Staff experiences of a newly developed blended learning program to improve diabetes management at orthopedic clinics

Abstract

Background

Errors in diabetes treatment are among the most frequently reported adverse events in hospitals and orthopaedic care. This study aimed to identify the learning needs of orthopaedic staff, develop a blended diabetes learning programme, and examine orthopaedic staff experiences of participating in the programme.

Methods

Nurses and physicians from endocrinological and orthopedic wards at three hospitals in the capital region of Denmark (Bispebjerg, Herlev, Nordsjællands Hospitals) participated in group concept mapping. A total of 193 orthopedic staffmembers completed an e-learning module and 174 attended one of 12 face-to-face classes. We used thematic analysis to analyze data from four focus group interviews (n = 14 nurses) and observations from face-to-face classes.

Results

We identified 12 learning objectives and identified three overall themes from thematic analysis: learning through cases, combining e-learning and face-to-face courses, and from learning to practice. These themes explained processes and contexts that facilitated or inhibited learning.

Conclusions

This study identified several key contexts (time, place, level of knowledge, nurse seniority, organisational support) and critical processes (educators’ facilitation, scaffolding, case-based learning) that influence physicians and nurses learning experience and applying it in practice.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09819-y.

Background

Diabetes is one of the most common comorbidities among hospitalized patients. In Denmark approximately 11% of all inpatients [1] and 10% of patients admitted to orthopaedic surgical departments have diabetes [2]. Across hospitalised patients in general, inadequate inpatient diabetes management is associated with inappropriate insulin dosing, episodes of hyper- and hypoglycaemia, increased risk of infections, and prolonged hospitalisation. Audits from orthopaedic surgery wards demonstrating similar deficiencies. [3, 4].

Educational initiatives aimed at improving patient safety and quality of care are essential.

Although healthcare professionals report a lack of knowledge and confidence about treating diabetes in hospitalized patients [5], they also find it difficult to prioritize time during busy work days to attend traditional educational programmes, which require time away from the clinical setting [5]. E-learning offers a flexible learning environment, allowing healthcare professionals to learn at their own pace, time, and preferred location [6, 7].

Although developing e-learning programs is costly, they provide standardized training for many learners over time [6, 7]. However, one-sided communication in e-learning may reduce engagement and motivation and leave important questions unanswered [8]. Therefore, a blended learning approach combining face-to-face (F2F) and computer-mediated training may leverage the benefits of both methods [9] Blended learning has been found to be at least as effective as traditional instruction and can positively impact knowledge acquisition and help develop health professionals’ clinical competencies [10–12].

Ensuring high-quality e-learning designs has proven crucial for maintaining motivation among learners [6, 13]. Interactive e-learning programs are designed to engage participants with the material by solving problems and receiving feedback. Such programs often include clear learning objectives, instructional elements that enhance knowledge accessibility, training components and opportunities for problem-based reflection and assessment [13, 14].

Case-based learning is another strategy for sustaining engagement in e-learning. Presenting real-life cases in a narrative format connects with participants’ own clinical experiences [15, 16]. Participants formulate hypotheses about correct decisions and receive feedback about the potential health consequences of their choices. Case-based learning has proved to effectively facilitate learning and promote positive changes in medical practice, including critical thinking, diagnostic reasoning and problem-solving skills [17–19].

The study objective was to examine the experiences of physician s and nurses participating in an educational diabetes programme tailored to orthopaedic care. Specifically, we aimed to:

• identify their learning needs related to diabetes management in orthopaedic hospital wards,

• examine their experiences of participating in a blended learning programme designed to meet these needs, and.

• examine how nurses and physicians experienced their knowledge and skills of diabetes management in orthopaedic wards after completing the educational programme.

Methods

The educational blended learning program was carried out in 2018 and 2021 with a one-year extension due to the COVID-19 pandemic. Each study phase—identifying learning needs and program development, assessing experiences and data analysis—was carried out over 12 months.

