Measurement of information and communication technology experience and attitudes to e-learning of...

REVIEW PAPER

Measurement of information and communication technology

experience and attitudes to e-learning of students in the healthcare

professions: integrative review

Ann Wilkinson, Alison E. While & Julia Roberts

Accepted for publication 17 November 2008

Correspondence to A. Wilkinson:

e-mail: Ann.wilkinson@kcl.ac.uk

Ann Wilkinson BA MPhil RSW

Lecturer in Learning Technology

King’s College London, Florence Nightingale

School of Nursing and Midwifery, UK

Alison E While BSc PhD RN

Professor of Community Nursing

Julia Roberts PhD RN RCNT

Senior Lecturer

Head of Department of Specialist Care,

WILKINSON A., WHILE A.E.WILKINSON A., WHILE A.E. & ROBERTS J . (2009)ROBERTS J . (2009) Measurement of informa-

tion and communication technology experience and attitudes to e-learning of

students in the healthcare professions: integrative review. Journal of Advanced

Nursing 65(4), 755–772

doi: 10.1111/j.1365-2648.2008.04924.x

AbstractTitle. Measurement of information and communication technology experience and

attitudes to e-learning of students in the healthcare professions: integrative review.

Aim. This paper is a report of a review to describe and discuss the psychometric

properties of instruments used in healthcare education settings measuring expe-

rience and attitudes of healthcare students regarding their information and

communication technology skills and their use of computers and the Internet for

education.

Background. Healthcare professionals are expected to be computer and infor-

mation literate at registration. A previous review of evaluative studies of com-

puter-based learning suggests that methods of measuring learners’ attitudes to

computers and computer aided learning are problematic.

Data sources. A search of eight health and social science databases located 49

papers, the majority published between 1995 and January 2007, focusing on the

experience and attitudes of students in the healthcare professions towards com-

puters and e-learning.

Review methods. An integrative approach was adopted, with narrative descrip-

tion of findings. Criteria for inclusion were quantitative studies using survey tools

with samples of healthcare students and concerning computer and information

literacy skills, access to computers, experience with computers and use of com-

puters and the Internet for education purposes.

Results. Since the 1980s a number of instruments have been developed, mostly in

the United States of America, to measure attitudes to computers, anxiety about

computer use, information and communication technology skills, satisfaction and

more recently attitudes to the Internet and computers for education. The

psychometric properties are poorly described.

Conclusion. Advances in computers and technology mean that many earlier tools

are no longer valid. Measures of the experience and attitudes of healthcare

� 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd 755

J A N JOURNAL OF ADVANCED NURSING

students to the increased use of e-learning require development in line with

computer and technology advances.

Keywords: attitudes, e-learning, experience, health professions education,

information and communication technology, literature review, measurement,

nurse education

Introduction

Successive reports on emerging technologies relevant to

higher education (New Media Consortium, 2006, 2007,

2008) indicate that the information literacy of students

entering higher education is not improving and that

academics are not keeping pace with the potential of

mobile technologies for education. Universities are expected

to educate healthcare professionals who, at the point of

registration, are computer and information literate. In the

United Kingdom, the Knowledge and Skills Framework

(Department of Health, 2004) requires registered healthcare

professionals to be aware of and keep up-to-date with the

knowledge base of their professions. Core skills include the

ability to use electronic libraries, critically appraise evi-

dence for healthcare, and provide health information for

service users.

Studies worldwide suggest that healthcare professionals are

not confident at the point of qualification. For example, 53%

of graduating Finnish nurses reported positive attitudes to

using IT for nursing but inadequate IT skills for practice

(Saranto et al. 1997). Similarly, a Canadian study (Balen &

Jewesson 2004) showed that registered pharmacists required

additional information and communication technology (ICT)

skills for effective practice. Elsewhere it is reported that

medical students are disadvantaged by poor access to online

knowledge resources needed to improve health outcomes

(Bello et al. 2004, Samuel et al. 2004). A national study of

Australian nurses identified both limited preregistration

training and lack of confidence with computers by Registered

Nurses (Hegney et al. 2006).

A UK literature review of computer-based learning (CBL)

(Lewis et al. 2001) showed that there were difficulties in

measuring students’ attitudes to CBL and no reliable

instruments. In addition, Lewis et al. (2001) and Chum-

ley-Jones et al. (2002) in the United States of America

(USA) noted that there was no good method for differen-

tiating between different learners and that more careful

attention needed to be paid to these variables in future

studies.

