When online learning becomes compulsory: Student nurses’ adoption of information communication technology in a private nursing education institution

Background Integrating the use of information communication technology (ICT) in nursing curricula when preparing student nurses for the digital health future such as the sudden online learning as a result of the coronavirus disease 2019 (COVID-19) pandemic is vital. However, when student nurses in a South African private nursing education institution, struggled to complete obligatory online learning courses, nurse educators had to search for solutions. Objectives To explore the barriers and enablers for ICT adoption by a diverse group of student nurses in a private nursing education institution in the Free State Province. Method Following a qualitative, explorative, interpretive-descriptive design, student nurses were invited to participate. Based on all-inclusive, purposive sampling with inclusion criteria enabled selecting, a total of 17 participants who took part in three focus groups and written narratives. Transcribed interviews underwent thematic analysis with co-coder consensus. The study adhered to strategies to enhance trustworthiness. Results Students shared their views related to ICT and online learning within their theory and practice training. Student nurses held positive, negative and contrasting views of ICT adoption and online learning. Actions to master ICT adoption and online learning are highlighted. Information communication technology brings a challenging interdependence between nurses and technology. Conclusion Integration of ICT into nursing programmes is important. The enablers and barriers to ICT are described. Expose students to different technologies, especially using smart phones to search for (academic/non-academic) information. The adoption of ICT should enhance the learning process and facilitate deep learning. Students preferred online learning for self-assessment and described how they tried to master ICT and online learning. Information communication technologies in the clinical setting highlight the challenged interdependence between nurses and technology. Context-specific recommendations are proposed.


Introduction
For preparing the future nurses for the digital world of health, it is imperative to integrate information communication technology (ICT) into training student nurses. This fact is further validated by the disruption causes by the coronavirus disease 2019  pandemic in all walks of life, especially students who were forced to adapt to online learning (Teräs et al. 2020:863). This unparalleled impetus to online learning (Teräs et al. 2020:863), necessitates revisiting students' adoption of ICT. Online learning (also referred to as eLearning) is inseparable from ICT. As Coopasami, Knight and Pete (2018:305) highlighted that for the first-year South African student nurses, the success of online learning is closely linked to technology and equipment. Nursing in a digital age requires integration of information technology (IT) into the larger body of knowledge in nursing and in addition training the student nurses to adapt to an IT-rich work environment (Gonen, Sharon & Lev-Ari 2016:1). In fact, the adoption of digital solutions is necessary to contribute to the new digital-based models of care (Golinelli et al. 2020:2) entering the healthcare sector globally. Raman (2015:663) argued that the integration of ICT into nursing curricula is necessary to prepare nurses for evidence-based patient care. Information communication technology is therefore a tool to be used in the classroom and in the clinical setting. Oermann (2015:55) reiterated that student nurses should be exposed to technology in their clinical work environment to bridge the gap between theory and practice.
http://www.curationis.org.za Open Access In this study ICT refers to the rapid convergence between IT (the hardware and software utilised to store, process and retrieve data) and communication technology (CT) (the electronic systems that enable communications between individuals and groups) (Huang et al. 2012:35). Furthermore, it is also a three-layered convergence between the cloud (the Internet and broadcasting services); the pipe (traditional telecommunications networks and cable networks); and the devices (personal electronic devices) (Huang et al. 2012:36). Information communication technology provides considerable benefits in achieving health goals; demonstrating what health outcomes are reached at what cost. In healthcare, ICT is utilised in electronic health records (eHealth records); routine health (e.g. web-based surveillance systems); vital registrations (e.g. births and mortality); consumer health informatics (e.g. self-management systems); mHealth apps (e.g. smart phones); telemedicine (e.g. ICTs for healthcare or -education distantly); virtual healthcare (e.g. a doctor consults the patient via Zoom) and health research (Hanna 2016:119). The National Digital Health Strategy of South Africa 2019-2024 referred to the above as digital health and digital health technologies (National Department of Health 2019:11). The Technology Acceptance Model (TAM) was developed in 1989 by Davis (from information systems), and presents a useful theoretical approach to understand why workers in general are unwilling to use ICT, despite having the available technology (Davis, Bagozzi & Warshaw 1989:982). The TAM outlines people's behavioural intention to use technology being influenced by their attitude and general impression thereof. Davis et al. (1989) proposed that all users exposed to a new technology should be presented with a perceived usefulness (PU) and perceived ease-of-use (PEOU). In the context of nurses in a hospital unit, PU implies whether nurses perceive that the digital thermometer will measure patient's temperature accurately; and PEOU means if this digital thermometer will be easy to use by all the nursing staff. User-friendly technology enables the use thereof.
The integration of ICT into higher education is a global phenomenon. Worldwide ICT is viewed as the vehicle to facilitate educational reform and develop communication platforms (Adarkwah 2020:1 Coopasami et al. (2018:305) confirmed that although student nurses value online learning, they lack computer skills and hardware and should be supported with these insufficiencies if they are to enhance their attitudes towards online learning. In KwaZulu-Natal, mobile devices are a functional professional and educational tool for student advance midwives (Chipps et al. 2015:1). These nurses regarded their own technology competence as low and required support from their nursing education institution to develop their mobile network literacy skills and optimise their use of mobile phones.

