ARTICLE IN PRESS

International Journal of Nursing Studies 45 (2008) 869–878

www.elsevier.com/locate/ijnurstu

Applying the technology acceptance model to explore

public health nurses’ intentions towards web-based learning:
A cross-sectional questionnaire survey
I. Ju Chena, Kuei-Feng Yangb, Fu-In Tanga, Chun-Hsia Huanga, Shu Yua,c,
a
School of Nursing, National Yang-Ming University, Taipei, Taiwan
b
Vascular Center, Taiwan Adventist Hospital, Taipei, Taiwan
c
Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
Received 27 October 2005; received in revised form 16 November 2006; accepted 28 November 2006

Abstract

Background: In the era of the knowledge economy, public health nurses (PHNs) need to update their knowledge to
ensure quality of care. In pre-implementation stage, policy makers and educators should understand PHNs’ behavioural
intentions (BI) toward web-based learning because it is the most important determinant of actual behaviour.
Objectives: To understand PHNs’ BI toward web-based learning and further to identify the factors influencing PHNs’
BI based on the technology acceptance model (TAM) in pre-implementation stage.
Design: A nationwide-based cross-sectional research design was used in this study.
Setting: Three hundred and sixty-nine health centres in Taiwan.
Participants: A randomly selected sample, 202 PHNs participated in this study.
Methods: Data were collected by mailing in a questionnaire.
Results: The majority of PHNs (91.6%, n ¼ 185) showed an affirmative BI toward web-based learning. PHNs rated
moderate values of perceived usefulness (U), perceived ease of use (EOU) and attitude toward web-based learning (A).
Multiple regression analyses indicated that only U revealed a significantly direct influence on BI. U and EOU had
significantly direct relationships with A; however, no significant relationship existed between A and BI. Additionally,
EOU and an individual’s computer competence revealed significant relationships with U; Internet access at the
workplace revealed a significant relationship with EOU.
Conclusion: In the pre-implementation stage, PHNs perceived a high likelihood of adopting web-based learning as their
way of continuing education. In pre-implementation stage, perceived usefulness is the most important factor for BI
instead of the attitude. Perceived EOU, an individual’s computer competency, and Internet access at workplaces
revealed indirect effects on BI. Therefore, increasing U, EOU, computer competence, and Internet access at workplace
will be helpful in increasing PHNs’ BI. Moreover, we suggest that future studies should focus on clarifying problems in
different stages of implementation to build a more complete understanding of implementing web-based learning.
r 2007 Elsevier Ltd. All rights reserved.
Keywords: Behavioural intentions; Continuous education; Public health nurses; The technology acceptance model (TAM); Web-based
learning

Corresponding author. Department and Institute of Nursing, National Yang-Ming University, No. 155, Sec. 2, Li-Nong St., Taipei
112, Taiwan, ROC. Tel.: +886 2 28267174; fax: +886 2 28229973.
E-mail addresses: yushu@ym.edu.tw, shuyuym@yahoo.com.tw (S. Yu).

