programming. School of medicine respondents reported that 'industry educational grants' were a main source of support for their distance education programs. The results suggest that a variety of funding sources are utilized by nursing schools to cover costs associated with the development and delivery of technology-based continuing professional education. Industry sponsorship appears to be of greater importance in supporting technology-based continuing professional education programming delivered through medical schools.

The majority of respondents from the organizational categories of schools of nursing, schools of medicine, and hospital / health care management boards reported that they had formed partnerships for the purpose of sharing financial, human, and / or technical resources. Across organizational categories, the most significant type of partnership was that which was formed with other educational institutions. Schools of nursing indicated that partnerships with other departments in the parent institution were also an important type of partnership. Schools of medicine, however, reported a much lower level of importance of partnerships with other departments in the parent institution. Partnerships with provincial and federal government organizations and community-based agencies were not identified as significant partnership types by the majority of respondents, nor were they identified as significant across the organizational respondent categories.

The distance education technologies that appear to be used the most by respondents in the delivery of continuing professional education by technology-based distance education are:

  • electronic mail;
  • web-based education;
  • videoconferencing;
  • correspondence materials;
  • video tapes; and
  • audio teleconferencing.

Electronic mail, web-based education technologies, and videoconferencing systems appear to be the technologies used to the greatest extent by the organizational respondents.

The majority of school of nursing and school of medicine respondents indicated that they were providing training and support to faculty and instructors who taught in their distance education programs. 'Faculty development seminars / workshops', 'instructional development support materials', 'mentoring by experienced instructors', and 'one-on-one consultation with an educational specialist' were the main types of faculty development activities reported by the majority of respondents across the organizational categories.

The main audiences of technology-based continuing professional education programs were 'regional' and 'provincial' in nature, and the majority of respondents reported that participants in their distance learning programs were not predominantly recent university graduates. A majority of school of medicine and hospital / health care management board respondents indicated that participants were predominantly rural practitioners. The majority of school of nursing, health professional association, and hospital / health care management board respondents indicated that participants did not require CHPE credit to maintain licensure, whereas accreditation and CHPE credit appeared to be more important for school of medicine respondents. These findings would suggest that experienced practitioners are accessing technology-based distance education programs, and CHPE programs provided through schools of medicine and hospital organizations are targeting rural practitioners. The rationale for these findings may be related to mandatory CHPE requirements for physicians, and the use of technology-based distance education programs by health care organizations to address the CHPE needs of rural and remote health care practitioners. Schools of nursing appear to be providing their distance education programs to a more diverse population of health professionals, including both urban and rural health care professionals.

An important purpose of the survey was to identify the type and extent of programming that CHPE providers were delivering to enhance capabilities in the use and application of information and communication technologies among health care practitioners. The results indicate that the most common ICT-related CHPE topics being provided across all organizational respondents included:

  • Using Computers;
  • E-mail Applications;
  • Using the Internet;
  • Presentation Software;
  • Hospital Computer Systems.
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The organizational influences scale encompassed items that were intended to measure the influence of organizational factors on the likelihood of ICT adoption in continuing professional education delivery. The results indicate that the type of organization (e.g., academic, hospital, industry, health professional association) did not influence perceptions of organizational influences, nor did years of experience in offering distance education programs. Organizations reporting that they were providing distance education programs did report a significantly higher score on the organizational factors scale. Organizational units reporting that they had access to the resources of a distance education division had formed partnerships for the purposes of technology-based distance education development and delivery. The parent institutions that offer distance education courses also reported higher organizational influence scores. Organizational factors included 'vision within my organization for technology-based distance education'; 'support from the leaders in my organization for technology-based distance education'; 'adequacy of my organization's technical infrastructure for technology-based distance education'; 'support of technology-based distance education in my organization'; 'funding and incentives for technology-based distance education that are available in my organization'; and 'experiences in the past that my organization has had with technology-based distance education'. Organizations reporting a positive perception of these organizational factors were more likely to be providers of technology-based distance education, have access to the resources of a distance education division, and have formed partnerships.

