The literature has demonstrated that the adoption of human resource development interventions can be helpful in increasing healthcare workers’ (HCWs) knowledge, skills, resilience, and quality of care ^[1][2], which is consistent with the human capital theory ^[2][3].

In the healthcare field, the need to ensure effective and economically sustainable training has led to a focus on technology-enhanced learning (TEL) and, specifically, to massive open online courses or MOOCs ^[3][4][4,5]. These courses can be regarded as a significant step forward in the educational field due to the ease of access and convenient content delivery they offer. More in detail, MOOCs are courses potentially aimed at an unlimited number of students (massive) who can attend them whenever and wherever they want. Moreover, they can register free of charge (open) and enjoy learning-oriented content accessible via the internet (online). Finally, the courses are characterized by a structured learning plan (course) developed by some of the world’s most prestigious scholars and universities ^[5][6].

The success of MOOCs is highlighted by the impressive number of individuals who have adopted them. These courses have reached over 220 million learners (40 million new learners in 2021 alone), with over 19.400 courses available and 1.416 covering the field of health and medicine ^[6][7]. The wide appeal of MOOCs in medical education can be explained by considering their potential both for HCWs and their organizations ^[7][8][8,9]. They represent an accessible and affordable choice by providing online learning in a more effective and timely manner compared with traditional education ^[9][10] since online learning has fewer time and space constraints ^[10][11]. Indeed, the quick implementation of this teaching mode has been proven to be particularly suitable for dealing with challenges concerning health emergencies by providing effective training for healthcare professionals ^[11][12][12,13]

Despite their great success, scholars and developers of online courses have expressed skepticism about their ability to offer relevant education which advances people in careers and socio-economic activities ^[13][14]. These reservations are supported by the higher dropout levels in MOOCs than in offline courses ^[14][15]. It is widely acknowledged that the number of trainees drops by the end of courses, rarely reaching more than 7–9% of the initial students ^[15][16][16,17]. With this in mind, researchers have argued that the ability of MOOCs structure to “tune” to participants’ needs is crucial to limit this phenomenon and, in turn, realize their learning objectives ^{[17][18][19][20]}[18,19,20,21]. Nevertheless, there is a scant amount of agreement about the definition of characteristics of a MOOC and its pedagogical foundations ^[4][5]. The reasons for this issue are twofold and are linked to the multifarious nature of this teaching mode ^[21][22]. The latter manifests itself in the extensive variations of the teaching model according to courses content, their aims, learners’ characteristics, and the innovations in TEL. Concerning the adoption of such a model in physicians’ training, few recent review studies ^[22][23][23,24] have systematically analyzed their effectiveness in this population, however, neglecting to investigate the factors that might explain these outcomes.