Research question
Expounded from the literature above, this article set out to answer 'What are the barriers and enablers for ICT adoption amongst student nurses in a private nursing education institution in the Free State, South Africa?'.

Research aim and objectives
To explore the barriers and enablers for ICT adoption by a diverse group of student nurses in a private nursing education institution in the Free State Province.

Problem statement
The private institution provided compulsory online learning courses that had to be completed in the classroom. Lecturers initially welcomed this technology because of the value proposition to strengthen the ICT integration. Student nurses however, presented with a negative attitude and a lowered pass rate. They highlighted the barriers and enablers for ICT adoption and online learning within the private nursing education institution. They shared how they used online learning and mastered ICT adoption and amplified the importance of exposure to technology. The student nurses preferred online learning for self-assessment and warned against superficial learning. Information communication technology in the clinical setting implies an interdependence between the nurse and technology in the digital world of nursing.

Research methods and design
A qualitative, explorative, interpretive-descriptive design was followed to identify the barriers to and enablers of ICT adoption by student nurses in a private nursing education institution in the Free State, South Africa. The nursing programmes include 1 year of training for an auxiliary nurse, referred to as a pupil nurse; and 2 years of training leading to registration as an enrolled nurse. Enrolled nurses apply for a 2-year bridging course, leading to registration as a general nurse. Inclusion criteria comprised of (1) a registered pupil-enrolled nurse or bridging nurse student at the private nursing education institution between 01 January 2015 and 31 December 2015; (2) willing to provide written, informed consent to participate voluntarily in focus groups (FGs) to be digitally voice-recorded and to be used for writing narratives; and (3) communicate in English as mode of instruction. Through purposive sampling (Botma et al. 2010:124), 17 student nurses aged between 18 to 46 years, from different indigenous cultures and language groups, participated in the research.
Data collection was realised in two phases. Phase 1 explored barriers to and enablers of ICT adoption, through three digitally voice-recorded FGs. Goodwill permission was attained from Company A -one of the largest private hospital groups in South Africa (pseudonym to protect the company's identity). A mediator, an administrative assistant at the private nursing education institution, recruited participants and an advertisement was posted on the students' notice board, inviting them to participate. The mediator explained informed consent at least 24 h before data gathering. To prevent bias and coercion, the researcher (a nurse educator at the identified nursing education institution) had no direct contact with the participants. The researcher maintained participants' anonymity and confidentiality externally by using codes, safekeeping the data in hard copy and digital format. An independent interviewer with a master's degree in Health Science Education conducted three FGs of approximately 1 h each.
All 17 participants wrote a narrative after the FGs. Digitally recorded voice notes from the FGs were transcribed and checked for accuracy. The transcripts and narratives thematically analysed following Creswell's six-step method of data analysis that included: (1) organising and preparation of data; (2) developed a sense of all the data; (3) coded data following the nine steps of Tesch; (4) identified and described themes; (5) representation of the findings; and (6) interpretation of the data (Creswell 2009:184). Trustworthiness (Lincoln & Guba 1985:218) was enhanced by pursuing truth value through credibility with prolonged engagement and reflection; applicability through transferability by providing a thick description of the full research process; consistency through dependability as evidenced by a detailed audit trail; and neutrality through confirmability by means of reflexivity.

Demographic profile
The demographic profile of the participants revealed that the average age of participants was 27.8 years, whilst the average age of newly registered nurses (all categories) according to the South African Nursing Council (SANC) is 33 years (SANC 2015). Besides one male student, the rest of the participants were all female. The information provides context and supports the demographic profile of the current study. Nursing as a profession in South Africa tends to be female-dominated with less males. This study were also female-dominated with less male participants. The participants spoke five of the 11 official languages in South Africa; the majority spoke Afrikaans. Of the total participants, 70.5% were in their second year of study. Refer to Table 1 for the demographic information of the participants.
Themes, categories and sub-categories Figure 1 presents the 3 themes, 11 categories and 18 subcategories that emanated from the data.. The themes are discussed in the following paragraphs and the participant number and FG number are indicated with direct quotes. In exploring the barriers to and enablers for ICT adoption, student nurses presented with positive, negative and contrasting realities of ICT and online learning. However, the student nurses also proposed how to not only adopt to ICT and online learning but master it. The student nurses didn't differentiate between teaching-learning and clinical care technologies but viewed it as an integrated whole and highlighted also how ICT brings new challenges to consider in nursing.

