Learning spaces for health sciences – what is the role of e-learning in physiotherapy and occupational therapy education? A literature review

Abstract

Our aim was to explore the current state of e-learning activities during physiotherapy and occupational therapy education, in relation to theories and models about learning. What kind of e-learning activities were described and which were the intentions behind the use of digital support expressed in current physiotherapy and occupational therapy literature? The search was done using four different search engines. Twenty articles met the inclusion criteria and where included. Three categories of e-learning activities were identified. (1) Communication space, (2) enabling learning activities, and (3) ambition to create a learning space. The first category revolved around the individual use of social media, how it could be developed and the benefits from it in a learning environment. The second category had a narrow focus on a specific element of the learning sequence and how it is mastered and/or perceived. The third category, the theoretical base, is varied covering considerations about the learning itself from constructivist and connectivist origin and theories pertaining to the design of teaching and learning activities. The underlying theoretical support for the activity developed was only described in some of the studies. To furthering the field clearer rationale informed by research developed theories and models would promote system alignment and educational development. This review maybe of value to educators in physiotherapy and occupational therapy as it proposes frameworks that may guide in identifying approaches to improve education.

Keywords:

• Physical therapy
• Occupational therapy
• Undergraduate education
• E-learning digital tools

Higher education is in a constant change and in interaction with its surrounding environment as are the humans involved. A part of this is the digitalization and the opportunities and challenges it offers. The digitalization era is emerging and all educators in higher education today are more or less involved in activities where digitalization plays a passive or active role. Digitalization could be something just occurring at random or carefully tailored to a situation.

As educators, what various aspects are on our minds when planning a course, module, or a program? When planning for learning at program level in the health sciences, most teachers would probably agree on that the intention and main concern is to develop knowledge, skills, and abilities required within the profession. On a more concrete level, as teachers, we need to care about the intended learning outcomes, teaching and learning approaches, literature, and other resources needed. The integration of knowledge, skills, and abilities required in the professions support the use of active learning approaches early on, where meaningful learning promoting a deeper understanding is a corner stone [1,2]. This maybe reflected by the use of a socio-constructivist approach and learning activities such as problem-based learning or case methods. Both methods used long before the opportunities to add digital support to learning were thought of. These methods promote student interaction and prompt the integration of knowledge and theory by authentic scenarios to explain or manage situations. [3] The main approach used (such as PBL) should also define or be supported by the approach used in other learning activities to assure alignment and rationale from the students’ learning perspective.

In addition to the learning activity itself, we as teachers also need to take responsibility for the learning spaces, on campus, at hospitals, and the virtual space. Lately, increased attention has been brought to how we design not only our learning tasks but also learning spaces in higher education. The learning spaces can be defined as the spaces created to support, facilitate, stimulate, or enhance learning and teaching [4].

In addition to the physical spaces, during the past 15 years, the use of e-learning has increased rapidly and could now be described as various digital learning spaces. E-learning offers opportunities to be utilized to facilitate class administration but also to promote learning and add new learning spaces. We would thereby argue that when we discuss e-learning, it is actually learning with the ‘e’ as a label of indication that the learning is intended to be supported by a digital learning space.

At many campuses, the classrooms available maybe a constraint when wanting to develop learning activities. The physical space is often not readily adaptable. In order to expand the operating learning space for us and for our students, the digital space maybe the one at our disposal. The question to be raised is then how the spaces are aligned to the intended purposes. To be coherent with our intentions, we need to take support in the same learning theories regarding the space, as we do when designing curricula.

In the general literature about the physical learning spaces, the active learning classroom has grown in interest [5]. The active learning classroom stems from research on learning, identifying that the student-to-student interaction is important both for knowledge development as well as developing collaboration skills. The active learning classroom is not new, as the paradigms of active learning such as problem-based learning and case methods do require spaces where student interaction is enhanced. Similar example maybe found in the literature about e-learning.

