Evaluating the impact of online and blended learning in ...



Evaluating the impact of online or blended learning versus face to face learning of clinical skills in undergraduate nurse education: a systematic review

Introduction

The use of online learning within higher education institutions (HEIs) continues to expand globally (Kiviniemi 2014, Porter et al 2014). Online learning in the 21st century has surpassed the early forms of distance education that were based on correspondence type courses, video conferencing and educational television programmes (Zhao et al. 2005, Moore et al 2011). Instead technology used in higher education today consists of internet courses such as Massive Online Open Courses (MOOCs) internet courses that provide large scale global access to higher education courses, web-based Applications (App.s), multimedia programmes and the more established virtual learning environments such as Moodle or Blackboard. Indeed in 2004 45.9% of all U.S. HEIs were reported to offer some component of online learning in all their undergraduate courses (Porter et al 2014).

The continued global expansion in the use of online learning has encouraged a wide variety of interpretation and innovation within nurse education (Moule et al 2010). Dearnley et al. (2013), in a review of innovation in health higher education, reported a global wide perspective of technological innovations in nurse education which included: simulation, digital teaching aids, online teaching and virtual learning environments. However, they also concluded that there is a gap in the evidence base available on innovative practice in higher education healthcare and that this needs to be explored further (Dearnley et al 2013). This gap in evidence base and the wide variety of online learning strategies available to nurse educators can often make the decision of best applied teaching method difficult.

Background

One of the core components of the undergraduate nursing curriculum is clinical practice, with emphasis placed on the importance of the practitioner developing clinical skills and competence. The traditional teaching of clinical skills has historically consisted of a ‘face to face’ lecture followed by a practical demonstration; students are then given the opportunity to practice this skill in the classroom environment. Although the clinical exposure a student can acquire in practice cannot be replicated in a classroom (Rowe et al. 2012) there remains a need to support and develop the students’ clinical proficiencies in the university setting. Internationally there is a recognised reduction in the opportunities available for nursing students in clinical practice, caused by resource shortages, staff turnover and the increased severity of patient co-morbidities (Bloomfield et al. 2008, Traynor et al. 2010). This has challenged nurse educators to develop and implement innovative methods that are both efficient and efficacious in educational outcome to try and meet this change to the development of undergraduate clinical nursing skills.

Although the development of clinical nursing skills is acknowledged as important, there is a lack of consensus to the best method of teaching delivery (Rowe et al 2012). This has to some extent led to the introduction of a blended learning approach, a combination of online and face-to-face learning, within clinical skills training. Garrison and Kanuka (2004, p96) described this form of learning as a ‘low risk strategy’ for HEIs to take, but that it has enabled the integration of online learning into educational programmes that have held a traditional didactic paradigm. Lewin et al. (2009) stated that blended learning, using the principles of adult education, enables greater flexibility and responsiveness to the learning process. Tselios et al (2011) argued that blended learning has the advantage to combine creative online learning with the best of traditional face-to-face learning. Such is the development of blended learning in HEIs that it is now considered as the ‘new normal’ in higher education (Norberg et al 2011). However, as Van der Linden (2014) reported, there is a lack of a unified and strategic approach to blended learning which can make the evaluation of evidence difficult. How educators incorporate the theoretical underpinnings in online and blended learning methods will necessitate greater levels of creativity and innovation to ensure currency in modern teaching and learning practice of clinical nursing skills.

This rapid spread of online learning approaches in higher education has led to numerous variances in delivery and uptake (Moule et al 2010). Educators are now faced with a selection of teaching methods to choose from such as online, face to face or blended learning. Similar to clinical practitioners, educators require robust evidence to support decision making in teaching and the synthesis and summary provided by a systematic review can help inform decisions on the appropriateness of teaching methods used (Cook et al. 2010). There are a number of literature reviews available that consider the subject of online and blended learning in higher education (Bloomfield et al. 2008, Means et al. 2010, Cook et al. 2010, Rowe et al 2012, Dearnley et al 2013). The review by Bloomfield et al. (2008) had a similar aim to this systematic review, but did not specifically consider blended learning versus traditional approaches. Also such has been the rapid growth and development of online and blended learning, that the studies examined in the Bloomfield et al. (2008) review would now be considered dated. This systematic review provides a current evaluated evidence base to support the nurse educator’s pedagogical decision on the best effective teaching methodology and appropriate technology resources for the instruction of clinical skills.

