Background

E-learning enables learning regardless of the learner’s geographic location and time [1, 2]. In recent years, it has become the mainstream choice for continuing education for nurses, and changes in learning formats prompted by the coronavirus disease 2019 (COVID-19) pandemic have further increased the uptake of e-learning [3,4,5]. E-learning can be synchronous, connecting learners with instructors and other students in real-time, or asynchronous, allowing learners to study at a time and place of their choice [6]. The asynchronous type is a learner-directed method suitable for adult learning which enables learners to balance professional development with personal and professional obligations, particularly for nurses with irregular work schedules [7, 8]. However, because of the high level of independence among learners using e-learning, the lack of motivation for learning is considered a serious issue, and various types of asynchronous e-learning models have been developed to overcome this challenge.

The asynchronous e-learning models and designs reported in the literature range from slide-based models to types that include interactive elements [9]. Delivery methods also vary, with the most common methods categorized as (a) enhanced or supplemental, serving as an aide to face-to-face classroom learning and providing students with relative independence; (b) blended e-learning models, integrating face-to-face classroom and online learning; and (c) pure online or fully online models that provide students with maximum independence with no classroom or traditional face-to-face learning [10]. In recent years, novel e-learning methods, such as gamification and augmented or virtual reality (AR or VR), have been developed using information communication technology (ICT) and other technologies [1, 11, 12].

The term technology-enabled and enhanced training (TEET) reflects the various contributions of technology to education [13]. TEET includes both technology-enabled and technology-enhanced training. Technology-enhanced training can improve the effectiveness of interactive learning using videos, graphics, images, or simulations [14]. TEET continues to evolve as it is closely aligned with technological advancements [14]. However, very few studies have examined the effectiveness of e-learning using innovative technology in continuing education for nurses [1].

Button et al. [15] conducted a literature review to identify the technologies used for e-learning and ICT in nursing education and the problems the learners and educators face. The results revealed issues related to learners’ e-learning, information technology use, educators’ pedagogy, workload, and staff development for e-learning and related technologies. However, this study was a 10-year-old literature review covering the period between 2001 and 2012, which differs from the current ICT situation, although the low level of computer literacy is still an issue. In addition, the e-learning format was simple, such as a PowerPoint slide format or simple video. Furthermore, because the target audience included clinical nurses and students, the characteristics of continuing education for health personnel, such as motivation to learn and outcome evaluation, were unclear.

Ngenzi et al. [14] conducted a scoping review to identify available and effective TEET options to provide continuing professional development to health care providers in Rwanda, a low-income country with a limited and widely distributed health workforce. Technologies were categorized into modes of delivery and technological approaches. The technological approaches are divided into two subcategories: enabling technologies and enhancing technologies. They found several valid TEET options for both pure e-learning and blended learning modes and internet-based technologies. In this previous review, all studies using technological approaches also measured changes in the health personnel’s knowledge, skills, and behaviors, leading to increased knowledge acquisition, skills and self-efficacy, and leadership skills [14]. However, this previous study concerns e-learning and ICT-based education. Therefore, with the current development of various novel asynchronous e-learning methods, we considered that by categorizing asynchronous e-learning in continuing education for clinical nurses within the framework of TEET options used by Ngenzi et al. (2021) [14], we could identify effective TEET options and their delivery methods and educational effectiveness. This scoping review is anticipated to provide suggestions regarding the features that can be included in asynchronous e-learning, which is expected to accelerate in the future, and is foreseen to clarify the effects of asynchronous e-learning and learner motivation, which is an issue in asynchronous e-learning.

Purpose and research question

This study aimed to identify the features of asynchronous e-learning for the continuing education of clinical nurses. The following research questions were addressed:

  1. (1)

    What technologies are used (TEET options) and their delivery modes in asynchronous e-learning for clinical nursing education?

  2. (2)

    What are the effective outcomes and outcome measures adopted in clinical nursing education using asynchronous e-learning?

  3. (3)

    What are the benefits and issues related to asynchronous e-learning?

Definition of terms

Asynchronous e-learning

A type of e-learning that does not have a human facilitator and allows self-directed learning at a time and place of the learner’s choice.

Synchronous e-learning

A type of e-learning wherein a human facilitator is present, and the learning takes place in real time at a fixed time. Learners are often able to interact with the instructor and other learners.