Further, in a similar manner to the space provided in terms of physical space, we may approach the digital space in different ways. It maybe present or we may develop it. During the best circumstances, it is driven from the learning needs of the learners. E-learning is not a concept describing how it is intended to enhance learning any more than campus or classroom does. It is therefore relevant to analyze how e-learning resources are designed and intended to enhance learning.

Our aim was to explore the current state of learning activities with digital support in relation to theories and models about learning.

Method

A literature review was conducted to analyze contemporary publications on e-learning during education of occupational therapy and physiotherapy students. The review was systematic, where the study findings were integrated and interpreted. We did not seek to evaluate the study results per se, but to analyze the qualitative descriptions behind what was developed and evaluated.

Searches were conducted in: Pubmed, Scopus, Cinahl, and Google Scholar. The exact search terms had to be adopted for each database and the details can be found in appendix. Inclusion criteria was that the paper should be about physical therapy or occupational therapy undergraduate education and the use of e-learning/digital tools, published in peer-reviewed journals as original research and available online. Publication dates were between 2014 and early 2017. Keywords were defined and combined; e-learning or digital tools AND physiotherapy education OR occupational therapy education, undergraduate, student. The searches and review of the papers took place from January to March 2017. Each database was searched and the results were then merged to identify duplicates.

The questions addressed were: What kind of e-learning activities were described and how were the intentions behind the use of digital support expressed in current literature? Were these intentions linked to models or theories about learning? A template based on the questions was developed in an iterative process during piloting of the literature review. The template was later also used as heading for Tables 1–3. Papers were randomly re-reviewed to ensure agreement in interpretation.

Table 1 The e-learning activities categorized into; communication space

Article	Learning theories	Aim	Study description	E-learning strategies	Student group	Conclusion
Maloney et al. [7]	Socially constructivist pedagogy	Identify use and behaviors with social networking sites and views on potential apps	Cross sectional	Psychological constructivist pedagogy, ‘cultural constructivism’	Physiotherapy	97% uses, learning networks in line with socially constructivist pedagogy. Students reluctant to formalize beyond peer groups, maintain privacy. Obtain information or ‘follow’ clinician. Avoid educator involvement
Usher et al. [8]		Determine the habits of use of social media and preferred media sourcing	Cross sectional		Students of health profession courses, physiotherapy 1.9%	The majority skilled. Universities could benefit regardless of platform. Guidance, support and professional conversation could enhance collegiality of the professional nationally and globally

Four manuscripts were reviewed by all four authors and in-depth discussed to reach agreement on interpretation. All manuscripts were then reviewed by at least one of the authors. When all papers were reviewed, the authors did a thematic analysis of the findings leading to categories of the learning activities.

The research group was represented by two educational developers, one lecturer in a physical therapy program and one occupational therapist with a master’s degree in medical education.

The various backgrounds of the members of the research group facilitated the critical reflection with multiple perspectives in discussions and interpretations.

Results

The searches resulted in 300 titles and abstracts (Figure 1) [6]. After identifying and removing duplicates, 290 abstracts remained. These abstracts were screened and 263 abstracts were excluded as they didn’t meet inclusion criteria, e.g. did not concerns the targeted student groups. The remaining 27 articles were then assessed for eligibility in full-text version which finally led to the decision to include 20 articles in this review.

Figure 1 PRISMA 2009 flow diagram

Notes: From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097. For more information, visit www.prisma-statement.org.

The e-learning activities were categorized into three themes; Communication space (Table 1) where the reasoning revolved around the individual use of social media, how it could be developed and the benefits from it in a learning environment. Only in one of the papers were the underlying learning theories and strategies clarified.

The second category: Enabling learning activities (Table 2), where the presentations had a narrow focus on a specific element of the learning sequence and how it was mastered and/or perceived. The articles mentioned the importance of technical aspects, only a few did clarify the learning theories underlying the activity.

