European Journal of Pediatrics

, Volume 168, Issue 4, pp 449–456

European online postgraduate educational programme in neonatology—the way forward?


    • Department of Neonatal MedicineSouthampton University Hospitals NHS Trust
    • Department of Neonatal MedicineThe Princess Anne Hospital
  • Marina Cuttini
    • Unit of EpidemiologyOspedale Pediatrico Bambino Gesù
  • Andreas W. Flemmer
    • Division of NeonatologyLudwig-Maximilian-University Munich
  • Gorm Greisen
    • Department of Neonatology, RigshospitaletUniversity of Copenhagen
  • Neil Marlow
    • Academic Division of Child HealthUniversity of Nottingham
  • Andreas Schulze
    • Division of NeonatologyLudwig-Maximilian-University Munich
  • Susan Smith
    • School of Nursing and MidwiferyUniversity of Southampton
  • Adolf Valls-i-Soler
    • Hospital de CrucesUniversity of the Basque Country Bilbao
  • Patrick Truffert
    • Service de Médecine Néonatale
  • Gráinne Conole
    • The Open University
  • Maarten de Laat
    • Exeter University
Original Paper

DOI: 10.1007/s00431-008-0770-6

Cite this article as:
Hall, M.A., Cuttini, M., Flemmer, A.W. et al. Eur J Pediatr (2009) 168: 449. doi:10.1007/s00431-008-0770-6


The provision of specialist postgraduate training is increasingly challenging for the acute medical specialties. There are often small numbers of trainees and tutors in any one centre, and service commitments may limit attendance at educational activities. Online learning can provide high-quality education to trainees from large geographical areas. We report the outcomes of an experimental educational project which provided an online postgraduate programme in neonatology. Ninety trainees from 14 countries, primarily European, participated. Six educational modules in neonatal topics were delivered over a 1-year period, within a “Virtual Learning Environment”. Trainees were divided into multi-national groups; two online tutors supported each group. Analysis of online activity demonstrated that active participation was high initially (100%) but gradually declined to 46% in the final module; tutor participation followed a similar pattern. Eighty-six trainees were contactable at the end of the programme, and 67 (78%) completed an evaluation questionnaire. Of these, 92% reported that participation had “added value” to their training, attributable to the high-quality curriculum, the educational resources, collaborative networking and the sharing of best practice. Eleven (79%) tutors completed the questionnaire, with all reporting that participation was of educational value. The main limiting factor for trainees and tutors was insufficient time. This project confirms that multi-national online education in neonatology is feasible and transferable, but for this approach to be viable formal accreditation and protected time for both trainees and tutors are required.




To date there has been no unified formal academic framework for the provision of postgraduate medical education (PGME) for specialist clinical training in Europe. Although the recent European Commission directive 93/16/EC [13] ensures equivalent recognition of qualifications, it does not define educational standards. In 1999 the Bologna Process identified the need for a “Europe of Knowledge” with the establishment of a system of credits [European Credit Transfer and Accumulation System (ECTS)] [33] but as yet this has not been implemented, and there remains little evidence of harmonization or benchmarking of PGME. However, if the concept of free movement across countries and the “globalization of medicine” [17] are to be facilitated, then there is a need for synergy and transparency both of defined standards and the European professional accreditation of PGME.

The Internet and associated multimedia technologies can and have been used to deliver medical education and continuing professional development (CPD) to large numbers of doctors who are dispersed over a wide area [14, 18, 1923]. It has been suggested that, for some specialities, this approach can be adapted to develop and deliver formal structured internet-based postgraduate educational training programmes and that there is a large international market for such programmes [16].

Neonatology is a sub-specialty of paediatrics and the Confederation of European Specialists of Paediatrics and the European Society for Paediatric Research (ESPR) have recently defined a European syllabus in neonatology [30]. However, to date, no academic institution or professional organization has taken responsibility for the co-ordination, accreditation, delivery, assessment and evaluation of the syllabus. This may be due in part to the many complex challenges involved, which include the relatively small numbers of trainees in any one centre, the financial viability of specialized courses, geographical separation of trainees and, in some countries, the conflicting pressures for trainees of providing a clinical service within the confines of the European Working Time Directive [10] while simultaneously participating in postgraduate educational activities.

In order to investigate the potential role of the Internet for postgraduate neonatal education and training in Europe a working group was formed, incorporating neonatologists from Denmark, France, Germany, Italy, Spain and the UK. The group designed, developed and provided an Internet-based educational programme for trainees in the specialty, funded by a grant from the European Commission. External evaluators with specific expertise in the evaluation of Internet-based educational technology and pedagogy were appointed to undertake a prospective formative and summative evaluation.