0020-7489/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.11.011
 ARTICLE IN PRESS
870 I.J. Chen et al. / International Journal of Nursing Studies 45 (2008) 869–878
What is already known about the topic?
 In the era of the knowledge economy, web-based
learning is expected to play an important part in
providing continuing education for health profes-
sionals, e.g. nurses. Behavioural intention (BI), which
could be used to predict behaviour, is the most
important determinant of behaviour. There have
been few studies to explore nurses’ BI toward web-
based learning, which is still at its preliminary stage.
 The technology acceptance model (TAM) is designed
to explain computer usage BI and actual behaviour.
However, regarding nurses’ web-based learning,
previous studies have lacked the theory base to
explore determinants of BI.
What this paper adds
 Web-based learning is a feasible way of PHNs’
continuing education. Based on our empirical find-
ings, in pre-implementation stage, perceived useful-
ness is the most important predictor for BI instead of
the attitude. Perceived EOU, an individual’s compu-
ter competency, and Internet access at workplaces
revealed indirect effects on BI.
1. Introduction
Continuing education is an important part of lifelong
learning and professional development. In order to
maintain competency in rapidly changing health care
systems and meet the challenge of overcoming tradi-
tional barriers to continuing education, nurses need
access to innovative educational delivery methods to
keep pace with updated information (Atack and
Rankin, 2002). As the Internet becomes increasing
accessible to more people, it is important to understand
its relevance to nursing. In particular, web-based
learning has been widely recognized in several countries
and has become a valuable and legitimate learning tool
for health care professionals in the 21st century. In UK
and USA, it has been used for nursing students and
continuing education (Fullerton and Ingle, 2003, Di-
Maria-Ghalili et al., 2005). The American Public Health
Association (APHA) indicated that web-based learning
can provide health professionals with more continuing
education (Horton, 2000).
Based on the advances of computer technology and
given the many benefits of web-based learning (or e-
learning), educators and administrators are starting to
consider how to make it more accessible. Nurses can
now select web-based learning methods as a suitable way
of continuing their education, thus creating more
opportunities for continuing education (Wills and
Stommel, 2002; Frith and Kee, 2003).
In Taiwan, pubic health centres (basic government
units which are responsible for promoting community
health; preventing disease, disability and premature
death; and for protecting the health of vulnerable
populations) play a major role in primary health care.
Among diverse health professionals in health centres,
public health nurses (PHNs) are the key health profes-
sionals (Yu and Chin, 1996). Because of the important
roles of PHNs and rapid changes in health information,
PHNs need to update their knowledge and skills
continually to deliver health services effectively and to
ensure the quality of health care (Gebbie, 1999). Web-
based learning should be one feasible way to continue
PHN’s education.
Previous studies indicated most PHNs revealed a
positive attitude towards web-based learning (Yu and
Yang, 2006). Prior to implementing web-based learning
programs (i.e. in pre-implementation stage), for reasons
ranging from saving costs and avoiding unnecessary
failure to the fact that web-based learning is not suitable
for every learner (Atack and Rankin, 2002), policy
makers and educators should investigate learners’ BI
toward web-based learning because BI are the most
important determinant and a predictor of actual
behaviour (Montano and Kasprzyk, 2002; Szajna,
1996).
Is there any theory that can be used to explore factors
relating to PHNs’ BI toward web-based learning?
The Theory of Reasoned Action (TRA), developed by
Fishbein and Ajzen, is a widely used model from
social psychology concerned with the determinants of
consciously intended behaviour and has been used in
exploring individual’s health behaviours. According
to TRA, a person’s performance of a specified behaviour
is determined by the person’s attitude and subjective
norm; BI is a prerequisite of the likelihood of per-
forming a specific behaviour (Ajzen and Fishbein,
1980). Davis et al. (1989) adapted the TRA and
introduced the TAM to attempt to explain computer
usage BI and actual behaviour. TAM postulates
that computer usage is determined by BI; a person’s
acceptance of an information system is hypothesized
to be determined by his or her intention to accept it. The
