Health, 2015, 7, 955-964
Published Online August 2015 in SciRes. http://www.scirp.org/journal/health
http://dx.doi.org/10.4236/health.2015.78113

Efficacy and Usability of an E-Learning
Program for Fostering Qualified
Disease Management Nurses
Kana Kazawa1, Michiko Moriyama1, Michiyo Oka2, Satsuki Takahashi3, Madoka Kawai4,
Masumi Nakano5
1

Chronic Disease Management Project Research Center, Institute of Biomedical and Health Sciences, Hiroshima
University, Hiroshima, Japan
2
Graduate School of Health Sciences, Gunma University, Gunma, Japan3
School of Nursing, Gunma Prefectural College of Health Sciences, Gunma, Japan
4
Division of Nursing Science, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima,
Japan
5
Hiroshima City Asa Hospital, Hiroshima, Japan
Email: kkazawa@hiroshima-u.ac.jp
Received 22 July 2015; accepted 10 August 2015; published 13 August 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract
In order to train nurses to perform disease management and telenursing, we developed an elearning education program, and assessed the efficacy. A single-group pre-test and post-test design was used. Nurses who worked at a medical institution or a disease management company
were included, and the duration of the program was set 2 months. We developed the program sothat it could grow attitude and improve knowledge and skills in disease management and patient
education. Of 55 subjects, 48 who completed the program were analyzed. After the program, subjects increased knowledge and interests in disease management and patient education. Almost of
the subjects answered that e-learning was a good learning method. Our program was effective atenhancing subject’s interests in disease management and patient education, and considered to
improve their skills in the future.

Keywords
E-Learning, Education Program, Disease Management, Telenursing

How to cite this paper: Kazawa, K., Moriyama, M., Oka, M., Takahashi, S., Kawai, M. and Nakano, M. (2015) Efficacy andUsability of an E-Learning Program for Fostering Qualified Disease Management Nurses. Health, 7, 955-964.
http://dx.doi.org/10.4236/health.2015.78113

K. Kazawa et al.

1. Introduction

With the change of disease composition, the healthcare system in the world has been required to change the targets from infectious diseases to non-infectious diseases (chronic diseases). However, since the structural reform
has not caught up the change, there are unmet needs for chronic disease care, resulting in disease worsening andmedical expense increase [1]-[3]. The situation is the same in Japan, and to solve this problem, in 2013, thegovernment obligated all health insurers to carry out a data-health project aimed at improving health in their insured people and keeping reasonable medical expense [4]. Before this motion, we put into practice a new modelthat provided chronic disease care based on the disease management methodology in Japan. These programs
were effective at preventing disease progression in patients with chronic illnesses and may contribute to thecontainment of medical costs [5]-[11]. Disease management was an outcome management method that was
proposed early by the Disease Management Association of America, in order to properly allocate limited medical resources and provide high-quality healthcare with containing medical expense [12]. Disease management
includes the following factors: 1) identification of a target population, 2) provision of standardized medical
treatment and patient education based on evidence-based clinical practice guidelines, 3) interprofessional collaboration, 4) analysis and evaluation of outcomes and processes, 5) feedback to health care professionals and patients [13]. In disease management, we considered that nurses were the best players because they were good atarranging with professionals and services and specialized for patient education. Therefore, we have fostereddisease management nurses (DM nurses) who perform disease management. Furthermore, we also consideredthat in order to provide care widely, the nurses should obtain the ability of practical telenursing that allowed
them to communicate with people in remote areas and contain healthcare expense. Therefore, we set up a program for fostering disease management nurses using electronic learning (e-learning) on disease management andpatient education for patients with a chronic disease (e-education for DM nurses). We developed our programusing e-learning, because we considered that e-learning could be a good way for nurses to learn at their own
pace at workplace or home and that it could ensure the number of disease management nurses nationwide andguarantee their quality. Regarding the efficacy of e-learning for students, several articles reporting e-learning
education used in nurse training faculties and they mentioned that e-learning was not inferior to the traditional
face-to-face education in improving subject’s knowledge and their practical ability as well as their satisfaction[14] [15]. Also, for the registered nurses, there are many articles reporting that education using e-learning resulted in improvement of subject’s knowledge and skills [16]-[18]. These reports used themes such as diseases
and nursing skills, and there has been no study on the theme of acquiring comprehensive ability including disease management and patient education. In addition, although it has been reported that patient education that is
structured based on theories and evidences can improve outcome [19]. However, no study has shown the processof developing e-learning on improving the ability of patient education, and incorporated theories.
Therefore, in this study, we developed the e-learning education program on nurses who implemented disease
management in order to foster comprehensive ability integrating knowledge and skills of disease management,
patient education, and behavior modification. Then, we assessed the efficacy and the operability. If we can assure the quality of disease management nurses above a certain standard, it would guarantee the quality of disease
management project in Japan.