The learning program was initiated, developed, and implemented by diabetologists and educators from Steno Diabetes Center Copenhagen (SDCC) in close collaboration with physicians and nurses from endocrinology and orthopaedic wards in the participating hospitals. These are large acute-care university hospitals (approximately 500–650 beds) located in urban (Bispebjerg), suburban (Herlev), and semi-rural (Noth Zealand Hospital) areas within the Capital Region of Denmark.

Data collection

Identifying learning needs

LLN, AJ and SMH had overall responsibility for identifying learning needs. A specialist diabetes nurse and an experienced endocrinologist from three endocrinology departments were first asked to brainstorm and list the learning needs of orthopaedic staff based on their experiences in assisting with diabetes-related problems in orthopaedic departments. Subsequently, the orthopaedic head of department and the orthopaedic head nurse from three orthopaedic departments one department for each hospital) invited all the physicians and nurses in the orthopaedic department to participate in an online questionnaire, where they were asked to list the diabetes-related challenges they found most difficult to manage in clinical practice, Group concept mapping was used to identify, organize and prioritize the learnings needs based on the brainstorm and lists of diabetes-related problems encountered in clinical practice [20, 21]. The lists from orthopaedic staff and diabetologists were merged and the final list was in an on-line form sent to all nurses and physicians in the orthopaedic departments, who were asked to rank the items by relevance and feasibility. Participation was voluntary. A total of 45 physicians and nurses from the three orthopaedic departments participated. The highest-ranking challenges were translated into learning objectives by the researchers and educators, based on Bloom’s taxonomy [22].

Developing the educational diabetes blended program for orthopaedic wards

LLN, AJ and SMH invited 1 manager, 2 senior physicians and 2 nurses from each orthopaedic and endocrinology departments of the 3 hospitals to participate in 3 workshops to develop e-learning content and cases. Guided by case-based learning principles [15, 16], the healthcare professionals identified cases addressing the most frequent and significant problems from everyday clinical practice in orthopaedic settings.

Using interactive e-learning principles [13, 14], SDCC educators collaborated with the Capital Region of Copenhagen’s e-learning department to transform the content into a self-directed e-learning module. This involved creating learning elements and activities, designing assessment, evaluation, and feedback mechanisms, and developing varied instructional formats.

A digital ‘knowledge bank’ was also created, comprising 23 knowledge areas with information presented in text and video formats, along with general diabetes management guidelines and external links to additional sources. The medical content in both the e-learning programme and the digital knowledge bank was based on the Danish national guidelines for in-hospital diabetes care [23] and supplemented with the ADA guidelines for in-hospital diabetes management [24], which largely correspond to the Danish recommendations. In cases of discrepancy, the Danish national guidelines were followed.

Participants could pause and resume the e-learning course at any time. The estimated time to complete the e-learning module was 60–120 min.

The F2F course was designed to supplement the self-directed e-learning with an interactive forum where participants could clarify questions and explore how their new knowledge and skills could be linked to daily practice. At all three hospitals, the courses were facilitated by the same team of educators—a diabetologist and a diabetes nurse.

The final blended learning program consisted of an e-learning module comprising five cases addressing the most frequent challenges in managing diabetes in orthopaedic hospitals (Fig. 1) and a 23-topic knowledge bank (Fig. 2) and a F2F session (Additional File 1).

Fig. 1.

Overview of the cases presented in the e-learning module (content and elements). Notes on content and elements: Cases were presented with photos illustrating patients and brief text introducing problem-based situations. Each case had five assignments in the form of practice-based diabetes-related questions based on the learning objectives with multiple answer options and followed by in-depth feedback. Participants received detailed feedback for both correct and incorrect answers; participants who answered incorrectly had a second opportunity to re-investigate the case and respond again before they were presented with the correct answer

Fig. 2.