The professional influences scale comprised items that were intended to measure the influence of professional factors. These included items such as: 'My peers and colleagues believe the Internet is an important tool'; 'In the professional field in which I work, many people are Internet users'; 'In the professional field in which I work, most people think that technology-based distance education is important'; 'Distance learning is likely to contribute to the solution of learning-related problems relevant to the professional field in which I work'; and 'It is my personal opinion that technology-based distance education will improve teaching and learning'. The results indicate that the type of organization (e.g., academic, hospital, industry, health professional association) did not influence perceptions of professional influences. Organizations reporting that they were providing distance education programs did not report a more positive perception of professional influences than providers who were not providing distance education. In addition, no relationship was found between years of experience in offering distance education programs; access to the resources of a distance education division; the formation of partnerships; whether a parent institution offered distance education or not; and perceptions of the influence of professional factors. Factors of professional influence do not appear to be a major impetus to the provision of distance education.

The strengths and resources scale included items related to the availability of resources (e.g., funding, human resources, facilities / equipment, instructors); telecommunication costs and infrastructure; availability of technology access among target audience; attitudes, commitment, and level of perceived computer experience among target audience; and support from employers of target audience. Perceptions of items related to infrastructure and to access to equipment and Internet services were more positive among those organizations that were providing technology-based distance education. Providers of distance education also reported higher mean scores on items related to experience, enthusiasm, and sufficient time commitment among target audience. Organizational respondents who were providing distance education reported that their target audience had high levels of computer experience, was enthusiastic about technology-based CHPE, and had sufficient time to commit to participation in CHPE.

Key Conclusions

  • Canadian schools of medicine and nursing are responsible for a significant number of the technology-based distance education programs offered as CHPE to health professionals.
  • Canadian schools of medicine and nursing report the highest level of experience in technology-based distance education programs offered as CHPE to health professionals.
  • Existing educational technology resources and expertise (human, technical, and infrastructure) within an organization are important factors influencing the likelihood of a CHPE organizational unit being a provider of technology-based distance education programs.
  • Factors related to 'financial gain' do not influence an academic CHPE organizational unit's decision to provide technology-based distance education. Academic CHPE providers are more likely to provide technology-based distance education as a means of addressing the needs of rural / remote health professionals, increasing opportunities for flexible CHPE access, and fulfilling an organization's mission.
  • Hospital / health care management boards favor technology-based distance education as a more 'cost-effective' means of addressing mandatory CHPE needs of health professionals.
  • Schools of medicine report a high level of dependency on 'industry' funding as a means of supporting technology-based distance education program development and delivery.
  • Partnering, whether it be with other organizations and institutions or with other internal departments, appears to be a significant characteristic of technology-based distance education program development and delivery by Canadian CHPE providers.
  • When compared to other academic organizations, schools of medicine reported a lesser importance of forming partnerships with other internal departments in the parent institution.
  • Partnerships with provincial and federal government organizations and community-based agencies were not identified as significant partnership types.
  • Internet-based technologies (e.g., e-mail and the World Wide Web) and videoconferencing are the most common educational technologies used by CHPE providers in technology-based distance education programming.
  • Technology-based Canadian CHPE providers are targeting mostly 'regional' and 'provincial' audiences, not international ones.
  • Participants in technology-based CHPE programs are varied, and include experienced health professionals.
  • School of medicine and hospital / health care management board respondents are addressing the needs of a predominantly rural practitioner audience. Schools of nursing are addressing the needs of both urban and rural practitioners through their technology-based CHPE programs.
  • The most common ICT-related CHPE topics being provided to Canadian health professionals include: using computers; e-mail applications; using the Internet; presentation software; and hospital computer systems.
  • Providers of technology-based CHPE distance education programs are more likely to report a positive perception of: supportive organizational factors; technological infrastructure; access to equipment and Internet services; and levels of computer experience, enthusiasm, and commitment among their distance education programming target audience.
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Recommendations

1. Information and communication technologies (ICT) play a significant role in the delivery of continuing health professional education (CHPE) programming that addresses the mandatory continuing professional education and lifelong learning needs of rural, remote, and northern health professionals. These technologies are essential in facilitating the effective distance education programming that maintains the competencies of these practitioners and reduces the level of professional isolation they experience. Access to and use of ICTs in CHPE delivery are vital components of any effective strategy to enhance retention and recruitment of rural health care providers.