2. E-Education for DM Nurses
2.1. Program Structure, Themes, and Goal Setting
The program structure is shown in Figure 1. Based on the classification of educational objectives proposed byBloom et al. [20], we incorporated three dimensions of attitude, knowledge and phsychomotor skills as theframeworks. The goal of our program was to “train generalist nurses to perform chronic disease management
and telenursing” and generalist nurses were defined as nurses who had graduated from a basic nursing education
course (professional school or university undergraduate education) and had clinical experience.
For the program structure, we selected outlines of disease management (including health assessment/nursing
process), knowledge about characteristics of chronic diseases that are keys for disease management, care coordination, communication and quality management as the 5 themes. As “disease management”, we included
items such as definition and structure of disease management, program-developing process, evidence based
medicine, patient education (including cognitive behavior therapy), and care triangulation (Emic: subjective956

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Figure 1. The structure of education program.

approach taking into account Illness Narrative and Etic: objective approach taking into account data based onevidence). For the developing process, we built it up to follow the same course as nursing process that goes thorough comprehensive health assessment on patient’s disease and risk factors from the physical, mental and social aspects, intervention, evaluation and feedback. For “knowledge of disease characteristics”, we included diseases with a high incidence, i.e. metabolic syndrome, diabetes, diabetic nephropathy, ischemic heart disease,heart failure and stroke, and constructed the contents for the disease, diagnosis, standard treatment, medical caremanagement and management goals and patient education, based on practice guidelines [21]-[25]. Furthermore,
we included detailed contents to support acquiring self-management skills. For “care coordination”, we definedthat it was to assess needs of medical resources, support the patient and their family’s decision making, andcoordinate multidisciplinary collaboration. Therefore, in addition to skill of stratification, we educated on methods to assess medical resources and create medical and local collaboration, methods and skills of care coordination, and methods to support families as a care unit. For “communication”, we educated on skills required forpatient education, communication with physicians and telenursing. As skills required for patient education, themotivation interview methods, coaching, cognitive behavior therapy and behavior change skills were included[26] [27]. For “quality management”, knowledge and skills required as research nurses (mainly, data monitoring,data management and personal data protection) and utilization of IT systems were included. Finally, as a summary of these lectures, we used videos illustrating physical examination and patient education techniques, suchas the techniques for actual interviewing and telenursing (role play with simulated patients), for motivation interview methods, for management of diseases.

2.2. Development of E-Learning
Characteristically, e-learning is a way to learn subjectively, individually and repeatedly at learner’s own pace,with enjoyment and easy understanding using senses of vision and hearing as well as a way to acquire the decision-making ability by following thinking process of experts in special fields [28]. We prepared lectures of 20 to
80 minutes for each theme and if the duration was longer than 20 minute, we divided it by 20 minutes, so that
subjects could learn easily and repeatedly at their own pace.
For each theme, physicians and nurses specialized in the field, nurses specialized for managing chronic diseases, nurses certified for motivation interview, specialists for behavior change, physical therapists for exercise
therapy and nutritionists for diet therapy performed the lecture. In the part of role play, nurses specialized forchronic disease management actually demonstrated. The screen layout of e-learning consisted of movies showing teachers giving their lecture and learning materials simultaneously.

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2.3. Evaluation Tests
For individual themes, we set 10 yes-no questions based on the lecture to evaluate acquisition levels of learning.

