Effects of the eLearning approach on knowledge transfer and retention among in-service nurses and midwives in Tanzania

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The World Health Organization predicts that by 2030, there will be a shortage of 10 million health workers primarily in low- and lower-middle income nations including South East Asia and Africa having the greatest needs-based shortages of nurses and midwives. [1] . eLearning for nurses and midwives is an alternative and innovative mechanism of reducing their reported shortage. eLearning programs increase the knowledge transfer, knowledge retention, upgrade in skills and competencies among nurses and midwives. Despite of the benefits of eLearning programs, there is still inadequate information on the extent to which such programs have influenced the parameters since eLearning programs were introduced in Tanzania. This study aimed to determine the extent to which eLearning has affected the knowledge transfer, retention, upgrading skills, and competencies among nurses and midwives in Tanzania. Methods The cross-sectional study design where by quantitative methods approach was used . Quantitative data were collected through a structured questionnaire and Likert scaled, with a sample size of 189 respondents [2] . Descriptive results were generated and multivariable logistic regressed whereby odds ratio was used as measure of effects, 95% confidence interval and 5% significance level. SPSS was used in conducting analysis. Results Majority of participants were female (60.4%, n=64) and 97.2% of all respondents aged less than 40 years old. About half of participants (48.1%, n=51) were working in hospitals. The majority of the nurses and midwives (95.3%, n=101) were students in the eLearning. There was strong consensus on knowledge transfer with eLearning being an accurate source (sCns>79.8%) except on entertainment (sCns=65.8%). The degree of consensus ranged between 65.8% and 79.8% as well as in the system quality (sCns=71.6% to 74.9%). The overall rate score on knowledge transfer was 79.7%. The knowledge retention was high with score marks from 64% to 99% except in diagnostic (28%) and problems of new babies (48%). The rate of skills and competencies was high (sCns=82.6% to 88.8%), but with insignificant higher odds of consensus that “eLearning helps knowledge transfer, increases skills and competencies” across exposures and demographic characteristics except gender variable. Conclusions eLearning has succeeded to transfer and retain knowledge, skills, and competencies to eLearning-trained nurses and midwives. Peer students’ support and use of multimedia emerged with insignificant higher consensus of odds in explaining knowledge transfer in the eLearning program. Retention of knowledge, skills and competencies have great effects on the health services quality. There was low retention in diagnostic and recognition of new-born babies’ problems. Henceforth, efforts are needed to change negative perceptions among nurses and midwives. [1] World Health Organization, information available at: https://www.who.int/health-topics/health-workforce#tab=tab_1 [2] Respondents are Nurses/Midwives, Principals/Coordinators, Mentor /Health Facility In charge and Tutors eLearning Nurses and Midwifery Peer Nurse and Midwives Students Knowledge transfer Knowledge retention Tanzania Background Nurses and midwives constitute more than 50% of the health workforce( 1 ). Although it is estimated that the shortage of nurses and midwives will reduce from 9 to 6 million by 2030 worldwide, the shortage in the African countries is expected to worsen ( 1 , 2 , 3 ) with Sub-Sahara Africa having only 3% of world’s health workers ( 2 ). In Tanzania ,1 nurse midwife serves 1,374 population, a ratio that is way far below the WHO recommended ratio of 1 nurse per 492 populations ( 4 , 23 , 26 ) The data above signifies a great need to upgrade the skills of nurses and midwives ( 5 ). Conventional training for health care providers has been the main modality of upgrading skills of mid-level health workers such as nurses and midwives. However, conventional training is known to require resources at both the individual and institutional level which could stand as a barrier in instances of constrained resources (Sissine, M., R. Segan, M. Taylor, B. et al 2014). Another hurdle with the conventional training is associated with absenteeism ( 24 ) Forty six percent of absenteeism have been associated with attendance of seminars and training (Manzi, F., J. A. Schellenberg, G. Hutton et al2012) hence compromising the quality of health care services in an already constrained health workforce. eLearning for nurses and midwives is an alternative mitigation of the health professionals’ scarcity ( 6 – 9 ). Evidence shows that eLearning program to nurses and midwives increases the knowledge transfer, retention, upgrade skills and competencies ( 3 , 10 – 12 ). Despite the benefits eLearning has, there is still inadequate information on its effects on increased knowledge and improved skills among nurses and midwives since the eLearning program was introduced in Tanzania. eLearning program for nurses and midwives in Tanzania was introduce in 2013. The aim of this study is to assess whether training of nurses and midwives through eLearning approach has led to an improvement in the quality of services provided at the health facilities as a result of knowledge transfer and knowledge retention. Study Methods and Materials Study Settings This study was conducted in seven ( 7 ) nurse and midwifery schools including Muhimbili School of Nursing; Hubert Kairuki Medical University (HKMU); Bugando School of Nursing; Ndanda School of Nursing; Mirembe School of Nursing; Tanga School of Nursing and Njombe Institute of Health and Allied Sciences. All these training schools and colleges are dedicated to training of nurses and midwives in Tanzania. Study Population and Sample Size The study population included principals of nursing schools, eLearning program coordinators; nurses and midwives participating in the eLearning program; nursing and midwifery tutors, clinical mentors and in-charges of health facilities (workplace of eLearning nurses and midwives). Using Yamane formula, 3 a sample size of 189 respondents was obtained from total population of 2,620 potential respondents. Refer Table S1 . The Yamane (1973) formula is used for sample size calculation for qualitative study. $$\text{n}= \frac{\text{N}}{1+\text{N}{\text{e}}^{2}}$$ Where n is the sample size; e = Margin of error and N = Is the total population size We set the margin of error at 0.07 at 95% confidence interval, and calculated the sample size to obtain n = 189 respondents. Data Collection and Tools In order to obtain data for respondents, we developed two questionnaires: one that was self-administered by nurses and midwives and had aimed at obtaining score rating based on their perception on whether eLearning program has had increased their knowledge transfer, retention, and skills. The second questionnaire was administered to in-charges and mentors in health facilities where eLearning-trained nurses and midwives’ practice. Health facility in-charges/mentors are responsible for supervising the nurses and midwives were considered to be the right group of respondents as they could notice possible changes related to service quality provided by the eLearning-trained nurses and midwives. Data Analysis The questionnaire for nurses and midwives had three parts: the first part assessed the extent to which eLearning platform has successfully been used as a tool to transfer knowledge to the trainees; the second part assessed knowledge retention; while the third part focused on the midwifery skills and competencies gained. The questionnaire asked nurses and midwives to express their opinions regarding the statements in the questionnaire on