The review

The aim of the review was to describe and discuss the

psychometric properties of instruments used in healthcare

education settings measuring experience and attitudes of

healthcare students’ regarding their ICT skills and their use of

computers and the Internet for education.

Design

A quantitative methodological review using an integrative

approach with narrative description of findings, as described

by Whitemore and Knafl (2005), was chosen to permit the

inclusion of studies using a variety of methods.

Search methods

The literature on computer experience and attitudes is

multidisciplinary; as a consequence, a separate search strategy

was formulated for each of the major bibliographic databases

in health, education and social science (Table 1). There were

three variables of interest: e-learning; attitude and experience;

and the healthcare professions. The search was limited to

papers written in English from 1995 to January 2007. This

timeframe coincides with the transition from small develop-

ments of CBL to ubiquitous Internet and ICTs (Smith 2005)

and worldwide expansion of higher education (Duke 2002,

Cornford & Pollock 2003). Preliminary searches, Zetoc Alerts

and reference tracking yielded earlier studies.

Search outcome

The results (n = 2628) were imported into Endnote and initial

filtering removed duplicates, non-peer reviewed papers, items

about patient education, staff/educator experience, satisfac-

tion studies and measures of learning styles, leaving 292 items

for detailed appraisal (Figure 1). The main exclusion criteria

were: instrument insufficiently described; experimental study

A. Wilkinson et al.

756 � 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd

with no measure of attitudes or experience of students; non-

health; and unpublished. Certain key papers pre-1995 which

provided evidence of a history of scale development (e.g.

Stronge & Brodt 1985, Parks et al. 1986) or instruments from

non-health settings which were adopted for healthcare educa-

tion (e.g. Maurer & Simonson 1984) were included.

Quality appraisal

Quality appraisal of individual studies was not undertaken as

the main purpose of the methodological review was to

determine psychometric properties of instruments. One

instrument has been extensively revalidated (Table 4).

Data abstraction and synthesis

Studies were synthesized under the following subheadings:

country, author and date of publication, study design, sample

and response rate, data collection instrument, number of

items in instrument and psychometric testing properties.

Where substantial data were missing, studies were excluded.

Forty-nine papers remained (Table 2).

Results

The studies originated from North America (n = 26), Europe

(n = 15) and the rest of the world (n = 8). Although there was

evidence that tool development was incremental, with

researchers drawing on previous studies, there was incon-

sistent reporting of the research methods used and it was not

always clear whether the instruments had been validated. The

majority of instruments reported originated in North

America and were derived from those first developed in the

1980s. Three approaches to instrumentation were identified;

first, the development and validation of instruments which

were subsequently used in healthcare education settings

(e.g. Loyd & Gressard 1984, Maurer & Simonson 1984,

Jayasuriya & Caputi 1996); second, those drawing on

previous studies to reproduce or revalidate a refined or

composite instrument (e.g. Agho & Williams 1995, Sinclair

& Gardner 1999, Lynch et al. 2000, Billings et al. 2001,

Cragg et al. 2003, DeBourgh 2003, Brumini et al. 2005, Sit

et al. 2005, Maag 2006); and, third, a small number of

instruments were author-created (e.g. Hollander 1999, Ray

& Hannigan 1999, Dorup, 2004; Balen & Jewesson 2004,

Bello et al. 2004).

Combined results of database searches (n = 2628)

Excluded (n = 2336)

Patient education, Staff/Faculty experience Satisfaction studies Measures of learning styles Qualitative studies Clinical education Simulation studies

Studies for evaluation (n = 292)

Included for review (n = 49)

Excluded (n = 247)

Instrument insufficiently described Experimental designs Non health discipline Unpublished

Figure 1 Selection of papers for review.

Table 1 Keywords used in database searches

Database Keywords

CINAHL Internet, World Wide Web, Information Technology,

Computers and Computerization’, computer literacy,

exp computerized educational testing or computerized

adaptive testing, Computer Environment, Computer

Assisted Instruction, virtual learning, VLE, (web-based

learning or web-based learning), (online adj3 learning),

(e-learning or elearning), (electronic adj3 learning),

(computer$ adj3 learn$), confidence, Fear, anxiety

or anticipatory anxiety, Aptitude, access to information

or remote access to information, expectation$, student

attitudes or student satisfaction, nursing education,

midwifery education, education, allied health or

education, dental hygiene or education, occupational

therapy or education, physical therapy or education,

physician assistants or education, social work

Specific search strategies were developed for BNI, Medline, ERIC,

BEI, AEI Web of Knowledge (ISI), PsycINFO and these may be

requested from the corresponding author.

