COAV | INT | PC | PEOU | PU | PEIP | |
---|---|---|---|---|---|---|
COVID-19_awareness | ||||||
Intention to participate in e-learning | 0.303 | |||||
Perceived challenges | 0.154 | −0.408 | ||||
Perceived ease of use | 0.079 | 0.538 | −0.283 | |||
Perceived usefulness | 0.205 | 0.794 | −0.346 | 0.567 | ||
Perceived educational institutions preparedness | 0.153 | 0.265 | −0.212 | 0.299 | 0.226 |
Discriminant validity (HTMT)
COAV | INT | PC | PEOU | PU | PEIP | |
---|---|---|---|---|---|---|
Intention to participate in e-learning | 0.346 | |||||
Perceived challenge | 0.222 | 0.431 | ||||
Perceived ease of use | 0.090 | 0.587 | 0.303 | |||
Perceived usefulness | 0.225 | 0.857 | 0.362 | 0.610 | ||
Perceived educational institutions preparedness | 0.173 | 0.280 | 0.217 | 0.326 | 0.234 |
Structural results
Hypothesis | -statistics | Sig | |
---|---|---|---|
: COVID-19_awareness → Intention to participate in e-learning | 0.192 | 3.220 | |
: COVID-19_awareness → Perceived usefulness | 0.243 | 2.748 | |
: COVID-19 awareness → Perceived ease of use | 0.081 | 0.890 | NS |
: Perceived challenges → Intention to participate in e-learning | −0.186 | 2.789 | |
: Perceived challenges → Perceived usefulness | −0.360 | 4.599 | |
: Perceived challenges → Perceived ease of use | −0.246 | 3.167 | |
: Perceived educational institutions preparedness → Intention to participate in e-learning | 0.022 | 0.389 | NS |
: Perceived educational institutions preparedness → Perceived usefulness | 0.112 | 1.267 | NS |
: Perceived educational institutions preparedness → Perceived ease of use | 0.235 | 2.365 | |
: Perceived ease of use → Intention to participate in e-learning | 0.110 | 1.780 | NS |
: Perceived usefulness → Intention to participate in e-learning | 0.623 | 9.225 | |
: Perceived ease of use → Perceived usefulness | 0.484 | 6.220 |
Multigroup analysis results
Path relationships | -statistics | Sig | ||
---|---|---|---|---|
Perceived educational institutions preparedness → PU | 0.261 | 1.995 | 0.05 | Male |
Perceived challenge → Intention to participate in e-learning | −0.310 | 3.828 | 0.001 | Female |
Perceived challenge → PU | −0.572 | 6.487 | 0.001 | Female |
Perceived challenge → PEOU | −0.335 | 3.981 | 0.001 | Female |
COVID-19 awareness → PEOU | 0.332 | 3.406 | 0.001 | Female |
Perceived educational institutions preparedness → PEOU | 0.331 | 2.161 | 0.031 | Group 1 |
COVID-19 awareness → Intention to participate in e-learning | 0.248 | 2.906 | 0.004 | Group 1 |
Perceived Challenge → Intention to participate in e-learning | −0.289 | 3.114 | 0.002 | Group 2 |
Perceived Challenge → PU | −0.279 | 2.518 | 0.01 | Group 2 |
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Home » Management Case Studies » Case Study of IBM: Employee Training through E-Learning
“E-learning is a technology area that often has both first-tier benefits, such as reduced travel costs, and second-tier benefits, such as increased employee performance that directly impacts profitability.” – Rebecca Wettemann, research director for Nucleus Research
In 2002, the International Business Machines Corporation (IBM) was ranked fourth by the Training magazine on it’s “The 2002 Training Top 100”. The magazine ranked companies based on their commitment towards workforce development and training imparted to employees even during periods of financial uncertainty.
Since its inception, IBM had been focusing on human resources development : The company concentrated on the education and training of its employees as an integral part of their development. During the mid 1990s, IBM reportedly spent about $1 billion for training its employees. However, in the late 1990s, IBM undertook a cost cutting drive , and started looking for ways to train its employees effectively at lower costs. After considerable research, in 1999, IBM decided to use e-Learning to train its employees. Initially, e-Learning was used to train IBM’s newly recruited managers.
IBM saved millions of dollars by training employees through e-learning. E-Learning also created a better learning environment for the company’s employees, compared to the traditional training methods . The company reportedly saved about $166 million within one year of implementing the e-learning program for training its employees all over the world. The figure rose to $350 million in 2001. During this year, IBM reported a return on investment (ROI)’s of 2284 percent from its Basic Blue e-Learning program. This was mainly due to the significant reduction in the company’s training costs and positive results reaped from e-learning. Andrew Sadler, director of IBM Mindspan Solutions, explained the benefits of e-learning to IBM, “All measures of effectiveness went up. It’s saving money and delivering more effective training,’ while at the same time providing five times more content than before.” By 2002, IBM had emerged as the company with the largest number of employee’s who have enrolled into e-Learning courses.
However, a section of analysts and some managers at IBM felt that e-Learning would never be able to’ replace the traditional modes of training completely. Rick Horton, general manager of learning services at IBM, said, “The classroom is still the best in a high-technology environment, which requires hands-on laboratories and teaming, or a situation where it .is important for the group to be together to take advantage of the equipment.”
Though there were varied opinions about the effectiveness of e-Learning as a training tool for employees, IBM saw it as a major business opportunity and started offering e- learning products to other organizations as well. Analysts estimated that the market for e-Learning programs would grow from $2.1 billion in 2001 to $33.6 billion in 2005 representing a 100 percent compounded annual growth rate (CAGR).