One of the distinguishing characteristics of a profession is the commitment by its members to the promotion of continued study and lifelong learning (Buchholz, 1979). In order to provide high-quality health care services, health professionals require access to effective ongoing professional development and continuing education programs. With the rapid advances that are occurring in the health sciences, it is becoming increasingly challenging for health care professionals to stay abreast of the latest health research information (Whitten, Ford, Davis, Speicher, & Collins, 1998). Knowledge in the health sciences is constantly expanding as new information is published, disseminated, and quickly updated or revised. In this context, the health care practitioner is placed in the unenviable position of having to provide the best health care to the public while trying to use and apply a rapidly changing body of knowledge (Lorenzi, Kues, & Anthony, 1984).

In Canada, the trend appears to be towards greater use of ICTs in the health care system and in the continuing education of health professionals. In recent years, Internet-based technologies have been adopted as a means of delivering information that can be linked to patient care issues in a timely and interactive fashion (Peterson et al., 1999; Anderson et al., 1999). The Internet has the potential to widen continuing education access, increase flexibility for health professionals, and improve the quality of the training and education they receive. The use of the Internet as a knowledge translation medium can also lead to improved cost-effectiveness by enabling new target groups to be reached and higher-quality learning outcomes to be gained at a lower marginal cost per adult learner. The use of Internet technologies and the increased capacities of ICTs are contributing to a movement away from traditional CHPE.

In this study, hospital / health care management board respondents reported that 'addressing mandatory CHPE needs of health professionals' was an important factor that influenced their decision to provide technology-based CHPE. This finding suggests the importance of employer-related responsibilities in ensuring that health professionals have access to accredited CHPE programming to maintain competencies. Although potential users of programs may or may not require mandatory CHPE credits to maintain licensure, the results do suggest that employers place a high level of importance on CHPE credits.

2. Academic institutions are responsible for providing the majority of continuing health professional education (CHPE) programming via technology-based distance education. Academic institutions view this programming as an important part of their mission and their commitment to addressing and supporting the lifelong learning needs of health professionals, particularly those practicing in rural and remote regions of Canada.

The results of this study confirm that Canadian schools of medicine and nursing are responsible for a significant amount of the technology-based distance education programs offered as CHPE to health professionals. Canadian schools of medicine and nursing also report the highest levels of experience in technology-based distance education programs offered as CHPE to health professionals.

These academic CHPE providers are more likely to provide technology-based distance education as a means of addressing the needs of rural / remote health professionals; to increase opportunities for flexible CHPE access; and to fulfill an organization's mission. These institutions are less likely to be providing technology-based CHPE as a way of increasing revenue for the institution. Canadian CHPE providers are mostly targeting 'regional' and 'provincial' audiences, and school of medicine and hospital / health care management board respondents are addressing the needs of a predominantly rural practitioner audience. Schools of nursing appear to be addressing the needs of both urban and rural practitioners through their technology-based CHPE programs.

3. The Internet and videoconferencing are the main educational technologies being used by Canadian continuing health professional (CHPE) providers in the delivery of technology-based continuing professional education.

Electronic mail, web-based education, and videoconferencing systems appear to be the technologies reported as being used the most by organizational respondents. The growth of the Internet and the World Wide Web have created new opportunities for providing distance education. Proponents of the Internet suggest that it has had a far greater impact on global communications than any other previous communication technology development. Greater Internet developments in the future will include continued improvements in the speed of Internet access as ISDN (Integrated Services Digital Network) line developments increase the potential for downloading large files, such as real time video. Proponents of online CHPE suggest that more and more courses will be delivered through the World Wide Web (WWW) by accredited CHPE web service providers. Health professionals will be able to pay for CHPE services with digital cash or credit cards, and submit online evaluations via the Web.

The Internet is an excellent location for medical reference material, as the information is universally available, easily updated, and quickly obtained (Huntley, 1998). The Internet allows CHPE to be easily delivered to the site of clinical activity (Peterson et al., 1999). Internet-based CHPE is advantageous also because it allows the user to select the content, pace, and place of learning. It allows health care providers to obtain CHPE from regional, national, and international experts, without having to travel. The main benefits of Internet-based CHPE include easy access, low expense, interactive multimedia format, and an ability to create interactive clinical cases (Tanner et al., 2001; Richardson & Norris, 1997). The flexibility of HTML, the language in which web pages are written, allows for high-quality video and audio to be presented (Allen, 2001). Using multimedia components such as sound and movies (Ruskin et al., 1996), electronic publishing can present ideas that could not possibly be offered in printed text. Much of web-based material can easily be stored on a CD-ROM and used locally within a PC with access speeds far higher than those achievable with most online courses. According to Turchin & Lehmann (2000), the WWW provides opportunities for the development of new educational tools, and facilitates learning through interactivity and self-paced study. Publication on the Internet offers the added advantages of world-wide information distribution, and ease and speed of updating to reflect the state of the art.