3. Methods
3.1. Subjects
Nurses who worked at an acute-care hospital or a disease management company, and agreed to participate in the
study. Clinical experience should be at least 3 years and those who were during the postpartum period or thechildcare leave could be included. We did not consider the specialized area of working and the level of basic
education (university (undergraduate, graduate) or professional school). Exclusion criteria were assistant nurses,
midwifes, nurses in manager positions (director of nursing, assistant director, ward manager).

3.2. Period of Analysis
April-December, 2014.

3.3. Research Design
A single-group pre-test and post-test design was used.

3.4. Primary and Secondary Endpoint
Evaluation indicators were set with reference to the classification of education targets [20]. In the classification,
it is considered that most behaviors that arise from learning results involve 3 domains, i.e. “the cognitive domain”
associated with acquiring knowledge, understanding and developing intellectual abilities, “the emotional domain”
associated with developing interests, attitude and sense of value as well as emotion, proper judgment and adaptability, and “the psychomotor domain” associated with technical skills and motor skills. In addition, it is also
considered that the emotional domain is corresponding to results from developing the cognitive domain. Basedon this, learning effects were measured for the 3 domains, while we operationally defined the cognitive domain
as “subjective evaluation on acquiring knowledge about disease management/patient education”, the emotional
domain as “interests in disease management and patient education” and the psychomotor domain as “acquiring
skills in patient education” and used them as primary endpoints for education effects. The scales to measureachieved level of each domain were prepared as follows by researchers using Likert scale (Table 1).
Secondary endpoints were test scores evaluating acquired knowledge of each e-learning theme. For each subject, the average score was calculated for each theme.
In addition, for the program operability, subjects were asked to evaluate 1) the duration of e-learning (20minutes sessions), 2) the numbers of themes and subthemes, 3) easiness of taking the program, 4) acceptance asa learning tool, in likert scale of 3 or 4 grades and also they could comment voluntary for the items.

3.5. Data Collection
Scores for the emotional domain, the cognitive domain and e-learning tests were obtained from subjects. The
score for the psychomotor domain was obtained by research assistants who evaluated skills of subjects performing patient education on an actual setting. The research assistants only performed the evaluation and were not
involved in analysis. As the schedule for data collection, scores for the emotional domain and the cognitive domain were collected at 2 time points before and after the program. Because we considered that it needed a lot oftime to learn skills for disease management and patient education, scores for the psychomotor domain were collected at 1 time point after the program. Scores of e-learning tests were obtained when the subjects answered
tests before and after completing each theme. Evaluation of the program was obtained at the end of the program.

3.6. Recruitment and Registration Procedures
Nurse managers who agreed to support this study introduced nurses who met the eligibility criteria. The researchers explained them about the objectives and contents of this program orally and in written form, after thatobtained a written consent.

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Table 1. Scales for evaluation of the emotional/cognitive/psychomotor domains.
Domain

Item

Point

Item
number

Score
range

1: not interested 4: interested

55 - 20

1: not understood 4: understood13

13 - 52

1: not achieved 4: achieved

46

46 - 184

Interest in disease management
Challenges for disease management
Emotional
domain(interest)

Disease management is a skill that helps my career as a nurse
Education for noncompliant/non-adherent patients
Confidence to change behavior of noncompliant/non-adherent patients
Disease management
How to apply evidence-based medicine to clinical practice
Pathophysiology of diseases
Treatments for diseases
Examinations for diseases
Self-management education

Cognitive
domain(knowledge)

Outline of care coordination
Care coordination: stratification skills
Care coordination: healthcare collaboration/local cooperation
Care coordination: necessary healthcare resources
Patient education
Cognitive behavioral therapy/cognitive behavior theory
Study method: study design, data management
Health assessment (incl. physical examination): 18 items
Patient education in self-management for behavioral change: 11 items

Psychomotor
domain(skills)

Tele-communication skills: 7 items
Communication with physicians: 5 items
Attitude and manner as a professional: 5 items

3.7. Program Implementation
We gave URL of the e-learning education program to subjects who agreed, and explained how to take the program and that they should complete the program within about 2 months from the enrolled day. We also told thatthey could take the program at any time and any place they wanted. In addition, from the view point of protecting intellectual property, we obtained a written consent to promise proper handling of the program URL.