Theme 1: Positive, negative and contrasting realities of ICT and online learning
Participants shared several realities of ICT and online learning and didn't confine it only to their theoretical learning but also to their training in the hospital where student nurses do their clinical practice work.
The positive realities of ICT related to convenience and fast on-demand access to information, subjective to connectivity. The participants explained that convenience implied having lightweight ICT devices such as smart phones, which facilitated access to information anywhere and anytime. Convenience also meant access to information from home after working a 12-h shift. The participants explained that they don't have to travel to libraries or spend hours searching for specific information anymore, as one participant explained: ICT, information communication technology. Technology to support healthcare.
Technology requires conƟnuous maintenance for accuracy.
Technology used to protect paƟents against human errors.
Easy access challenges paƟent privacy and confidenƟality. PaƟents experience technology as intrusive. Learn more about healthy food throught adverƟsements.
Convenience verus not supporƟng the learning process due to superficial learning.
Easy access versus unreliability.
Expensive data and airƟme.
Limited access to computer devices and conncƟvity (internet and intranet).
Benefits of being exposed to various types of technologies.

Benefits of MicrosoŌ PowerPoint in presentaƟons.
Online learning enabled self-assessment for exam preparaƟons.
Digital devices in hospital safe with fast data retrieval.

Convenience of ICT.
Fast on-demand access if connecƟvity is available, aŌer hours, less searching in books, no heavy textbooks, email assignments and get test results immediately. Another positive reality of ICT and online learning was the use of various applications, such as Microsoft PowerPoint slides, which improved clinical facilitation and lecturing in a large class settings especially when students have limited time to make class notes. In the past the student nurses had to write posters by hand, but by using PowerPoint, they could share patient case studies faster with more students. One participant explained that one can: 'Present it (patient case studies) for everybody and that whatever you are presenting orally, you can also demonstrate on the PowerPoint.' (Participant 5, FG 1) Besides the positive realities of ICT and online learning, the participants also highlighted the negative realities. The first negative reality is that although all the student nurses had mobile or smart phones, they neither possessed nor had access to tablets or laptops to prepare assignments. Phones can be used for internet searches and communication, but the students required a tablet, laptops or computers to be able to type and complete the assignments: 'Not all of us have laptops, not all of us have internet. We've all got cell phones, but they can't do a whole project on a cell phone. So, to type the project and to go onto internet to find the information becomes a struggle if you don't have the laptop and the internet, and so forth.' (Participant 3, FG 1) Because the online learning programmes and the limited computers that were available to access these programmes were accessible only through the Company A's intranet, students could not access the online learning platform outside their workplace or from home. As participant explained: The participants shared realities that had both positive and negative aspects, referred to as the contrasting realities related to ICT and online learning. Participants described that although information is easily accessible through the web, the scientific unreliability thereof, especially from nonacademic websites, is concerning: ' Furthermore, participants explained that whilst ICT and online learning are convenient, one might become too lazy to research and read books. Also, online learning might lead to superficial learning: 'I think it makes us lazy because the internet is here you get everything there and the information is there. Our assignments we don't go to the library to find books to go through every page. So, it makes us lazy.' (Participant 5,FG 2) Participants explained that they used the internet to obtain quick answers for immediate questions. However, the participants acknowledged that they didn't fully grasp what they were supposed to learn in the same manner that they would have if they had to assimilate information from a hardcopy book. Participant acknowledged that everything is faster electronically, but also stated that: 'When on the internet, … I think for me personally you get the feeling that you understand and that you adapt quickly more quickly compared to the information that you get on the internet because you just browse through everything where with the books there is more focus in terms acquiring information. With the internet you just tap a word, and you get all these other information …' (Participant 2, FG 1) '… there is too much information that is accessed at a particular point compared to when you have a book.' (Participant 2, FG 1) With the benefits of speed, on-demand access and ease-of-use of the internet for online learning, participants highlighted the negative side also. This is the side of being exposed to too many information and superficial learning:

Theme 2: Developing information communication technology adoption and online learning
The second theme described how participants developed their ICT and online learning skills. Participants explained the importance of being exposed to technology. Technoexposure is introducing student nurses to technology in their teaching and learning and in the clinical practice. By exposing student nurses to technologies, it enables them to experience the use of these technologies regularly in healthcare and training: '… [S]he is an adult learner and that she wasn't exposed to all this technology but now that she is doing E-learning, that gave her the courage, the oomph to go on because she must do her things a certain way and because she wants her qualification.' (Participant 3, FG 2) The participants described how they utilise their phones as the go-to device to do quick searchers. The participants explained that they used their phones in their training and in the context of the healthcare to browse the internet. The participants explained that they used their phones in their training and in the context of the healthcare to browse the internet to find quick references: 'I think we could get quick references … I go to my phone and Google it. So, we don't have to wait …' (Participant 1, FG 1) 'Cell phones are used to access information.' (Participant 5, Participants explained that they started to use computers and laptops to type and complete assignments. In general, it seemed as if the participants all were active users of their phones but didn't have the basic computer and typing skills when they enrolled for their nursing training: 'I never had background in school like of using a laptop or whatever. I was only exposed to that when I started learning.' (Participant 3, FG 2) The participants seemed to be aware of the vast array of information provided on the internet and that not all information is valid and trustworthy. They also noted the propensity to plagiarise when using internet information sources: 'We find sources and some of the sources are not reliable.' and '… we aren't allowed to use specific websites soos by voorbeeld [for example] Wikipedia. We aren't allowed to use it because anyone can add information on a certain website.' (Participant 5, FG 1) 'Also with the internet usage, plagiarism is more where some of the educators wouldn't know the site.' (Participant 6, FG 1) Finally, participants voiced that online learning was a valued self-assessment tool for exam readiness, but the participants had contradictory views of ICT and online learning as learning tools. The structured nature of the online learning and the timeous feedback from the online learning were appreciated. It guided students to know where they are in the lesson and gave them feedback on their current knowledge levels. However, some participants did voice that a deeper level of learning happened when they had to acquire information using books: 'To me it makes it easier because with the E-learning they give you, they explain to you what you must do, how you must do it and what more or less will be in the test. So if you have any questions or anything you can run through your books because you will know where in the books it is. It's multiple questions which are also easier to just comprehend and it's faster.' (Participant 1, FG 2) 'E-learning teaches you by pictures and diagrams.' (Participant 5, FG 3) 'When on the internet, the weight of it becomes lesser but when you physically go look for it in the books I think for me personally you get the feeling that you understand and that you adapt quickly more quickly compared to the information that you get on the internet because you just browse through everything where with the books there is more focus in terms acquiring information.' (Participant 2, FG 1)

Theme 3: Information communication technology brings new challenges to nursing
Participants seemed uncertain about when to use technology or continue with manual nursing activities. The participants explained that technology brings ambiguity regarding accuracy. Older medical devices are more trusted by older medical practitioners, whilst digital devices are fast and more convenient. However, digital medical devices might also be inaccurate if not properly charged. Participants stated: 'Always keep up to date on the manual ways of doing stuff.' (Participant 5, FG 3) 'Some Doctors still prefer the BP (blood pressure) taken manually. They feel it's more accurate and I encounter this problem with the electronic system where you find on the manual reading, where the glucose is four pluses where on the machine itself, is two pluses for the glucose in the human. There is always a variance between the manual and electronic gadgets … For us as nurses specifically might lead us to address a patient wrongly or treat the patient wrongly.' (Participant 2, FG 1) Participants explained the interdependence between nurses and technology. Technology should be an instrument that supports healthcare of patients and requires continuous maintenance to ensure its accuracy. They explained that although technology can speed-up activities and improve convenience for nurses, its reliability remains dependent on nurses' maintenance: 'So, if the people don't take care of the machine's, from day one, it can in the end give you some problems.' (Participant 1, FG 1) Furthermore, participants described that technology is also applied to protect patients against the human error. The participants continued that technology can be used with a digital audit trail of backed-up data per patient, when there is mistrust about the competence and integrity of nurses: 'They (nurses) get to a patient and they in a hurry, so they don't really count the respiration. Hulle skat (they estimate), So, it's going to be more accurate if we are able to do things more electronically if we could get something to electronically read the respiration and the temperature that is accurate.' (Participant 3, FG 1) 'Instead of having an abnormal patients BPM out of range, we will just take and write down whatever they feel is normal … I think if it's uploaded on the patients profile anyone could see the reflection from the readings and those that have been noted down.' (Participant 2, FG 1) It was interesting when participants explained that a caring nursing presence can be challenged within a technological environment: 'I think the one thing that we must be careful of is that we don't totally move away from the patient because after all nursing is that touch and caring and that. So, I think that is one thing that we must be very careful about. Participants agreed that patients may experience technology as intrusive to their care: '… [T]he patient is a first time in the hospital doesn't know our gadgets; they will have a fright of a life time … So, you will have an increase of blood pressure and everything and it will affect the patient negatively because they will actually feel bad, and they will feel unsafe in the environment.' (Participant 1, FG 2)