TAM explained the causal links among ‘‘perceived
usefulness’’ (U) and ‘‘perceived ease of use’’ (EOU),
attitude (A), and BI (BI). According to TAM, A
is a major determinant of BI (A–BI link), which is
influenced by U and EOU (A ¼ U+EOU). U has
also been linked to BI (U–BI link). Besides, the TAM
proposed that U and EOU are affected by various
external variables (such as user characteristics and
organizational factors, etc.). External variables are
expected to influence BI by affecting beliefs (U
and EOU) and attitudes (A) and then influencing
actual behaviour (Davis et al., 1989; Davis, 1993)
(Fig. 1).
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I.J. Chen et al. / International Journal of Nursing Studies 45 (2008) 869–878
Fig. 1. Factors related to behavioural intention toward web-based learning: based on the original technology acceptance model
(TAM).
There have been few studies to explore nurses’ BI
toward web-based learning. Therefore, we reviewed the
literature regarding attitudes toward computer use or
other computer use behaviour to help us to clarify
external variables. As to user characteristics, previous
studies indicated that age (Liu et al., 2000), education
(Chuang and Chuang, 2002), nursing job experience
(years and job position) (Ngin and Simms, 1996;
Chuang and Chuang, 2002), and previous web-based
learning experience (Ngin and Simms, 1996), as well as
one’s own computer competence (also known as
computer skill) (Kenny, 2000; Liu et al., 2000; Yu and
Yang, 2006) are determinants of attitude toward web-
based learning or computer use behaviours.
Organizational factors, such as work load (Yu and
Yang, 2006) and the types of health centre, may also
influence nurses’ interest in computer use (Hendrickx,
1998) or attitude toward web-based learning (Yu and
Yang, 2006). Hence, these two variables were selected as
organizational factors to examine the relationships with
PHNs’ U and EOU. In Taiwan, health centres are
categorized into four types according to urbanization
level: metropolitan, county, township, and village.
PHNs who work in different types of health centres
might be expected to play different roles and might have
different resources for continuing their education. For
example, PHNs who work in village-type health centres
might possess fewer opportunities to participate in
traditional face-to-face continuing education because
of traffic barriers.
Additionally, previous studies indicated that compu-
ter equipment and Internet use were related to nurses’
attitude, which may also influence nurses’ BI. For
example, Garland (1993), Ngin and Simms (1996), and
Yu and Yang (2006) indicated that computer equipment
and Internet access were determinants to an individual’s
willingness to participate in web-based learning courses,
attitudes toward web-based learning, and computer use.
Chuang and Chuang (2002) indicated that nurses’
computer use experience (e.g. time spending on-line)
was related to their attitude toward computers. All
public health centres in Taiwan are computerized
871
(Department of Health, 2000), but only part of them
have Internet connections. Hence, we selected Internet
access at the workplace and at home, as well as time
spent on-line, as in Internet access and use factors to
investigate the relationships with U and EOU.
In this study, we hypothesized that PHN’s acceptance
of web-based learning programs is determined by his or
her intention to accept it. We tried first to understand
PHNs’ BI toward web-based learning and further to
identify the factors relating to PHNs’ BI. For determi-
nant analysis, we applied the TAM as our theory base
(Fig. 1). The hypotheses included:
H1. Attitude toward web-based learning will have a
significant positive effect on BI toward web-based
learning.
H2. Perceived usefulness will have a significant positive
effect on BI toward web-based learning.
H3. Perceived usefulness will have a significant positive
effect on attitude toward web-based learning.
H4. Perceived ease of use will have a significant positive
effect on attitude toward web-based learning.
H5. Perceived ease of use will have a significant positive
effect on perceived usefulness.
H6. External variables (including user characteristics,
Internet access and use factors, and organizational
factors) will have significant effects on perceived
usefulness.
H7. External variables (including user characteristics,
Internet access and use factors, and organizational
factors) will have significant effects on perceived ease
of use.
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2. Methods Table 1
Distribution of PHNs in different types of public health centres
2.1. Design between population and sample