a 5-point Likert scale from 1) strongly disagree; 2) disagree; 3) not sure; 4) agree; and 5) strongly agree. The questionnaire covered four aspects of knowledge transfer namely: information quality, service quality, system quality, and satisfaction and the rating consensus was used to reveal the level of agreement to the statements. To further analyze the data, we generated a logistic regression model based on the statement ‘‘information quality, service quality, and system quality of the eLearning course I have attended has helped me gain more knowledge than before the course ” being the dependent variable, while the other Likert scale statements. The second part of the questionnaire assessed the extent to which knowledge gained through eLearning has been retained by trained nurses and midwives. The questionnaire consisted of six multiple-choice questions that covered some expected outputs from the eLearning modules. eLearning-trained nurses and midwives were asked to select one correct answer. The last section of the questionnaire assessed midwifery and nursing skills and competencies after completing the eLearning program. Trained nurses and midwives were required to express their opinion on the statements regarding midwifery and nursing skills on a 5-point Likert scale from 1) strongly disagree; 2) disagree; 3) not sure; 4) agree; and 5) strongly agree. The degree of consensus (sCn) was calculated to attain the level of agreement with the group regarding the midwifery and nursing skill and competencies. Data processing was conducted through data cleaning and transformation of variables which was followed by collapsing the Likert scale (1 to 5 rate score) items into two categories (1 = agreed, 0 = disagreed). Descriptive statistics were generated as frequencies and percentages including the rate mean scores in the rated items. The inferential statistics based on the predictive logistic regression model with the statement ‘‘information quality, service quality, and system quality of the eLearning course I have attended has helped me gain more knowledge than before the course ” and ‘‘ overall, the eLearning approach has helped me increase my midwifery skills ” as the response variables across other Likert scale statements under skills was built. On the other hand, the questionnaire for in-charges and mentors describing had 16 items of service quality in health facilities. Facility in-charges and mentors were asked to rate their level of satisfaction with item in view of how they observe eLearning-trained nurses and midwives performed against those items. Each item was rated based on a 5-point Likert scale from 1) totally dissatisfied; 2) dissatisfied; 3) somehow/relatively satisfied; 4) satisfied; and 5) totally satisfied. A 17th item/statement was added “eLearning course helped the eLearning-trained nurse/midwife to provide BETTER service quality.” as the dependent variable while the other 16 statements were independent variables. In analyzing the data for in-charges and mentors, results were reported based on the coefficients, unstandardized and standardized, and the corresponding p-values for predictor variables and the variables at 5% significance level of consensus in measuring the outcomes. In addition, we ran our analysis of overall sample and repeated the regressions on different subgroups of in-charges and mentors based on their demographic characteristics. The multivariable logistic regression was obtained by adjusting Likert statements and demographics characteristics were to assess the level of consensus on the overall domains. This was done to assess if there were higher chances across the rated statements and demographic characteristics to predict the level of services provided and services’ quality due to eLearning program. Independent variables were added one after another and those with significant results (at 5% significance level) in the univariate were adjusted in the multivariable model. All predictors with sufficient evidence of increasing multi-collinearity (with variance inflation factor larger than 10, VIF > 10) were removed in the models in order to have best fitted (parsimonious) models. [3] Yamane, T. (1973) Statistics: An Introductory Analysis. 3rd Edition, Harper and Row, New York Results Majority of study participants were female: (60.4%, n = 64) for nurses and midwives) and (72.2%, n = 13) for in-charges and mentors. Over 77% of in-charges and mentors were aged over 40 years whereas over 97% of nurses and midwives were under the age of 40 years. Nearly half of participants (48.1%, n = 51) worked in hospitals whereas most of nurses and midwives (95.3%, n = 101) were students in the eLearning program (Table S2 & Table S3). There was high degree of consensus (sCn) among nurses and midwives that eLearning helps knowledge transfer (sCn > 70%). Likewise, there was a high degree of consensus that eLearning increases the quality of healthcare provision (sCn = 70.8–77.9%) (Table S4). Nurses and midwives agreed that eLearning increases knowledge retention (sCn = 70–99%) except on the area of diagnostic services (sCn = 28%) and on solving newborn babies’ problems (sCn = 48%) (Figure S1 ). Most of nurses and midwives strongly agreed that eLearning helps to increase skills and competencies (sCn = 82.6–88.8%) (Table S6). Multivariable logistic regression models showed higher odds of consensus that eLearning helps increase knowledge transfer because “eLearning platform tells exactly when support will be performed" (adjusted odds ratio (AOR):15.6; 95% CI:0.4-211.9) and that “eLearning platform simplifies the ways of getting support among students” (AOR:1.9; 95% CI:0.1-625.6). There were higher odds of consensus that eLearning platform increased the skills of nurses and midwives in providing care to women with abnormal puerperium without supervision (AOR:6.1; 95% CI:0.19–193.8). Results also show that male nurses and midwives had lower odds of consensus on eLearning platform’s ability to transfer skills and competencies compared to their female counterparts (AOR: 0.7: 95%CI:(0.0-6.1) (Table S7). In-charges and mentors strongly agreed that eLearning-trained nurses and midwives had increased the quality in their healthcare provision particularly on their technical competency (sCn = 70.3%), on their interpersonal skills (sCn = 72.9%), on their communication skills (sCn = 61.0–68.0%), on family care components (sCn = 58–61.0%) as well as on hospital services (sCn = 65.3%) (Table S8). In-charges and mentors with more than 10 years’ experience had higher odds of consensus compared to their counterparts with less than 10 years (AOR: 2.3; 95% CI:(0.3–30). Likewise, there were higher odds of consensus that eLearning affects quality healthcare provision (AOR: 4.45; 95% CI: 0.06–299) and that eLearning nurses and midwives have the ability of recognizing their patients’ opinions (AOR: 7.29; 95% CI:0.06–887) (Table S 9). Discussion In this study, we assessed the extent to which the eLearning approach has contributed to the knowledge transfer, knowledge retention, improved skills, and the quality of provision of healthcare services by eLearning-trained nurses and midwives. Our findings have shown that eLearning-trained students had positive perceptions on the information quality, service quality and system quality in transferring knowledge as most of them agreed to the statement ‘‘ Information quality, service quality, and system quality of the eLearning course I have attended has helped me gain more knowledge than before the course “. Our findings are similar to those reported in a Nepalese study which found out that eLearning-trained students had positive perceptions on the course irrespective of their gender ( 10 ). Likewise, our study are similar to studies conducted in South African and Jordanian universities with slight divergence on some issues of the Internet which was reported as one of factors contributing to negative perceptions ( 11 , 12 ). Our findings also have shown that eLearning-trained students were more likely to agree that information quality helped them in the transfer process of knowledge because “ eLearning platform entertains ” even though a previous study in Tanzania( 4 ) provided a contradicting results ( 13 ). There was however a different experience revealed from a randomized trial study conducted in the Netherlands which found that “E-learning improved the performance in case of simulations and the self-efficacy of the nurses in the detection of child abuse.”