Since the inception of IBM, its top management laid great emphasis on respecting every employee. It felt that every employee’s contribution was important for the organization. Thomas J. Watson Sr. (Watson Sr.), the father of modern IBM had once said, “By the simple belief that if we respected our people and helped them respect themselves, the company would certainly profit.” The HR policies at IBM were employee-friendly. Employees were compensated well – as they were paid above the industry average. in terms of wages. The company followed a ‘no layoffs’ policy. Even during financially troubled periods, employees were relocated from the plants, labs and headquarters, and were retrained for careers in sales, customer engineering, field administration and programming.
IBM had emphasized on training its employees from the very beginning. In 1933 (after 15 years of its inception), the construction of the ‘IBM Schoolhouse’ to offer education and training for employees, was completed. The building had Watson Sr.’s ‘Five Steps of Knowledge’ carved on the front entrance. The five steps included ‘Read, Listen, Discuss, Observe and Think.’ Managers were trained at the school at regular intervals.
To widen their knowledge base and broaden their perspectives, managers were also sent for educational programs to Harvard, the London School of Economics, MIT and Stanford. Those who excelled in these programs were sent to the Advanced Managers School, a program offered in about forty colleges including some in Harvard, Columbia, Virginia, Georgia and Indiana. IBM’s highest-ranking executives were sent to executive seminars, organized at the Brookings Institutions this program typically covered a broad range of subjects including, international and domestic, political and economic affairs. IBM executives were exposed to topical events with a special emphasis on their implications for the company.
In 1997, Louis Gerstner (Gerstner), the then CEO of IBM , conducted a research to identify the unique characteristics of best executives and managers. The research revealed that the ability to train employees was an essential skill, which differentiated best executives and managers. Therefore, Gerstner aimed at improving the managers’ training skills. Gerstner adopted a coaching methodology of Sir John Whitmore, which was taught to the managers through training workshops.
However, after some time, Gerstner realized that the training workshops were not enough. Moreover, these workshops were not ‘ just-in-time .’ Managers had to wait for months before their turn of attending the work shops came. Therefore, in most of the cases, during the initial weeks at the job, the employees did not possess the knowledge of critical aspects like team building.
IBM trained about 5000 new managers in a year. There was a five-day training program for all the new managers, where they were familiarized with the basic culture, strategy and management of IBM. However, as the jobs became more complex, the five-day program turned out to be insufficient for the managers to train them effectively. The company felt that the training process had to be continuous and not a one-time event.
Gerstner thus started looking for new ways of training managers. The company specifically wanted its management training initiatives to address the following issues:
The company required a continuous training program, without the costs and time associated with bringing together 5000 managers from all over the world. After conducting a research, IBM felt that online training would be an ideal solution to this problem. The company planned to utilize the services of IBM Mindspan Solutions to design and support the company’s manager training program. This was IBM’s first e- learning project on international training.
In 1999, IBM launched the pilot Basic Blue management training program, which was fully deployed in 2000. Basic Blue was an in-house management training program for new managers. It imparted 75 percent of the training online and the remaining 25 percent through the traditional classroom mode. The e-Learning part included articles, simulations, job aids and short courses.
The founding principle of Basic Blue was that ‘learning is an extended process, not a one-time event.” Basic Blue was based on a ‘4- Tier’ blended learning model’. The first three tiers were delivered online and the fourth tier included one -week long traditional classroom training. The program offered basic skills and knowledge to managers so that they can become effective leaders and people-oriented managers.
The managers were provided access to a lot of information including a database of questions, answers and sample scenarios called Manager QuickViews. This information addressed the issues like evaluation, retention, and conflict resolution and so on, which managers came across. A manager who faced a problem could either access the relevant topic directly, or find the relevant information using a search engine. He/she had direct access to materials on the computer’s desktop for online reading. The material also highlighted other important web sites to be browsed for further information. IBM believed that its managers should be aware of practices and policies followed in different countries. Hence, the groups were foremen virtually by videoconferencing with team members from all over the world,”
In the second tier, the managers were provided with simulated situations. Senior managers trained the managers online. The simulations enabled the managers to learn about employee skill-building, compensation and benefits, multicultural issues, work/life balance- issues and business conduct in an interactive manner. Some of the content for [his tier was offered by Harvard Business School and the simulations were created by Cognitive Arts of Chicago. The online Coaching Simulator offered eight scenarios with 5000 scenes of action, decision points and branching results. IBM Management Development’s web site, Going Global offered as many as 300 interactive scenarios on culture clashes.
In the third tier, the members of the group started interacting with each other online. This tier used IBM’s collaboration tools such as chats, and team rooms including IBM e-Learning products like the Team-Room, Customer-Room and Lotus Learning Space. Using these tools, employees could interact online with the instructors as well as with peers in their groups. This tier also used virtual team exercises and included advanced technologies like application sharing, live virtual classrooms and interactive presentation: on the web. In this tier, the members of the group had to solve problems as a team by forming virtual groups, using these products. Hence, this tier focused more on developing the collaborative skills of the learners.
Though training through e-Learning was very successful, IBM believed that classroom training was also essential to develop people skills. Therefore, the fourth tier comprised a classroom training program, own as ‘Learning Lab.’ By the time the managers reached this tire, they all reached a similar level of knowledge by mastering the content in the first three tiers. Managers had to pass an online test on the content provided in the above three tiers, before entering the fourth tier. In the fourth tier, the managers had to master the information acquired in the above three tiers and develop a deeper understanding and a broader skills set. There were no lectures in these sessions, and the managers had to learn by doing and by coordinating directly with others in the classroom.