Types of health Population Sample w2

This study employed a cross-sectional research design. centres
n % n %
2.2. Participants Metropolitan 335 13.54 26 12.9 0.09
city (d.f. ¼ 3)
A cluster random sampling method was used to select County 434 17.54 36 17.8
samples. In this sampling method, first all health centres Townships 337 13.62 27 13.4
were divided into four strata. Then, health centres in Village 1368 55.30 113 55.9
each stratum were proportionally selected by a cluster
Total 2474 100.00 202 100.00
random sampling, and the public health nurses who
worked at the selected health centres comprised the Abbreviation: d.f., degree of freedom.
study sample. Data were collected by mailed question- P40.05.
naires. To increase the response rate, three strategies,
including making prior contacts, tracing (weekly for
three times), and giving rewards, were used in this study.
2.3.1.3. Organizational factors. This category included
Among 237 subjects, 202 subjects mailed back their
the types of health centres and work load (i.e.
completed consent forms and questionnaire. The re-
population serviced).
sponse rate was 85.2%. Using a w2-test, no significant
differences were seen in the response rates from PHNs in
the four levels between the sample and the population of 2.3.2. Perceived usefulness of web-based learning (U)
PHNs (w2 ¼ 0.09, P40.05); the sample was representa- U is defined here as ‘‘the degree to which a PHN
tive of the population (Table 1). believes that using web-based learning would enhance
her or his job performance’’. Five items with a five-point
2.3. Instruments Likert scale were answered with a response ranging from
five to one, representing ‘‘strongly agree’’, ‘‘agree’’, ‘‘no
A self-administered questionnaire was used to collect comment’’, ‘‘disagree’’, and ‘‘strongly disagree’’. The
data in this study. The questionnaire was developed by total score ranged from 5 to 25 points; a higher score
reviewing literature, conducting personal interviews and indicated a higher usefulness of web-based learning
consulting experts. The questionnaire consisted of five perceived by PHNs.
parts:
2.3.3. Perceived ease of use (EOU)
2.3.1. External variables EOU is defined as ‘‘the degree to which a PHN
2.3.1.1. User characteristics. This category included believes that using web-based learning would be free of
age, education, working years of nursing job, job effort’’. Five items with a five-point Likert scale were
position, basic computer competence, and previous answered with a response ranging from five to one,
web-based learning experience. As to basic computer representing ‘‘strongly agree’’, ‘‘agree’’, ‘‘no comment’’,
competence, ‘‘the Basic Computer Competence Scale’’ ‘‘disagree’’, and ‘‘strongly disagree’’. The total score
was used in measuring PHNs’ five major categories of ranged from 5 to 25 points; a higher score indicated a
computer competencies including use of Microsoft higher degree of perceived ease of use perceived by
Office, Word, Excel, PowerPoint, Windows 95/98/ PHNs.
2000/XP, Internet Explorer (IE)/Netscape and e-mail
use. A 26-item five-point Likert scale was used, with five
2.3.4. Attitude toward web-based learning (A)
representing very proficient and one representing incap-
A is defined here as ‘‘a PHN’s positive or negative
able. The total score using this scale was from 26 to 130
feelings about performing web-based learning as her or
points, where a higher score indicated a better basic
his way of continuing education’’. Five items with a five-
computer competence.
point Likert scale were answered with a response
ranging from five to one, representing ‘‘strongly agree’’,
2.3.1.2. Internet access factors. This category included ‘‘agree’’, ‘‘no comment’’, ‘‘disagree’’, and ‘‘strongly
computer and Internet equipment at home and at the disagree’’. The total score ranged from 5 to 25 points;
workplace as well as time spent on-line both at home a higher score indicated a higher positive attitude
and at workplace/per week. toward web-based learning.
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I.J. Chen et al. / International Journal of Nursing Studies 45 (2008) 869–878
2.3.5. BI toward web-based learning
BI is defined here as ‘‘a PHN’s perceived likelihood of
adopting web-based learning as her or his way of
continuing education’’. BI is a measure of the strength of
a PHN’s intent to perform web-based learning. In this
study, we used a 4-point Likert scale to measure the
strength of PHNs’ BI toward web-based learning.
‘‘Definitely possible’’, ‘‘possible’’, ‘‘impossible’’, and
‘‘definitely impossible’’ corresponded to 4, 3, 2, and 1
point(s), respectively. A higher score indicated a higher
behavioural intent.