3.8. Method of Analysis
To compare indicators over time, we used the t-test or the Wilcoxon signed-rank test, and the significance level
was set at p < 0.05. Comments answered voluntarily were summarized inductively.

3.9. Ethical Considerations
Approval was obtained from the ethics committees of Hiroshima University. The researchers explained to subjects about the purpose of this study, learning content, data collection, confidentiality, how the results would be
published, and that they would be free to withdraw. Subjects gave a written consent.

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4. Results
4.1. Outlines of Subjects
Among 55 nurses who agreed to participate in the study, 48 completed the e-education (the completion rate:
87.3%). Seven nurses dropped out the e-education because they were too busy with their work or care giving.
As basic characteristics of subjects, there were 45 females (93.8%) and 3 males (6.2%), and 30 subjects(62.5%) had graduated from a nursing school/a junior college (3-year course), 16 (33.3%) had graduated from a
4-year college, while 2 completed a graduate school as their last academic record.

4.2. Efficacy of E-Learning Program
1) Changes in scores for cognitive domain and emotional domain/ scores for psychomotor domain
Changes in scores for the emotional and the cognitive domains over time and scores for the psychomotor domain are shown in Table 2. Scores for the cognitive and the emotional domains were significantly increased after program (p < 0.01).
2) Changes in test scores for each theme of e-learning
Changes in scores for each e-learning theme before and after completing the theme are shown in Table 3. For
all the items, scores were significantly increased after e-learning (p < 0.001). Especially, scores for knowledge
about disease characteristics rose higher than else scores.
Table 2. Scores for the three domains.
N = 48Mean ± standard deviation

p valuen

Before e-learning

After e-learning

Cognitive domain

48

27.5 ± 4.5

38.9 ± 5.0<0.001***

Emotional domain

48

15.6 ± 2.5

16.7 ± 1.90.001**

Psychomotor domain

19128.0 ± 17.9

Wilcoxon signed-ranks test**p < 0.01, ***p < 0.001.

Table 3. Scores for each e-learning theme.
n = 48Theme

Mean ± standard deviation

Sub themes

p valuen

Before e-learning

After e-learning44

7.2 ± 0.9

8.6 ± 1.0

<0.001***

Metabolic syndrome42

7.1 ± 0.8

9.1 ± 0.9

<0.001***Diabetes

41

6.9 ± 0.8

9.1 ± 0.8

<0.001***Diabetic nephropathy

40

6.8 ± 1.1

9.0 ± 0.7

<0.001***Ischemic heart disease43

7.8 ± 0.9

9.3 ± 0.9

<0.001***

Heart failure44

6.7 ± 1.2

8.8 ± 1.2

<0.001***

Stroke43

7.8 ± 1.2

9.2 ± 0.8

<0.001***

Self-management skill education

43

6.7 ± 1.5

8.8 ± 1.4

<0.001***

Care coordination

45

7.1 ± 1.0

9.0 ± 0.9

<0.001***

Communication

37

7.3 ± 1.0

9.1 ± 0.8

<0.001***

Mean score for all tests

32

7.1 ± 0.8

9.1 ± 0.6

<0.001***

Disease management

Knowledge
about diseasecharacteristics

t-test***p < 0.001.

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4.3. Evaluation on Program Operability by Subjects

Evaluations on the program operability by subjects are shown in Table 4. As a learning method, 47 subjects(97.9%) rated e-learning as “good” or “relatively good”. Regarding the easiness of taking a course, 40 subjects(85.5%) rated e-learning as “easy” or “relatively easy”. There were 7 subjects (14.6%) who rated as “difficult totake” mainly because “it was difficult to write down contents and I wanted a text” or “I want to know my course
record and past test results”.
Regarding the duration of e-learning, 25 subjects (52.1%) rated as “appropriate” and other 22 (45.8%) rated as“too long”. For the numbers of themes included in the e-learning, 14 subjects (29.2%) rated as “appropriate” and34 (70.8%) rated as “too many”. Those who replied that the duration of e-learning was “too long” or that the
number of themes included in e-learning was “too many”, also described “since the course was divided into
short sessions, it was easy to focus on, but it is too hard to complete the all sessions within the term.”
As voluntary comments, we had some distinctive answers, e.g. the learners said that they could repeatedly
learn about disease management based on evidence, and they thought that they understood the processes of patient education and could utilize it in the practice.