Discussion
Student nurses perceived ICT as a tool for quick and easy access to information (Sá, Nabais & Oliveira 2019 It is however imperative that nursing education institutions support students in providing ICT infrastructure (hardware) and develop student nurses' computer skills (Coopasami et al. 2018:305). Higher education institutions are adopting ICT to enhance education as directed by the National Plan for Higher Education and the Draft Paper on e-Education (2003) (as in Ravjee 2007:29). Student nurses did view that ICT and online learning facilitated the learning process and contribute to their decision-making abilities (Sá et al. 2019) both in the classroom and the clinical work environment. Surprisingly, the internet-generation nurses don't hold an automatically positive view of technology-based healthcare (Van Houwelingen et al. 2017:717).
Information communication technology should enhance the learning process of student nurses. Superficial learning involves cognitively passive learning, in contrast to cognitively active deep learning (Weimer 2012). Deep learning and organising comprehensive events into one long-term memory can be hindered by cognitive loading, such as an overload of over-stimulating web-based information (Stanger-Hall 2012:1). Online learning can be applied as a useful self-assessment tool when knowledge evaluation is the end goal (Mettiäinen 2015:42) and can be useful in teaching nurses to conduct self-assessments (Smith et al. 2010).
Health information systems with insufficient data-capture rules, alarm fatigue, combined with human error, multitasking and high workloads, could become unreliable (Wachter 2015). Digital medical equipment should be managed with caution, given its sensitivity. For example, the reliability and accuracy of a Dinamap 8100 (digital blood pressure machine) evaluated against international criteria concluded that systolic blood pressure measurements were accurate, but diastolic pressures were not (Heinemann et al. 2008:1). Furthermore, patient data security should be guaranteed because unauthorised access might be possible (Singh & Muthuswamy 2013:1533. Techno-ethics in nursing requires further exploration (Korhonen, Nordman & Eriksson 2015:561) because nurses are the interpreters of technology for their patients (Korhonen et al. 2015:572).
Three FG discussions with a diverse group of student nurses enabled within and across group saturation. Although the interview schedule questions focused on barriers and enablers, student nurses' response to ICT adoption wasn't limited to the classroom only but included all technology in the clinical setting as well. Also, it was challenging to accommodate student nurses who had to do clinical work as well, into the FGs that suited them and the interviewer. For future reference, synchronised FG discussions might bring in a larger number of participants. However, the mediator supported the researcher to schedule appointments with students at times when the majority of them were available.
It is recommended to integrate ICT meaningfully into nursing curricula to facilitate deep learning from an approach of learning through instruction and not learning with instruction. With improving access to uncapped Internet in South Africa, employers could provide monitored access to the Internet, be it at a designated communal area (i.e. staff rooms) or Wi-Fi Internet access for use on personal mobile phones. In doing so, it would remove some of the barriers experienced by this cohort, and likely most South African nurses, and enable active learning by means of continuous access to information as questions may arise. Start with using online learning as a selfassessment tool for student nurses who can develop towards a deeper learning process. With the rapidly changing technological landscape towards new technologies (such as extended realities and artificial intelligence), it would be best to bridge technological gaps earlier rather than later.

Conclusion
This study confirmed that ICT must be integrated into the teaching, learning and clinical work environment of student nurses because ICT is closely linked to online learning. ICT adoption enablers are: convenience; fast and on-demand access to information; memory function of devices; selfassessment and being exposed to technology. Barriers to ICT adoption included: insufficient access to devices and connectivity; contextual challenges such as costs, loadshedding and crime. Contradictory views about ICT adoption were that ICT was convenient but supported superficial learning and that ICT was user-friendly but not always accurate. Ensure that ICT is utilised meaningfully to enhance the learning process (learning through instruction) and facilitate programme outcomes. Student nurses require affordable, stable connectivity outside the training institution's/workplace's infrastructure. ICT skills and online learning develop through technology exposure, using phones to browse the Internet and computers to do assignments. Student nurses preferred online learning for self-assessment and exam preparation. Within their clinical setting, student nurses were uncertain about the accuracy of older, manual versus digital technologies, and concerned about caring presence of nurses in technology-driven healthcare environments.