( 9 ). The observed difference could probably be due to issues of study design, sample size and population dynamics compared to previous studies in Tanzania( 4 ). Other studies (such as that in the Netherlands and others) have shown that transfer of knowledge through eLearning approaches improved nurses and midwives’ work performances( 5 , 9 ). Use of eLearning platforms seem to be an important study approach that helps students gaining knowledge and in improving their ability of delivering quality healthcare ( 14 , 15 ). Contrary to findings from the Netherlands study ( 9 ), our study has found that eLearning-trained nurses and midwives had weaknesses in performing diagnostic procedures and in dealing with common problems in newborn babies. As reported among in-charges and mentors, performing of diagnostic procedures among eLearning-trained nurses and require more improvement in the Tanzanian eLearning guidelines ( 16 – 18 ) in order to increase knowledge retention among nurses and midwives. Our results have also shown that eLearning students had increased perception of their midwifery skills and competencies in antenatal, postnatal, general newborn care and conducting deliveries ( 9 , 14 ). While our results agree on eLearning program’s support in transferring skills and competencies to learners ( 19 , 20 ), it is also important to notice that individual characteristics of nurses and midwives may have contributed to variations from one nurse/midwife to another ( 4 ). Most nurses and midwives accepted that the quality of their healthcare provision had increased as a result of increased knowledge transfer and retention ( 19 , 21 ) suggesting that the eLearning program is essential for nurses and midwives in the absence of their in-charges and mentors. Previous studies from Tanzania, Malawi and Kenya ( 19 , 21 , 22 ) have also shown similar suggestions of improved provision of quality health care through eLearning approaches. In-charges and mentors were moderately satisfied with the services offered by the eLearning-trained nurses and midwives on technical skills and competency in providing healthcare similar to results reported in a study conducted in New York, United States of America( 25 ) but contrary to a similar study conducted in France and Hispania( 5 ). Previous studies have shown that eLearning programs reduced clinicians’ workload, and that such programs upgrade health professionals’ quality of providing healthcare to patients, and that eLearning programs increased interactive teaching and learning mechanisms ( 4 , 9 , 15 ). Our study also revealed that eLearning-trained nurses and midwives were moderately involved in providing better services to patients’ family member and friends during clinical assessments. Evidence from previous studies showed that communications and ethical components of care provision among nurses and midwives increased patients’ satisfactions( 10 , 16 , 17 ). Limitations The study interviewed a relatively smaller number of in-charges and mentors of nurses and midwives and could have benefited from a much bigger sample size. Due to self-administration of the survey, it is possible that nurses and midwives could have overrated their scores towards knowledge transfer and knowledge retention. On the other hand, our study did not have baseline values for evaluating changes among nurses and midwives after their training in eLearning program. Future studies should therefore consider a larger sample size of respondents and consider recruiting a cohort of nurses and midwives, with a baseline survey conducted to help establish status before they start their eLearning program. Conclusion eLearning programs for nurses and midwives in Tanzania have shown to be a successful tool for knowledge transfer and retention and in improving the quality of healthcare provision. Despite its observed benefits, there is still a low knowledge retention among nurses and midwives in recognizing problems with newborn babies and in providing relevant diagnostic services to the newborn. Tanzanian guidelines on eLearning programs for nurses and midwives should be updated to incorporate improvement in all reported areas to require such improvements. Abbreviations NIMR National Institute of Medical Research; GSK Glaxo Smith Kline ICD Institute of Capacity Development OR Odds ratio; AOR Adjusted Odds Ratio; CI Confidence interval MoHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children IMF Institutional Management Framework sCns Degree of Consensus Declarations Acknowledgements An appreciation is extended to the NIMR under MOHCDGEC, and GSK for giving ethical approval to conduct this study. We acknowledge the MoHCDGEC for provision of guidelines and health policies to the people in the country, as without this service, many people would not be alive today. An appreciation is extended to all the staff of Amref Health Africa Tanzania who worked day and night to make sure that eLearning program becomes successful in Tanzania. We acknowledge the health care workers who are part and parcels of the eLearning project towards reducing infant and maternal morbidity and mortality. Last but not least, we acknowledge the Glaxo Smith Kline (GSK) for funding the eLearning project and Amref Health Africa’s Institute of Capacity Development (ICD) for coordination and technical support. Authors' Contributions PM and LK conceptualized the original idea; GK organized data collection, analyzed the data, interpreted the results, and drafted the initial manuscript; AN, PM, LK, AK, RM and VM coordinated the study and contributed to revising the manuscript. Ethics approval and consent to participate. Ethical approval and consent to partipate for this study were obtained from the National Institute for Medical Research (NIMR)- Tanzania with certificate of clearance number NIMR/HQ/R.8a/Vol. IX/3240.The NIMR has the National Health Research Ethics Committee (NatHREC) which is responsible for ensuring health research proposal are reviewed to safeguard the dignity, rights, safety and wellbeing of research participants. In recruiting study participants, interviewers asked all respondents for permission and informed consent forms signed before interviews began. The study observed participants’ right of privacy, confidentiality, and anonymity. In addition, all methods were performed in accordance with the relevant guidelines and regulations of the approval committee. Consent for publication. Not Applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to sensitive information about the participants. Also, the participants did not provide their approval for the sharing of their information. However, data are available from the MERL directorate at Amref Health Africa Tanzania on reasonable request. Competing interests The authors declare no potential conflicts of interest with respect to the research, authorship and/publication of this article. Funding Funding for this study was granted by Amref Health Africa Tanzania, headquarter office in Dar es Salaam. The funding was used in the design of the study and data collection, analysis, and interpretation of data and manuscript. References Hall S. People first: African solutions to the health worker crisis. Engineering. AMREF UK Clifford’s Inn Fetter Lane London EC4A 1BZ; Sarah Hall, Louise Orton, Colin O’Connor, Robin Hammond; 2015. AMREF. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2938789","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":206350243,"identity":"5a8176e4-6610-4c35-ac31-f983bb92dff5","order_by":0,"name":"Lupyana Kahemela","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBACPh4GNhAtw8DewMAME2VswKOFDaqFh4HnAMlaJBKI1nL42YOPOTY8/DPfGH4uqLBh4G9vYJOcgU8Lb5u54cxtaTwSt3OMpWecSWOQOHOATXIDPi38DGbSvNsO8zDczjGQ5m07zGAgkcAm+QCvFvZv0n+3/eeRv3nG+DdxWnh7zKQZtx3gMbjBY4awBa/DeM6USfZuS+YxPJNWZs1zBuipMwebLfF5n58nfZvEz212cnLHD2++zVNhI8ff3nzwZg8eLUiAwwBE8hCIFRTA/oBYlaNgFIyCUTDCAABznUNHVymDwQAAAABJRU5ErkJggg==","orcid":"","institution":"Amref Health Africa, Tanzania. Ali Hassan Mwinyi Road Plot 1019 P O Box 2773, Dar es Salaam, Tanzania","correspondingAuthor":true,"prefix":"","firstName":"Lupyana","middleName":"","lastName":"Kahemela","suffix":""},{"id":206350245,"identity":"5a83be26-673e-48dd-b0d3-1ab4d651433f","order_by":1,"name":"Patrick Mwidunda","email":"","orcid":"","institution":"Freelance Researcher, Dar Es Salaam","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Mwidunda","suffix":""},{"id":206350249,"identity":"f620d3d3-1553-4a80-becc-825772b1fbb2","order_by":2,"name":"Annagrace Katembo","email":"","orcid":"","institution":"Amref Health Africa, Tanzania. Ali Hassan Mwinyi Road Plot 1019 P O Box 2773, Dar es Salaam, Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Annagrace","middleName":"","lastName":"Katembo","suffix":""},{"id":206350250,"identity":"417845c2-f6dc-40c2-9415-24f749ee4de5","order_by":3,"name":"Anthony Ndjovu","email":"","orcid":"","institution":"Amref Health Africa, Tanzania. Ali Hassan Mwinyi Road Plot 1019 P O Box 2773, Dar es Salaam, Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"","lastName":"Ndjovu","suffix":""},{"id":206350251,"identity":"e5aecf92-c32f-4c6b-859a-17bb755b0e59","order_by":4,"name":"Rita Mutayoba","email":"","orcid":"","institution":"Amref Health Africa, Tanzania. Ali Hassan Mwinyi Road Plot 1019 P O Box 2773, Dar es Salaam, Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Rita","middleName":"","lastName":"Mutayoba","suffix":""},{"id":206350254,"identity":"42b336d1-3d2c-4af8-9ff3-611b3d85aa19","order_by":5,"name":"Vumilia Mmari","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Vumilia","middleName":"","lastName":"Mmari","suffix":""},{"id":206350255,"identity":"cd8599c9-048c-4d52-af30-097fdc3b82ec","order_by":6,"name":"Gregory Kabadi","email":"","orcid":"","institution":"Tawi Consult","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"","lastName":"Kabadi","suffix":""}],"badges":[],"createdAt":"2023-05-15 16:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2938789/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2938789/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":38225591,"identity":"541752cc-6fb2-48b2-a64f-dd0c26e8fb1e","added_by":"auto","created_at":"2023-06-08 12:59:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":271418,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2938789/v1/7ee27cf2-a41d-4c11-8fdf-e6e9fd16d7b5.pdf"},{"id":38069079,"identity":"7d183e8f-0852-48c8-b8ed-72faba375e54","added_by":"auto","created_at":"2023-06-06 06:48:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":38851,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-2938789/v1/f6d9b06548a8e0fa307a5cf3.docx"},{"id":38069080,"identity":"6aa16c98-b496-4ed1-a169-4eee6a4f5150","added_by":"auto","created_at":"2023-06-06 06:48:52","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":23360,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixFigure.docx","url":"https://assets-eu.researchsquare.com/files/rs-2938789/v1/948b75493dbceb21bb6d8b31.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of the eLearning approach on knowledge transfer and retention among in-service nurses and midwives in Tanzania","fulltext":[{"header":"Background","content":"\u003cp\u003eNurses and midwives constitute more than 50% of the health workforce(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although it is estimated that the shortage of nurses and midwives will reduce from 9 to 6\u0026nbsp;million by 2030 worldwide, the shortage in the African countries is expected to worsen (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) with Sub-Sahara Africa having only 3% of world\u0026rsquo;s health workers (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In Tanzania ,1 nurse midwife serves 1,374 population, a ratio that is way far below the WHO recommended ratio of 1 nurse per 492 populations (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) The data above signifies a great need to upgrade the skills of nurses and midwives (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConventional training for health care providers has been the main modality of upgrading skills of mid-level health workers such as nurses and midwives. However, conventional training is known to require resources at both the individual and institutional level which could stand as a barrier in instances of constrained resources (Sissine, M., R. Segan, M. Taylor, B. et al 2014). Another hurdle with the conventional training is associated with absenteeism (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Forty six percent of absenteeism have been associated with attendance of seminars and training (Manzi, F., J. A. Schellenberg, G. Hutton et al2012) hence compromising the quality of health care services in an already constrained health workforce.\u003c/p\u003e \u003cp\u003eeLearning for nurses and midwives is an alternative mitigation of the health professionals\u0026rsquo; scarcity (\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Evidence shows that eLearning program to nurses and midwives increases the knowledge transfer, retention, upgrade skills and competencies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite the benefits eLearning has, there is still inadequate information on its effects on increased knowledge and improved skills among nurses and midwives since the eLearning program was introduced in Tanzania. eLearning program for nurses and midwives in Tanzania was introduce in 2013. The aim of this study is to assess whether training of nurses and midwives through eLearning approach has led to an improvement in the quality of services provided at the health facilities as a result of knowledge transfer and knowledge retention.\u003c/p\u003e"},{"header":"Study Methods and Materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Settings\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in seven (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e) nurse and midwifery schools including Muhimbili School of Nursing; Hubert Kairuki Medical University (HKMU); Bugando School of Nursing; Ndanda School of Nursing; Mirembe School of Nursing; Tanga School of Nursing and Njombe Institute of Health and Allied Sciences. All these training schools and colleges are dedicated to training of nurses and midwives in Tanzania.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Population and Sample Size\u003c/h2\u003e\n\u003cp\u003eThe study population included principals of nursing schools, eLearning program coordinators; nurses and midwives participating in the eLearning program; nursing and midwifery tutors, clinical mentors and in-charges of health facilities (workplace of eLearning nurses and midwives). Using Yamane formula,\u003csup\u003e3\u003c/sup\u003e a sample size of 189 respondents was obtained from total population of 2,620 potential respondents. Refer Table \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe Yamane (1973) formula is used for sample size calculation for qualitative study.