Methods

A scoping review was selected as this study’s methodology. A scoping review provides an overview (mapping) of a broad body of literature, allowing for a comprehensive survey of current research and identification of areas where research has not yet been conducted (research gaps) [16, 17]. The scoping review methodology was conceptualized by Arksey and O'Malley [18] in 2005 and was subsequently developed by Levac et al. (2010) [19] and the Joanna Briggs Institute [20]. In 2018, Tricco et al. published guidelines for reporting scoping reviews as an extension of the PRISMA statement (i.e., Preferred Reporting Items for Systematic Reviews and Meta-Analysis) [17] (PRISMA-ScR: PRISMA extension for Scoping Reviews). The present review was conducted following the PRISMA-ScR protocol. The review framework consisted of 5 steps: (1) defining the research question; (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; and (5) collecting, summarizing, and reporting the results.

Identifying relevant studies

The lead author (RK) and our university librarian devised the search strategy. The period covered was between 2011 and 2021. The following indexing databases were searched: PubMed, CINAHL, Cochrane Library, ERIC, Embase, and Ichu-shi Web. The inclusion criteria were intervention studies and practice reports on asynchronous e-learning in clinical nursing education written in English or Japanese. Notably, the same educational system training program provides post-graduate education for nurses and midwives in Japan. Therefore, midwives were included in the target population. The exclusion criteria were as follows: studies with no description of whether the e-learning method was synchronous or asynchronous or of the TEET option used, conference proceedings, and studies that included nursing students. The search terms used are listed in Table 1. The target population was clinical nurses and midwives; however, we decided to include cases in which nurses were part of the health care team. Therefore, the search terms were not limited to nurses but also included health personnel. With the expert help of our librarian, we checked each database for the inclusion of nurses in the subterms of health care professionals. In addition, many studies did not specify whether the type of e-learning was synchronous or asynchronous; therefore, we searched extensively for terms relating to e-learning. The Patient, Concept, Context (hereafter, “PCC”) framework shown in Table 1 was used as follows; Patient: Health personnel, Concept: Asynchronous e-learning and TEET, and Context: Clinical setting. The search string was created by connecting search terms related to each PCC category with OR and combining them with AND. The search formula used in PubMed was as follows:

  • ((“e-learning”[Title/Abstract] OR “electronic learning”[Title/Abstract] OR “web based learning”[Title/Abstract] OR “online-learning”[Title/Abstract] OR “ICT”[Title/Abstract]　OR “distance learn*”[Title/Abstract] OR “computer assisted instruction”[MeSH Terms] OR “internet based learning”[Title/Abstract] OR “technology enhanced learning"[Title/Abstract]) AND (“health personnel”[MeSH Terms] OR “health professional*”[Title/Abstract] OR “nurse”[Title] OR “nurses”[Title] OR “midwi*”[Title]) AND (“education, continuing”[MeSH Terms]).

Table 1 Search terms
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We searched each database with the librarian, checking each subword so that the other databases would follow the same search formula.

The search was conducted on February 18, 2022, with a follow-up search on June 12, 2023, to add new literature. The Rayyan software was used to manage the search results.

Selection of studies

An overview of the article selection process is presented in the PRISMA-ScR flow diagram (Fig. 1). In total, 1428 articles were selected, and after removing duplicate references using automation tools, 1344 articles were selected for screening. In the first stage, two researchers (RK and MM) independently and manually screened the titles, abstracts, and inclusion or exclusion criteria. The authors were blinded to each other’s judgment. They classified the studies using Rayyan as included, excluded, or undecided, and the authors discussed the articles classified as “conflicting” and “undecided.” The screening process yielded 294 studies, of which 283 were eligible for full-text review. After excluding 11 that were unavailable, a second screening was conducted similarly. Consequently, studies that did not include nurses in the target population (n = 77), did not focus on asynchronous e-learning (n = 23), or had different objectives (n = 123) were excluded, and 60 reports were finally selected (Table 2).

Fig. 1
figure 1

PRISMA-ScR flow diagram of the article selection process. * Total number of records identified across all databases/registers, and number of records identified from each database searched. **Number of records excluded by manually

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Table 2 Summary of the selected articles (Excel)
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Charting the data

Data were extracted from the 60 articles, and data were charted for the following items: author, publication year, country, target population, study design aims, type of e-learning, outcomes, measurement tool of outcomes, benefits or effects related to e-learning technology, and issues or needs related to e-learning technology. The e-learning modes of delivery and technologies used were classified into modes of delivery and technological approaches (i.e., TEET) using the classification of Ngenzi et al. (2021) [14]. The quality of the articles was not examined as this step was not part of the study’s objective.