The tremendous success of the Basic Blue initiative encouraged IBM to extend training through e-Learning to its-sales personnel and experienced managers as well. The e-Learning program for the sales personnel was known as ‘Sales Compass,’ and the one for the experienced managers, as ‘Managing@ IBM.’ Prior to the implementation of the Sales Compass e-Learning program, the sales personnel underwent live training at the company’s headquarters and training campuses. They also attended field training program, national sales conferences and other traditional methods of training. However, in most of the cases these methods proved too expensive, ineffective and time-consuming. Apart from this, coordination problems also cropped up, as the sales team was spread across the world. Moreover, in a highly competitive market, IBM could not afford to keep its sales team away from work for weeks together.
Though Sales Compass was originally started in 1997 on a trial basis to help the sales team in selling business intelligence solutions to the retail and manufacturing industries, it-was not implemented on a large scale. But with the success of Basic Blue, Sales Compass was developed further. The content of the new Sales Compass was divided into five categories including Solutions (13 courses), industries (23 courses), personal skills (2 courses), selling skills (11 courses), and tools and job aid (4 aids).
The sales personnel of IBM across the globe could use the information from their desktops using a web browser. Sales Compass provided critical information to the sales personnel helping them to understand various industries (including automotive, banking, government, insurance etc) in a much better manner. The information offered included industry snapshot, industry trends, market segmentation, key processes, positioning and selling industry solutions and identifying resources.
It also enabled the sales people to sell certain IBM products designed for Customer Relationship Management (CRM) , Enterprise Resource Planning (ERP) , Business Intelligence (BI) , and so on. Sales Compass also trained the sales personnel on skills like negotiating and selling services. Like the Basic Blue program, Sales Compass also had simulations for selling products to a specific industry like banking, about how to close a deal, and so on. It also allowed its users to ask questions and had links to information on other IBM sites and related websites.
Sales Compass was offered to 20,000 sales representatives, client relationship representatives, territory representatives, sales specialists, and service professionals at IBM. Brenda Toan (Toan), global skills and learning leader for IBM offices across the world, said, “Sales Compass is a just-in-time, just-enough sales support information site. Most of our users are mobile. So they are, most of the times, unable to get into a branch office and obtain information on a specific industry or solution. IBM Sales Compass provides industry-specific knowledge, advice on how to sell specific solutions, and selling tools that support our signature selling methodology, which is convenient for these users.”
IBM also launched an e-Learning program called ‘Managing @ IBM’ for its experienced managers, in late 2001. The program provided content related to leadership and people management skills, and enabled the managers to meet their specific needs. Unlike the Basic Blue program, this program enabled managers to choose information based on their requirements. The program included the face-to- face Learning Lab, e-learning, and Edvisor, a sophisticated Intelligent Web Agent. Edvisor offered three tracks offering various types of information.
By implementing the above programs, IBM was able to reduce its training budget as well as improve employee productivity significantly. In 2000, Basic Blue saved $16 million while Sales Compass saved $21 million. In 2001, IBM saved $200 million and its cost of training per-employee reduced significantly – from $400 to $135. E-learning also resulted in a deeper understanding of the learning content by the managers. It also enabled the managers to complete their classroom training modules in lesser time, as compared to the traditional training methods used earlier. The simulation modules and collaboration techniques created a richer learning environment. The e-learning projects also enabled the company to leverage corporate internal knowledge as most of the content they carried came from the internal content experts.
IBM’s cost savings through E-Learning
Basic Blue | 16.0 |
Going global | 0.6 |
Coaching simulators | 0.8 |
Manager Quick-Views | 6.6 |
Customer-Room | 0.5 |
Sales Compass | 21.0 |
The e-Learning projects of IBM had been successful right from the initial stages of their implementation. These programs were appreciated by HR experts of IDM, and other companies. The Basic Blue program bagged three awards of ‘Excellence in Practice’ from the American Society for Training & Development (ASTD) in March 2000. It was also included among the ten best ‘world-class implementations of corporate learning’ initiatives by the “E-Learning across the Enterprise: The Benchmarking Study of Best Practices” (Brandon Hall) in September 2000.
IBM continued its efforts to improve the visual information in all its e-Learning programs to make them more effective. The company also encouraged its other employees to attend these e-learning programs. Apart from this, IBM planned to update these programs on a continuous basis, using feedback from its new and experienced managers, its sales force and other employees.
IBM used e-Learning not only to train its employees, but also in other HR activities. In November 2001, IBM employees received the benefits enrollment material online. The employees could learn about the merits of various benefits and the criteria for availing these benefits, such as cost, coverage, customer service or performance using an Intranet tool called ‘Path Finder.’ This tool also enabled the employees to know about the various health plans offered by IBM. Besides, Pathfinder took information from the employees and returned a preferred plan with ranks and graphs. This application enabled employees to see and manage their benefits, deductions in their salaries, career changes and more. This obviously, increased employee satisfaction. The company also automated its hiring process. The new tool on the company’s intranet was capable of carrying out most of the employee hiring processes. Initially, IBM used to take ten days to find a temporary engineer or consultant. Now, the company was able to find such an employee in three days.