\u003c/p\u003e\n\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\n\u003cdiv id=\"FileID_Equa\" class=\"mathdisplay\"\u003e$$\\text{n}= \\frac{\\text{N}}{1+\\text{N}{\\text{e}}^{2}}$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eWhere n is the sample size; e\u0026thinsp;=\u0026thinsp;Margin of error and N\u0026thinsp;=\u0026thinsp;Is the total population size\u003c/p\u003e\n\u003cp\u003eWe set the margin of error at 0.07 at 95% confidence interval, and calculated the sample size to obtain n\u0026thinsp;=\u0026thinsp;189 respondents.\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" alt=\"\" /\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Collection and Tools\u003c/p\u003e\n\u003cp\u003eIn order to obtain data for respondents, we developed two questionnaires: one that was self-administered by nurses and midwives and had aimed at obtaining score rating based on their perception on whether eLearning program has had increased their knowledge transfer, retention, and skills. The second questionnaire was administered to in-charges and mentors in health facilities where eLearning-trained nurses and midwives\u0026rsquo; practice. Health facility in-charges/mentors are responsible for supervising the nurses and midwives were considered to be the right group of respondents as they could notice possible changes related to service quality provided by the eLearning-trained nurses and midwives.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eThe questionnaire for nurses and midwives had three parts: the first part assessed the extent to which eLearning platform has successfully been used as a tool to transfer knowledge to the trainees; the second part assessed knowledge retention; while the third part focused on the midwifery skills and competencies gained. The questionnaire asked nurses and midwives to express their opinions regarding the statements in the questionnaire on a 5-point Likert scale from 1) strongly disagree; 2) disagree; 3) not sure; 4) agree; and 5) strongly agree. The questionnaire covered four aspects of knowledge transfer namely: information quality, service quality, system quality, and satisfaction and the rating consensus was used to reveal the level of agreement to the statements.\u003c/p\u003e\n\u003cp\u003eTo further analyze the data, we generated a logistic regression model based on the statement \u003cem\u003e\u0026lsquo;\u0026lsquo;information quality, service quality, and system quality of the eLearning course I have attended has helped me gain more knowledge than before the course\u003c/em\u003e\u0026rdquo; being the dependent variable, while the other Likert scale statements. The second part of the questionnaire assessed the extent to which knowledge gained through eLearning has been retained by trained nurses and midwives. The questionnaire consisted of six multiple-choice questions that covered some expected outputs from the eLearning modules.\u003c/p\u003e\n\u003cp\u003eeLearning-trained nurses and midwives were asked to select one correct answer. The last section of the questionnaire assessed midwifery and nursing skills and competencies after completing the eLearning program. Trained nurses and midwives were required to express their opinion on the statements regarding midwifery and nursing skills on a 5-point Likert scale from 1) strongly disagree; 2) disagree; 3) not sure; 4) agree; and 5) strongly agree. The degree of consensus (sCn) was calculated to attain the level of agreement with the group regarding the midwifery and nursing skill and competencies.\u003c/p\u003e\n\u003cp\u003eData processing was conducted through data cleaning and transformation of variables which was followed by collapsing the Likert scale (1 to 5 rate score) items into two categories (1\u0026thinsp;=\u0026thinsp;agreed, 0\u0026thinsp;=\u0026thinsp;disagreed).\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were generated as frequencies and percentages including the rate mean scores in the rated items. The inferential statistics based on the predictive logistic regression model with the statement \u003cem\u003e\u0026lsquo;\u0026lsquo;information quality, service quality, and system quality of the eLearning course I have attended has helped me gain more knowledge than before the course\u003c/em\u003e\u0026rdquo; and \u0026lsquo;\u0026lsquo;\u003cem\u003eoverall, the eLearning approach has helped me increase my midwifery skills\u003c/em\u003e\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e as the response variables across other Likert scale statements under skills was built.\u003c/p\u003e\n\u003cp\u003eOn the other hand, the questionnaire for in-charges and mentors describing had 16 items of service quality in health facilities. Facility in-charges and mentors were asked to rate their level of satisfaction with item in view of how they observe eLearning-trained nurses and midwives performed against those items. Each item was rated based on a 5-point Likert scale from 1) totally dissatisfied; 2) dissatisfied; 3) somehow/relatively satisfied; 4) satisfied; and 5) totally satisfied. A 17th item/statement was added \u003cem\u003e\u0026ldquo;eLearning course helped the eLearning-trained nurse/midwife to provide BETTER service quality.\u0026rdquo;\u003c/em\u003e as the dependent variable while the other 16 statements were independent variables.\u003c/p\u003e\n\u003cp\u003eIn analyzing the data for in-charges and mentors, results were reported based on the coefficients, unstandardized and standardized, and the corresponding p-values for predictor variables and the variables at 5% significance level of consensus in measuring the outcomes. In addition, we ran our analysis of overall sample and repeated the regressions on different subgroups of in-charges and mentors based on their demographic characteristics.\u003c/p\u003e\n\u003cp\u003eThe multivariable logistic regression was obtained by adjusting Likert statements and demographics characteristics were to assess the level of consensus on the overall domains. This was done to assess if there were higher chances across the rated statements and demographic characteristics to predict the level of services provided and services\u0026rsquo; quality due to eLearning program. Independent variables were added one after another and those with significant results (at 5% significance level) in the univariate were adjusted in the multivariable model. All predictors with sufficient evidence of increasing multi-collinearity (with variance inflation factor larger than 10, VIF\u0026thinsp;\u0026gt;\u0026thinsp;10) were removed in the models in order to have best fitted (parsimonious) models.\u003c/p\u003e\n\u003cp\u003e[3] Yamane, T. (1973) Statistics: An Introductory Analysis. 3rd Edition, Harper and Row, New York\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMajority of study participants were female: (60.4%, n\u0026thinsp;=\u0026thinsp;64) for nurses and midwives) and (72.2%, n\u0026thinsp;=\u0026thinsp;13) for in-charges and mentors. Over 77% of in-charges and mentors were aged over 40 years whereas over 97% of nurses and midwives were under the age of 40 years. Nearly half of participants (48.1%, n\u0026thinsp;=\u0026thinsp;51) worked in hospitals whereas most of nurses and midwives (95.3%, n\u0026thinsp;=\u0026thinsp;101) were students in the eLearning program (Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e \u0026amp; Table S3).\u003c/p\u003e \u003cp\u003eThere was high degree of consensus (sCn) among nurses and midwives that eLearning helps knowledge transfer (sCn\u0026thinsp;\u0026gt;\u0026thinsp;70%). Likewise, there was a high degree of consensus that eLearning increases the quality of healthcare provision (sCn\u0026thinsp;=\u0026thinsp;70.8\u0026ndash;77.9%) (Table S4). Nurses and midwives agreed that eLearning increases knowledge retention (sCn\u0026thinsp;=\u0026thinsp;70\u0026ndash;99%) except on the area of diagnostic services (sCn\u0026thinsp;=\u0026thinsp;28%) and on solving newborn babies\u0026rsquo; problems (sCn\u0026thinsp;=\u0026thinsp;48%) (Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Most of nurses and midwives strongly agreed that eLearning helps to increase skills and competencies (sCn\u0026thinsp;=\u0026thinsp;82.6\u0026ndash;88.8%) (Table S6).