Aims and objectives

The primary aim of this experimental educational project was to explore the feasibility of developing and delivering a structured postgraduate educational training programme for European trainees in neonatology. The specific objectives were to:
  1. 1)

    recruit a cohort of doctors in Europe who were training in neonatology;

  2. 2)

    develop a Virtual Learning Environment (VLE) which could provide the overarching infrastructure for the programme;

  3. 3)

    develop and deliver an interactive online programme comprising six specialist modules based on the European syllabus for training in neonatology;

  4. 4)

    facilitate the acquisition of key skills for junior doctors;

  5. 5)

    establish networking links and collaboration;

  6. 6)

    evaluate the effectiveness of the programme.



All members of the European Society for Neonatology (ESN) or ESPR who were known to be neonatologists were contacted by e-mail and sent copies of promotional material for the project. They were asked to identify trainees who met the criteria for participation and to give them copies of the promotional material which contained our contact details. The criteria for acceptance on the programme were that participants should:
  • be qualified doctors who were undertaking postgraduate training in neonatology with the intention of becoming neonatologists or paediatricians whose responsibilities included neonatal intensive care;

  • be competent in spoken and written English;

  • have regular access to a computer with predefined specifications, including online access;

  • be able to commit to spending approximately 4 hours per week on the project.

The trainees were contacted by e-mail and invited to apply. The potential participants were informed that each module would run over 6–8 weeks, for a total duration of 12 months. All applicants completed an online application form which explored their previous neonatal experience, English proficiency, level of computer literacy, prior experience of e-learning and their reasons for wanting to undertake the programme. Prior to starting the programme, the participants completed an online induction module, which was aimed at acquainting them with the “online” skills required for participation, enabling them to become familiar with the VLE and to “meet” their peers and tutors online.

A faculty of online tutors was also recruited to ensure that each of the small multi-national groups was supported by at least two tutors. The online tutors all completed an induction module aimed at providing instruction and insight into the subtle differences between the more traditional role of a tutor and that of an online tutor [24, 27].

Six members of the working group each had responsibility for developing one of the following specialist modules. For the development of three of the modules (1, 3 and 5) professionals with specific expertise were also involved. The focus of the six modules was as follows:-
  1. Module 1

    Neonatal Neurology

  2. Module 2

    Perinatal Epidemiology

  3. Module 3

    Ethics and Neonatal Practice

  4. Module 4

    Early Care of the Very Low Birth Weight Infant

  5. Module 5

    Neonatal Nutrition

  6. Module 6

    Neonatal Respiratory Management

An overview of the key indicative content of each module is presented in Table 1. The modules were developed over a 1-year period using interactive multimedia (video clips, a virtual neonatal respirator, X-rays and ultrasound scans) and case-based scenarios.
Table 1

An overview of the six modules


Key indicative content

Neonatal Neurology

Birth asphyxia

Neonatal seizures

Brain lesions in the preterm infant

Clinical cases

Perinatal Epidemiology

Perinatal regionalization

Introduction to the EUROPET project

Maternal and neonatal transfer policies in Europe. Evaluation of perinatal transfers: a review of recent evidence

Variations in the organization of obstetric and neonatal intensive care in Europe.

Ethics and Neonatal Practice

Introduction to medical ethics and principle-based approach

Beneficence and non-maleficence: best interest and burden-to-benefit balance

Autonomy and informed proxy consent

Justice and non-discrimination

Case discussion

Early Care of the Very Low Birth Weight Infant

Perinatal management - the evidence base

Immediate care in the delivery room - current concepts

Early care in the neonatal intensive care unit - the evidence base

Linked to European Training Syllabus in Neonatology

Neonatal Nutrition

Gastrointestinal development


Recommended key nutrients—parenteral and enteral and weaning

Nutritional assessment and growth monitoring/ feeding surgical infants

Neonatal Respiratory Management

Respiratory system development and physiological foundation

Non-invasive respiratory support

Special modes of mechanical ventilation

Respiratory gas conditioning and humidification

Difficult airway access

Non-mechanical supportive therapeutic modalities in respiratory failure and BPD

Clinical cases and virtual neonatal respirator

The main curriculum was only offered in English. It had been established at the time of application that the trainees were aware of this and that they were satisfied with their own capability to study in English. One of the project’s objectives was to investigate the use of machine translation (MT) tools that would have enabled the trainees to translate the curriculum. During the developmental phases a short pilot of the effectiveness of the MT tools was undertaken; a component of the curriculum was translated into Spanish, Dutch and German, and members of the ESPR were asked to review the validity and reliability of the translation. The results confirmed that the use of MT tools would not be feasible in this medical specialty and, therefore, the curriculum was presented in English. In terms of the VLE, however, it was possible for the trainees to customize their personal desktop such that it was in their own language—although this facility was not available for the synchronous discussions.