In summary this systematic review will identify and provide a narrative summary of all the available studies that compared online and blended learning versus face to face instruction of clinical skills in undergraduate nursing. The review will report on the evidence that is available to nurse educators to determine whether the use of an online or blended learning paradigm has the potential to enhance the teaching of clinical skills in undergraduate nursing.

The review

Aim

The overall aim of this review was to answer the following question:

What is the impact of both online and blended learning versus face-to-face learning of clinical skills in undergraduate nursing students?

The primary objective is to explore the outcomes related to learning clinical skills through either an online or blended learning as opposed to a face-to-face approach.

Design

Traditionally systematic reviews have relied solely on data retrieved from quantitative studies. Recent challenges to this ideology have indicated that the inclusion of qualitative research evidence is beneficial in reflecting the experiences of target groups which can enhance the review and guide practice (Gough 2007, JBI 2008, Cochrane Qualitative and Implementation Methods Group 2012). To provide a wide evidence base The Joanna Briggs institute (JBI) SUMARI User guide version 5 (JBI 2013) has been used as a template for the design of this mixed methods systematic review.

Search Methods

The search methods used here are similar to those reported by McColgan and Blackwood (2009) in a systematic review protocol developed for a review into teaching in higher education. Prior to commencing a systematic search for primary literature, a search for any existing systematic reviews was undertaken through the Database of Abstracts and Reviews (DARE). This initial step did not identify any studies relevant to this review. A search to identify unpublished studies was undertaken by scanning OCLC dissertation, Index of Thesis, ISI conference proceedings and Cambridge Scientific Abstracts. This search did not identify any relevant studies to this review. The main search of primary literature identified a wide range of studies capturing an extensive review of current thinking on the subject of online-learning and nurse education. Computerized searches of MEDLINE, CINAHL, BREI, ERIC and AUEI were undertaken to enable data collection. Although introduced in 1991, increased popularity of the internet and the World Wide Web did not occur until the mid 1990’s a search period from 1995- 2013 was identified as an applicable starting point to use when searching all data bases.

Specific search terms were used and the descriptors included synonyms for e-

learning such as Massive Open Online Courses (MOOCs) and applications (Apps).

The first database search undertaken was MEDLINE with MeSH terms considered

in addition to text words. Successive database search terms originated from the MEDLINE strategy and were adapted for each database (Table 1).

Table 1 Medline search terms

Language restrictions were applied to this review and only papers published in English were accepted. A small number of abstracts were available in English but the subsequent retrieval of these papers revealed a non English publication and these were therefore excluded after the independent review of eligible studies. The bibliographies from relevant studies were checked to identify missed papers from the initial search. A total of four papers were identified via this search and were included in the review. A citation search using the Science Citation Index was also conducted.

A search of the following websites was undertaken to ascertain any ongoing research studies:

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Inclusion/exclusion criteria

All articles were assessed against the inclusion criteria identified in the systematic review protocol and listed below.

Types of studies

This review includes studies that evaluate the impact of online learning and/or blended learning for undergraduate nursing students. Experimental design studies such as randomised controlled trials (RCTs) and quasi-controlled trials (QCT) are considered as are observational studies, cohort studies and surveys.

Qualitative studies that detail the nursing students’ perceptions on the impact or effect of online learning are included such as case reports and action research studies.

Systematic reviews that report on the impact of online learning and blended learning for teaching clinical skills in undergraduate nursing are included.

Pilot studies of new educational resources/ interventions that have a powered sample size and report on effect are included. Pilot studies which are based on intervention refinement and have small sample size have been excluded.

Types of participants

Studies included involve nursing students who are receiving learning through an online-learning modality. This review includes students at any stage of their undergraduate training.

Studies involving post graduate and post registration students are excluded.

Studies that report only on instructor/teacher experience are excluded.

Studies that are not primarily about nursing students have been excluded.

Types of Intervention

Included are studies that explore the effect of either a blended or an online learning teaching strategy for the development of a clinical skill. Online learning is recognised as a mode of learning that is technology based and is primarily conducted through the Internet and is exclusive of face-to-face contact with a lecturer. Online learning strategies that are web based stand alone educational software, pure computer screen simulation and internet discussion forums are included in this review.

Simulation studies have been excluded as this occurs mainly in simulation laboratories with instructor supervision. E-learning strategies that are purely print based correspondence, video conferencing, broadcast, television or radio have been excluded.

Studies have been excluded if the online learning teaching strategy used is for the primary development of theoretical knowledge in nursing and not clinical skills.