Videoconferencing, also known as video teleconferencing or interactive television, is a presentation mode that can link an instructor and adult learners at various remote sites using a two-way audio and video connection (Havice & Knowles, 1995; Kaufman & Brock, 1998; Sen Cupta, Wallace, Clark, & Bannan, 1998; Brown, 1994). Videoconferencing technology has been rapidly emerging as an increasingly useful tool for improving patient care delivery and expanding access to CHPE. As the pressure mounts to reduce health care delivery costs and increase access to quality medical care, the efforts of many individual hospitals, regional health care systems, and governments to install interactive videoconferencing systems have quickly been intensifying (Brown, 1994). The emergence of relatively inexpensive, compressed video systems that permit two-way video and audio interactions has increased the acceptance of this communication modality in situations where face-to-face instruction had been the established norm.

Videoconferencing systems have undergone significant growth in recent years, due to increased digital transmission options at reduced costs, vast improvements in video compression technologies, and improvements in the systems, with an associated decrease in their cost. The main interest in videoconferencing is based on the interactive, real time, two-way communication it permits. This interactive communication allows participants at two or more sites to receive immediate clarification, and it also enables instructors to garner immediate feedback from participants and adjust their presentations accordingly (Fairbanks & Viens, 1995; Burleson & Sugimoto, 1984). Video transmissions appear on a monitor resembling a traditional television, while sound emanates through the system's speakers. The signal transmission is usually so rapid that sender and receiver can interact in a simultaneous manner.

4. Organizational support is a critical factor in the development and expansion of resources for the successful and sustainable delivery of technology-based distance education to rural and remote health professionals.

The availability of technological infrastructure and specialist support to CHPE providers are important factors influencing the likelihood of technology-based CHPE delivery. In this study, providers of technology-based CHPE distance education programs were more likely to report a positive perception of supportive organizational factors. Organizational support, through the provision of human and financial resources and technical infrastructure, is essential for success. According to Bates (2000), appropriate technology infrastructure is an essential requirement for technology-based education. The integration of technology into education and training places an increasing priority on an institution's technology plan. As a result, there is often a need for a systematic process in which training and education needs are identified and taken into account in technology planning (Bates, 2000).

Existing educational technology resources and expertise (human, technical, and infrastructure) within an organization are important factors influencing the likelihood of a CHPE organizational unit being a provider of technology-based distance education programs. The majority of nursing and medical schools that indicated involvement in technology-based CHPE delivery also reported that their parent organization offered distance education courses, and that they had access to distance education resources within the parent institution. Institutional experience was an important characteristic of those organizational units involved in technology-based distance education delivery.

The development of high-quality web-based education systems necessitates a range of specialist skills. Educational technology staff, such as graphic designers and HTML programmers, will be required to support the development and application of educational materials. Educational technology specialists who provide instructional design, faculty development, project management, and evaluation support to faculty will also be required to support the use of technology for training and education (Graves et al., 1997). According to Bates (2000), the centralization of educational technology support services may be appropriate in a new institution with a commitment to make ICTs a focus of its vision and strategy. However, such a strategy is less likely to be appropriate for the old or well-established divisional universities with large and powerful faculties. In this study, medical schools were less likely to report the formation of partnerships with internal departments within the parent institution. This might suggest the existence of a certain level of concern among medical school academic units that centralization of educational technology services may weaken the school's control over the teaching process. These organizations may prefer to establish their own 'flexible learning or multimedia unit'. This type of model could contain a mix of centralization and decentralization. A small 'Center for Educational Technology', with a few highly specialized and skilled staff, could coordinate and facilitate collaboration between faculty members, subject matter experts, and support units.

5. The use of information and communication technologies (ICTs) in the delivery of continuing health professional education (CHPE) places unique and special demands on instructors and subject matter experts (SMEs) who are unfamiliar with these technologies in training and educational delivery. Faculty and instructional development support are key services in assisting instructors and trainers in the effective use of ICTs in continuing professional education.

