BMJ Support Palliat Care 2:292-293 doi:10.1136/bmjspcare-2012-000375
  • Editorials

Can e-learning be used to teach end-of-life care?

  1. Bee Wee
  1. Sir Michael Sobell House, Churchill Hospital, Oxford OX3 7LE, UK
  1. Correspondence to Dr Bee Wee, Harris Manchester College, University of Oxford, UK; bee.wee{at}

Caring for people approaching the end of their lives is intensely personal. Experiential teaching is regarded as one of the more reflective and suitable ways of teaching about end-of-life care. Doctors and medical students are used to bedside teaching. Lectures, especially didactic ones, may be comfortingly familiar, but their impact is variable. E-learning has been around for quite some time, but in terms of learning about end-of-life care, it is a relatively ‘new kid on the block’.

Many clinicians and educators regard e-learning with scepticism, especially in relation to a subject as personal and sensitive as end-of-life care. This is especially the case if they have been exposed to poorly designed e-learning programmes, or those that appear irrelevant, simplistic or not rooted in the real world of practice. The increasing pressure to complete requirements for statutory and mandatory training through e-learning programmes has increased the aversion that some clinicians have toward this whole way of learning.

One of the major advantages that e-learning has over the more traditional forms of teaching is that it can reach great numbers of learners at the same time. This is why e-learning was identified as key to delivering training to the health and social care workforce across England, estimated to be 2.5 million people, when the End of Life Care Strategy was published in 2008.1 Commissioned by the Department of Health in England, and developed under the auspices of the e-Learning for Healthcare Programme, End of Life Care for All, known as e-ELCA, was launched in 2010 ( This e-learning programme for end-of-life care provides over 150 e-learning sessions, covering the core topics of the strategy: assessment, advance care planning, communication skills and symptom management, as well as other additional areas.

The e-learning programme needs to be fit for the purpose

Designing an e-learning programme for end-of-life care requires careful thought about what learners need. A balance must be struck between what needs to be taught and what can be taught by e-learning. In developing e-ELCA, assumptions had to be challenged right at the beginning. For example, the question ‘can communication skills be taught through e-learning?’ had to be reframed as ‘what aspects of communication skills can be enhanced using e-learning?’.

Some e-learning programmes are designed to stand alone; others have an element of continuing support, or moderation, whereby learners get the opportunity to ask questions and receive responses from a ‘teacher’. From the outset it was known that there would not be the luxury of ongoing support for e-ELCA, so the content of each session had to be clear and straightforward. Feedback on questions had to be carefully predesigned, because there was no way of modifying feedback to each individual's response.

Like any other mode of teaching, values influence the way teaching is approached. In the case of e-ELCA, trusting learners to make choices for themselves, encouraging them to reflect on their own experiences, and reinforcing learning through formative rather than summative assessment were fundamental. Although some guidance is offered and learners are supplied with a list of self-explanatory session titles, they can select any session they wish, and in any order they wish. Varied assessments are positioned throughout each session, all to reinforce learning, so they can repeat the assessment as often as they need to, without any lasting record being kept of their responses.

The credibility of those who design and develop an e-learning programme is critical to its acceptance to the learners. In e-ELCA, the session authors were virtually all practitioners. Each author was matched up with an instructional designer whose expertise was in conveying the information into an interactive learning format. Each session was peer reviewed and checked by the module editor and clinical lead. This ensured that the sessions were grounded in the reality of day-to-day practice, rather than based solely on theory.

Benefits and limitations of e-learning

Accessibility is one of the most obvious advantages of e-learning. Learners can choose when, and for how long, they wish to learn. They control the pace at which they work through a session or module of e-learning. In most cases, they can work through the session repeatedly until they are confident that they have mastered the content. Unlike face-to-face teaching, the content is reproducible each time, so every learner receives the same information. Good e-learning programmes have a built-in level of interactivity. Some sophisticated e-learning programmes can incorporate a greater ability to respond to learners, but even then, they simply cannot have the level of flexibility that face-to-face interaction with a human teacher can achieve.

E-learning requires a certain amount of self-discipline. It is much easier to walk away from a computer than it is to walk out of a face-to-face teaching session. For some, this can be an insurmountable barrier. Strategies, like working through a session with a buddy, or arranging to meet up afterwards to reflect on a learning session with a few peers, can be helpful.

Computer shyness can be a significant hurdle, at least at a psychological level. A really good e-learning programme that entices a computer novice to enter, can generate learning of computer skills as a bonus. However, registration processes and logging-in to computer systems to gain access to e-learning programmes are often intensely frustrating. Most e-learning programmes have a standard format, so once the learner has made a few attempts at getting into the system and working his/her way through a session, it becomes reasonably familiar. Age, lack of previous learning, and lack of previous skills have not been found to be barriers to learning.2 What is sometimes more difficult to overcome is the lack of computing facilities in the workplace. Even an internet connection is not always available in busy clinical settings and care homes.

How should we use e-learning to teach end-of-life care?

Most teachers and learners recognise that e-learning is rarely truly effective on its own. Some e-learning programmes are set up to be used independently, but most should be supplemented (or ‘blended’) with other forms of learning, for example bedside teaching. The analogy of a standard library is used. On the whole, library readers do not read every single book on the shelf, or in the order that they are set out. Instead, they browse and select a book they like, read and replace it, and choose another one. Sometimes, their selection is based on need; other times on interest alone.

At this stage, it is not possible to make any assertion about the effectiveness of e-learning as a means for improving end-of-life care. Such evidence is difficult to gather, not least because improvement in end-of-life care reflects a variety of interdependent factors. Ruiz et al3 found that most studies of effectiveness of e-learning, though limited in their scientific design, have consistently explored three aspects: product utility, cost-effectiveness and learner satisfaction.

In relation to e-ELCA, positive feedback has been received about the first (apart from registration issues) and the last mentioned above; of the three, cost-effectiveness is not yet something that has been formally evaluated. To date, the focus has been on raising awareness about the existence of e-ELCA and its use for teaching end-of-life care, both in England and globally. The launch of the ‘e-ELCA getting started and support pack’ in September 2012, will help those who are new to this programme, as well as clinicians who are working to improve end-of-life care in both community and hospital settings. More importantly, it should stimulate interest in all forms of learning about end-of-life care.


  • Competing interests BW is National Clinical Lead for e-ELCA.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Received 24 September 2012.
  • Accepted 26 September 2012.