Presentation of the frontpage of the e-learning knowledge bank

Staff experiences of participating in the program

All three orthopaedic department managers invited all doctors and nurses to participate in the learning program. Participation was voluntary. Demographic information (name, hospital department and occupation) was collected through an online platform hosting the e-learning programme. Demographic information was restricted to the variables available within the e-learning platform, which only captured participants’ name, hospital department, and occupation. Information on educational level and years of professional experience was not available. The number and occupational backgrounds of participants in the face-to-face (F2F) sessions were recorded by the instructors. The programme was evaluated through nine participant observations of the F2F courses and four focus group interviews conducted by LLN (a trained learning specialist), AJ (a research psychologist), and SMH (a certified diabetes nurse). SMH, LLN, and AJ were familiar with the training concept and methodology, and SMH also had specific subject-matter expertise in diabetes care.

Physicians and nurses were invited to focus group interviews via their managers at the orthopaedic departments. Four focus groups were formed with one group of two, two groups of three and one group of four nurses. Physicians opted out on the interviews. LLN, AJ, and SMH conducted observations of nine F2F courses without participating actively, taking field notes and using an open ethnographic approach to document the process and the content of the discussions.

Focus groups followed a semi-structured interview guide with open-ended questions based on pre-determined themes (e.g., engagement with new knowledge and skills, collaboration within departments, organizational barriers and facilitators, and application of learning in clinical practice). See supplement for a copy of the interview guide. Focus groups were held 1–2 months after completing the e-learning and F2F sessions, allowing investigation of how they applied their newly acquired knowledge in practice. Interviews were audio-recorded and fully transcribed.

Data analysis

CW and SMH analysed the focus group interviews and observational data three to six months after data collection. The analysis followed Braun and Clarke’s reflexive thematic analysis (TA) approach [25], situated within a contextualist epistemological framework, which assumes that meaning is neither purely discovered nor wholly constructed, but co-produced through the interaction between participants’ accounts and researchers’ interpretive engagement.

The analysis was guided by a primarily inductive approach within a reflexive thematic analysis framework, while incorporating a light deductive orientation at the outset to ensure alignment with the study aims.

In line with reflexive TA, themes were conceptualised as interpretative analytic outputs, developed through iterative and reflexive engagement with the dataset, rather than as pre-existing entities awaiting identification. In line with reflexive thematic analysis, we did not aim to achieve inter-coder reliability or coding consensus. Instead, analytic discussions between researchers were used to deepen interpretive engagement with the data and to critically examine emerging themes. This approach emphasises reflexivity and the researchers’ active role in knowledge production rather than seeking objective agreement.

The research team’s theoretical and professional positioning informed this analytic process. The team comprised researchers with backgrounds in clinical psychology, medicine, nursing, and patient education, which supported attentiveness to both experiential and clinically situated dimensions of participants’ accounts. Importantly, these orientations were not treated as neutral but were subjected to ongoing reflexive scrutiny to critically examine how they shaped coding decisions, theme development, and interpretive emphasis.

Interview guide topics were used only as provisional analytic entry points to ensure coverage of study aims. These were not treated as predefined thematic categories or a coding framework and were iteratively modified, reorganised, or discarded as analysis progressed.

Analytic phases

• Familiarisation: CLW engaged in immersive reading of the full dataset (observational notes and focus group transcripts) to identify salient and potentially unfamiliar phenomena. This process involved repeated, iterative engagement to deepen familiarity with the breadth and nuance of the data.

• Initial coding: Open, inductive coding was conducted across the dataset, privileging participants’ meanings and expressions. Codes were generated flexibly and iteratively and subsequently organised into preliminary candidate themes based on shared patterns of meaning.

• Iterative theme development: Candidate themes were continuously reviewed and refined against the dataset. This involved recursive processes of collapsing, splitting, renaming, or discarding themes to ensure analytic coherence and fidelity to the data.

• Defining and refining themes: Through sustained engagement, themes were developed beyond descriptive summaries to capture underlying, conceptually coherent patterns of meaning.