Pre- and post-module formative assessments were integrated, and the learning outcomes were defined using Bloom’s taxonomy [2, 3]. A range of group projects, including the formulation of evidence-based clinical guidelines, were included to promote collaboration and the sharing of best practice. A blended approach was used to deliver the core theoretical material [12]; this provided participants with the choice of accessing the content at any time via the Internet or CD-ROM with the minimum of inconvenience. Participants could either work through the modules using a linear systematic approach, or sections of each module could be accessed at random.

The password-protected VLE was designed to promote an integrated learning environment, providing resources to support online learning, including a comprehensive generic and subject-specific electronic library, access to learning resources, including an image gallery, technical support and the main link to the online conferences. The following asynchronous “conferences” were provided:
  • plenary conference area— to enable “discussion”, which was accessible to all trainees and tutors;

  • small multi-national group conferences—which were accessible only to individual group members and their tutor;

  • a tutors’ conference area—to enable tutors to share issues from their respective tutor forums;

  • a notice board—for postings related to holidays, absences and deadline;

  • a “coffee room”—for everyone to participate in social discussion.

In order to ensure that as many participants as possible had access to the content of the “chat” discussions, the transcripts were saved and converted to Word documents which could then be accessed or downloaded later. The VLE provided tracking activity data on both the trainees and the tutors. It was possible to record automatically individual participant login time and date, length of time online and activity in terms of postings and areas visited within the VLE.

Neither the trainees nor the tutors received any financial remuneration for participation in the project, and they were expected to participate in their own time unless specific study leave was negotiated locally.

Evaluation methodology

External qualitative and quantitative evaluation were incorporated as part of the project design. Internal formative evaluation provided constructive feedback to the trainees, tutors, the evaluation team and the European Commission at the mid-point of the project. The evaluation included the following:
  1. 1)
    Mid-point and end- of- project evaluation questionnaires. Both trainees and tutors were asked to complete these either online or as a print-based version. The same questionnaire was used on both occasions and it focused on:
    • whether the programme had matched the initial expectations;

    • the participant’s perception of the modules with regard to the structure, content and achievement of the learning outcomes;

    • whether this mode of learning had anything “extra” to offer compared to traditional learning;

    • whether participants would consider involvement in future internet-based programmes.

  2. 2)

    Analysis of data gathered via the VLE for each module. This focused on the login activity of the participants and the online tutors, the number of “postings” and the amount of assessment activity that was undertaken within each module. For the purposes of evaluation, “active participation” was defined as logging onto the VLE.



Recruitment data


The exact number of trainees who were approached is not known, but 116 completed online applications, of whom 109 were accepted. The remaining seven were refused as they were too experienced and could therefore not be classified as being “in training”.

The 109 applicants originated from 14 countries (Fig. 1); 52% were female. The median age of the trainees was 33 years (range 25–45 years), and their median length of previous neonatal experience was 2.6 years (range <6 months to 10 years). Of these 109 applicants, 19 were not able to participate as intended and formally withdrew before or during the course of the first module. Reasons for withdrawal included: promotion (n = 6), pregnancy (n = 5), personal reasons (n = 4), leave of absence (n = 2) and unknown (n = 2). The final number of active participants was, therefore, 90.
Fig. 1

Country of origin of registered applicants


Six of the working group members assumed the role of online tutor and an additional eight neonatal clinicians were recruited—three from Germany, two from the UK, two from Spain and one from Denmark.

Evaluation responses from trainees

At the end of the programme contact was made with the entire cohort of 90; four e-mails were returned unopened. A total of 67 questionnaires (78%) were completed and returned. For the trainees and tutors, the induction module proved valuable both as an introduction to the concepts of online learning as well as by providing the opportunity to either acquire or improve skills and expertise within the VLE and with online learning. The most widely reported reason for non-participation or attrition was a lack of time (53%). Of those responding, 84% felt the aims and objectives of the programme had been achieved, and 92% reported that they had gained something that they could not have acquired elsewhere; 59% identified this as the up-to-date curriculum, 10% cited the value of the course having a multi-national dimension and 5% specifically highlighted the value of the online chats. When asked what the least valuable aspect of the programme was, 43% provided no answer and 21% reported this to be the amount of time required. Ninety percent of the trainees stated that they would participate again, and 92% would recommend the programme to colleagues.