Collating, summarizing, and analyzing data

A table summarizing the articles’ characteristics and findings was prepared, and a list of articles was compiled. An overview of the studies was conducted by systematically counting the geographic distribution of the articles, year of publication, TEET options, outcomes, and content analysis of the studies to identify the benefits, effects, and challenges related to e-learning technologies. The results were shared among the researchers, and the classification and results of content analysis were discussed to ensure consensus on the perceptions. Content analysis was conducted using the conventional content analysis method by Hsieh and Shannon (2005) [78]. The article’s content was read and summarized in the first stage according to semantic units (primary codes). In the second stage, primary codes were grouped and converted into secondary codes in light of the research objectives and analysis categories. In the third step, the codes were grouped into subcategories by comparing them from the viewpoint of similarity and difference. As for the fourth step, the codes were categorized based on the relationships among the subcategories.

Results

Characteristics of selected studies

Between 2011 and 2023, 11 studies were published in 2020, 10 in 2017, and seven in 2015; 39 of the 60 studies were published in 2017 or later (Fig. 2). Data on country of publication are shown in Fig. 3. The most common continents of publication were Asia (25 articles: China, three [27, 32, 40]; Japan, 11 [29, 34, 56, 61, 63, 64, 68, 70, 71, 75, 76]; South Korea, six [26, 30, 44, 47, 65, 69]; Singapore, two [12, 67]; Turkey, one [38]; Israel, one [66]]; Iran, one [25]), followed by North America (21 articles: US, 18 [11, 21, 24, 31, 39, 43, 46, 48,49,50, 52, 54, 55, 58, 60, 62, 72, 73]; Canada, three [9, 23, 57]), Europe (eight articles: UK, two [35, 45]; Spain, one [36]; Italy, one [59]; Switzerland, one [74]; Netherlands, one [77]; Sweden, one [37]; Finland, one [51]) and Australia (six articles [22, 28, 33, 41, 42, 53]). Of the 60 studies, three were systematic review articles (Table 3) [9, 12, 41], while the remaining 57 were intervention studies. The study population in the 37 articles included only nurses, two included only midwives [34, 63], and 21 included health personnel, such as physicians and therapists. The total number of healthcare professionals included in the intervention studies examined in this study was 26,273. Of the study designs, the most common was pretest–posttest (n = 34), followed by quasi-experimental design (n = 8) and randomized controlled trial (n = 8), and systematic review (n = 3).

Fig. 2
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Year of publication

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Fig. 3
figure 3

Country of publication

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Table 3 Description of the reviews (Excel)
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Technologies used (TEET options)

Table 4 shows the classifications of technological approaches based on the two categories mentioned by Ngenzi et al. (2021) [14]. The most commonly used technologies among enabling technologies were interactive online modules (25 articles) [11, 21,22,23,24, 28, 29, 31, 33, 35, 37, 42, 43, 45, 48,49,50, 53, 54, 56, 57, 62, 65, 66, 72] and videos (25 articles) [11, 24, 26, 30,31,32, 34, 35, 38, 42, 44, 50, 52, 57, 61, 65, 68, 70,71,72,73,74,75,76,77]. The next most commonly used technologies were slides or PowerPoint (11 articles) [11, 34, 39, 46, 47, 58, 59, 63, 69, 73, 77] and online discussions (seven articles) [11, 26, 28, 31, 54, 57, 72]. The most commonly used enhancing technology category was scenario-based learning (nine articles) [31, 32, 42, 51, 53, 54, 59, 62, 76], followed by resource access (eight articles) [24, 26, 28, 33, 35, 53, 59, 60] and narrated PowerPoint (eight articles) [23, 27, 46, 57, 60, 64, 71, 75], computer simulation or virtual reality (three articles) [31, 49, 62], and gamification (three articles) [11, 50, 67]. Five studies used multiple enhancing technology options [31, 53, 59, 60, 62]. Overall, there was a marked trend toward using various TEET options after 2017.

Table 4 Descriptions of the study mode of delivery, technological approach, and outcomes (Excel)
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Modes of delivery

According to Ngenzi et al. (2021) [14], delivery modes can be classified into three categories: face-to-face or on-campus delivery, blended delivery, and pure online delivery. Blended delivery is “a mode of study that encompasses both online and face-to-face learning”, and pure online delivery “encompasses online learning.” Of the 57 studies, 46 used purely online learning, and 11 used blended learning [37, 43, 44, 48, 51, 54, 63, 66, 68, 70, 77].