As to the validity and reliability of the questionnaire,
six experts in the areas of web-based learning, health
information, informational technology, nursing educa-
tion, and community health nursing established the
questionnaire’s content validity. Three PHNs completed
the face validity test. For internal consistency, the
Cronbach’s a of ‘‘the Basic Computer Competence
Scale’’, ‘‘the Scale of Perceived usefulness of web-based
learning’’, ‘‘the Scale of Perceived ease of use’’, and ‘‘the
Scale of Attitude toward Web-based Learning’’, were
0.92, 0.60, 0.63, and 0.63, respectively. These results
indicated the acceptable reliabilities of these instruments.
2.4. Ethical considerations
The study protocol and informed consent form were
reviewed and approved by the Institutional Review
Board, Taipei Veterans General Hospital, to guarantee
the subjects’ rights and interests. All subjects partici-
pated in this study based upon confidential and
voluntary participation. Informed consents were ob-
tained from all participants in this study.
2.5. Data analysis
Data from valid questionnaires were transferred
directly into personal computers. Analyses were per-
formed using the Statistical Package for the Social
Sciences, Version 10.0 (SPSS Institute, Inc., Chicago,
IL). The statistical methods used included frequency,
percentage, mean and standard deviation (S.D.) for
univariate analysis. In addition, a series of linear
regression analyses were performed to estimate the path
coefficients (standardized regression weights, b) asso-
ciated with the TAM.
3. Results
3.1. External variables of PHNs
Regarding user characteristics, the mean age of the
participating subjects was 39.14 years (S.D. ¼ 7.96),
with approximately three-fourth (73.7%, n ¼ 149) aged
between 30 and 49 years. Most of the subjects (69.3%,
873
n ¼ 140) had graduated from college or above. On
average, PHNs had 16.79 years of nursing experience
(S.D. ¼ 7.50). 71.8% (n ¼ 145) of the subjects worked
as registered nurses (RNs), 21.2% (n ¼ 43) worked as
registered profession nurses (RPNs) with more authority
and expectancy in management and leadership skill than
RNs, and 6.9% (n ¼ 14) of the subjects were head
nurses. Both RPNs and head nurses occupied 28.2%
(n ¼ 57). Among 202 subjects, 91.1% (n ¼ 184) had
never joined any web-based learning programs. As to
basic computer competence, PHNs revealed a moderate
degree of computer competence (mean7-
S.D. ¼ 57.56722.08, range ¼ 26–130). Regarding Inter-
net access and use factors, the percentage of workplaces
with an Internet connection was 59.4% (n ¼ 120); the
percentage of households with an Internet connection
was 76.7% (n ¼ 155). On average, PHN’s spent 3.54 h
(S.D. ¼ 5.57) on the Internet per week (both at home
and at the workplace). With respect to organizational
factors, 55.9% (n ¼ 113) of the subjects worked in
village health centres. The rest of the subjects worked in
metropolitan, county, and township type health centres,
12.9% (n ¼ 26), 17.8% (n ¼ 36), and 13.4% (n ¼ 27),
respectively. 53.5% (n ¼ 108) of the subjects serviced
populations less than 10,000; however, 46.5% (n ¼ 94)
of the subjects serviced populations equal to or more
than 10,000 (Table 2).
3.2. Descriptive statistics for the constructs in the TAM
Table 3 shows the U, EOU, A, and BI scores
regarding web-based learning among the PHNs involved
in this study. PHNs present a highly affirmative
behavioural intent toward web-based learning. Most of
subjects (91.6%, n ¼ 185) expressed that it was ‘‘defi-
nitely possible’’ or ‘‘possible’’ for them to participate in
web-based learning program for the purpose of con-
tinuing education. PHNs present a moderate degree of
perceived usefulness (mean score was 18.02 out of a
possible 25; S.D. ¼ 2.17), perceived of ease of use (mean
score was 16.99 out of a possible 25; S.D. ¼ 2.34), and
attitude toward web-based learning (mean score was
16.99 out of a possible 25; S.D. ¼ 2.31).
Table 4 contains the results of linear regression
analyses based on the relationships suggested in the
TAM. First, for the relationships between external
variables and U as well as EOU, only Internet access
at workplace revealed a significant effect on EOU.
Those PHNs having Internet access at their workplaces
perceived a high degree of perceived ease of use.
Personal computer competence revealed a significant
effect on U. Those PHNs having better computer
competence perceived a higher degree of usefulness.
Second, for the relationship between EOU and U, EOU
revealed a significant direct effect on U. Those PHNs
perceiving higher degree of ease of use also perceived
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Table 2
Background data of the subjects (n ¼ 202)