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The literature fell into two groups in focus and method:

studies from the fields of dentistry, medicine and pharmacy

and those from nursing and allied health professions.

Dentistry, medicine and pharmacy

Information and communication technology skills and

literacy

In dental, medical and pharmacy education the majority of

studies used self-report surveys of students’ ICT skills,

information literacy and computer ownership (Grigg &

Stephens 1999, Hollander 1999, Ray & Hannigan 1999,

Lynch et al. 2000, Dorup, 2001, Mattheos et al. 2002, Seago

et al. 2002, Walmsley et al. 2003, Balen & Jewesson 2004,

Bello et al. 2004, Rajab et al. 2005) rather than educational

use. Questionnaires, with the exception of that by Lynch

et al. (2000), were author-developed, with little reported on

validation. Samples were homogeneous and demographic

variables other than sex were rarely reported. A USA cross-

sectional survey of medical students (Lynch et al. 2000)

examined preparedness for computer-based testing (CBT)

using eight items taken from the Loyd and Gressard (1984)

Opinions about Computers Scale and Maurer and Simon-

son’s (1984) Computer Anxiety Scale. Internal consistency of

the modified scale (a=0Æ79), although good, was lower than

for the original scales (a = 0Æ94 and 0Æ95 respectively), which

raises questions about the reliability of the modified scale.

Lynch et al. (2000) isolated three predictive factors indicating

preparedness for CBT: opinions about computers; sex and

sex interacting with previous experience of CBT.

A number of researchers surveyed successive cohorts of

dental or medical students (Grigg & Stephens 1999, Seago

et al. 2002, Dorup 2004) or, simultaneously, several year-

groups (Hollander 1999, Lynch et al. 2000, Walmsley et al.

2003, Rajab et al. 2005). Repeated surveys indicated that

students’ reported that their ICT skills improved over time;

their skills were not always sufficient for their course, and

they needed further training (Grigg & Stephens 1999,

Mattheos et al. 2002). These studies clearly built on the

experiences in previous studies; for example, Rajab et al.

(2005) derived their items from three previous dental surveys

(Grigg & Stephens 1999, Mattheos et al. 2002, Walmsley

et al. 2003) but no psychometric data were reported.

E-learning in medicine

Four further studies explored attitudes to e-learning among

medical students. A US study of medical students (Steele et al.

2002) used a combination of two previously-published scales

to create a two-part Computer Attitude Survey (CAS). Sub-

scale CAS-g, previously validated with healthcareTable

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professionals and students in practice (Startsman & Robinson

1972), surveyed general attitudes to computers, and CAS-e

explored attitudes and comfort with computers for education.

Post-learning intervention respondents also completed CAS-p

evaluating the computer assisted instruction. No details of

validation of the modified scales were given, which compro-

mises the results, given the different sample and the time

elapsed since some items were developed. In Finland, Vuorela

and Nummenmaa (2004) explored medical and sociology

students’ performance and self-confidence in a web-based

collaborative learning environment, predicting that those who

reported positive attitudes and high computer self-efficacy

would engage with the environment. They used five scales:

attitude measurement; computer self-efficacy (Compeau &

Higgins 1995); approaches to learning; computer state anxi-

ety. Vuorela and Nummenmaa (2004) found that expectation,

confidence and learning approach could not be used to predict

outcomes in the learning environment in their sample.

A Swedish study (Masiello et al. 2005) employed an IT-

Learning Questionnaire, with items from two previous

studies and new items. Pre-existing scales were presumed to

be more reliable, although the papers cited (Dewhurst et al.

2000, Slotte et al. 2001) presented no information about

validation. The internal consistency of sub-scales was satis-

factory and three principal components were identified: IT

Orientation, Independent Orientation and Blended Orienta-

tion. These three constructs explained 49% of the variance,

which is just under the 50–60% required to agree factor

structure (Netemeyer et al. 2003). Finally, an online study of

Austrian medical students (Link et al. 2006) examined

computer literacy, computer and Internet use and attitudes

to e-learning. An index on usefulness of e-learning was found

to be moderately reliable, but including two additional items

reduced reliability. No further validation was reported.

Nursing and allied healthcare professions

More systematic efforts to develop or adapt instruments to

measure students’ attitudes to computers and experience of

e-learning are found in the nursing and allied healthcare

literature (Table 3). Few instruments, however, have been

repeatedly used and tested.