• Reflexive synthesis: CLW and SMH engaged in ongoing analytic dialogue to interrogate interpretations, resolve divergences, and refine thematic structure [26]. Additional analytic discussions with KL and UBC supported critical examination of theme boundaries and interpretive claims. CLW produced the final thematic framework.

Throughout the analytic process, reflexivity was actively and explicitly maintained, including critical consideration of how researchers’ disciplinary backgrounds, clinical experiences, and assumptions influenced analytic attention, interpretation, and meaning making.

Results

Identifying learning needs

The group concept mapping process resulted in 12 learning objectives (Table 1). The primary learning needs identified were correct insulin dosing and administration, knowledge of handling hyper- and hypo-glycemia, general knowledge of diabetes management and prescribing in electronic medical record systems.

Table 1.

Learning objectives

	After completing the blended learning programme, the participating health professionals should be able to:
1	Identify diabetes diagnosis and medication in orthopaedic surgical patients by:• Reviewing the patient’s medical record for a diabetes diagnosis• Assessing the latest HbA1c measurement• Asking the patient or checking for prescribed antidiabetic medication in the medical record• Utilize this information to ensure correct treatment and diabetes management during hospitalization and surgery.
2	Explain the significance of diabetes in orthopaedic surgical care by: • Discussing factors that can increase blood sugar during hospitalisation and surgery • Describing the recommended approach for treating high blood glucose levels.
3	Identify the recommended blood glucose level for hospitalised patients with diabetes: • When they are eating • During surgery • When treatment with intravenous insulin and glucose is required.
4	Demonstrate how to calculate and adjust the correct dose of insulin and potassium in intravenous glucose drips, based on blood glucose level and kidney function, to prevent hyper- and hypoglycaemia during fasting and surgery.
5	Explain the recommended frequency for measuring and calculating blood glucose levels. Demonstrate how to accurately record blood glucose measurements in the patient’s chart.
6	Identify the various actions that can be taken to regulate differing blood sugar values among orthopaedic surgical patients with diabetes. Analyse and evaluate interventions for different blood glucose values in orthopaedic surgical patients to stabilize their blood sugar levels.
7	Outline the symptoms and risk factors of hypoglycaemia and demonstrate how to prioritize treatment to rapidly restore blood sugar level above 5 mmol/l.
8	Explain when and how to administer fast-acting insulin and apply the correct insulin injection techniques to ensure correct duration and effect.
9	Describe how to involve patients in managing their diabetes during surgery. Discuss key information that the patient should receive about diabetes and surgery. List the advantages and disadvantages of self-administered insulin and blood glucose measurement.
10	Explain how to find and review treatment guidelines for inpatient diabetes management. Demonstrate the correct way to document diabetes treatment and observations in the electronic patient journal.
11	Relate required knowledge and competencies to daily practice.
12	Promote interprofessional collaboration to enhance diabetes care on orthopaedic wards.

Participation in the learning program

Within a total of 365 physicians and nurses from the three wards invited to participate, 149 (41%) were physicians and 216 (59%) were nurses, with the majority representing primary two hospitals (Table 2). Available staff characteristics were limited to information captured through the e-learning platform, which included name, hospital department, and occupation. Data on educational level and years of professional experience were not collected within the platform and were therefore not available for analysis.

Table 2.

Characteristics of orthopaedic staff who were offered participation (n = 365) in the educational programme

	Staff, n (%)(n = 365)
Orthopaedic department
1	186 (50)
2	160 (43.8)
3	19 (5.2)
Type
Physicians	149 (40.8)
Nurses	216 (59.2)
Participation
Signed up for e-learning	258 (70.7)
Completed e-learning	196 (52.9)
Attended face-to-face classes	174 (47.7)

A total of 258 participants (71%) enrolled in the e-learning module, of whom 193 (53%) completed it. Twelve F2F courses were conducted with 174 participants, corresponding to a 47% participation rate (Table 2).