Variables n % Mean7S.D. Range

User characteristics
Age 39.1477.96 23–59
20–29 years old 27 13.4
30–39 years old 74 36.6
40–49 years old 75 37.1
50 years old and above 26 12.9
Educational level
College and above 140 69.3
Vocational senior high school 62 30.7
Years of nursing job experience (years) 16.7977.50 2–32
Job position
Registered nurse (RN) 145 71.8
Registered professional nurse (RPN) and head nurse 57 28.2
Previous web-based learning experience
Yes 18 8.9
No 184 91.1
Basic computer competence 57.56722.08 26–130

Internet access and use factors

Internet access at worksite
Yes 120 59.4
No 82 40.6
Internet access at home
Yes 155 76.7
No 47 23.3

Time spent on-line (per week) 3.5475.57 0–40

At worksite (Hours spent per week) 1.4972.82 0–24
At home (Hours spent per week) 2.0673.68 0–25
Organizational factors
Type of health centres (classified by urbanization level)
Metropolitan type 26 12.9
County type 36 17.8
Townships type 27 13.4
Village type 113 55.9
Population serviced
Less than 10,000 persons 108 53.5
Equal to or more than 10,000 persons 94 46.5

Abbreviation: S.D., standard deviation.

higher degree of usefulness. Third, perceived usefulness
(U) and perceived ease of use (EOU) revealed a
significant direct effects on attitude (A) and accounted
for 45.2% of the variance in A (F ¼ 81.995, Po0.001).
Those PHNs who perceived high usefulness and believed
that using web-based learning would be free of effort
possessed a positive attitude toward web-based learning.
Forth, for BI, only U had a significant, direct effect
(b ¼ 0.258) as hypothesized in the model, but A
(b ¼ 0.037) did not. According to the prediction
equation, those PHNs who perceived high usefulness
possessed an affirmative BI toward web-based learning.
4. Discussion
4.1. PHNs’ BI toward web-based learning
Among the 202 PHN participants in this study, most
PHNs (91.6%, n ¼ 185) expressed a high likelihood of
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Table 3
Descriptive statistics for the constructs in the TAM (n ¼ 202)

Statements Mean S.D. Min. Max.

Perceived usefulness (U) 18.02 2.17 12 24

Perceived ease of use (EOU) 16.99 2.34 10 24
Attitude toward web-based learning (A) 16.99 2.31 11 23
Behavioural intentions toward web-based learning (BI) 3.26 0.60 2 4

Abbreviation: S.D., standard deviation; Min., minimum; Max., maximum.