Attitudes to computers

The presence of anxiety is considered likely to affect perfor-

mance; thus, Maurer and Simonson (1984) sought items which

would describe behaviour likely to indicate anxiety. They drew

on previous measures of anxiety, and added new items

generated by students; these were then reduced and modified in

two pilot tests. The instrument was then tested for reliability

using test–retest a = 0Æ90, yielding internal consistency of

r = 0Æ94 on test-retest and r = 0Æ96 using a random sample

from a normative study. The new instrument was correlated

against responses to a separate generalized measure of anxiety

and observation of students using computers when they were

assessed as anxious; neutral or comfortable. The refined

instrument was then further validated in a state-wide norma-

tive study with computer professionals, computer users, school

and university students, staff and a non-specific group. It has

been used in studies in nursing (Wilson 1991), allied healthcare

(Agho & Williams 1995, Williams et al. 1996) and medicine

(Lynch et al. 2000). In a US study the unmodified Computer

Anxiety Index (CAIN) (Wilson 1991) was used to test levels of

computer anxiety experienced by students in five schools of

nursing, whether anxiety varied in relation to level of computer

experience and whether there were differences between degree

and associate degree students. While no difference was found

between associate and degree students, more practical experi-

ence of computers was associated with less anxiety. Wilson

(1991) concluded that the CAIN was a valid measure of anxiety

with computers and measured three separate factors: positive

usefulness, expressed fear of computers, and dislike and mis-

trust of computers. Agho and Williams (1995) and Williams

et al. (1996) explored US allied healthcare students’ attitudes to

computers and perceptions of computer literacy using CAIN

(Maurer & Simonson 1984) and a modified computer knowl-

edge survey (Parks et al. 1986). They found the instruments to

have high reliability in their study and the 26 items of Maurer

and Simonson (1984) formed a single factor (Table 2).

Stronge and Brodt (1985) developed the Nurses’ Attitudes

Towards Computerisation (NATC). The initial 66 item self-

report questionnaire was reduced to 20 items in a pilot study

in the workplace with US nursing students. They proposed

the instrument as a reliable 6-factor scale but the sub-scales

were challenged in later studies with larger samples. It has

been adopted, adapted or revalidated (Table 4) by a number

of authors for use with both Registered Nurses and nursing

students (Schwirian et al. 1989, Scarpa et al. 1992, Stockton

& Verhey 1995, Jayasuriya & Caputi 1996, McBride &

Nagle 1996, Bachman & Panzarine 1998, Brumini et al.

2005). Schwirian et al. (1989) used the NATC in a compar-

ative study of nursing students and Registered Nurses. While

confirming that overall reliability was high, they proposed

three subscales: Computers and Patient Care, Computers and

Personal Security, and General Attitude. Three items, how-

ever, did not fit into any construct and there were small

variations in the factor loadings between students and nurses.

A replication study (Scarpa et al. 1992) with a sample of

nurses with varying demographic profiles showed that

only previous computer experience was related to positive

A. Wilkinson et al.

attitude. While they established similar reliability to that in

the previous study, their factor analysis identified five factors

different from those of Stronge and Brodt (1985). Three items

did not load on to a single factor and all positive items loaded

on to one factor. Further testing with larger samples was

proposed.

Stockton and Verhey (1995) conducted reliability testing of

the instrument using US hospital nurses in two phases over

16 months. There were personnel changes between Time 1

and Time 2, but the populations were described as demo-

graphically similar. They confirmed the instrument’s overall

high reliability but expressed doubts about the number of

sub-scales and, after factor analysis, questioned whether, out

of three identified, the factors were independent as the

reliability was reduced in two factors and all the positive

items were located in factor 1.

Jayasuriya and Caputi (1996) retrieved 72 items from

international studies, including Stronge and Brodt’s (1985)

instrument, and reduced the number using a review panel to

yield a 40-item instrument, the Nursing Computer Attitudes

Inventory (NCATT). The instrument was then administered

to nursing students. Following factor analysis, five factors

were identified which contributed to 57% of the variance.