Evaluation responses from online tutors

Of the original 14 online tutors 11 provided evaluation data. All of the respondents would participate again, and 91% would recommend the programme to colleagues. The most valuable aspects of the programme were reported to be the high-quality, up-to-date materials and specialist moderators (36% for each), personal learning and a good supportive environment for learners (9% for each). The least valuable aspect was the time commitment required (36%).

Analysis of trainee online activity

Signs of the development of a collaborative online community emerged in the first module where there was evidence of the small multi-national groups working both individually and collaboratively with each other on the group projects. There was a gradual decline in the login and posting activity of the trainees throughout the year (Fig. 2). At the mid-point of the programme, 76 (84%) of the cohort were still actively participating, but by the end of the programme this had dropped to 41 (46%). A number of strategies were used to try to promote and encourage participation, including personal e-mail contact, regular project updates and reminders of the dates of “chats” or debates. After the second module, it was apparent that there was an imbalance of trainee online activity between the seven multi-national groups. In response to this, it was decided to reduce the numbers of groups to five—with the aim of promoting and increasing activity among both the trainees and the tutors. As a result, the number of trainees in each group was increased. Group tasks were integrated in the modules to promote collaboration and interaction, and these were successfully completed in Module 1, but this was not as evident in the subsequent modules. In the end-of-project evaluation, some trainees expressed their frustration and disappointment with their peers and their lack of commitment in completing the group projects, with 10% of the respondents citing the group work as the least valuable aspect of the programme.
Fig. 2

Number of “active” trainees Modules (Mod) 1–6

Trainee attrition related to nationality

The attrition rates among trainees by country are shown in Fig. 3. The origin of the trainees seemed to have no effect on attrition; the rate for those trainees who originated from the countries represented by the European Working Group and the tutors was 54% compared with an attrition rate of 55% for trainees who originated in non-author countries, suggesting that the nationality of the tutors had no correlation with ongoing participation.
Fig. 3

Nationalities of active trainees at the start of the programme and during the final module

Analysis of tutor online activity

The activity (the sum of logins and postings) of the 12 most active tutors during the course of the project is shown in Fig. 4. There was a wide range of online activity amongst the tutors, some logging in and posting regularly while others just logged in without posting any messages; only four of the 12 active tutors demonstrated consistent patterns of interactive activity.
Fig. 4

Activity scores (logins + postings) of the 12 most active tutors during the programme

Analysis of synchronous online discussions (“chats”)

Of the respondents, 61% found the “chats” to be useful while 20% found them of less value. Trainees reported the “chats” to be “informative and interactive”, providing a “good debate and instant feedback” and an opportunity to discuss clinical practice with “small groups and experts”. All of the tutors rated the chats as useful and of value in consolidating and applying the core content of the modules. Reasons given for non-participation of the trainees included the time of day when the “chats” were held. If trainees were not able to attend the chat sessions, it appeared that many did take the opportunity to download the transcript as a Word document: for example, in Module 6, although only 16 trainees participated in the four chats, 42 transcripts were downloaded.


This collaborative structured online experimental educational programme was delivered to a cohort of doctors training to become neonatologists, the majority of whom were based in Europe. The principles of online learning were integrated, and the VLE used an instructional design to promote learner-tutor interaction, collaboration among learners, prompt feedback and active learning [7]. Although every attempt was made to incorporate interaction during the course of the programme, this remained a challenge and confirmed recent results from an online study which reported, although it is possible to attract users to log-in, the challenge then is to demonstrate the “additional value of participation in more active learning” [25]. It is also important to note that with such a multi-national cohort, it is likely that the process of online participation—either synchronous or asynchronous—will only suit some learning styles, and some may just want to participate on a “viewing only” basis [28].

Retention and participation rates may have been higher if there had been some formal accreditation or academic credit attached to the programme. Trainees and tutors were participating in their own time, and even though all the trainees had intended to commit to the required 4 h of study each week, time constraint was still one of the main impediments to progress identified by both the trainees and tutors. It appears that—at the present time across Europe—there is a wide variation in the amount of protected time which is allocated for education and training. To promote equity and parity in terms of access to educational opportunities and benchmarking standards, this issue will need further clarification and evaluation.