Participation in focus groups

Four focus group interviews lasting 60–75 min were held with 14 nurses from two departments. The group sizes varied from 2 to 4 participants: one group included 2 participants, and the remaining three groups each included 4 participants.

(designated X1-X8 and Y1-Y6 in Tables 3, 4 and 5) 1–2 months after course completion. Due to the COVID-19 pandemic, the planned number of interviews and observations were reduced; no physicians were able to attend focus groups. Although 12 F2F classes were conducted, only nine classes were accessible for observation.

Table 3.

Overall theme: Learning by cases (themes, subthemes, and examples of quotes)

Theme	Sub-theme	Example quotes
Signs of learning with interactive case-based e-learning	Relevant, recognizable, useful and engaging	It was as taken out of our everyday life […] then it is really useful […]. X3 These are relevant cases. It is well written. Exciting reading. So, it is not such an ‘oh no, another e-learning course’. I remember thinking it was wildly exciting. You come out on the other side with valuable learning. X2
	Case narratives help understand problem areas and remember what is learned	I think it’s better that I get a case about some experiences that I know from real life. It’s better […] than just getting facts first, then I don’t think I would be able to remember it at all. I remember it better when I see the cases. Y5
	Reflecting and acting professionally in similar situations	Sometimes when we get people in with diabetes, they want to control it themselves, but they don’t always fully understand that their blood sugar level may suddenly change. Then it’s nice to have knowledge about diabetes and be able to justify why and say: ‘we’re in control of this and we will make sure that it doesn’t go wrong with your diabetes.’ Y1
Differentiation in e-learning design	Interesting to solve cases and receive feedback	Interviewer: You get feedback if you have answered incorrectly, but also in-depth feedback if it is correct. What do you think about that? X1: It was wildly cool. X3: Yes, I think we learned from that. X2: Yes. In fact, I think I learned more from that than a thorough theoretical review. Now it’s like this: I’ve chosen this one, but why is it wrong? It’s wrong because so and so. Oh! Interviewer: So, it works? X2: Yeah, I think that was really good. And I guess that was probably what I personally got the most out of – the feedback.
	E-learning as a test of knowledge (less experienced nurses)	Y4: I think there should have been some teaching before we had to complete those cases […]. Maybe also because I am a recent graduate […]. That had motivated me more. Interviewer: Should we have switched the F2F and e-learning? Y4: Yes, I think I would have learned more from that. And I also wanted to have F2F afterwards, because then you can ask about the things you are unsure of.

Table 4.

Overall theme: Combining e-learning and F2F courses (themes, subthemes and examples of quotes)

Theme	Sub-theme	Example quotes
Experiences with F2F learning design	Gaining new knowledge	To get this teaching with very competent colleagues - a doctor who is simply so good at explaining and has the patience to come and ask: ‘what about this and this’? In other words, it was unimaginable amounts of knowledge that could be extracted from these good teachers. Y1
	Creating a safe and engaging learning space	I think it was really good that when you had been through all the cases, you could ask questions in F2F, and say: I do not quite understand it anyway? Can’t you explain it in another way?” Y2
Experiences with blended learning design	E-learning and F2F classes complemented each other	I think the combination was very good […] I think they complemented each other very well. I don’t know if it necessarily should be in that order, […] when you participate in F2F you are forced to consider, okay, where should I actually find this information? And that is what we are going to do in our everyday lives, we must look it up ourselves and find out how to use the instructions. So, it was a good combination. I don’t think one can replace the other. Y3
	E-learning provided a common foundation for F2F	When it comes to F2F teaching, everyone has the same knowledge base from e-learning, so you can ask some relevant questions. In other words, it is more in-depth than the very basic knowledge, such as ‘what is diabetes? ‘. Y2
Motivating sceptical participants in F2F		Field notes from F2F class participant observation: A few critical questions are raised, but the teacher responds convincingly with well-founded answers. […] By the end of the meeting, the physicians are highly motivated to begin e-learning, with several emphasizing the need for it. After the F2F session, physicians have a more positive attitude toward e-learning and express interest in trying it.