\u003c/p\u003e \u003cp\u003eMultivariable logistic regression models showed higher odds of consensus that eLearning helps increase knowledge transfer because \u0026ldquo;eLearning platform tells exactly when support will be performed\" (adjusted odds ratio (AOR):15.6; 95% CI:0.4-211.9) and that \u0026ldquo;eLearning platform simplifies the ways of getting support among students\u0026rdquo; (AOR:1.9; 95% CI:0.1-625.6). There were higher odds of consensus that eLearning platform increased the skills of nurses and midwives in providing care to women with abnormal puerperium without supervision (AOR:6.1; 95% CI:0.19\u0026ndash;193.8). Results also show that male nurses and midwives had lower odds of consensus on eLearning platform\u0026rsquo;s ability to transfer skills and competencies compared to their female counterparts (AOR: 0.7: 95%CI:(0.0-6.1) (Table S7).\u003c/p\u003e \u003cp\u003eIn-charges and mentors strongly agreed that eLearning-trained nurses and midwives had increased the quality in their healthcare provision particularly on their technical competency (sCn\u0026thinsp;=\u0026thinsp;70.3%), on their interpersonal skills (sCn\u0026thinsp;=\u0026thinsp;72.9%), on their communication skills (sCn\u0026thinsp;=\u0026thinsp;61.0\u0026ndash;68.0%), on family care components (sCn\u0026thinsp;=\u0026thinsp;58\u0026ndash;61.0%) as well as on hospital services (sCn\u0026thinsp;=\u0026thinsp;65.3%) (Table S8). In-charges and mentors with more than 10 years\u0026rsquo; experience had higher odds of consensus compared to their counterparts with less than 10 years (AOR: 2.3; 95% CI:(0.3\u0026ndash;30). Likewise, there were higher odds of consensus that eLearning affects quality healthcare provision (AOR: 4.45; 95% CI: 0.06\u0026ndash;299) and that eLearning nurses and midwives have the ability of recognizing their patients\u0026rsquo; opinions (AOR: 7.29; 95% CI:0.06\u0026ndash;887) (Table S 9).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we assessed the extent to which the eLearning approach has contributed to the knowledge transfer, knowledge retention, improved skills, and the quality of provision of healthcare services by eLearning-trained nurses and midwives. Our findings have shown that eLearning-trained students had positive perceptions on the information quality, service quality and system quality in transferring knowledge as most of them agreed to the statement \u0026lsquo;\u0026lsquo;\u003cem\u003eInformation quality, service quality, and system quality of the eLearning course I have attended has helped me gain more knowledge than before the course\u003c/em\u003e \u0026ldquo;. Our findings are similar to those reported in a Nepalese study which found out that eLearning-trained students had positive perceptions on the course irrespective of their gender (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Likewise, our study are similar to studies conducted in South African and Jordanian universities with slight divergence on some issues of the Internet which was reported as one of factors contributing to negative perceptions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Our findings also have shown that eLearning-trained students were more likely to agree that information quality helped them in the transfer process of knowledge because \u0026ldquo;\u003cem\u003eeLearning platform entertains\u003c/em\u003e\u0026rdquo; even though a previous study in Tanzania(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) provided a contradicting results (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere was however a different experience revealed from a randomized trial study conducted in the Netherlands which found that \u0026ldquo;E-learning improved the performance in case of simulations and the self-efficacy of the nurses in the detection of child abuse.\u0026rdquo;(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The observed difference could probably be due to issues of study design, sample size and population dynamics compared to previous studies in Tanzania(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Other studies (such as that in the Netherlands and others) have shown that transfer of knowledge through eLearning approaches improved nurses and midwives\u0026rsquo; work performances(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUse of eLearning platforms seem to be an important study approach that helps students gaining knowledge and in improving their ability of delivering quality healthcare (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Contrary to findings from the Netherlands study (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), our study has found that eLearning-trained nurses and midwives had weaknesses in performing diagnostic procedures and in dealing with common problems in newborn babies. As reported among in-charges and mentors, performing of diagnostic procedures among eLearning-trained nurses and require more improvement in the Tanzanian eLearning guidelines (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) in order to increase knowledge retention among nurses and midwives.\u003c/p\u003e \u003cp\u003eOur results have also shown that eLearning students had increased perception of their midwifery skills and competencies in antenatal, postnatal, general newborn care and conducting deliveries (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). While our results agree on eLearning program\u0026rsquo;s support in transferring skills and competencies to learners (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), it is also important to notice that individual characteristics of nurses and midwives may have contributed to variations from one nurse/midwife to another (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Most nurses and midwives accepted that the quality of their healthcare provision had increased as a result of increased knowledge transfer and retention (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) suggesting that the eLearning program is essential for nurses and midwives in the absence of their in-charges and mentors.\u003c/p\u003e \u003cp\u003ePrevious studies from Tanzania, Malawi and Kenya (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) have also shown similar suggestions of improved provision of quality health care through eLearning approaches. In-charges and mentors were moderately satisfied with the services offered by the eLearning-trained nurses and midwives on technical skills and competency in providing healthcare similar to results reported in a study conducted in New York, United States of America(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) but contrary to a similar study conducted in France and Hispania(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious studies have shown that eLearning programs reduced clinicians\u0026rsquo; workload, and that such programs upgrade health professionals\u0026rsquo; quality of providing healthcare to patients, and that eLearning programs increased interactive teaching and learning mechanisms (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Our study also revealed that eLearning-trained nurses and midwives were moderately involved in providing better services to patients\u0026rsquo; family member and friends during clinical assessments. Evidence from previous studies showed that communications and ethical components of care provision among nurses and midwives increased patients\u0026rsquo; satisfactions(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study interviewed a relatively smaller number of in-charges and mentors of nurses and midwives and could have benefited from a much bigger sample size. Due to self-administration of the survey, it is possible that nurses and midwives could have overrated their scores towards knowledge transfer and knowledge retention. On the other hand, our study did not have baseline values for evaluating changes among nurses and midwives after their training in eLearning program. Future studies should therefore consider a larger sample size of respondents and consider recruiting a cohort of nurses and midwives, with a baseline survey conducted to help establish status before they start their eLearning program.