Table 4
TAM regression tests

Dependent R2 Independent variables b S.E. b t-Value Significant

variables level

U 0.334 Constant 10.326 1.512 6.831 0.000

(F ¼ 7.891, Age 0.037 0.035 0.138 1.062 0.290
Po0.001) Educational level 0.206 0.336 0.044 0.612 0.541
Nursing job experience (years) 0.034 0.038 0.118 0.897 0.371
Job position (RN/RPN) 0.217 0.314 0.045 0.691 0.491
Previous web-based learning 0.355 0.462 0.047 0.768 0.443
experience (yes/no)
Computer competence 0.017 0.007 0.175 2.390 0.018
Internet access at worksite (yes/ 0.036 0.287 0.008 0.125 0.900
no)
Internet access at home (yes/no) 0.089 0.321 0.017 0.277 0.782
Time spent on-line (per week) 0.040 0.027 0.104 1.503 0.134
Types of health centres 0.033 0.164 0.017 0.202 0.840
(urbanization level)
Population serviced (10,000 and 0.360 0.366 0.083 0.983 0.327
above/10,000 and below)
EOU 0.468 0.058 0.500 7.990 0.000
EOU 0.101 Constant 17.247 1.416 12.177 0.000
(F ¼ 1.936, Age 0.044 0.044 0.148 0.989 0.324
P ¼ 0.037) Educational level 0.357 0.420 0.071 0.852 0.395
Nursing job experience (years) 0.044 0.047 0.143 0.938 0.350
Job position (RN/RPN) 0.102 0.393 0.020 0.260 0.795
Previous web-based learning 0.465 0.577 0.057 0.806 0.421
experience (yes/no)
Computer competence 0.011 0.009 0.104 1.232 0.220
Internet access at worksite (yes/ 1.032 0.351 0.217 2.944 0.004
no)
Internet access at home (yes/no) 0.241 0.400 0.044 0.601 0.549
Time spent on-line (per week) 0.008 0.034 0.019 0.236 0.814
Types of health centres 0.230 0.205 0.110 1.123 0.263
(urbanization level)
Population serviced (10,000 and 0.037 0.458 0.008 0.081 0.935
above/10,000 and below)
A 0.452 Constant 3.490 1.091 3.199 0.002
(F ¼ 81.955, U 0.321 0.066 0.302 4.857 0.000
Po0.001) EOU 0.454 0.061 0.460 7.395 0.000