Table 5.

Overall theme: From learning to practice (themes, subthemes and examples of quotes)

Theme	Sub-theme	Example quotes
Transfer of learning into practice	Applying acquired knowledge and developing new insights in practice	I think it’s cool, it [the intervention] has created a dialogue here. So, we’re talking about it [diabetes]. Yes, so it has become visible. X3 Yes, also the fact that we have become better at encouraging physicians by saying: ‘Couldn’t it be an idea that we got an endocrinologist to take look at this patient? Because he has been unstable lately’. X2 It is my experience that our physicians have been happy with it, really, because they often have some prescriptions where they do not quite know what to do. So, the fact that we have participated in this course and that we can spar with each other more easily - I think they also appreciate that. Especially when we must set insulin drips up, they sometimes have problems with what to prescribe. It’s gotten better now, I think. X4
Barriers and opportunities in organizational learning design	Facilitating information sharing	From participant observation field notes: The physicians express that it [expectation to complete the course] is new to them. They express that they do not intend to take the course and there is no comment on this from the teacher.
	Allocating worktime for participation	From participant observation field notes: Some physicians emphasised in very clear and dissatisfied terms that they spent their free time on the e-learning course.
	Environmental barriers for learning	From participant observation field notes: We are sitting in the lunchroom where people are having lunch. Throughout the session several people come and go. When the teaching begins, there are 7 participants including the department nurse. At its peak, the group reaches eight participants. At the end of the class, only 4 participants remain.

X and Y followed by numerals denote individual focus group participants

Thematic analysis

Three overall themes were identified: learning through cases, experiences with the F2F learning design, and from learning to practice.

Learning through cases (e-learning)

Overall, participants found the five case narratives in the e-learning module relevant and useful, enabling them to build on prior knowledge and translate newly learned knowledge to real- world clinical challenges (Table 3). Many participants reported that the cases helped them recall challenging situations from their daily work, such as patient communication and diabetes management strategies. These examples from daily work facilitated reflections and gave insight into how best practice could be improved.

Experienced nurses found the case-based approach engaging, motivating and meaningful, particularly the feedback provided during the e-learning process. However, some less experienced nurses struggled with the case narratives and reported need of more basic knowledge. Although the knowledge bank was developed to provide readily available basic knowledge, they however reported that they found the data bank overwhelming and discouraging. More experienced nurses saw the knowledge bank as an opportunity to expand their skills, whereas less experienced nurses felt it highlighted their lack of knowledge, triggering insecurity and demotivation.

Combining e-learning and F2F courses

Most participants who had completed both the e-learning and F2F courses found the combination relevant and valuable (Table 4). They viewed the e-learning primarily as a foundation for sharing knowledge among staff. The F2F sessions provided a safe and engaging space for clarification, discussion, and application of learning. Researchers’ observations of the F2F courses revealed that some participants initially expressed negative expectations about e-learning and a lack of motivation to participate in the course. In these cases, it was noted how the teachers balanced promoting a safe atmosphere for participants to voice and validate frustrations with challenging negative expectations about e-learning by exhibiting confidence and providing convincing arguments for the value of using their precious time to improve their diabetes treatment skills through blended learning. The F2F sessions complemented the e-learning by addressing unmet learning needs, which ranged from basic diabetes knowledge to complex case discussions. Additionally, some participants were motivated to complete or re-visit the e-learning module after attending the F2F sessions.

From learning to practice

This overall theme covers how participants applied their learning in practice as well as their experiences of barriers to implementation (Table 5). One to two months after course completion, participants noted several improvements in work practices, such as more interprofessional exchange and discussions about diabetes. For example, the e-learning cases were used as reference points for discussing new challenges with diabetes management on the wards. In one department, the increased awareness of diabetes led to additional interprofessional education about specific aspects of diabetes.