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eeLearning programs for nurses and midwives in Tanzania have shown to be a successful tool for knowledge transfer and retention and in improving the quality of healthcare provision. Despite its observed benefits, there is still a low knowledge retention among nurses and midwives in recognizing problems with newborn babies and in providing relevant diagnostic services to the newborn. Tanzanian guidelines on eLearning programs for nurses and midwives should be updated to incorporate improvement in all reported areas to require such improvements.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNIMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Institute of Medical Research;\u003c/p\u003e\n\u003cp\u003eGSK \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Glaxo Smith Kline\u003c/p\u003e\n\u003cp\u003eICD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Institute of Capacity Development\u003c/p\u003e\n\u003cp\u003eOR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Odds ratio;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAOR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Adjusted Odds Ratio;\u003c/p\u003e\n\u003cp\u003eCI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Confidence interval\u003c/p\u003e\n\u003cp\u003eMoHCDGEC \u0026nbsp;\u0026nbsp;Ministry of Health, Community Development, Gender, Elderly and Children\u003c/p\u003e\n\u003cp\u003eIMF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Institutional Management Framework\u003c/p\u003e\n\u003cp\u003esCns \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Degree of Consensus\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn appreciation is extended to the NIMR under MOHCDGEC, and GSK for giving ethical approval to conduct this study. We acknowledge the MoHCDGEC for provision of guidelines and health policies to the people in the country, as without this service, many people would not be alive today. An appreciation is extended to all the staff of Amref Health Africa Tanzania who worked day and night to make sure that eLearning program becomes successful in Tanzania. We acknowledge the health care workers who are part and parcels of the eLearning project towards reducing infant and maternal morbidity and mortality. Last but not least, we acknowledge the Glaxo Smith Kline (GSK) for funding the eLearning project and Amref Health Africa\u0026rsquo;s Institute of Capacity Development (ICD) for coordination and technical support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePM and LK conceptualized the original idea; GK organized data collection, analyzed the data, interpreted the results, and drafted the initial manuscript; AN, PM, LK, AK, RM and VM coordinated the study and contributed to revising the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval and consent to partipate for this study were obtained from the National Institute for Medical Research (NIMR)- Tanzania with certificate of clearance number NIMR/HQ/R.8a/Vol. IX/3240.The NIMR has the National Health Research Ethics Committee (NatHREC) which is responsible for ensuring health research proposal are reviewed to safeguard the dignity, rights, safety and wellbeing of research participants. In recruiting study participants, interviewers asked all respondents for permission and informed consent forms signed before interviews began. The study observed participants\u0026rsquo; right of privacy, confidentiality, and anonymity. In addition, all methods were performed in accordance with the relevant guidelines and regulations of the approval committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to sensitive information about the participants. Also, the participants did not provide their approval for the sharing of their information. However, data are available from the MERL directorate at Amref Health Africa Tanzania on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no potential conflicts of interest with respect to the research, authorship and/publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was granted by Amref Health Africa Tanzania, headquarter office in Dar es Salaam. The funding was used in the design of the study and data collection, analysis, and interpretation of data and manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHall S. People first: African solutions to the health worker crisis. Engineering. AMREF UK Clifford\u0026rsquo;s Inn Fetter Lane London EC4A 1BZ; Sarah Hall, Louise Orton, Colin O\u0026rsquo;Connor, Robin Hammond; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAMREF. Transforming Lives BY building sustainable health systems in Africa 2015. Kenya; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmref. Amref Health Africa in Tanzania, Annual Report, 2018. Excel and tell. Tanzania; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMboineki JF, Chen C, Gerald DD, Boateng CA. The current status of nurses\u0026ndash;doctors collaboration in clinical decision and its outcome in Tanzania. Nurs Open. 2019;6(4):1354\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Khalifa AJ. People first. JPT, J Pet Technol. 2006;58(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLahti M, H\u0026auml;t\u0026ouml;nen H, V\u0026auml;lim\u0026auml;ki M. Impact of e-learning on nurses\u0026rsquo; and student nurses knowledge, skills, and satisfaction: A systematic review and meta-analysis. Int J Nurs Stud. 2014;51(1):136\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKihoza PD, Bada.K J. A Framework for Online Resources and ELearning Implementation (OREI) in Tanzania Secondary Schools. Arusha, Tanzania; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZuvic-Butorac M, Nebic Z, Nemcanin D, Mikac T, Lucin P. Establishing an Institutional Framework for an E-learning Implementation \u0026ndash; Experiences from the University of Rijeka, Croatia. J Inf Technol Educ Innov Pract. 2011;10:043\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmeekens AEFN, Broekhuijsen-van Henten DM, Sittig JS, Russel IMB, Ten Cate OTJ, Turner NM, et al. Successful e-learning programme on the detection of child abuse in Emergency Departments: A randomised controlled trial. Arch Dis Child. 2011;96(4):330\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHart L, Searle S, Geetal L, Peter J, Trump A, Taylor M, et al. Using The Skoool \u003csup\u003eTM\u003c/sup\u003e he Platform: ELearning Implementation Guide. An Afil Johns Hopkins Univ. 2015;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTudor Car L, Kyaw BM, Atun R. The role of eLearning in health management and leadership capacity building in health system: A systematic review. Hum Resour Health. 2018;16(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmeekens AEFN, Henten DMB, Sittig JS, Smeekens AEFN, Henten DMB, Sittig JS, et al. Successful e-learning programme on the detection of child abuse in Emergency Departments: a randomised controlled trial Successful e-learning programme on the detection of child abuse in Emergency Departments : a randomised controlled trial. 2011;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhimire SR, Bhandary S. Students\u0026rsquo; Perception and Preference of Problem Based Learning During Introductory Course of a Nepalese Medical School. J Patan Acad Heal Sci. 2015;1(1):64\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNCUBE L. Students\u0026rsquo; Perceptions of E-Learning In The Department of Information Science at The University of South Africa. Open Rubric. 