BI 0.078 (F ¼ 8.43, Constant 1.807 0.370 4.881 0.000

Po0.001) U 0.072 0.023 0.258 3.163 0.002
A 0.010 0.021 0.037 0.453 0.651

Abbreviation: U, perceived usefulness; EOU, perceived ease of use; A, attitude toward web-based learning; BI, behavioural intention
toward web-based learning.
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adopting web-based learning as their method of
continuing education. This finding is similar to those
of Chapman (2000) and Kooker et al. (2000) indicating
that health professionals believe web-based learning (or
e-learning) would help them achieve the goal of
professional development and lifelong learning. We
therefore recommend that web-based learning is a highly
feasible way to further PHNs’ continuing education.
4.2. Hypotheses testing: factors influencing PHNs’ BI
toward web-based learning
Among the seven research hypotheses, except for H1,
the rest of hypotheses were totally (H2–H5) or partially
(H6, H7) supported by our data.
H1. Attitude toward web-based learning will have a
significant positive effect on BI toward web-based
learning.
In this study, attitude toward web-based learning did
not reveal a significant effect on BI. This finding is
similar to those of Davis et al. (1989). However, this
finding is dissimilar from those of Chapman (2000) and
Davis (1993). The reasons might be related to the stage
of implementation. Davis et al (1989) indicated that in
pre-implementation stages, attitude is not a determinant
of BI; BI is influenced by U and EOU.
H2. Perceived usefulness will have a significant positive
effect on BI toward web-based learning.
Our data supported the hypothesis. The findings for
U have a significant, direct effect on BI are similar to
those of Davis et al. (1989), Davis (1993), and Szajna
(1996). Only the PHNs who perceived high values of
usefulness tended to adopt web-based learning as their
ways of continuing education. In other words, in pre-
implementation stage, perceived usefulness (U) might be
the determinant of BI instead of attitude (A); an
individual tended to rely on their perceptions of
usefulness to form their intentions. This finding is
similar to those for Davis et al. (1989). Davis et al.
(1989) indicated that constructs (i.e. U, EOU, A) in
TAM may play different roles in determining an
individual’s BI in different stages. Davis et al. (1989)
had revised the TAM to form a pre-implementation
version which is similar to our findings. Meanwhile, in
this study, regression analysis on BI only accounted for
7.8% of the variance (Table 3). Thus, other unknown
factors will account for approximately 92% of the
variance on BI. Further studies should focus on how to
improve the predictability of BI.
H3 and H4. Perceived usefulness and perceived ease of
use will have a significant positive effect on attitude
toward web-based learning.
Our data supported these two hypotheses. If PHNs
believe that web-based learning would enhance her or
his job performance and would be easy to use, then they
tend to participate in web-based learning programs.
However, in this study, the PHNs’ attitude toward web-
based learning is not the main factor of BI.
H5. Perceived ease of use will have a significant positive
effect on perceived usefulness.
This hypothesis was supported by our data. The result
was similar to those of Davis (1989, 1993), and Szajna
(1996). EOU had a significant positive effect on U. Due
to a significant relationship between U and BI, EOU had
an indirect effect on BI via U. Thus to effectively
increase PHNs’ BI, increasing PHNs’ perceived useful-
ness (direct effect) and increasing PHNs’ perceived ease
of use (indirect effect) might be more appropriate than
increasing PHNs’ attitude directly.
H6. External variables will have significant effects on
perceived usefulness.
Except EOU, among external variables, only compu-
ter competence had a significant effect on perceived
usefulness. This finding is similar to those of Jayasuriya
and Chapman (1997), Kenny (2000) and Yu and Yang
(2006) all indicating that basic computer competency is a
major determinant of attitude toward web-based learn-
ing. Therefore, government strategies for training
PHNs’ basic computer competence will first strengthen
PHNs’ readiness and perceived usefulness and then
increase their BI toward web-based learning.
H7. External variables will have significant effects on
perceived ease of use.
Among external variables, only Internet access at the
workplace had a significant relationship with EOU. This
finding is congruent with those of Khoiny (1995) and
Jayasuriya and Chapman (1997) indicating that the
availability of computers and on-line hardware is the
prerequisite of developing web-based learning programs.
Why does Internet access at home not reveal a
significant relationship with EOU, even though the
percentage of Internet access at home (76.7%, n ¼ 155)
is higher than at workplace (59.4%, n ¼ 120)? It might
imply that PHNs are more likely to participate in web-
based learning programs at their workplaces. Thus,
there is a continuing need for government support to
enable more PHNs to access the Internet, promising
PHNs that they may continue their education via web-
based learning.
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I.J. Chen et al. / International Journal of Nursing Studies 45 (2008) 869–878
5. Conclusions and suggestions
In conclusion, web-based learning is feasible with a
high likelihood to be used as a learning model for PHNs
(indeed for all health professionals). In this study, the
technology acceptance model (TAM) proposed by Davis
et al. (1989) was applied to explore determinants of
PHNs’ BI toward web-based learning. Based on
empirical findings, perceived usefulness (U) played the
most important role on BI instead of attitude in pre-
implementation stage. Perceived ease of use (EOU) had
an indirect effect on PHNs’ BI via U. Both U and EOU
revealed significant relationships with attitude; however,
no significant relationship was found between A and BI.
Therefore, in pre-implementation stage, the TAM might
be revised to exclude the attitude construct in predicting
BI. Except EOU, among external variables, only an
individual’s computer competence revealed a significant
relationship with U. For EOU, Internet access at the
workplace was the only variable which significantly
affected EOU. To successfully develop web-based
learning programs as one way of continuing education
for PHNs’ (and indeed for all health professionals),
improving PHNs’ computer competence, ensuring Inter-
net access at workplace, and increasing the feeling of
ease of use would be helpful in increasing the percep-
tions of usefulness and then would be helpful in
increasing PHNs’ BI to participate in web-based
learning programs.
6. Limitations
The main weakness of this study is that the related
variables in this project were not strong enough to
predict PHNs’ BI toward web-based learning. A single
item was used to measure PHN’s BI might be one limit
of this study. Nevertheless, applying the TAM in
different stages (e.g. pre-implementation, implementa-
tion and post-implementation stage) could provide a
whole picture to increase our understanding of web-
based learning development.
Acknowledgement
We acknowledge the National Science Council of
Taiwan for funding this project (project number: NSC
91-2314-B-010-065).
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