For many participants, the blended learning program created awareness of the need to continuously update staff knowledge about diabetes and led to new initiatives at the leadership level, such as repeating the e-learning annually and making it an integral part of training programs for new nurses and physicians. Most of the barriers to applying learning to practice were attributed to obstacles with implementing the courses at the departments.

The experience of being treated unfairly by management could have a negative impact on participants’ motivation to spend time gaining new knowledge. Nurses were allocated two paid hours to complete the e-learning course, while physicians were expected to complete it in their free time, leading to frustration and lower participation rates. Some physicians were unaware of the e-learning module before participating in the F2F class. Some participants were unable to attend the entire F2F lesson due to time constraints and workload.

Another obstacle was the quality of the learning environments. Some participants struggled to find information or locate the classroom. At least one F2F class was held in a noisy environment where people were eating lunch, and a dishwasher was running. Due to room shortages, some F2F classes had to be abbreviated. Finally, technology issues, such as browser incompatibilities or no computer sound output, prevented some participants from completing the e-learning.

Many nurses who completed the e-learning during work hours reported frequent interruptions, making it difficult to focus. Some would have preferred to complete the course at home or as a small group in a hospital classroom where they could have concentrated on learning.

Discussion

Twelve identified learning objectives addressed knowledge gaps among orthopaedic staff and essential skills required for diabetes care in orthopaedic wards, including insulin dosing and administration, hyper- and hypo-glycemia, general knowledge of diabetes management and electronic medical record prescribing. The blended learning program was tailored to meet these learning needs while enhancing motivation, engagement and problem solving in daily practice. This was achieved by incorporating interactive e-learning and problem-based learning principles [6, 13, 14]. The overall theme of learning through cases indicated that case-based learning successfully mirrored situations from daily clinical scenarios, facilitating ‘scaffolding’ [27], a process in which new knowledge builds upon existing knowledge. However, the success of case-based learning varied with nurses’ experience with diabetes management. Experienced nurses found the cases engaging, motivating and applicable to daily practice, but less experienced nurses struggled with the level of complexity, which inhibited their engagement with the e-learning module. In keeping with finding from previous studies [10–12], the theme of combining e-learning and F2F courses reflected the fact that the F2F course addressed gaps not met by e-learning alone.

However, the findings also highlight the critical role of educators in facilitating the F2F sessions. Educators needed to create a psychologically safe environment for participants to express concerns, address negative expectations by providing clear justifications for blended learning and encourage engagement with the e-learning module. The findings reflect previous studies emphasising psychological safety as a way for teams to take interpersonal risks, speaking up and asking questions [28]. Psychological safety is also associated with improved team learning [28, 29] and team performance [30–32]. This highlights the importance of skilled educators who can navigate emotional and motivational barriers to learning.

The theme of from learning to practice reflected participants’ actively application of newly acquired skills in orthopaedic care practices. This supports theoretical assumptions that case-based learning facilitates real-world application [15, 16]. Participation rates were higher for e-learning than for the F2F course (Table 2), supporting previous findings that e-learning provides a flexible learning environment allowing healthcare professionals to learn at their own pace, time and preferred location [6, 7]. However, the results also identified several barriers to implementation. Despite its benefits, the programme was hindered by organizational factors, such as unequal terms for participation (e.g. paid, protected time for some professions but not others), competing clinical demands, suboptimal learning environments (noisy rooms, room shortages leading to abbreviated sessions), and technical barriers (e.g. browser and audio issues) were associated with participants’ experience of being treated unfairly by management, which reduced motivation and limited opportunities for full engagement.

Noisy locations and technical issues also made it difficult to focus and concentrate. The results suggest that clear course guidelines for management informing staff about the programme, allocating paid time for all participants providing a suitable learning environment should be included as important components of the learning module to ensure organisational commitment and staff participation.