IBM also started exploring the evolving area of ‘mobile learning’ Analysts felt that for mobile sales force of IBM, m-Learning was the next ideal step (after e-Learning). IBM leveraged many new communication channels for offering its courses to employees. IBM also started offering the courses to its customers and to the general public. In early 2002, American Airlines (AA) used IBM’s e-Learning package, which enabled its flight attendants to log on to AA’s website and complete the ‘safety and security training’ from any place, at any time. The content included instruction clips, graphics, flash animation, and so on. This made the airlines annual safety training certification program guides more effective. Shanta Hudson-Fields, AA’s manager for line training and special projects, commented, “The full service package that IBM offers has allowed us to develop an effective online course for our large group of busy attendants. In addition to providing a flexible training certification experience for our attendants, American has also brought efficiency and cost savings to our training processes using IBM’s e-Learning solution.” The company had trained 24,000 flight attendants by November 2002.
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BMC Medical Education volume 24 , Article number: 707 ( 2024 ) Cite this article
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The effects of many treatments in healthcare are determined by factors other than the treatment itself. Patients’ expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in eliciting placebo and nocebo effects. We aim to develop and evaluate an innovative communication training, consisting of an e-learning and virtual reality (VR) training, for healthcare providers across all disciplines, to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training, conducted in The Netherlands.
The development of both the e-learning and the VR training consisted of four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the communication training, there was ongoing structural collaboration with healthcare providers as future end users, experts in the field of placebo/communication research, and educational experts in all phases.
Placebo/communication researchers and healthcare providers evaluated the e-learning positively (overall 7.9 on 0–10 scale) and the content was perceived as useful, accessible, and interesting. The VR training was assessed with an overall 6.9 (0–10 scale) and was evaluated as user-friendly and a safe method for practicing communication skills. Although there were some concerns regarding the authenticity of the VR training (i.e. to what extent the virtual patient reacts like a real patient), placebo and communication researchers, as well as healthcare providers, recognized the significant potential of the VR training for the future.
We have developed an innovative and user-friendly communication training, consisting of an e-learning and VR training (2D and 3D), that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. Future studies can work on improved authenticity, translate the training into other languages and cultures, expand with additional VR cases, and measure the expected effects on providers communication skills and subsequently patient outcomes.
Peer Review reports
The effects of many regular clinical treatments in healthcare are partially determined by factors other than the treatment itself [ 1 , 2 ]. Patients’ expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in placebo and nocebo effects [ 3 ]. We define placebo and nocebo effects as the changes in patient outcomes that can be explained by the expectations someone has about the treatment[ 4 ]. The underlying biopsychosocial processes involved in placebo and nocebo effects have been extensively studied. These processes include learning mechanisms (e.g. patients’ previous experiences or clinicians’ suggestions) and the healthcare provider-patient relationship (e.g. emphatic behavior) that can influence patient expectations and trust [ 3 , 5 , 6 , 7 , 8 ]. As the healthcare provider-patient interaction plays such an important role in eliciting placebo and nocebo effects [ 9 , 10 , 11 , 12 ], training healthcare providers’ communication with their patients is pivotal for optimizing healthcare.
Experts in placebo research consented that there are several strategies to optimize placebo effects and minimize nocebo effects through communication in clinical practice [ 4 , 13 ]. For example, healthcare providers could enhance treatment effects if they outline the expected benefits from treatment [ 14 ], prevent side effects by fine-tuning the information they give to patients [ 15 , 16 , 17 ], and increase trust and satisfaction through an empathetic attitude [ 18 , 19 , 20 , 21 ]. However, experts also agree that these communication strategies are currently underutilized, and that healthcare providers should preferably be trained to address placebo and nocebo effects via their communication [ 13 ].
Our goal was to develop and evaluate an innovative communication training for healthcare providers to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. We aimed for the training to be suitable for healthcare providers across disciplines at every level, whether they are actively practicing or still in training, thus ensuring its broad applicability. The communication training will exist of two advanced eHealth components: an e-learning and virtual reality (VR) training. Using these eHealth techniques has the potential for great outreach as it can be easily offered online. Other advantages over hiring teachers or actors are: costs-efficiency, standardized teaching and practicing, safe learning environment, and opportunities for extensive repetitive practice [ 22 , 23 , 24 , 25 ]. Additionally, the use of virtual patients yields comparable learning effects compared to role-playing actors [ 26 , 27 ]. The aim of the communication training was threefold: 1) to familiarize healthcare providers with state-of-the art knowledge on placebo and nocebo effects, 2) to raise awareness about the role of placebo and nocebo effects in everyday clinical practice, and 3) to teach communication techniques that can optimize placebo effects and minimize nocebo effects in clinical practice. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training.
The content of the communication training was based on the most recent scientific insights and expert consensus on placebo and nocebo effects, which has been investigated systematically during the first [ 4 ] and second [ 13 ] official Society for Interdisciplinary Placebo Studies (SIPS) conferences in 2017 and 2019. The training consists of two parts. First, the background theory, empirical evidence and communication skills are taught in an e-learning. Second, hands-on practice is offered in a VR training. Both the e-learning and the VR tool were developed in Dutch.
The e-learning was developed first and its content was the starting point for the VR training. The development of both the e-learning and the VR training took place between May 2021 and October 2022 and was divided into four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the training, in all phases there was ongoing structural collaboration with a group of experts. This group consisted of all authors and the experts mentioned in the acknowledgements, in total including two general practitioners, two anesthesia practitioners (one physician and one physician assistant), one VR expert (and his team members) who developed the VR application, one educational expert (and her team members) who developed the e-learning, and fifteen national and international researchers (most with backgrounds in biomedical and health sciences, some of whom are also working in clinical practice). The authors together set up the content and design of the training. Throughout the phases, updates were consistently shared with the other experts for feedback and approval. The studies were conducted in The Netherlands and approved by the Ethical Committee of Psychology Research of Leiden University (2022–03-01-A.W.M. Evers-V2-3783 and 2022–06-10-A.W.M. Evers-V2-4051).