Outcomes

As shown in Table 4, all of the included papers reported some outcomes. Knowledge acquisition was the most frequently reported outcome (41 articles), followed by behavior (14 articles) [11, 24, 32, 33, 35, 39, 42, 45, 47, 49, 52, 59, 64, 76], attitude (12 articles) [11, 30, 32, 35, 40, 44, 45, 49, 52, 53, 59, 66], satisfaction (nine articles) [22, 24, 30, 34, 36, 38, 57, 59, 71], and skills (nine articles) [43, 50, 61, 62, 67, 68, 70, 72, 77].

The studies did not use a common method for assessing the outcomes. The following scales and tools were used in the studies: the knowledge, confidence, and attitudes scale [53]; self-efficacy toward helping scale [45]; professional comfort and capability instrument [55]; sexual healthcare practice scale [26]; attitudes regarding the use of restraints scale [44]; and other existing scales as well as independently developed tests, scales, and questionnaires such as comprehension, awareness, and confidence [28, 29, 33, 34, 47,48,49, 63, 65, 69, 72]. Attitude and behavioral outcome items were previously the main assessment items, but recent years have shown a trend toward assessing skills. In addition, among the enhancing technologies that have been used since 2017, those using computer simulation or virtual reality, scenario-based learning, and gamification were effective in improving knowledge acquisition and actual behavior-related outcomes such as skills, behavior, performance, and attitude [11, 49, 50, 53, 62, 67].

Benefits of asynchronous e-learning

The benefits of asynchronous e-learning were as follows: cost-effective [25, 30, 32, 39, 47, 57, 70], time-saving and efficient [9, 25, 32, 47, 52, 68, 69, 75, 76], immediate feedback [11, 47, 68], self-paced learning [9, 11, 25, 47, 53, 57, 70, 76], flexibility [50, 70, 72, 75], ease of participation despite location and time limitations [26, 32, 50, 52, 53, 57, 63, 72], ease of participation [30, 35, 51,52,53, 57, 68], and repeated learning [53].

In addition, the following description of the benefits of the onboard features was provided: the simulation of interactive materials allows for a proxy experience on the screen. The proxy experience enhances self-efficacy, provides motivation, and leads to continued motivation to learn [29]. No one dropped out because the interactive materials kept them engaged [29]; the variety of interactive, multimedia, and hands-on elements helped maintain the nurses' curiosity and interest [43]; fun quiz formats could be used [26]; and innovative and interactive features retained the participants' interest [35]. Regarding motivation, the authors stated that adding incentives increased extrinsic motivation [11], and the connection of learning content to clinical experience increased intrinsic motivation [71]. Creating an active learning experience that promotes a sense of accomplishment among learners to increase motivation is necessary [30].

Issues related to asynchronous e-learning

The challenges related to asynchronous e-learning were as follows: the need for communication between learners and educators [57, 58]; lack of real-time feedback [71]; the influence of module and evaluation design on learning effectiveness [58]; possible failure to complete the entire module by some participants [58]; lack of time to study lengthy content [26, 51, 62]; lack of computer skills [33, 37, 51]; internet connection problems [9, 33]; lack of follow-up to prevent dropping out [56]; and lack of incentives to stay motivated [26]. Consequently, the need to provide opportunities to observe actual situations [71] has been highlighted, as asynchronous e-learning was considered insufficient for improving confidence [47] and practical skills [22, 71].

The onboard features in gamification present some risks; for instance, in situations involving differences or discontinuities in spatial position and timing of movements between practice with web-based game scenarios and real-life scenarios, game users might negatively modify their performance, and an inappropriate transfer of skills may occur. Moreover, a negative transfer may occur when game users find that the skills they see in the game differ from those needed in real life [67]. It was also stated that research designs to measure the educational effectiveness of e-learning are insufficient because there is a lack of good-quality RCTs to compare the effects of purely digital education [12]. In particular, few studies have measured outcomes on the impact of gamification, and those that have identified educational or clinical outcomes have low power and little clear evidence [67].

Discussion

Interactive modules and videos are the most frequently used enabling technologies under TEET. In contrast to face-to-face learning or synchronous e-learning, asynchronous e-learning lacks the feeling of being taught directly in real-time. As learners can engage with e-learning modules at their own pace, this may affect their motivation levels. Cheng [79] explored the relationship between intrinsic and extrinsic motivation in nurses’ e-learning. Interaction was one of the most essential factors in the e-learning environment. Based on the Technology Acceptance Model and flow theory, three types of interaction factors (i.e., learner-system interaction, instructor-learner interaction, and learner-learner interaction) that lead to nurses’ acceptance of e-learning systems were studied. The results revealed that instructor–learner interaction was the most crucial antecedent factor impacting nurses’ extrinsic motivation. Notably, learner-learner interaction greatly influences nurses’ intrinsic motivation, suggesting it can promote their learning persistence [79].