Types of outcome measures

This review reports on all learning outcomes reported in the included studies. Outcome measures of significance for this review are those that explore impact on the development of clinical skills, actualisation of learning and assessment of knowledge.

This review reports on all outcomes that investigate student learning, student attendance, professionalism and student satisfaction and any other non learning outcome measures described by the author.

All outcomes that investigate the impact and effect of supplementary face to face instruction including student responsiveness, knowledge, engagement in the learning activity and skill development are reported.

All outcomes that are teacher /instructor focused have not been considered in this review.

Search outcome

A total of 197 citations were retrieved. The titles and abstracts were then independently reviewed by two reviewers, using a study eligibility form derived from the inclusion criteria. All reasons for exclusion were recorded. The reviewers then met to review results and agreement was reached to obtain full copies of 31 papers (Figure 1).

Figure 1 Flowchart of systematic review results

Quality appraisal

All of the thirty one studies identified as meeting the inclusion criteria established in the reviews eligibility form were appraised for methodological quality by two independent reviewers. Both reviewers were blinded to each other’s quality appraisal review. After independent review the results were then collected by the primary reviewer and a small number of discrepancies were discussed with a third reviewer.

To assist in the identification of a studies risk of bias two appraisal tools were used. The quantitative studies were assessed using a critical appraisal tool adapted from the JBI-MAStARI and the qualitative studies were assessed using a critical appraisal tool adapted from JBI-QARI.

The questions asked in the critical appraisal tools have four possible responses. Yes (the criteria is clearly identifiable); Unclear (the criteria is not clearly identified); No (the criteria failed to be applied appropriately); N/A (This differentiates between experimental and observational studies). Following this each study is classified into low, moderate or high risk of bias (Table 2).

There were no exclusions made on the basis of a minimum quality threshold. However, nine studies were excluded because they failed to meet the specified inclusion criteria (Figure 1).

Table 2

Quality Appraisal risk of bias of included papers

Data extraction

For the purpose of data extraction, two standardized data extraction forms developed by JBI were used; one for experimental/observational studies and one for interpretative and critical research. Both independent reviewers received training in the use of the data extraction forms prior to undertaking any assessments to reduce the risk of error. Prior to implementation, the two data extraction forms were piloted on two papers.

Both reviewers met following independent data extraction to obtain agreement of all included studies and resolve any disagreements. Three papers used a mixed methods approach; data from these papers was extracted using both the qualitative and quantitative data extraction forms.

Synthesis

Data synthesis was initially conducted by the primary reviewer, but discussed regularly with the review team. The process of categorizing common outcomes and relationships from the data is essential to enable clarity and focus to the findings. The outcomes and the associated interventions provide the narrative format and structure for this report. Similar to data synthesis used in previous literature reviews (Bloomfield et al 2008, Rowe et al 2012) predetermined themes of method/research design; study aims; sample population; outcome measure and results were used to abstract data (Figure 2). The included papers from the systematic search were analyzed using a narrative synthesis approach.

Results

The review identified 19 published papers, 14 quantitative (13 with a comparison group and 1 observational with no comparison), 1 qualitative paper, 3 mixed methods paper and 1 integrative review (Figure 2). The studies ranged from date of publication from 1993-2012 and included eight different countries.

Method/research design

The quality of the studies varied. The older studies tended to be less scientifically reported on, with a lack of detail on the sample size, ethical considerations, demographics and selection processes.

Quantitative

Overall the quality of the studies was weak: eleven studies were rated with either a moderate to a high risk of bias. There were a high number of studies that failed to discuss appropriately participant selection or the inclusion criteria. The majority of studies used non validated instruments to measure outcomes and lacked detail on the research tools reliability and validity. The overall generalisability from the selected studies was considered limited.

Qualitative

The one included qualitative study, Kenny (2002) met all the required criteria for quality appraisal and had a clear aim and an appropriate research design. The findings were well structured and presented clearly and the research was considered valuable in adding to the evidence base around the outcome of student satisfaction. Due to the lack of qualitative studies the independent synthesis of qualitative evidence alone was not possible. However, the JBI (2008) mixed method systematic review, enables the integration of this single piece of qualitative evidence into the overarching synthesis of results.

Mixed methods

The three mixed methods studies are representative of some of the most current studies included in the review. This is indicative of the increased acceptance of an integrative methodology in healthcare related research. However, the qualitative aspect in each of these studies lacked detail and depth of response thereby questioning reliability. The balance of methodological approach in each study was weighted more towards a quantitative approach with qualitative aspects appearing more haphazard in research design. Following the JBI approach to systematic reviews the evidence abstracted from these studies are included in the overall narrative synthesis of results.