5. Discussion
5.1. Operability of Program
Among the subjects, 97.9% replied that e-learning was a good learning method, and 85.5% replied that it waseasy to take, which indicates a high evaluation for the program quality. In addition, the completion rate of the
program was 87.3% and all subjects who stopped the program did so because they were too busy. In this study,
taking into account the operability, we set the time frame at 2 months. However, since some subjects commented in program evaluation that they felt it as a burden to complete the whole program within the limited time,
the operability may be improved if we set a longer time frame.

5.2. Efficacy of Program
Telenursing is a concept that was defined by the International Council of Nurses in 1998, and there have beenvarious reports abroad and in Japan on improvement of disease management and containment of healthcare expenses by telenursing in patients with a chronic disease [29]-[33]. ICN states that the skill of telenursing is a tool
to perform nursing process including assessment, diagnosis, planning, exercise and evaluation for patients, andthat the ability to perform nursing process as well as development of partnership influence the quality of telenursing. In addition, in order to perform disease management, not only evidence-based patient education but also the abilities to support practice and collaborate with other professionals are required [34]. We developed ourlearning program to train and evaluate nurses so that they could acquire knowledge and skills related to them.
The subjects of our program increased scores of e-learning for the emotional domain (interests in disease
management and patient education) and the cognitive domain (subjective evaluation on acquiring knowledge
about disease management and patient education). Also, for the psychomotor domain (patient education skills),
Table 4. Evaluation of the program by the subjects.
N = 48 n (%)
Good

Relatively goodNot so goodBad

25 (52.1)

22 (45.8)

1 (2.1)0 (0.0)

Easy

Relatively easy

Difficult33 (68.8)

8 (16.7)

7 (14.5)

Duration ofe-learning

Too long

Appropriate

Too short

22 (45.8)

25 (52.1)

1 (2.1)

Themes includedin e-learning

Too many

Appropriate

Too few

34 (70.8)

14 (29.2)

0 (0.0)Overall view of
e-learning
Easiness of
e-learning

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we set items that could evaluate skills required for face-to-face and telenursing patient education. However, theevaluation for the psychomotor domain was made only after the program. Although there is the limitation of thestudy, we consider that since we achieved our intended results, the program was structured appropriately.
Knowls stated that in adult learning, it is important to utilize their own experience as abundant learning resources and to show how to apply them in the practice [35]. Also, there were voluntary comments by subjects
such as “I could learn by comparing with my actual experience” and “I would like to make good use in everyday
practice”, and these comments indicate that they could learn deeply using they own experience and that they
could obtain some suggestion for the actual practice. Therefore, we consider that repeated learning using experience and contents along with thinking process of experts based on the practice were effective.
Furthermore, it has been reported that in chronic disease management, education to improve patient’s abilityof self-management is most effective in improving patient’s outcome [19] [36], and it is essential for disease
management. To understand how the intervention by nurses who enhanced their skills in patient education after
our e-learning program could improve outcomes in patients with a chronic disease, it would be necessary to
conduct further investigation.

6. Limitations of the Study and Future Challenges
As the design of our study, we performed tests before and after only in an intervened group and did not set acontrol group, because the nurse administrators of the facilities desired that all nursing staff needed to learn theskills. Also, the evaluation term was short with 2 months, but it is considered that in order to evaluate skill acquisition, a longer term for before-after evaluation and comparison was necessary. However, the positive result
from this study suggests that further investigation with a controlled comparison and a longer-term evaluation
may demonstrate more valuable results.

7. Conclusion
We carried out a nurse training program using e-learning on disease management and patient education, and it
improved subject’s knowledge and interests. We consider that knowledge enhancement through e-learning andlearning along with the process of patient education can contribute to improvement of patient education skills.

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