Table 2 The e-learning activities categorized into; Enabling learning activities

Article	Learning theories	Aim	Study description	e-learning strategies	Student group	Conclusion
Gallagher et al. [9]	Video-based instruction enables students to direct the pace of their learning or repeat portions of the desired skill. Repetition can aid in the retention of psychomotor skills	Determine the efficacy of a DVD-based teaching approach compared with the traditional face-to-face (F2F) approach to teach students to transfer a patient using a hoist	Single-blind randomized controlled pilot trial	Four steps when teaching clinical skills:	Occupational therapy	Inconclusive whether DVD-assisted training was as effective as F2F training
				*demonstration
				*deconstruction
						No significant difference as to improvement. F2F class had higher level of perceived confidence in completing the task, more satisfied with the training
				*formulation
				*performance, can lead to a passive learning environment. Clinical expertise and small groups of students can be a challenge
Da Costa Vieira et al. [10]	Distance education could be positive, negative or equal	To assess the level of retention	Prospective randomized controlled trial, blinded	Advantages and disadvantages with e-learning, contradictory results, impressions, biases	Physiotherapy	E-learning led to the same retention, thus promoting this methodology
McAlistar [11]	Asynchronous technology facilitates repetition and feedback at the students preferred pace but also promotes student control and self-directed learning M-learning	Explore how students enrolled in a kinesiology course perceived the value of implementing instructor-produced YouTube videos of in-class assessment demonstrations	Cross sectional, pilot	Occupational therapy		Students perceived that the videos improved the quality of the course, increased their level of engagement and learning, and boosted confidence in their manual skills. Survey results also found that students correlated the instructor’s willingness to develop online videos with a commitment to student learning
Snodgrass. et al. [12]	The importance of feedback. OSCE	Describe the administration of this examination and the evaluation from the academic´s view	Implementation, cross sectional	Physiotherapy, occupational therapy		Immediate individualized feedback. Not all examiners and course coordinators were comfortable with the technology
Snodgrass et al. [13]	Personal digital assistants (PDA) might facilitate transfer of knowledge and skills from the educators to the students. Feedback to achieve reflection on performance and skills in a timely and individualized manner	Explore the perceptions of examiners and students of this feedback system	Implementation, cross sectional, pilot	Occupational therapy, physiotherapy, speech pathology	May facilitate. Students: adjunct to verbal feedback, more and more useful. Clinical supervisors thought loss of time but more regular and accurate documentation. Technology- related issues problems
Westwater-Wood & Moore [14]	Feedback best close to assessment, constructive feed-forward feedback	Compare three modes of providing feedback	Cross sectional, prospective	Physiotherapy	Time saving. Feed forward. Preferred individual. F2F for discussion. Unclear about importance of mode
Fernández-Lao et al. [15]	mLearning any time, on the move	To see if a mobile app as a supplement to traditional learning, would be useful in acquisition palpation and ultrasound skills	Single-blinded, randomized controlled.	Physiotherapy	Some significant impact of mLearning on physical skills
					Group using app better on most of the practical tests, but no significant differences as to theoretical knowledge

The third category: Ambition to create a learning space (Table 3), where the theoretical base varied covering considerations about the learning itself from constructivist and connectivist origin and theories pertaining to the design of teaching and learning activities.

Table 3 The e-learning activities categorized into; creating a learning environment