Content determination.
For the development of the e-learning we collaborated with a non-profit medical education provider, the Dutch Institute for Rational Use of Medicine (IVM). To determine the specific design and content topics of the e-learning, a brainstorm session was organized with an expert group of national and international clinicians and placebo/communication researchers (i.e. all authors and experts mentioned in acknowledgements). Subsequently, a content framework was created in collaboration with an education developer from IVM, which was sent to the expert group for approval. All involved experts agreed on the topics to be included (Fig. 1 ).
Overview of the e-learning’s main structure and contents
The e-learning structure is based on leading didactic theories [ 28 , 29 , 30 , 31 ]. To activate and motivate, the e-learning starts with a welcome video, followed by an audio message from a general practitioner (AS) who already makes extensive use of the communication techniques. Second, healthcare providers are challenged to think about their own knowledge and skills, and what they want to improve. Third, an introduction about placebo and nocebo effects in clinical practice is given. This introduction is followed by five substantive modules (Fig. 1 ). Each module contains a video, which focuses on background knowledge, and textual information, which focuses on practical skills. Subsequently, an assignment is given (‘step-by-step case’) in which the healthcare provider can practice the learned techniques on an own (imaginary) patient. During this assignment, several questions are asked on how to act in a certain situation, followed by specific automated feedback. In a final take home assignment, the healthcare provider is encouraged to plan a moment to apply the learned knowledge in clinical practice. The e-learning ends with an optional test (15 multiple choice questions; pass after ≥ 10 correct answers) after which accreditation points could be obtained (Dutch accreditation available for: ABC 1, Kwaliteitsregister V&V and Verpleegkundig Specialisten Register). Thirty five test questions were developed to provide variety when a test had to be retaken.
The e-learning was evaluated twice: mid-term evaluation and final evaluation. The mid-term evaluation took place directly after finishing the development of the first version of the e-learning and the collected feedback was used for optimization of the e-learning. In the final evaluation, the e-learning was re-evaluated by a new group of participants to measure if the adjustments led to improvement and to determine if the training was ready to be used in practice.
In both evaluations, we asked healthcare providers (future users) to evaluate the e-learning. During the mid-term evaluation we additionally included placebo/communication researchers to assess the e-learning for accuracy and quality of the content. In both evaluations, participants were recruited from the professional network of the research group members, for example researchers and healthcare professionals from Leiden University Medical Center (LUMC) and Radboud University Medical Center (RadboudUMC). In the final evaluation, participants were also recruited via (social) media (e.g. on LinkedIn and in the newsletter of IVM). Healthcare providers could follow the e-learning for free and they indicated whether they agreed to use their data for research before they started. In the mid-term evaluation, placebo/communication researchers ( N = 4) and healthcare providers (nurse N = 3; unknown N = 2) assessed the quality of the e-learning (whether the content is correct) and tested the user experience and realism of the e-learning. In the final evaluation, the e-learning was evaluated by healthcare providers (physician N = 5; nurse N = 4, other [unspecified] N = 9).
In both evaluations, participants went through the e-learning by themselves, at a self-chosen moment, from their own computers. No researcher was present during this process. To evaluate the e-learning two questionnaires were designed: 1) General questionnaire and 2) Specific questionnaire. The General questionnaire, offered through the e-learning environment, included 14 questions: Five questions about the participants’ background (e.g. ‘What is your job function?’), five multiple choice questions (e.g. ‘Do you think that the e-learning is user-friendly? yes/ reasonable/not really/no’), three open ended questions (e.g. ‘How can we improve the e-learning?’), and one rating (‘What grade do you give this e-learning? scale 1–10’). Table 1 (first column) shows the multiple choice questions. The Specific questionnaire, sent by e-mail, included 14 rating questions (scale 1–10) to evaluate each separate part of the e-learning (see the first column of Table 2 ; e.g. ‘How would you rate the quality of the information in Module 1? 1 = very poor quality 10 = very good quality’), and one open question (‘Do you have any additional feedback?’). During the mid-term evaluation, participants completed both questionnaires. During the final evaluation, participants completed only the General questionnaire.
In the VR training, healthcare providers interact with simulated patients in two different scenarios while using VR headsets. The VR training focused on training those techniques that have been agreed upon by the expert group in determining the content of the e-learning, as described above. To optimize placebo effects, the provider is taught to explain why the chosen treatment is offered, to emphasize what its short- and long-term benefits are, and to display a warm and empathic attitude (e.g. by maintaining eye contact with the virtual patient). To minimize nocebo effects, the provider learns techniques such as how to identify patients at risk by recognizing negative expectancy patterns, and how to carefully introduce potential side effects of a treatment. For development of the VR training, we collaborated with The Simulation Crew (TSC). TSC is a Dutch company that specializes in developing interactive VR communication training courses using Artificial Intelligence (AI) based speech technology and simulation techniques for training and feedback. In order to ensure that the VR training fits well with conversations in clinical practice, there was structural collaboration with two clinicians (ToH and AS). During the creation of the patient cases, roleplay sessions with three nurses were conducted. Throughout the development process, intensive consultations took place between the researchers, VR developers, and involved clinicians. The researchers took into account the empirical evidence, the VR developers the developmental feasibility, and the clinicians the comparison with clinical practice. Two patient cases were designed (Fig. 2 ). The names within the described cases have been contrived for development of the training and do not pertain to actual individuals under any circumstances. In selecting the features of the patients, we endeavored to be as diverse as possible, by incorporating variations in gender and age.