Reviews

One integrative review, Bloomfield et al. (2008) was included. Six studies from the Bloomfield et al. (2008) review are also included in this systematic review. Although dated in terms of technology development, the review findings were well structured and presented clearly and were considered valuable in adding to the evidence base of this systematic review. As indicated by JBI Reviewers Manual (2014), to avoid duplication and over reliance of the Bloomfield et al. (2008) review, the results from this existing research synthesis have been summarised and have not been re-synthesized within this reviews results.

Figure 2 Overview of included studies

Sample Population

The sample sizes for the most recent studies were of a reasonable size and ranged from n=82 to n=231. The earlier studies with the exception of Beeson & Kring (1999) n=104, had smaller sample sizes between n=21 and n=77. However, the study with the largest sample size, Bloomfield et al. (2010), reported a significant attrition rate at eight week follow up with n=l86 students remaining from a sample size of n=231. This leaves the interpretation of a significant result for the control group (p=0.024) at eight weeks open to bias. None of the papers reported on the power calculation used to establish the sample size thereby increasing the risk of a Type ‖ error.

Outcome measures and results

Synthesis of impact for both online and blended learning versus face-to-face learning for undergraduate nursing students in relation to clinical skills, focused on the following four main outcomes, performance/clinical skill, knowledge, self-efficacy/clinical confidence and user experience/satisfaction (Table 3).

Table 3 Quantitative and qualitative synthesis

Knowledge

The outcome measures used to evaluate knowledge varied between studies. Only one study reported post intervention recall in the medium term (8weeks) (Bloomfield et al. 2010). There were thirteen papers that assessed knowledge following the intervention of an online learning modality. Seven papers reported highly significant results that indicated a higher level of knowledge following an online learning teaching modality (Jeffries 2001, Jeffries 2003, Kaveevivitchia et al. 2010, Gerdspaset et al. 2010, Gerdspraset et al. 2011, Keefe & Wharrad 2012). Two papers reported on a higher level of knowledge following face to face teaching (Beeson & King 1999, Jang et al 2005). Five papers reported no significant difference in the students’ level of knowledge between online or face-face learning (Kim et al. 2003, Gega et al. 2007, Reime et al. 2009, Bloomfield et al. 2010, Drumaz et al. 2010) (figure 2).

Performance/ Clinical Skill

The outcome measures used to evaluate clinical skill and student performance varied between studies. Thirteen papers reported on clinical skill following an online learning intervention. Six of the most recent studies reported significant results in relation to students’ skill performance following online learning (Jang et al. 2005, Bloomfield et al. 2010, Kaveevivitchia et al. 2010, Gerdsprasert et al. 2011, McMullan et al. 2011, Drumaz et al. 2012). Drumaz et al. (2012) reported on significant difference with only one of the pre surgical care skills (p=0.04) and found that all other skills evaluated had no significant difference. Bloomfield et al (2010) also reported no significant difference between groups at two weeks but a significant difference at week eight follow up was observed p=0.024. One study, Bauher and Huyhn (2001), reported that the CAL group had a lack of adherence to performance standards for blood pressure monitoring than the groups taught by lecture and demonstration or lecture demonstration and CAL. Six studies reported no significant difference between groups (De Amicis 1997, Beeson & Kring 1999, Jeffries 2001, Jeffries et al. 2003, Kim et al. 2003, Gega et al. 2007)(Figure 2).

Self efficacy/ confidence

There were three papers that reported on self efficacy and clinical confidence each using different outcome measures (Kenny 2002, McConville & Lane 2006, McMullan et al. 2011). McMullan et al. (2011) reported no significant difference in students’ self efficacy pre and post drug calculation training. McConville & Lane (2006) observed a significant increase with students self efficacy scores following the use of online video clips toward dealing with difficult situations. One qualitative study, Kenny (2002), reported that although students found online learning stressful and anxiety provoking the majority of students found that it increased their confidence in working with computers (Figure 2).