Among the strengths of the study are the strong design of the blended programme, which was tailored to learning needs identified in close collaboration with orthopaedic care staff and the robust theoretical underpinnings of the course elements. Furthermore, the thematic analysis draws on two data sources (observations and focus groups interviews), enhancing validity of the findings. A limitation of the study is the lack of physicians participating in the focus group interviews due to the COVID-19 pandemic. Their contributions might have provided further perspectives. A limitation of the study is that demographic information was restricted to the variables available within the e-learning platform, which only captured participants’ name, hospital department, and occupation. This limited our ability to explore potential variation in experiences across levels of training and professional seniority.

Although staff shortages and high workloads are persistent challenges in most Western healthcare systems, the COVID-19 pandemic may have introduced additional barriers and limited the generalizability of the findings to post-pandemic settings.

A methodological consideration relates to the epistemological foundations of reflexive thematic analysis. In this study, themes were treated as analytic constructions developed through iterative engagement with the dataset, rather than as features that passively emerge from the data. Consistent with this approach, we did not aim to achieve inter-coder reliability or coding consensus, as these logics are not aligned with reflexive TA.

While approaches emphasising inter-coder agreement may be valued within more positivist research traditions, our analysis instead prioritised reflexivity and theoretical transparency. Initial assumptions were critically examined and revised throughout the analytic process, and themes were continuously refined in dialogue with the data. From this perspective, the analytic process is not understood as self-validating, but as an interpretive and reflexive engagement with the dataset.

The scope of this study was limited to developing the intervention. Nevertheless, the content of the e-learning and knowledge bank focused on improving glycaemic management, preventing hyper- and hypoglycaemia, and supporting guideline-concordant treatment at discharge—areas that, according to ADA guidelines [C], may improve diabetes control as well as improving the staff members confidence in handling these patients. To strengthen the evidence base, a follow-up study should evaluating the interventions effectiveness in terms of adherence to diabetes care standards, glycemic outcomes, and key complications relevant to the orthopaedic setting.

Conclusion

This study identified key contextual factors and processes influencing the learning experiences of physicians and nurses participating in a blended diabetes education program. Case-based and interactive e-learning facilitated knowledge retention and practical application. However, the feedback suggest that the content must be tailored in two levels, one for inexperienced staff and one for experienced staff to maximize engagement. The F2F courses can complement e-learning by accommodating unmet needs if they are facilitated by skilled educators who can address emotional needs and manage learning expectations. Finally, future programmes should set out clear organisational commitments—covering communication, protected time, and suitable learning environments—to support successful implementation and sustained engagement.

Abbreviations

F2F

Face-To-Face

SDCC

Steno Diabetes Center Copenhagen

Authors’ contributions

UBC, LLN developed the research questions. LLN and SMH performed the data collection and the Group Concept Mapping Analysis. CLW wrote the first draft of the manuscript and carried out the qualitative analysis. All authors CLW, SMH, PLK, PBP, TA, OLS, KBH, CS, LLN, AJ, KL, MAN helped revise methods, analysis, and interpretations of results. MAN wrote the final version of the manuscript.

Funding

This study was funded by the Department of Education, Steno Diabetes Center Copenhagen. The Department of Education is supported by a yearly grant by the Novo Nordisk Foundation (award/grant number not applicable). The Novo Nordisk Foundation has not been involved in any part of this study.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to institutional regulations but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

In Demark no Ethics Committee reviews studies that do not include biological material (‘The Danish Act on Research Ethics Review of Health Research Projects’). The Ethical Committee of the Capital Region of Copenhagen was asked in a letter ref nr 63795 and confirmed that a review an ethical review was not necessary. However, we nevertheless adhered to ethical principles (e.g., voluntary participation, informed consent, anonymity, confidentiality, avoiding harm and free from scientific misconduct) as, for example, outlined in the Declaration of Helsinki. According to the Danish Act on Research Ethics Review of Health Research Projects participants consent is not needed in a study like this. Participants written approval was collected for alle interviews.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.