The majority of school of nursing and school of medicine respondents indicated that they were providing training and support to faculty and instructors who taught in their distance education programs. 'Faculty development seminars / workshops', 'instructional development support materials', 'mentoring by experienced instructors', and 'one-on-one consultation with an educational specialist' were the main types of faculty development activities reported by the majority of respondents across the organizational categories. Support for instructors and SMEs in the use of information and communication technologies (ICTs) is an essential prerequisite for successful technology-based instruction. A comprehensive and systematic approach to technical and professional support for faculty is required (Bates, 2000). The establishment of an educational technology support unit to assist faculty with development activities is a necessity, as is a focus on faculty development programs and services. Faculty development is reported to work best when the institution has "a culture pervaded by the use of technology and supported by a wide range of strategies...a strong strategic plan in which the use of technology for teaching plays a prominent role....support from senior leadership for the use of technology for teaching....support, in a wide variety of ways, for faculty members who wish to use technology for teaching" (Bates, 2000, p. 99).

According to Ranstrom (1997), ample orientation efforts must be targeted at faculty and learners in order to assist them in becoming familiar with the variety of equipment they may need to use. Orientation sessions may be of particular importance for faculty, many of whom may need to alter their teaching styles in order to use the equipment most effectively (Fairbanks & Viens, 1995; Dirksen, 1993). An orientation session can provide faculty with the opportunity to learn new strategies for overcoming the challenges of facilitating learning at a distance (Kaufman & Brock, 1998).

6. Health professionals require a fundamental understanding of information and communication technologies (ICTs) in order to be able to utilize these technologies in pursuing lifelong and continuing professional education opportunities. Appropriate stakeholders need to ensure that optimal efforts are made to provide continuing health professional education (CHPE) opportunities, so that health care practitioners can develop the skills needed for optimal use of ICT systems.

It will become increasingly difficult to accept people as being fully educated if they do not know how to use the Internet to communicate with other professionals, or if they do not know how to find web sites that will provide relevant and reliable information in their field of study (Bates, 2000). Learning in the workplace will be initiated by individuals as part of their working lives. It will be informal (i.e., not leading to any formal qualification), self-directed, and piecemeal (i.e., broken into small chunks of learning, some as small as a few minutes a day) (Bates, 2000). The learning context will also need to enable people to work alone, interact with learning material (which may be available locally or remotely), and work collaboratively (and in equal relationship) with peers at different remote sites (Bates, 2000).

According to Moehr and Grant (2000), Canadian health professional students need a basic knowledge of the capabilities and limitations of information systems. Rowe et al. (1995) surveyed all first-year family medicine residents from Canadian university-affiliated programs. Only 13% of respondents reported being very or extremely comfortable with computers, while 29% indicated they were somewhat comfortable and 24% were not at all comfortable. Seventy-one percent of residents (71%) believed that teaching computer use should be a mandatory component of family medicine training programs, and 42% of respondents thought that evaluation of this training should be incorporated into The College of Family Physicians of Canada program evaluation. The results of this study indicate that the most common ICT-related CHPE topics being provided to Canadian health professionals include: using computers; e-mail applications; using the Internet; presentation software; and hospital computer systems.

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7. Technology-based continuing health professional education (CHPE) development and delivery costs are generally higher than those associated with face-to-face CHPE delivery. Many organizations undertake these programs as a means of addressing the mission of their institution or the mandatory CHPE requirements of rural, remote, and northern health professionals. External funding to support such initiatives is essential, in order to offset those costs that are normally not covered in institutional operating budgets.

In this study, the majority of school of nursing respondents reported that 'tuition / registration fees' and 'provincial government grants' were main sources of support for their distance education programming. School of medicine respondents reported that 'industry educational grants' were the main source of support for their distance education programs. According to Bates (2000), if technology-based CHPE is to be a key component of the institution, then the institution has to build it into its base operating budget (Bates, 2000). Provincial and federal government departments and agencies also have an important role to play in terms of funding technology-based CHPE. Bates (2000) believes that 'earmarked government funding' is a good strategy for getting institutions to pay attention to developing and delivering technology-based distance education.