They subsequently used the NCATT instrument with

Australian Registered Nurses in practice and nursing students

at university. The student sample also completed Dambrot

et al. (1985) Computer Attitude Scale (CATT), which was

extracted from a 20-item tool (a = 0Æ84). The NCATT scale

Table 3 Details of computer attitude self-report measures

Instrument Developed by Used or adapted by Used in

Computer Attitude

Scale (30 items,

3 factors, overall

Cronbach’s a = 0Æ95)

Loyd & Gressard

Sinclair & Gardner 2004,

Lynch et al. 2000,

Curtis et al. 2002,

University & Schools;

education, medicine,

nursing

Computer Anxiety Index

(CAIN) (26 items,

test retest r = 0Æ90, overall

Cronbach’s a = 0Æ94)

Maurer & Simonson

Wilson 1991, Williams

et al. 1996, Lynch

et al. 2000, Agho &

Williams 1995,

University, allied health,

medicine, nursing

Nurses attitude toward

Computerisation

(NATC) (20 items,

split half r = 0Æ90)

Stronge & Brodt

Schwirian et al. (1989);

Scarpa et al. (1992);

Stockton & Verhey

1995, Jayasuriya &

Caputi 1996, McBride &

Nagle 1996, Bachman &

Panzarine 1998, Brumini

et al. 2005,

Hospital and University;

nursing

Computer knowledge

survey

Parks et al. 1986 Agho & Williams 1995,

Balen and Jewesson (2004)

drew some items

Staff, students and graduate

students School of Nursing

Computer self-efficacy

10 items IC of

constructs reported >0Æ8

Compeau and

Higgins (1995)

Masiello et al. 2005, Business computing,

medical education

Nursing computer attitudes

inventory (NCATT)

Jayasuriya and

Caputi (1996)

Registered Nurses and

nursing students

Current student inventory

(item bank, no psychometric

information)

Ehrmann, 1997 Billings et al. 2001

Evaluating Educational

Uses of the Internet

(EEUWIN); Sit et al.

2005; Billings et al. 2005,

Schools of Nursing

Technology Attitude Scale (TAS) McFarlane et al., 1997 modified by Maag (2006) Teachers, nursing students

Online Learner Support Instrument

(OLSI) a = 0Æ95

Atack & Rankin, 2002 Registered nurse students

Attitudes to the Educational use

of the Internet (ATEUI)

Duggan et al. 2001 Undergraduate students

(communication, health

promotion)

itudes

(1985)

(1989)

studen

(1995)

Caputi

(1996)

studen

(1996)

studen

(1998)

(2005)

reduce

(14�

reduce

refined

=0Æ 9

studen

lingnes

studen

effici

impact

confiden

expansi

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studen

Confiden

studen

report

A. Wilkinson et al.

was further reduced to 22 items following factor and item

analysis and correlation with the CATT scale. Jayasuriya and

Caputi (1996) identified three factors which contributed to

90% of the variance. One of the factors: Computer Anxiety

correlated highly with the CATT (r = 0Æ51). They reported

that none of the items were derived from the Stronge and

Brodt (1985) NATC items, which may be a further indication

that they had become dated.

The report of a Canadian cross-sectional study of Regis-

tered Nurses and nursing students also critiqued the Stronge

and Brodt instrument (McBride & Nagle 1996) following a

review of previous reported uses of the scale. The authors

questioned the validity of this scale since their findings could

only explain 50% of the variance for the Registered Nurses

and 48% for the students. This finding is congruent with that

of Stockton and Verhey (1995). McBride and Nagle (1996)

also found greater scale consistency for the Registered Nurses

than the student sample. They suggested that the lack of

consistency may in part be attributed to the age of the scale

reducing item validity. The findings from this group of studies

show considerable variability in the number of factors

identified, which may indicate that either the researchers

are using different criteria in conducting the analysis or that

individual items are not valid.

A US study of Registered Nurses undertaking an Internet-

based course on IT (Bachman & Panzarine 1998) used the

Stronge and Brodt instrument. The aim of the study was to

evaluate the impact of a pilot online course. Internal

consistency of the whole scale was different pre- and post-

intervention. Additional subscales on computer use, per-

ceived computer skill and knowledge of the Internet were

developed by the authors in the absence of appropriate

measures. Content validity was assessed by raters and the

reliability of the Perceived Computer Skill sub-scale was

reported (pre a = 0Æ89 post a = 0Æ88).

The Stronge and Brodt instrument focused predominantly

on the introduction of computers to the workplace and, as

well as being dated, it is also less likely to be valid in an

academic setting. In a two-site workplace study with

Croatian nurses, Brumini et al. (2005) used a modified

version of the NATC, with new items from an unpublished

study. Half the 30 items on attitudes to computers were

negatively phrased. Having performed factor analysis, they

decided to work with a 1-factor solution. Limitations of their

study included the cross-sectional design and respondents

being observed as they completed the survey.