The guiding framework for developing asynchronous e-learning modules for healthcare professionals by Sinclair et al. (2017) [80] provides 10 guidelines for creating engaging and effective asynchronous e-learning programs. It states that because many purported e-learning programs have limited interactivity, developing and delivering engaging and pedagogically sound e-learning programs must be based on evidence-based instructional design principles. Interactive elements are required to provide learning guidance, content, and feedback [80]. Therefore, considering the three types of interactions (learner–system, instructor–learner, and learner–learner), using interactivity at the necessary stages can help maintain learners’ motivation.

Video module was the most frequently used enabling technology among the TEET options. Videos and other images can promote a person-centered approach in health professional education and motivate learners by using text, videos, and audio files to introduce them to the “person” under their care. This indicates that by relating to the patient or person who needs nursing care, learners experience a sense of connection and are motivated despite the individualistic asynchronous e-learning method. This method would help learners view their learning as a meaningful engagement with real people [32, 80]. Personal stories are powerful and effective methods for adult learners to retain information [81]. Videos are an effective means of learning because they provide a realistic sense of a particular place or scenario.

Regarding technological enhancement, there was no significant increase in innovations aimed at enhancing internal motivation, but scenario-based learning and gamification are likely to develop further [82]. Innovative e-learning is also being developed to integrate technologies such as virtual reality, virtual patient simulation, and virtual hands-on training to provide activities beyond the linear presentation of information in an e-learning format [1, 12]. These novel e-learning programs are expected to be adopted in clinical education and e-learning in future nursing studies. Using such innovative e-learning methods is expected to benefit knowledge acquisition and the ability of learners to connect what is learned with clinical practice, behavioral change, clinical judgment, and clinical reasoning levels.

The results of the present scoping review also revealed that, in recent years, many studies using video technology and simulation had evaluated skills as outcomes. In the past, the educational effects of e-learning on the continuing professional development of health personnel had focused mainly on learner satisfaction and knowledge acquisition, as the impact on practical behavior change has been considered difficult to assess [80]. There is limited research on evaluating more advanced aspects of education, such as behavioral change and the application of learning in clinical practice [80]. Therefore, there is a need for evaluation metrics or indicators aimed at behavioral change and skill development from innovative e-learning modules [83].

In addition, e-learning and evaluation metrics for TEET options and delivery methods should consider factors that facilitate and inhibit e-learning. Regmi and Jones [10] conducted a systematic review to identify and integrate the facilitating and inhibiting factors influencing e-learning in health sciences education. Their conceptual framework included three broad factors: “design and delivery,” “learning outcomes,” and “policy context” [10]. Because the authors found a clear link between the delivery mechanism of e-learning and the potential learning outcomes, developing asynchronous e-learning modules in light of these three factors can help increase external motivation among nurses.

Our scoping review had some limitations. The TEET modules used for e-learning were not standardized, so we judged based on the text descriptions, which may have caused a selection bias. We may also have missed some functions not detailed in the text. As gray literature was not searched, it is possible that some studies were missed. To grasp a wide range of data on asynchronous e-learning in this scoping review, we included pure online and blended learning. While we extracted content related to asynchronous e-learning in terms of benefits and challenges, the results were likely influenced by the effect of blended learning.

Considering that limiting the scope of this study to nurses would eliminate a wide range of asynchronous e-learning methods, we also expanded the scope to health personnel. However, nurses accounted for a large proportion of the health personnel. As more and more research on asynchronous e-learning is expected to be conducted in the future, subsequent reviews may focus on only nurses to determine the results of the review strategy.

Conclusions

Using data from the 60 articles on asynchronous e-learning, we categorized the technological approaches, modes of delivery, and outcomes. The most commonly used TEET options were interactive online modules and videos. The popularity of other advanced TEET options, such as computer simulations and gamification, is expected to increase in the future. Furthermore, outcome measures need to be continuously developed, considering that e-learning continues to evolve. Three types of interactions, namely, learner–system, instructor–learner, and learner–learner, are important for asynchronous e-learning. Therefore, using interactive features at necessary stages can help promote motivation among the learners.