Article	Learning theories	Aim	Study description	E-learning strategies	Student group	Conclusion
Bernard Ashton et al. [16]	PBL	Investigate the effect of habituation (student experiences in using e-learning automatically) on student performance in one PBL module	Retrospective cohort	Assist students’ ability to study and revise material anytime and anywhere. Blended learning, constructivism theory of learning design. Connectivism. Social constructivist e- learning environment	Occupational therapy	No significant difference between 2 cohorts. When well e-learning activities crafted into PBL and students habitual users of the VLE, they perform better in the summative assessments than students who are novice users
Bodell & Hook [17]	Social media seen as a tool for continuing professional development (CPD). Social constructivism emphasizing conceptual development through integration of ideas, opportunities for reflection, having ownership of a given task	Evaluate an extracurricular blended learning opportunity aiming to equip students with the knowledge and skills required to use online social media to create professional networks and facilitate CPD	Qualitative, pilot	Portfolios blog	Occupational therapy	An increased confidence about online professionalism
				Networking. Face to face (F2F). Blended learning		The package was effective in preparing students to use the online environment for CPD
Gaida. [18]	Teaching skills: explanation, demonstration, practice and feedback. Traditional learning; passive, superficial. Implementation of technology, flipped classroom, rewards the prepared learner	To evaluate a flipped classroom teaching method to stimulate learner engagement	Cross sectional, qualitative	E-learning similar to traditional learning, but better than no intervention	Physiotherapy	Thematical analysis: power shift towards the student, enhanced skill development + improved efficiency. Pay-back-time 3 yrs for video production
Green et al. [19]	Time flexibility, interactive, student centered. Pros and cons as to online discussion. If posting on forums – improved learning outcomes	To investigate if the use of asynchronous online discussion forums is an independent factor leading to an improved course mark	Cross sectional		Physiotherapy	Asynchronous online discussion could be a prerequisite for higher final marks. Engagement
Green & Whitburn [20]	Advantages of blended learning and how it can look. More blended ‘pedagogies’, convenience, flexibility, financial benefits, more engaging and meaningful for learners	Describe the implementation of a blended course and evaluate the effectiveness of the design	Retrospective cohort		Physiotherapy	Improved student learning outcomes. Blended learning was well-suited to gross anatomy teaching if well planned and rigorously developed including peer-reviewed content. Keep blended not only online. Interaction components online, high level of engagement
Harvey et al. [21]	Massive Open Online Course (MOOC)	To describe the outcomes of a MOOC in terms of user participation, satisfaction and changes in knowledge	Descriptive audit of a 5 week MOOC	Online virtual classroom often fostering a sense of collectiveness that helps maintain motivation to learn. Free and provide students from all countries access to the same level of education	Physiotherapy and junior PTs with little experience of the specific field	Did not indicate the effectiveness of MOOCs for learning. Only students’ and physiotherapists’ willingness to participate in this style of learning and their satisfaction with the learning experience. Participants were interested and willing to participate in MOOCs although negative aspects were also brought forward
McKenna et al. [22]	Interprofessional education (IPE)	Examine health professional students’ perspective on the value of using online delivery to facilitate interprofessional understandings and learning	Qualitative	Online learning, e-learning, web-based learning. Online learning increase collaboration between learners as well as facilitators. Benefits – overcoming geographical challenges and scheduling	Emergency health (paramedic), nursing, occupational therapy, physiotherapy, nutrition, dietetics	The online delivery of IPE has the potential to enhance learning and overcome some of the barriers to F2F delivery, while still resulting in effective interprofessional understanding by means of for instance, watching how other health professionals worked via videos
Murray et al. [23]	Blended learning stronger learning	Outcomes of traditional learning (TL) as to flipped classroom (FL) in a specific course. Short-term knowledge retention when basic content was online instead of F2F	Cohort case control	Cognitive efficiency in the classroom, mode considered	Physiotherapy	No significant difference but higher score for FL. FL gave more flexibility + accountability. Challenge higher level thinking in class
Myers & O´Brien [24]	Importance of close communication on line. Critical thinking and clinical reasoning, prompts for online discussion. Aspects of online courses	Describe the development and implementation of an IPE course between two institutions, using best teaching practices for online education and assessment (SoTL)	Retrospective, qualitative and quantitative		Occupational therapy, physiotherapy, speech pathology	Increased understanding and more critical thinking. Effective use of online technology requires engagement of all involved as well as purpose, guidance + feedback
Rowe [25]	Student oriented. Interaction rather than information and negotiation of knowledge. Course – space for student engagement not container of information. Collaboration, non-discipline specific skills, different perspectives in the courses. Authentic learning, situated cognition. Benefits of open online course (OCC)	Determine if generic graduate attributes could be developed using principles of authentic learning in an OCC	Cross sectional, qualitative		Physiotherapy	The OOC gave opportunities to reason beyond discipline- specific knowledge and development of an internally motivated learning drive, acknowledge differing perspectives, opportunities to challenge the idea of knowledge and authority, and growth as empathic communicators. So the students had developed some components
						If well designed OCC – possible to develop generic graduate attributes
Sjödahl Hammarlund et al. [26]	Theory of connectivism. Active learner, self-directed	Identification of factors influencing learning processes and self-directed learning online	Cross sectional, qualitative	Constructive perspective. Motivation aspects	Physiotherapy	Pedagogical design, clarity of purpose, goals and guidelines as well as continuous opportunities for communication and collaboration was perceived as important in an online course. As well as internal factors for instance, low self-efficacy