The provision of an equitable and sustainable level of health care in rural communities is a challenge, due in part to the difficulties associated with recruiting and retaining rural health care providers. Rural health care delivery is a demanding and challenging form of practice, regardless of the profession. As an example, the rural physician or nurse practitioner frequently practices in an isolated environment, with inadequate resources and limited or distant specialist back-up resources. This isolation necessitates a level of clinical competence beyond that of his / her urban health care peers. This isolation also makes it difficult for the health care provider to maintain his / her professional competencies. Professional isolation is believed to be related to job dissatisfaction with rural practice. Rural health care providers are generally dissatisfied with their opportunities for participation in CHPE.

8. Partnerships involve the combining of expertise and resources. Partnerships are essential in the development and delivery of technology-based continuing health professional education (CHPE). Partnering helps to avoid duplication and allows organizations to share limited resources, equipment, and infrastructure. CHPE providers need to partner with other organizations and communities in the development and delivery of technology-based CHPE programs, in order to ensure program sustainability and acceptance. Municipal, provincial, and federal levels of government have a role to play in encouraging, facilitating, and supporting such partnerships.

Partnering, whether it be with other organizations and institutions or with other internal departments, appears to be a significant characteristic of technology-based distance education program development and delivery by Canadian CHPE providers. Building and strengthening a collaborative approach between institutions has the advantage of avoiding duplication, and accessing higher levels of infrastructure and resources than would otherwise be possible. More importantly, it enables institutions to learn and grow from the experience of working together, and to leverage important qualitative improvements and economies of scale (Bates, 2001). Partnership arrangements work best when partner institutions are of roughly the same status and have complementary strengths (i.e., different areas of research or subject expertise that complement the others). The main advantage of partnering, in addition to a reduction of cost, is that learners are able to access a wider range of expertise.

One model of partnering that appears to be applicable to technology-based CHPE is that of 'consortia'. In a consortium model, different institutions share common resources (such as marketing, electronic and human networks, distance education expertise, and learning centres) and agree among themselves to avoid duplication and to work together whenever possible on joint course development and delivery (Bates, 2001, p. 61). Successful consortia need funding mechanisms that reward and facilitate collaboration, and they need a change of culture within organizations from one of fierce competitiveness between institutions to one of trust and goodwill between the partner organizations.

9. Governments have an important role to play in stimulating efforts in the development and delivery of technology-based continuing health professional education (CHPE). Apart from funding to support the development and delivery of technology-based CHPE and appropriate technological infrastructure networks, there is a role for government to play in facilitating partnerships between institutions and organizations.

According to Bates (2000), the roles of government in managing technological change in education and training can include the following: stimulator of 'best practices'; 'enabler, funder, and broker of partnerships'; 'creator of technology networks'; and 'informer and protector of consumers'. Governments can also play a key role in articulating a collective vision with respect to the place of ICTs in health professional education and training. Information and communication technologies have a great deal of relevance in the enhancement of health care delivery in rural, remote, and northern regions of Canada. Professional isolation is a key factor influencing the recruitment and retention of health professionals in these areas, and a shortage of rural health care professionals is having a significant effect on the nature of health care services available in rural regions. Government can influence public policy decisions in this area by:

  • enabling the delivery of cost-effective CHPE to rural and remote health professionals;
  • increasing the capacity of organizations and institutions to utilize the power of technology to carry out their teaching, research, and service functions;
  • enhancing a better conception of what constitutes best practice in the field of e-learning, distributed learning, and distance education (Bates, 2001).

Strategies for the use of information and communications technologies in health services need to be embedded within a wider framework of government policy for health care delivery. At present, several countries are leading significant e-learning initiatives in the area of online CHPE. According to Bates (2000), governments may want to consider the establishment of different centres of excellence in different institutions, in order to ensure the development of programming for different market niches. Governments can also lever economies of scale, and concentrate scarce skills in developing and running e-learning programs by encouraging or building strong national consortia.

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Dissemination of Findings

A web page will be developed in order to highlight the results of this study. This report will be located in the research section of the Office of Professional Development web site (www.med.mun.ca/pdmed). A number of key stakeholders in the continuing health professional education field will also be forwarded copies of this report. Dissemination to national audiences at annual meetings (such as the Association of Canadian Medical Colleges Annual Meeting in Quebec City, in April 2003, and the Canadian Association of Continuing Health Education Annual Meeting in Halifax, in Sept 2003), via posters and presentations, is also planned. Moreover, the results will be adapted for publication in relevant academic and professional journals.

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Date Modified: 2004-10-01

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