Brief description of the patient cases in the VR training
The two patient cases were integrated into an app, which can be utilized in 2D on mobile devices and in 3D with the Oculus Quest 2 VR headsets. Only the 3D version was tested in this study since the 2D version was developed later. Healthcare providers can talk aloud in the VR environment and the patient talks back. Artificial Intelligence (AI) tools, such as speech recognition and natural language processing/understanding , ensured that providers can freely interact with the patients in the VR environment and that they can explore the impact of different communication strategies on the patient. During the mid-term evaluation, the patient had a computer voice. To ensure natural responses from the virtual patients, between the mid-term and final evaluation TSC recorded all possible reactions with motion capture (gestures), facial capture (facial expression), and human voice. Moreover, the AI tracked and detected gaze direction which was used for feedback on keeping eye contact with the patient. After completing the consultation with the virtual patient, healthcare providers received personalized feedback on how they communicated with the patient, and what they could do to improve their skills.
The VR training (3D version) was evaluated twice: during a mid-term evaluation and a final evaluation. During the mid-term evaluation, both patient cases were assessed separately because case 2 was developed after the first evaluation of case 1. During the final evaluation, both cases were re-evaluated to measure if the adjustments led to improvement and to determine if the training was ready to be used in practice.
In both evaluations, we asked healthcare providers (future users) to evaluate the VR training. During the mid-term evaluation we additionally included placebo/communication researchers to assess the training for accuracy and quality of the content. In both evaluations, participants were recruited from the professional network of the research group members, for example researchers and healthcare professionals from Leiden University Medical Center (LUMC) and Radboud University Medical Center (RadboudUMC). During the mid-term evaluation, placebo/communication researchers ( N = 7) and healthcare providers (physician N = 7, nurse N = 2) assessed the VR training on quality, user experience, and authenticity (i.e. to what extent the virtual conversation corresponds with a real conversation). During the final evaluation, the VR training was evaluated by healthcare providers (nurse N = 10; physician N = 8; psychologist N = 2; unknown N = 2; researcher N = 1). Five participants were part of both evaluations.
Both evaluations were in person and several test days were organized in collaboration with TSC. In addition, some individual test appointments were scheduled. The procedure and materials were the same for both evaluations. Participants put on the VR headsets and went through one or both VR cases, having a conversation with the virtual patient multiple times. Participants’ interim feedback was noted by the researcher/TSC and the first impression was discussed and noted after the test. At the end of the appointment, all participants were asked to complete an evaluative questionnaire. The questionnaire contained five questions about the participants’ background (e.g. ‘What is your job function?’), multiple choice questions (e.g. ‘do you think the structure of the case is logical? Yes/Reasonable/Not really/No’), ratings (e.g. ‘how user-friendly do you find the VR training? scale 1–10’), and room for comments. See the first column of Table 3 for the multiple choice questions and ratings.
The background characteristics of all participants are summarized in Table 4 .
During the mid-term evaluation, all components of the e-learning were rated positively (range M = 7.5 – M = 8.4) except the take-home assignment ( M = 5.9, SD = 1.64) (Table 2 ). The alternation between the different types of information (e.g. text, video, assignment) was experienced as positive, as well as the structure, user-friendliness, and level of the e-learning (Table 1 ). The e-learning as a whole was assessed with a 7.9 ( N = 7 , SD = 0.90). Figure 3 shows some qualitative comments of participants per study.
Qualitative quotes evaluation studies
Based on the quantitative and qualitative analysis of the mid-term evaluation, the following adjustments were made to optimize the e-learning:
- The take home assignment was offered as an optional, instead of a required part of the training.
- We added a clear overview screen at the beginning of the e-learning with the aim, the structure, the welcome video and an overview of the chapters.
- More example phrases, that healthcare providers can use in daily practice, were added (e.g. how to explore expectations).
- Detailed feedback on grammar and the general layout of the e-learning was processed when possible.
The e-learning improved in terms of user-friendliness (‘yes’ from 43 to 72%) and applicability in practice (‘yes’ from 29 to 72%), see Table 1 . The overall assessment was equal in both evaluation moments ( N = 7 , M = 7.9, SD = 0.90 vs. N = 18, M = 7.9, SD = 0.76). Quotes of participants confirmed that the added practical examples were helpful: e.g. “Design, amount of information and usefulness of the information was good. Even though I am not a doctor, I will certainly use the knowledge and tips I have gained in my nursing role” . Enhancing the quality of the videos or including healthcare provider-patient interaction videos are potential suggestions for improvement (see quotes in Fig. 3 ).
During the mid-term evaluation, case 1 was rated less positively than case 2 ( M = 5.9; SD = 2.13 vs.
M = 7.4; SD = 0.48). More than half of the participants scored case 1 as difficult , however all participants perceived case 2 as either doable or easy . In both cases, participants indicated that the interaction with the simulated patient was difficult because the tool does not always understand everything they said (due to speech recognition limitations). This resulted in a stiff and sometimes unnatural conversation flow. The user-friendliness, on the other hand, was immediately assessed as sufficient in both cases ( M = 7.1; SD = 2.09 and M = 7.4; SD = 1.55, respectively), see Table 3 and Fig. 3 .