Discussion

The stated intentions for implementing digital tools were manifold and it became obvious that they sometimes were applied in an intuitive way rather than informed by specific pedagogical research-based framework. Some were aiming at a specific educational aspect and fairly distinct in their choice of tool. Others declare profound ambitions of creating a learning environment characterized by opportunities to develop multiple competences. Intentions to promote collaboration, interprofessional understanding and providing challenges to further develop problem-solving competencies became visible.

The papers included in the review were clustered into three categories based on the complexity of the digital support and its intention. These categories may serve as a guiding framework for educators within a course, to clarify the different degrees of change in the learning space and the different approaches to improve education. However, we would like to emphasize that one may not gain to expected outcome if a learning activity aligned in one specific context is taken into another context without adjusting and adapting it to the learning approach used. Different interpretations of the concept of e-learning relates to different theoretical approaches. Depending on whether the intentions were focused on creating communication spaces, enabling learning activities or creating an entire learning environment the theoretical base and its clarity of alignment did differ.

From education program perspective, based on our findings, we propose that the use of digital tools could be described as having four different overarching purposes: for administrative purposes, where the digital environment is used as a container for input and output of documentation which previously was administered face to face, where the design is more a matter of practicality than learning. Secondly, for communication enhancement, such as the use of social media, the digital space is an addition to some other spaces for learning. Here, the underlying learning theories should be described and one should expect specific strategies being clarified for the purpose of the communication. In the present review, only two papers were assessed to have this purpose, and the underpinning theoretical information was sparse. The third category, namely to practice authentic digital competences needed in the profession should have a clear learning purpose and ground in learning theories. Examples of activities in this category would range from student-driven activities such as creating digital patient information, to more technology advanced tools such as wearables [27]. In this category, the digital space has a twofold purpose of both for learning and as learning. The last and most complex category would be to augment learning by the use of digital tools at a programmatic level. This can be achieved in a learning platform by the use of learning analytics or gamification and more sophisticated solutions like augmented reality may, where the digital space has a purpose to create new and unique opportunities for learning and as learning.

In this literature review we could see the different purposes represented, even though the administrative purposes were not the aim of these research studies and the studies mainly approached a change at course level rather than program level. The chances of meeting the needs of the individual student in a specific context and to increase involvement maybe enhanced if the menu of learning spaces is expanded. Some articles addressed aspects of motivation [25,26,21] and argued that the online format could provide a fruitful combination of scaffolding structure and degrees of freedom. Several articles brought up the crucial importance of engagement [25,18,19]. This has previously been identified to be an important factor. However, here little was mentioned about how this was used in progression or other programmatic approaches which may seem important.

It has been shown that technologically enhanced learning spaces have a positive impact on student learning [28]. From a teaching perspective, various motives can be present. One motive for implementing digital tools can be to nourish communicative aspects and even teaching skills; to develop the ability to explain concepts and to demonstrate skills. The digital environment provides opportunities for exchange of feedback in procedures integrated in the learning process. When designing for development of critical thinking and clinical reasoning skills, the online collaboration may have advantages such as the time independence, the transparency and the durable access to accumulated contributions [29].

In designing a learning environment with digital support considerations about the sequence appear to be vital. To harvest optimal benefit of all educational components, the digital tools can have a key role in various phases of the process; for preparations, in teaching and learning activities as well as in assessment.

Regardless of the intentions behind the digital tools, the underlying aim seems to be the boost of self-directing learning [30]. By providing opportunities to engage in a learning environment where the digital tools are an integrated part might be a way to expand our ‘zone of proximal development’ according to Vygotsky [31]. Underpinning the use of digital tools in teaching can seem to be derived from various sources. One can clearly identify social constructivist inspiration as well as the ambition to enhance the quality of learning founded in a taxonomy like Bloom’s [32].