The lack of available time for trainees is not unusual within the context of online postgraduate education, and similar findings have been reported recently in another PGME online project when it was noted that in this learning context “insufficient time was the most frequent reason given for non-participation” [6]. The lack of active participation is an issue which has the potential to, and did, frustrate some trainees; it may even have acted as a demotivator. This has previously been noted by Berge [5] who reported that his study participants “expressed disappointment with fellow students who were not timely and relevant in their message postings”.

For learners in this context who do not have protected study time, there will always be challenges with time management in terms of the tension between service provision, educational and professional development and personal work/life balance issues. This is also an issue for online tutors, who in this project found that the time commitment required was much greater than had been initially anticipated. This could also explain the lack of activity among some tutors who may have underestimated not only the amount of time involved but also the ongoing commitment in terms of trainee motivation and support. The amount of time needed for appropriate tutor support in the online environment has been emphasized elsewhere in the literature [1, 31], and it has been estimated that this mode of instruction requires up to 40–50% more work on the teacher’s part in comparison with the traditional mode of delivery [4]. It has also been suggested that the ongoing support of online learners is the biggest and least costed aspect of online learning [26], and it may be that for future courses, recognition and possible remuneration of online tutors will be needed to promote ongoing sustainability.

Further analysis revealed that participation in the different elements of the course (materials, “chat” tools, and discussion forums) varied among trainees and that it was probably dependent on a complex set of inter-related factors, including prior experience, learning approaches, personal preferences and interests. The online environment is almost unique in that it can promote learning across communities where learners have a range of learning styles and preferences [8]. In this context, the trainees engaged with the resources and adopted a blended learning approach, spontaneously selecting the offerings of the course to meet their individual needs; for example, some liked to attend and participate in the synchronous online communication sessions (“chats“), while others downloaded the discussions as archived transcripts. These findings mirror other recent studies of learners’ use of and expectations of technologies [9].

There is evidence that the way that professionals want to learn is changing; in the USA, 14% of the credit hours for continuing medical education in 2004 were obtained online, which is double the figure for 2 years previously [28], and the British Medical Journal e-learning has had an increase of more than 60,000 users in less than 3 years [32]. The opportunity for integrating a wide range of Web 2.0 technologies for educational use is increasing and with this comes a concomitant decrease in the distance between countries [11]. On a personal level, many individuals are now familiar with podcasting, instant messaging, blogs, wikis and social networking sites [29]; this suggests that the trainees of the future will not only want to have a more flexible approach to education in terms of time and place but that they will also want to maximize the potential of the available technology if it can enhance their learning opportunities and experiences.

Our study confirms that this flexible online approach to postgraduate education can provide many of the positive features that have been suggested to be important for PGME [19] and, in addition, there is also the opportunity to meet a range of learning needs and styles that is not easy to replicate in other contexts. Furthermore, there is now increasing evidence that online learning is ideally suited to promote the application of knowledge into practice and collaboration [15]. Both the participants and the online tutors found the experience challenging and stimulating and of personal educational benefit. The majority of the tutors and 90% of the trainee respondents would choose to participate again, and more than 90% of both groups would recommend the programme to colleagues. Online learning can provide added value in terms of access to specialists, cross-cultural collaboration and a greater understanding of challenges faced by others working in different circumstances. The quality of online discussions and collaboration with colleagues across Europe was enjoyed by all the participants and was rated as one of the primary success factors of the course.

Global learning environments which offer flexible learning are likely to increase given the need for CPD and lifelong learning within the context of professional mobility. Learners will expect to access structured educational programmes that are tailored to their own learning, cultural, and social needs whilst also promoting benchmarking of academic and professional practice. The findings from this online experimental educational project and the underpinning educational principles are not limited specifically to the neonatal context. There is scope for further development and transferability across many paediatric specialties, but for this approach to become integrated into future educational programmes consideration would need to be given to accreditation, professional recognition and the allocation of protected time.


Funding for this work was provided by The European Commission: Leonardo Da Vinci Programme. Gérard Bréart, Eduardo Doménech, Esther Fackeldey, Christian Heiring, Chris Jarvis, Begoña Loureiro-Gonzalez, Maggie Meeks, Jalshan Sabir, Tore Nilstun, Ryan Watkins.

Copyright information

© Springer-Verlag 2008