Two nursing studies (Curtis et al. 2002, Sinclair &

Gardner 1999) drew on Loyd and Gressard’s (1984) Com-

puter Attitude Scale developed for use in schools. Sinclair and

Gardner (1999) surveyed diploma nursing students in North-

ern Ireland to measure their perceived competence, attitudes

and previous IT training against a knowledge test. Three

factors were identified: confidence in using computers,

motivation to use, and perception of career-related impor-

tance of computers. Those with previous knowledge and

training had statistically significantly higher levels of confi-

dence (P < 0Æ001) and motivation (P < 0Æ01) but there was

no statistically significant difference in their perception of

career-related importance. Sinclair and Gardner (1999)

recommended a change from identifying students’ basic skills

to identifying their ability to apply those skills in practice.

Curtis et al. (2002) used the scale with small amendments to

survey Irish undergraduate Registered Nurses and found

positive attitudes and moderate to high skills but did not

report confidence levels or validation. A further Irish study

(Adams & Timmins 2006) with Registered Nurses on a part-

time access to degree programme used an author-developed

instrument with items developed from the literature (a = 0Æ86)

to explore access to and use of computers and the Internet and

the relationship to demographic variables and usage patterns.

However, as no further psychometric data were reported there

was little potential to draw on or replicate these studies. A

subsequent US national study (Maag 2006) drew on Sinclair

and Gardner (1999) work and suggested that sound education

about the use of technology would have an impact on nursing

students’ future use of technology for patient care. To provide a

baseline for educators, they developed a modified Technology

Attitude Scale (TAS) to explore students’ attitudes and views

towards using technology. In common with previous studies,

the TAS addressed education to use computers and not

educational use.

e-Learning

A small number of recent studies have used instruments to

explore healthcare students’ experience of using computers

specifically for education. A US study (Duggan et al. 2001)

identified a lack of instruments to measure student attitudes to

the educational use of the Internet and the researchers devel-

oped and validated an 18-item scale, Attitudes to the Educa-

tional Use of the Internet (ATEUI), in three stages. Educational

literature provided a pool of 60 statements, subsequently

reduced to 33 and administered to students to determine the

scalability of items and then operationalised with a new sample

when 18 items were retained. The pilot AETUI, combined with

behavioural statements, was completed by a further student

sample (a = 0Æ89). The final instrument was administered with

a further group of students enrolled on communication and

health promotion courses (a = 0Æ91).

The findings of Duggan et al. (2001) suggest that students

who are in control of their learning have positive attitudes,

and this theme is echoed in a UK cross-sectional study with

postgraduate teacher trainees and pre and postregistration

nursing students (Wishart & Ward 2002), which suggested

that there was an association between attitude to computers

and user sense of internal control. Wishart and Ward (2002)

chose the previously-validated Duttweiler Internal Locus of

Control Index (Duttwieler 1984). An additional seven items

focused on computer attitudes and questions about their

computer use, ownership and experience. There is no

evidence that the amended instrument was validated as part

of the study.

Atack and Rankin (2002), in a pre and post-test evaluation

of web-based learning (WBL) by Canadian Registered

Nurses, developed a two-part instrument. Items on computer

skills and access were combined with five sub-scales measur-

ing interaction, design, technology, environment and impres-

sions. The authors highlighted the variation in responses

concerning interaction and learning from the work environ-

ment, which were congruent with the findings of larger

studies (DeBourgh 2003, Billings et al. 2005, Sit et al. 2005).

In a similar UK pre and post-test pilot study, Wilkinson et al.

(2004) used an author-developed instrument,with seven

subscales to explore computer use; online learning; distance

learning; evaluation (post); learning outcomes; support; and

utility with Registered Nurses on four courses. Respondents

reported more positive orientation to online (P = 0Æ04) and

distance learning (P = 0Æ02) post-course. Those who reported

prior use of ICTs were more likely to complete the course.

Both these studies were small, exploratory and uncontrolled

and had participant attrition.

