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Midwife Participation in Continuing Education:

Online Education versus Home Study.

Ellen J. Cramer
DCTE 700/800 Research Methods ~ Winter Institute 1998
Dr. Steve Terrell
Nova Southeastern University



Online learning can provide a convenient and cost-effective tool for education, training, and testing that helps to solve logistical problems because of it's "anytime, anywhere" flexibility (Axelson, 1997; McCartney, 1996). It is hoped that by offering online continuing education, midwife participation would increase and thereby improve midwives' competency as healthcare providers. In addition, online education provides an avenue for communication among midwives who feel isolated (Gordon & Erickson, 1993; Kurokawa, 1996). This research paper will compare the way that continuing education is delivered and its effect on participation and sense of community: online education format versus more traditional home study programs.

Research questions:

1. Can online education increase continuing education participation of midwives?

2. Will midwives report a sense of community when participating in online education?



Review of the Literature

The review of the literature investigates continuing education barriers and the option of online solutions for increasing midwives' participation. The first section addresses the limitations and assumptions of the need and benefits of continuing education for midwives and how technology may be viewed by midwifery. The second section looks at finding solutions to poor access and availability of continuing education. The results of studies that have implemented online continuing education are included in the third section. The fourth section discusses online communities. This is followed by the conclusion and the null hypotheses.

First Section: Limitations/Assumptions

Midwives want to provide safe care with good outcomes (Meng & Morris, 1995; Waddell, 1991). A survey of 75 midwives in the United Kingdom revealed that midwives were committed to continuing education despite the difficulties in accessing it due to the demands of clinical practice (Hunt, 1996). The midwives recognized how crucial maintaining and developing clinical skills is to improving patient care (Hunt, 1996). In another study, 83 midwives were surveyed to find motivational factors for continuing education. The researchers found that midwives participate to learn for professional and personal development, fulfill legal requirements, and for social interaction in that order (Laszlo & Strettle, 1996).

Will midwives choose to participate in online learning? Midwifery texts do not include the jargon of computer technology and telecommunications, but this is not a statement of midwives willingness to use computers. A survey study done in 1994, showed that 84% of the midwives had access to a personal computer and 40% had Internet access (Scupholme et al., 1995). Philosophically, midwives prefer not to use interventions or medical technology unless there is a sound medical rationale because of the possible repercussions or untoward side effects of the technology to the mother and child (Mitford, 1992). This is a separate issue from computer technology for personal use or education. The midwifery population is 98% women and women do have a lower confidence level with computers in general than men, but this is not shown to be obstructive to women using computers (Truong, 1993). In a 1996 survey study by Katz and Aspden (1997a), the three biggest barriers to getting online were cost, "no idea how to do it," and discomfort using computers. Of the 2500 respondents, 46% of the users were female, showing a gender closure from a previous 1995 study of 34% female users.

In January 1995, the Vice President of the American College of Nurse-Midwifery Foundation (Bash, 1995) introduced a regular computer technology exchange in the refereed Journal of Nurse-Midwifery. This was done to help midwives keep up with emerging advances in technology. A more recent exchange in the Journal of Nurse-Midwifery (Kurokawa, 1996) discusses the needs of rural midwives due to isolation and the benefits of electronic communication. Kurokawa (1996) discusses the use of the original electronic midwifery bulletin boards set up for and by midwives several years ago and shares how easy it is to do online research using "Grateful Med" ( and other electronic libraries.

Second Section: Continuing education barriers and the online delivery option

The National Congress on Rural Education (Beckner & Barker, 1994) identified barriers to the improvement of rural education as geographic isolation, shortages in staff, and low enrollments. Although this information analysis is looking at children, the same barriers exist for midwives. The recommended solutions in this study for these barriers include personal computers, software, and distance learning and telecommunication technologies such as interactive television, email, bulletin boards, online databases, and information networks.

Midwives in Wales were interviewed (N=50) in a structure-process-outcome model (Nolan, Owen, & Nolan, 1995). Attention was focused on the outcomes of continuing education and the structure and process variables that facilitate or inhibit success. The midwives indicated a strong commitment to the principles of continuing education and were able to identify a complex range of benefits. The barriers, which inhibit both the uptake and achievement of continuing education, were identified as access, availability and selection of topic. The authors recognize the need for "an equitable, well-resourced system" (Nolan, Owen, & Nolan, 1995, p551).

A survey study was done in Scotland to assist with the planning and implementation of continuing education programs for midwives. A demand for distance learning was voiced by the midwives. The study concluded that distance learning format and timing would facilitate midwife participation in continuing education events and career development (Mitchell, 1997).

Third Section: Studies on implementing online continuing education

Professional training and education will be best met by networked, online interactive technologies that allow professionals to create individualized learning experiences while participating in supportive online learning communities (Teplow, 1996). There were two different studies (Craig, 1992; Jennett, 1990) conducted where medical professionals were set up to use online information searches to alleviate the sense of isolation in rural areas. Both situations were considered successful in reducing isolation and increasing satisfaction in the effective use of the online searches.

The University of Oregon and the International Society for Technology in Education offered a professional development course entirely online using email, computer conferencing, and database searching. In the feasibility study and follow up evaluation, students reported positive responses to the course and the technology as an effective way to learn material otherwise unavailable to them (Schrum, 1992a; Schrum, 1992b).

A statistics professor from California State University split his class and taught one group in a traditional format and another group in an online version using the WWW, email, and a chat room. The online group scored better on the midterm and the final, and more pertinently, both the traditional and online students finished the course (McCollum, 1997).

Fourth Section: Communities in online environments

Internet users were asked in the 1995 survey by Katz and Aspden (1997b) the extent that they participated in online communities. Thirty-one percent of long-time users and 17% of recent users felt they were part of one or more Internet communities. Of the 601 Internet users identified in this same study, 14% reported that there were people they knew only through the Internet that they considered friends.

Cutler (1995) wrote a theory-building paper on cyberspace that surmises that the application of communication technology creates new social spaces.

Just as the work world of the information society has become distributed, so it should come as no surprise that the social world of the information society finds its affiliations through distributed "places" and presences. In the aggregate, distributed places and presences attempt to meet social and emotional needs for commitment, intimacy, and a sense of belonging. (Cutler, 1995, p.27)

According to Groff (1995), distance learning will sustain learning communities at two levels, students and alumni. The students and alumni, who are online through the Internet, will continue sharing communications and problem resolution without geographic boundaries, with the potential to create a proactive global community.

Conclusion of the review of the literature

Midwives are motivated to learn and they believe it helps patient care (Hunt, 1996; Laszlo & Strettle, 1996). Some of the barriers to receiving continuing education are access and availability (Kurokawa, 1996; Macdonald, 1994; Nolan et al., 1995). Midwives appear to possess the awareness that computers are a part of our collective future (Bash, 1995; Kurokawa, 1996; Scupholme et al., 1995). As bandwidth capabilities expand, education resources will also increase. According to the literature, online delivery of education is a good option to consider for reducing barriers to participation in continuing education and in the process improve patient care (Mitchell, 1997; Waddell, 1991). Another benefit of using online education might be found with increased professional job satisfaction via the increased sense of midwifery community not limited by space or time (Cutler, 1995; Groff, 1995; Hiltz & Wellman, 1997).

Null Hypotheses:

1. Continuing education participation levels will not be higher in online delivery compared with journal home study delivery.

2. Continuing education participants will not report an increased sense of community in online delivery compared to journal home study delivery.


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March 1998