The concept of authenticity appears in the current material as an important aspect of a digital learning environment. Authenticity in the meaning of creating a learning context that mimics a future working environment and thereby facilitating transfer of knowledge and skills, based on a constructivist approach [3]. Authenticity may often align well with meaningful learning approaches. The use of blogging as a development tool and sharing E-portfolios with the group for instance, as was the case in the article by Bodell and Hook [17] have the potential to facilitate meaningful learning as it provides opportunities for students to try to make sense of their experiences by means of reflection. The students become active in their own learning and collaborate with the group constructing new knowledge. Meyer [33] describes meaningful learning as going beyond the cognitive processes of retention and recalling to also include transfer. It is not enough to only possess knowledge. One also has to know how to use that knowledge to solve problems and understand new concepts [2].

One may conclude that learning and teaching in the digital age is not fully served by the learning theories we have relied on up until now. To pinpoint the outcome of digital endeavors, teachers might need to consort with theories that have connectivist connotations [34,35]. One example to augment conditions for learning as well as for learning space, is through collaboration between the students. Peer reviewing being one way to develop eligible content, as demonstrated in some of the articles in this review. In order for students to develop collaborative skills yet be independent self-directed learners, we need to provide tools that can be of assistance. In a digital learning context, the student can be supported in the meta-cognitive monitoring of their learning [36].

Immediate feedback on performance is beneficial to quality learning [37] and in a digitally supported learning environment, this practice can be introduced and sustained [38]. Some examples could be the use of quizzes, another example could be gamification and other reflective activities where the students develop skills in assessing their own performance – which is a lifelong professional skill of giving oneself immediate feedback. We did not find any papers describing more profound investments of this kind. A way to scaffold the learners path through the education could be to engage in continuous assessment with digital support providing feed forward [39] from oneself, peers, teachers, and possibly patients.

Also teachers may use the digital learning spaces for immediate feedback to our teaching and learning design by the access to learning analytics, [40], an underused source of information, making it possible to follow the learning in a non-intrusive way in order to develop overall as well as tailor the learning space to fit each individual.

Another way of looking at the learning space is to define if it is intended to enhance professional skills or if it is only intended to be the mean for learning. In physiotherapy and occupational therapy education, we do have the opportunity to use digital enhancement both for creating a community of learners, as well as catering for professional enhancement. We should consider the digital space as an important arena for future health care and during education; we can speed up the process of professional development by also being part of development and research in the use of the digital learning space. If we see patients and other clients as learners where we may facilitate a healthier life or enable maintenance of good health.

Limitations

It is important to be aware of some limitations when interpreting the results. This review only reflects publications during 2014–early 2017. Also, we did not search for gray literature. It is also possible that papers were missed if they did not state in the title or abstract that the student group was physiotherapy or occupational therapy students.

Conclusions

Our review indicate that e-learning activities are not always grounded in a theoretical learning perspective and seems to be more frequently planned or studied in a short perspective (course) rather than aligned to a whole program. We propose that to ensure that digital tools are fit for purpose, a clear intention related to learning theories and expectations of the learning space are needed.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Jeannette Unge is working as a lecturer at the Division of Physiotherapy at the Department of Health Sciences at Lund University.

Pernilla Lundh is currently working as an Adjunct Clinical Lecturer and an Occupational Therapist at Karolinska University Hospital, Stockholm, Sweden.

Christina Gummesson is Associate Professor with a background in Physiotherapy. Her current research interest involves learning augmented by digital support and approaches to authenticity in learning. Currently she is the Director at the Centre for Teaching and Learning at the Faculty of Medicine, Lund University, Sweden

Gunilla Amnér has a PhD in Psychology. One focus of interest is how to support communication in the digital learning environment. She is working as Educational Developer at the Centre for Teaching and Learning at the Faculty of Medicine, Lund University, Sweden