Researchers have used the national evaluation programme

of the American Association of Higher Education (AAHE)

(Billings et al. 2001), which is focused on educational

technology. In this national evaluation programme conducted

by the AAHE and known as the Flashlight programme (now a

non-profit Teaching Learning Technology Group) an item

bank of ‘validated’ questions, the Current Student Inventory

Toolkit (CSI), on educational technology was created for

researchers to use (See http://www.tltgroup.org/flashlightP.

htm). Billings et al. (2001) drew upon this bank of questions to

develop and pilot an online 52-item instrument called Eval-

uating Educational Uses of the Internet (EEUWIN) to validate

an educational model with nursing students across three

universities. The reliability of the 52-item EEUWIN was good

but no data were reported for its sub-scales. In the pilot study

positive relationships were identified between student distance

from the campus, older age and convenience, satisfaction and

connectedness. In a later study, Billings et al. (2005) investi-

gated generational differences among nursing students across

six universities using a revised 57-item EEUWIN.

In a Hong Kong study with Registered Nurses taking one

or more online courses researchers also used 27 items from

the CSI to ask questions about overall satisfaction with

online courses and the perceived barriers to online study

(Sit et al. 2005). The items were reviewed by an educational

team for content validity related to six themes. Internal

consistency and test–retest reliability of the CSI were

evaluated but the data were not reported. The researchers

found seven facets which explained 54% of overall

satisfaction: convenience; confidence to tackle difficult tasks;

understanding concepts; taking responsibility for learning;

interactivity; supplementary face-to-face interaction; and

multimedia. Convenience was the most important factor in

satisfaction but a major hindrance was lack of face-to-face

interaction.

A US study of Registered Nurses (DeBourgh 2003) had

similar findings using a 59-item Student Satisfaction Survey

derived from an existing instrument, with added items on

computer-mediated communication identified from literature

searches on student satisfaction with distance education.

DeBourgh (2003) tested reliability coefficients for eight facets

(five student and three teacher characteristics) and these

varied from poor to good. Technical aspects cited as the most

frequent source of negative attitudes in the literature.

DeBourgh (2003), however, concluded that the human

interface issues represented by quality of the instructor

remained the most important factor in satisfaction with

distance learning. This study was limited by its small

homogeneous sample. The ability of teachers to apply

educational principles to the use of technology was a major

influence on students’ satisfaction in another US cross-

sectional study (Bloom & Hough 2003) exploring nurse

and health science students’ engagement with technology-

enhanced learning before and during their course and the

quality of the experience. The author-developed instrument

was validated by a rating panel and pilot test. Reliability for

the second part of the instrument concerning experience and

comfort with technology-enhanced learning was a = 0Æ85.

New studies are emerging from other regions of the world.

In a Canadian/Chinese study of Registered Nurses, Cragg

et al. (2003) combined and made small changes to existing

scales to measure Attitudes Toward Computers (ATC) The

authors developed a new scale Attitudes Towards the Internet

based on the ATC scale which, except for the affordability

sub-scale (a = 0Æ53), had similarly good to excellent reliabil-

ity. The scales were translated into Chinese and validated. In

New Zealand, Honey (2004) surveyed Registered Nurses

using an author-developed instrument incorporating items

from previous studies in a cross-sectional study to scope the

feasibility of introducing online learning. There was no

A. Wilkinson et al.

description of instrument development or psychometric data,

although reference was made to previous research.

A Taiwanese study (Yu & Yang 2006) explored the

attitudes of a random sample of public health nurses to WBL

using an author-developed questionnaire with items gener-

ated from review of the literature, interview and expert panel

resulting in two sub-scales: Basic Computer Competence and

Attitude toward WBL. Overall, nurses were positive about

WBL but rural nurses were statistically significantly more

positive than those in urban settings. Those with computer

skills and access to computers in the workplace were more

positive. There were, however, indications that respondents

had concerns about the quality of learning materials and

being isolated, similar themes to those identified by

DeBourgh (2003) and Sit et al. (2005). A Canadian study

with physiotherapists (Mathur et al. 2005) employed an

author-developed instrument previously used by one of the

authors and amended for face validity and pilot tested but not

further validated. Level of education, level of access to the

Internet, frequency of use, skill and practice area were

positively related to interest in CAI. In contrast to the work of

Billings et al. (2001)and Yu and Yang (2006), distance from

education centres was not related to interest in CAI.

There is some emerging work on the development and

validation of instruments to explore student responses to use

of computers and the Internet for education (Table 3) but

currently no single instrument has been developed and refined

using large samples across a variety of settings. Furthermore,

few such instruments have been either reused or revalidated.