The first step towards VR training improvement was that all possible reactions/movements of the virtual patient were recorded by an actor in a motion-sensitive suit. This improvement gave the simulated patient a more human appearance. The following adjustments were also made to optimize the VR training:
- The recognition and vocabulary of the simulated patient was expanded, allowing the system to better understand what the participant is saying and improve the responses.
- After the participant welcomed the patient, the patient starts talking directly instead of waiting for a question from the trainee, which makes the start of the conversation smoother.
- More instructions were added to guide the participant through the conversation.
- The visuals were optimized (e.g. enhanced legibility of the computer screen in the virtual environment).
The final evaluation showed that case 1 improved in terms of structure, level and overall rating (see Table 3 ). Case 2 was assessed almost equal as in the mid-term evaluation. In both cases about half of the participants perceived the acquired knowledge as directly applicable in clinical practice (44% and 50%, respectively), almost the other half perceived it as reasonably applicable (39% and 44%, respectively). The comments also indicated that the VR training was perceived as valuable: e.g. “I think very valuable to use in education” . For additional quotes, see Fig. 3 . The VR training as a whole was assessed with a 6.9 ( N = 22, SD = 1.19). Instances where the avatar does not understand the participant or gives inappropriate responses remain a focus point for improvement in the future.
We developed and evaluated an innovative communication training, consisting of an e-learning and VR training, for healthcare providers to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. Results of the evaluation studies show that both healthcare providers and communication/placebo researchers were mostly positive about the communication training. The e-learning was experienced as user-friendly and the content was perceived as accessible, interesting, and easily applicable in clinical practice. Enhancing the quality of the videos or including healthcare provider-patient interaction videos are potential suggestions for improvement. The VR training was experienced as user-friendly as well, and as offering a safe learning environment. Instances where the VR avatar does not understand the participant or gives inappropriate responses remain a focus point for improvement in the future.
The growing acknowledgement of the power of communication in healthcare is a positive development that results in an increase in communication training programs for healthcare providers. Existing communication training courses often focus on shared decision making [ 32 ], person centered care [ 33 ], or serious illness communication [ 34 , 35 , 36 ]. Fewer training courses focus on how to utilize placebo effects in clinical practice [ 37 , 38 , 39 ]. What our training adds to the existing training courses is that we focus on both optimizing placebo effects, and also minimizing nocebo effects. In addition to educating healthcare providers about the potential impact of expectations and empathy, we also train them in effectively informing patients about placebo and nocebo effects. We utilize various learning methods, including text, video, assignments, and virtual reality, and aim to be accessible to healthcare providers in all disciplines.
Setting up this e-learning and VR training presented some limitations and taught us some lessons that may also be helpful for others. First an issue, common in interdisciplinary collaborations [ 40 ], that arose at the initial stage of the development was that the researchers and educational experts (IVM and TSC) experienced lack of expertise in each other’s field. Learning each other's language was time-consuming, but frequent consultation at the beginning of the project has been helpful. The growth of knowledge of each other's field is reflected in the finding that VR case 2, which was developed after a first version of case 1 was evaluated, was immediately assessed better than case 1. Second, a well-known problem of VR is that it remains difficult to be authentic (i.e. to what extent the virtual patient reacts like a real patient) due to technical challenges [ 23 , 40 , 41 ]. In our VR training, we decided to use the technique natural language processing , instead of the more conventional choice-based dialogue . The use of natural language processing enables a real conversation with the virtual patient, however it is also more challenging and time-consuming to ensure a smooth conversation flow. Our results reveal that the authenticity did improve as we progressed in the development. More use of the VR training will improve speech recognition, due to the self-learning abilities of the applied AI. Third, during the final evaluation of the e-learning, we were not able to ascertain the specific medical roles of the participants involved, as the response option 'other' could not be elaborated upon. Fourth, the initial plan was to develop and evaluate the e-learning and the VR training simultaneously as one product. However, due to practical considerations (e.g. time constraints and the distribution of required expertise among multiple partners) separate developmental and evaluation phases were needed. Consequently, this separation led to relatively small sample sizes for all evaluations, which are a limitation of this study. Nonetheless, the separate development has also resulted in an additional benefit: the e-learning and VR training are two self-contained, full-fledged and complementary training tools. These tools can be offered independently or combined as a full training. Combining both training tools, starting with the e-learning followed by the VR training, may enhance the effectiveness of the training [ 35 ].
Development of this first-of-its-kind communication training offers opportunities for future directions. In a follow-up study the effect of this training on healthcare providers’ communication should be studied. To assess the improvement of healthcare providers' theoretical knowledge, the e-learning test can serve as a measurement instrument for both pre- and post-training evaluations. In the VR training, healthcare providers' communication is already being assessed through a scoring system, which is currently used to determine the personalized feedback. The score could potentially serve as a pre- and post-measurement, or it can be studied whether there is an enhancement in the scores when healthcare providers go through the case studies multiple times. Next, it can be investigated whether the acquired communication skills impact patient outcomes on both short- and long-term levels. Some potentially expected outcomes may include increased treatment effectiveness, higher levels of satisfaction and trust, as well as reduced anxiety and perceived side effects [ 18 , 42 , 43 , 44 ]. Another direction for the future is translation of the training. The current training has been developed from a Dutch (East European) perspective and is only available in Dutch. Translating the training to other languages and cultures is an important next step, where cultural differences and preferences must be taken into account [ 45 , 46 ]. A last valuable direction is expanding the VR training with more specific cases to connect even better with healthcare providers from all (para)medical disciplines (e.g. physiotherapists and psychologists). When developing new cases in the future, it is important to strive for diversity in patient features, such as gender, age, and culture. In future AI developments, it's essential to stay informed about ongoing advancements, potential biases, and ethical discussions.