2. The MOOC Model in the Healthcare Field

Although medicine is traditionally slow in adapting to new trends ^[23][24], the MOOC revolution has strongly impacted this field. It must be noted that the widespread use of such a teaching method has been established in a relatively short time ^[24][25]. The first generation of MOOCs, or cMOOCS, are inspired by connectivism ^[25][26] due to their emphasis on social learning, cooperation, creativity, and knowledge sharing. The second generation of MOOCs, or xMOOCs, are based on a more traditional classroom structure centered around the teacher rather than a community of students and, thus, they provide limited communication space between participants ^[26][27]. Even though xMOOCs have been criticized for not providing adequate learner support and engagement, this teaching model has shown a high degree of flexibility and scalability ^[13][14]. These features have made it the primary teaching mode in online learning, contributing, in this way, to the broad adoption of MOOCs in various fields (e.g., engineering, math, law, social and healthcare sciences) and at different educational levels (e.g., primary, middle and high schools, undergraduate, postgraduate, and continuing education courses) ^[27][28]. More specifically, these online courses are capable of meeting organizations’ demands for properly trained employees since, as the Human Capital Theory ^[28][29][30][29,30,31] states, investing in employees’ training positively affects their performance. Valuable education and skills training contribute, indeed, to an increase in both employees’ and organizations’ performances, evaluated in terms of outcomes such as job satisfaction, motivation, mental health, better standing, the development of new services, increased market share, and improved quality of services ^{[31][32][33][34]}[32,33,34,35]. The latter is a critical success factor for field service organizations, since it depends mainly on customer satisfaction and the perceived value of the services rendered, as shown by Parasuraman et al. ^[35][36]. In this vein, employees’ training can manifest itself in the form of continuing education, which may be defined as the process of engaging in educational activities in order to update one’s professional knowledge and skills ^[36][37]. This is the main dimension of human resources management practices due to its potential to capitalize the intangible assets of knowledge, skills, and abilities possessed by organizational actors, which, in turn, can translate into a competitive advantage in the market ^[37][38] and the achievement of organizations’ aims ^[38][39]. Regarding the teaching methods required to implement such a strategy, it is important to note that healthcare has been marked by the rise in TEL ^[39][40] fostered by steadily growing internet access and the wide adoption of web-based platforms in individual lives ^[40][41]. More precisely, massive open online courses or MOOCs have been the main subject of this interest. As mentioned above, MOOCs provide effective, flexible, and economically sustainable training ^[41][42], responding to the need to improve the quality of care and, at the same time, improve cost efficiency ^[42][43]. As Mangalji and Karthikeyan ^[43][44] argue, the integration of MOOCs into medical training could contribute to improving students’ preparation, specifically through case-based learning, since it can lead them to focus on interactive aspects (e.g., problem-solving, team-based skills, and knowledge application). On that note, MOOCs that include active learning modules, feedback to learners, and the possibility to choose between different activities can foster students’ engagement and retention of information ^[43][44][44,45]. Moreover, MOOCs reported equal or better performance compared to traditional teaching ^[22][23][23,24]. The above-mentioned advantages, mainly related to the high flexibility of MOOCs, blend well with continuing education in the healthcare field since physicians require regular updates of the knowledge needed to be effective in the medical profession and deal adequately with health emergencies ^[11][12][12,13]. Hence, the adoption of the MOOC model represents a good way to provide continuing professional development ^[45][46] by combining physicians’ demand for high-quality training—in line with their time and resources—and the organizations’ efforts to achieve their goals. In spite of their multiple benefits, MOOCs have several weaknesses, which translate into high dropout rates ^[46][47][47,48]. The latter can be explained by considering factors such as the easy registering process, high passiveness, low student motivation, and demands (including time) that are incompatible with participants’ private and professional duties, as well as the lack of necessary knowledge and skills to attend courses ^[16][48][49][17,49,50]. Following this reasoning, a MOOC should be built through the accurate selection of the most suitable parameters according to learners’ characteristics, although it is not easy in the presence of a considerable number of participants, which is typical of this teaching model. Thus, to develop an effective MOOC for physicians, it is necessary to gain adequate knowledge about the factors that contribute to the success of this teaching model among the medical population. In this regard, Milligan ^[50][51] (p. 1882) stated that “understanding the nature of learners and their engagement is critical to the success of any online education provision, especially those MOOCs where there is an expectation that the learners should self-motivate and self-direct their learning”. In recent years, a large number of reviews have been conducted by considering studies on MOOCs related to healthcare workers in general ^[51][52][53][52,53,54], whereas few studies have focused on physicians by paying attention solely to the outcomes of such courses. More precisely, Zhao et al. ^[23][24] performed a meta-analysis based on the examination of four articles reporting no significant differences between the efficacy of the MOOC teaching model and that of the traditional one. A subsequent meta-analysis study by Gao et al. ^[22][23], considering the same topic, reported that students enrolled in a MOOC performed better than those who attended traditional courses. However, it is important to note that this research included only studies at colleges or universities in China. In light of this evidence, the need to better understand the strategies and methods underlying the effectiveness of these courses is clear. Such recognition is fundamental for the passage from a theoretical to a practical level, offering, in this way, valuable help to developers in designing MOOCs for physicians that are capable of achieving their specific learning goals.