Discussion

The literature search identified instruments used to collect data

on four main topics: assessing ICT and information literacy

skills (e.g. Parks et al. 1986, Maag 2006); measuring attitudes

to computers or computerisation in practice (e.g. Stronge &

Brodt 1985, Jayasuriya & Caputi 1996); attitude and access to

computers and the Internet (e.g. Mattheos et al. 2002, Cragg

et al. 2003); and exploring attitudes to computers and the

Internet for education (e.g. Duggan et al. 2001, Atack &

Rankin 2002, Bloom & Hough 2003). All the studies were

cross-sectional or pre and post- test studies, with no longitu-

dinal studies with repeated measures, and the pre and post-test

intervention studies were of single units or modules of WBL

with consequential small sample sizes (Atack & Rankin 2002).

More recent studies have focused on attitudes to web-based

and distance education and have explored interrelationships

between all the above topics.

Methodological details of many studies were inadequately

described, creating concerns about instrument validity and

reliability (e.g. Grigg & Stephens 1999, Mattheos et al. 2002,

Seago et al. 2002, Hegney et al. 2006). In descriptions of the

instruments, face and content validity were more consistently

discussed than other aspects of validation and included the

use of subject experts, reference groups or themes derived

from the literature (e.g. Mathur et al. 2005, Hegney et al.

2006). Since the 1980s there have been substantial changes in

the capacity and incidence of ICT use in higher education,

and therefore items designed to report their usage, responses

to and comfort with ICT may have lost their validity over

time. The only instrument that was repeatedly tested in

healthcare education and practice (Stronge & Brodt 1985) is

now dated and proved more reliable with nurses working in

hospitals than with nursing students. The variation in factors

identified by successive investigators also limits comparison

across studies. Earlier instruments which were rigorously

developed had higher reliability than those described more

recently, but this may be the result of rapidly-changing ICT.

Methodological detail was reported less in the medical

literature than in the nursing and allied healthcare studies

included in the review. A number of reports, the majority

medical, gave limited information on instrument design, pilot

work or psychometric properties (Hollander 1999, Ray &

Hannigan 1999, Steele et al. 2002, Walmsley et al. 2003,

Bello et al. 2004). While items were often derived from

previous measures, it was not always clear where individual

items originated, and the final instrument was rarely pub-

lished (Curtis et al. 2002, Honey 2004). There are few studies

where the samples were derived from more than one

institution and/or discipline group, so that there are limits

to the transferability of findings. Replication of studies is

difficult as the work of Scarpa et al. (1992) demonstrated,

since prior reports did not give complete psychometric

information for useful comparative analysis. There was often

no consistency in the demographic sections of instruments,

and authors presented very varied and often limited infor-

mation about study samples. This may be a result of

homogeneous populations in many studies, but this is not

always made explicit; therefore, issues remain concerning

differentiating between groups of learners.

To date, no instrument has demonstrated high reliability in

measuring student attitudes to e-learning over more than one

group. However, studies are emerging from outside the US

which address the use of ICT for learning by different

populations (e.g. Sit et al. 2005, Link et al. 2006, Yu & Yang

2006). Online learning has been targeted by universities as an

area of growth, but there have been examples where such

initiatives have failed, for example the UK e-University

(House of Commons Education & Skills Committee 2005).

This review suggests that little is known about either the

preparedness or views of healthcare students in relation to

online education. Furthermore, the items in early instruments

no longer reflect terminology used in connection with current

ICT skills and rarely consider the use of communication other

than e-mail.

Conclusion

Further research is needed to identify what should be

measured. Previous tools used to gather reports of respondents’

ICT skills need to be updated if they are to be relevant and valid

for contemporary healthcare professionals. The requirement

for nurses, for example, to access information, critically

appraise and then synthesise it for others indicates that

instruments which survey students’ ability and confidence to

make more complex use of ICTs are required. ICT use is

becoming ubiquitous in higher education and the workplace,

and so educators need to know whether students on healthcare

programmes are equipped with the requisite skills.

While there have been a number of studies exploring the

skills, attitudes and experience of healthcare students regard-

ing ICTs and ICTs for education, there have been no large

scale or longitudinal studies exploring whether attitudes

change during and after education. Continued expansion of

web-based learning at all levels, the mobility of the healthcare

workforce and the need for this workforce to have flexible

modes of continued education mean that it is imperative to

develop and validate instruments to explore students’ expe-

riences with e-learning and to develop models for engaging

students in e-learning.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Author contributions

AW, AEW & JR were responsible for the study conception

and design. AW performed the data collection. AW per-

formed the data analysis. AW was responsible for the

drafting of the manuscript. AEW & JR made critical revisions

to the paper for important intellectual content. AEW & JR

supervised the study.

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