The e-learning and VR training (2D and 3D) are already offered in The Netherlands and available via the websites of IVM and TSC. After completing the e-learning, Dutch accreditation is available for: ABC 1, Kwaliteitsregister V&V and Verpleegkundig Specialisten Register.
Training introduction video: https://www.youtube.com/watch?v=3N6r_Syk2SA
IVM: https://www.medicijngebruik.nl/scholing/e-learning/4942/behandeleffecten-verbeteren-via-communicatie
TSC: https://thesimulationcrew.com/producten/placebo/
To conclude, we have developed an innovative and user-friendly communication training that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. The training consists of an e-learning and VR training (2D and 3D) which can be followed separately or together. Placebo/communication researchers and healthcare providers have provided a favorable evaluation of the training. However, the training’s potential effect on the communication of healthcare providers has not yet been studied. Future studies can focus on translating the training into other languages and cultures, improving the authenticity of the VR training, expanding with additional VR cases, and measuring the expected effects on healthcare provider communication skills, and subsequently, on patient outcomes.
The data generated and/or analyzed during the current study will be made available upon request (corresponding author: [email protected]) after publication via the DataverseNL research data repository.
Dutch Institute for Rational Use of Medicine (Instituut Verantwoord Medicijngebruik)
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We thank the expert group of national and international clinicians and placebo/communication researchers for their involvement in the development of this communication training: Adam Hirsh, Jeremy Howick, Luana Colloca, Fabian Wolters, Judy Veldhuijzen, Antoinette van Laarhoven, Henriët van Middendorp, Aleksandrina Skvortsova, Hans van Lennep, Simone Meijer, Marc Godfried, Bram Thiel. We thank nurses Liz Tenhagen, Suzanne Kok en Kim Nijboer-Vliegen for their contribution to the role plays. We would like to thank the employees of the Dutch Institute for Rational Use of Medicine (IVM) and The Simulation crew (TSC) for their contribution to the development of the training. We would like to thank research assistants Marrit Veenstra and Eva Rümke for their support in data collection and analysis. Last, we would like to express our gratitude to all healthcare providers and placebo/communication researchers who participated in the evaluation studies of the training.
This project was funded by a European Research Council grant awarded to prof. dr. A.W.M. Evers (ERC proof of concept grant; 966785-COMMUNICATE-HEAL-TH).
Authors and affiliations.
Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
Janine Westendorp, Liesbeth M. van Vliet, Stefanie H. Meeuwis, Kaya J. Peerdeman & Andrea W. M. Evers
Center for Interdisciplinary Placebo Studies (IPS) Leiden, Leiden, The Netherlands
Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
Tim C. olde Hartman
General Medical Practice Van Lennep Huisartsenpraktijk, Driebergen, The Netherlands
Ariëtte R. J. Sanders
The Simulation Crew (TSC), Nijmegen, The Netherlands
Eric Jutten
Dutch Institute for Rational Use of Medicine (IVM), Utrecht, The Netherlands
Monique Dirven
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Study conceptualization: AE,SM, KP and LvV; Training development: JW, LvV, KP, SM, ToH, AS, EJ, MD, and AE. Data collection and analyzation: JW. JW drafted the full manuscript and all authors contributed to the revision of the manuscript. All authors read and approved the final manuscript.
Correspondence to Janine Westendorp .
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Ethical permission was obtained from the Ethical Committee of Psychology Research of Leiden University (2022–03-01-A.W.M. Evers-V2-3783 and 2022–06-10-A.W.M. Evers-V2-4051). Informed consent was obtained from all participants.
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Author Eric Jutten is CEO of The Simulation Crew. The Simulation Crew sells the VR training. The other authors have no conflicts of interest to declare.
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Westendorp, J., van Vliet, L.M., Meeuwis, S.H. et al. Optimizing placebo and minimizing nocebo effects through communication: e-learning and virtual reality training development. BMC Med Educ 24 , 707 (2024). https://doi.org/10.1186/s12909-024-05671-0
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Received : 27 October 2023
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DOI : https://doi.org/10.1186/s12909-024-05671-0
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Abunasser, B.S., Abu-Naser, S.S. (2024). Predicting Customer Revenue in E-commerce Using Machine Learning a Case Study of the Google Merchandise Store. In: Saeed, F., Mohammed, F., Fazea, Y. (eds) Advances in Intelligent Computing Techniques and Applications. IRICT 2023. Lecture Notes on Data Engineering and Communications Technologies, vol 210. Springer, Cham. https://doi.org/10.1007/978-3-031-59711-4_3
DOI : https://doi.org/10.1007/978-3-031-59711-4_3
Published : 30 June 2024
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The OECD designs international standards and guidelines for development co-operation, based on best practices, and monitors their implementation by its members. It works closely with member and partner countries, and other stakeholders (such as the United Nations and other multilateral entities) to help them implement their development commitments. It also invites developing country governments to take an active part in policy dialogue.
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The OECD works with governments, civil society organisations, multilateral organisations, and others to improve the quality of development co-operation. Through peer reviews and evaluations, it periodically assesses aid programmes and co-operation policies, and offers recommendations to improve their efficiency. The OECD also brings together multiple stakeholders to share good and innovative practices and discuss progress.
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