2015;(June).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGasaymeh A. A Study of Faculty Attitudes toward Internet-Based Distance Education: A Survey of Two Jordanian Public Universities. Learning. 2009. p.\u0026nbsp;212.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMzava K, Kalinga EA. Determinants of nurses\u0026rsquo; intention to use eLearning in Tanzania. J Health Inform Dev Ctries. 2017;11(2):unpaginated.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKokol P, Blažun H, Mičetić-turk D, Abbott PA. e-Learning in Nursing Education \u0026ndash; Challenges and Opportunities. 2006;387\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeldacker C, Pintye J, Jacob S, Chung MH, Middleton L, Iliffe J, et al. Continuing professional development for medical, nursing, and midwifery cadres in Malawi, Tanzania and South Africa: A qualitative evaluation. PLoS One. 2017;12(10):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathew D, Alkawaz MH. Adoption of E-Learning Systems in Tanzania\u0026rsquo;s Universities: A Validated Multi-Factors Instructor\u0026rsquo;s Model. J Theor Appl Inf Technol. 2018;96(20):1817\u0026ndash;3195.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAydın B, Bektaş M. Pediatric Pain Management Knowledge Levels of Intern Nursing Students. Pain Manag Nurs. 2019;(August).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy H, Robert O, Elija O. A model for evaluating e-learning systems quality in higher education in developing countries Kennedy Hadullo Technical University of Mombasa, Kenya Robert Oboko and Elijah Omwenga University of Nairobi, Kenya. Int J Educ Dev using Inf Commun Technol. 2017;13(2):185\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShoo R, Matuku W, Ireri J, Nyagero J, Gatonga P. The place of knowledge management in influencing lasting health change in Africa: an analysis of AMREF\u0026rsquo;s progress. Pan Afr Med J. 2012;13 Suppl 1(Supp 1):3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSue K, Rosenberg J, Weintraub R. Addressing Tanzania\u0026rsquo;s Health Workforce Crisis Through a Public-Private Partnership: The Case of TTCIH. Cases Glob Heal Deliv. 2016;GHD-034:1\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRouleau G, Gagnon MP, C\u0026ocirc;t\u0026eacute; J, Payne-Gagnon J, Hudson E, Dubois CA, et al. Effects of e-learning in a continuing education context on nursing care: Systematic review of systematic qualitative, quantitative, and mixed-studies reviews. J Med Internet Res. 2019;21(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOHSW. Curriculum for Basic Technician Certificate in Clinical Medicine NTA LEVEL 4. United Republic of Tanzania, Department of Human Resource Development 6 Samora Avenue 11478, Dar es Salaam. Curriculum; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanzania Ministry of Health. Tanzania eHealth Strategy. 2012;\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"eLearning, Nurses and Midwifery, Peer Nurse and Midwives Students, Knowledge transfer, Knowledge retention, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-2938789/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2938789/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals are in short supply worldwide, with nurses and midwives accounting for more than 50% of the current shortage. The World Health Organization predicts that by 2030, there will be a shortage of 10 million health workers primarily in low- and lower-middle income nations including South East Asia and Africa having the greatest needs-based shortages of nurses and midwives.\u003ca href=\"https://www.researchsquare.com/article/rs-2938789/admin/draft#_ftn1\"\u003e[1]\u003c/a\u003e . eLearning for nurses and midwives is an alternative and innovative mechanism of reducing their reported shortage. eLearning programs increase the knowledge transfer, knowledge retention, upgrade in skills and competencies among nurses and midwives. Despite of the benefits of eLearning programs, there is still inadequate information on the extent to which such programs have influenced the parameters since eLearning programs were introduced in Tanzania. This study aimed to determine the extent to which eLearning has affected the knowledge transfer, retention, upgrading skills, and competencies among nurses and midwives in Tanzania.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe cross-sectional study design where by quantitative methods approach was used . Quantitative data were collected through a structured questionnaire and Likert scaled, with a sample size of 189 respondents\u003ca href=\"https://www.researchsquare.com/article/rs-2938789/admin/draft#_ftn2\"\u003e[2]\u003c/a\u003e. Descriptive results were generated and multivariable logistic regressed whereby odds ratio was used as measure of effects, 95% confidence interval and 5% significance level. SPSS was used in conducting analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority of participants were female (60.4%, n=64) and 97.2% of all respondents aged less than 40 years old. About half of participants (48.1%, n=51) were working in hospitals. The majority of the nurses and midwives (95.3%, n=101) were students in the eLearning. There was strong consensus on knowledge transfer with eLearning being an accurate source (sCns\u0026gt;79.8%) except on entertainment (sCns=65.8%). The degree of consensus ranged between 65.8% and 79.8% as well as in the system quality (sCns=71.6% to 74.9%). The overall rate score on knowledge transfer was 79.7%. The knowledge retention was high with score marks from 64% to 99% except in diagnostic (28%) and problems of new babies (48%). The rate of skills and competencies was high (sCns=82.6% to 88.8%), but with insignificant higher odds of consensus that “eLearning helps knowledge transfer, increases skills and competencies” across exposures and demographic characteristics except gender variable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eeLearning has succeeded to transfer and retain knowledge, skills, and competencies to eLearning-trained nurses and midwives. Peer students’ support and use of multimedia emerged with insignificant higher consensus of odds in explaining knowledge transfer in the eLearning program. Retention of knowledge, skills and competencies have great effects on the health services quality. There was low retention in diagnostic and recognition of new-born babies’ problems. Henceforth, efforts are needed to change negative perceptions among nurses and midwives.\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://www.researchsquare.com/article/rs-2938789/admin/draft#_ftnref1\"\u003e[1]\u003c/a\u003e World Health Organization, information available at: https://www.who.int/health-topics/health-workforce#tab=tab_1\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://www.researchsquare.com/article/rs-2938789/admin/draft#_ftnref2\"\u003e[2]\u003c/a\u003eRespondents are Nurses/Midwives, Principals/Coordinators, Mentor /Health Facility In charge and Tutors\u003c/p\u003e","manuscriptTitle":"Effects of the eLearning approach on knowledge transfer and retention among in-service nurses and midwives in Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-06 06:48:47","doi":"10.21203/rs.3.rs-2938789/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1fc4bb53-96c2-4eac-97a4-aa962c41d048","owner":[],"postedDate":"June 6th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-31T10:32:50+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-06 06:48:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2938789","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2938789","identity":"rs-2938789","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}