User Satisfaction with online learning

Satisfaction and user experience with online learning was reported on in eleven papers. Qualitative data was collected in the form of individual interviews or focus groups in four of the papers (Kenny 2002, Reime et al. 2009, Kaveevivitchia et al. 2009, Gerdprasert et al. 2010). Kenny (2002) found that although students started out wanting some didactic teaching they became frustrated by this form of teaching and wanted more online training. Five studies indicated that students had a higher satisfaction with online learning (Jeffries 2001, Kim et al. 2003, Kaveevivitchia et al. 2009, Gerdspraset et al. 2010, McMullan et al. 2011). Reime et al. (2009) reported that although students found the online learning interactive and exciting, some felt disadvantaged that they only had online training. Four papers reported no significant difference with student satisfaction (De Amicis 1997, Jeffries et al. 2003, Jang et al. 2005, Gega et al. 2007).

A number of other outcomes were reported on in a few of the studies which were outside of the main aim and objectives of this review, such as time spent engaging in online learning (Jang et al. 2005, Reime et al. 2008), the reflections of an educator (Kenny 2002) and the effect of age on engagement with online resources (Reime et al. 2008). Jang et al. (2005) and Reime et al. (2008) reported no significant difference in time spent engaging in learning between traditional taught groups and online learning groups. Kenny (2002) reported on some of the challenges faced by educators in introducing this form of teaching such as the steep learning curve and the time required to produce online teaching products. Reime et al. (2008) reported that younger students performed better than older students highlighting the need for educators to be conscious of the range of students’ learning styles.

Discussion

Review limitations

This systematic review has followed a robust protocol and the guidelines for systematic reviews based on the JBI guidance (JBI 2013). However, although the systems of data extraction and quality appraisal have been rigorously followed, some limitations must be acknowledged. Four studies were excluded due to language restrictions of non-English papers. Pilot studies or feasibility studies were excluded when they reported on intervention optimization and were not appropriately powered to test effect. The exclusion of these papers may have biased this review.

The quality appraisal stage of the review although clearly presented in terms of risk did not exclude any papers. If a minimum threshold had been applied to this review, a number of studies would have been excluded. It was considered important to include all studies irrespective of quality appraisal risk to enable a more comprehensive picture of the reviews question to be achieved. However, it is acknowledged that the lack of a minimum threshold may hold some limitations for the findings of the review.

Findings of the review

Ten out of thirteen studies reported that online learning proved to have a similar if not improved benefit to students’ clinical skill knowledge. However, four of the studies were poorly designed with an imbalance of educational instruction between the control and intervention groups. This imbalance was mainly reflected in the supplementary nature of the online intervention (Gerdprasert et al. 2010, Gerdprasert et al. 2011, Drumaz et al. 2012, Keefe & Wharrad 2012). The highly significant results observed in the intervention groups could be attributed to and expected following the addition of supplementary training. This makes the results from these studies potentially biased as the control group failed to receive additional or a similar level of instruction. However, it has been suggested that the supplementary use of online learning in clinical skill may help close the theory-practice gap and promote enhanced clinical skill learning (Dujin et al 2014). The limited findings from this review would tend to support that opinion, but further review on the use of supplementary technology would be essential prior to any implementation due to resource and cost implications.

The thirteen papers that evaluated the impact of the students clinical skill or performance following online or a blended learning approach reported that there was a higher or similar level of clinical skill compared to the traditional learning method. One possible explanation for this result is highlighted by a recent study by Duijin et al. (2014), where the student’s ability to repeat the online activity and review the content at their own pace enhanced their learning and skill performance. The studies evaluated in this review failed to include a specific time limit or a limited access to the online learning material similar to that delivered by the traditional control group. As one of the benefits of online learning is the flexibility in educational delivery (Tselios et al 2011) this is a reasonable design feature for any online activity. However, this flexibility introduces a lack of consistency between the study arms which could potentially bias the results in favour of the intervention arm. The future design of online studies should include time specific or synchronized access and singular limited access similar to control groups to enable accurate interpretation of results.

Five out of eleven studies reported that students had a higher level of satisfaction compared to traditional style teaching methods. This is similar to other reviews of student satisfaction with online resources in undergraduate education (Bloomfield et al 2008, Cook et al 2010). However, four studies reported a lesser satisfaction level with online resources; this result is consistent with students enrolled in other programmes of undergraduate study (Johnson et al 2013, Wong et al 2014). The student’s age, computer experience, learning style and attitude towards technology have been identified in other HEI studies as affecting the student’s level of engagement and satisfaction with online learning (Tallent-Runnells et al 2006, Cook et al 2010, Moule et al 2010, Johnson et al 2013, Wong et al 2014). Unfortunately the studies reported on in this review failed to include consideration of these aspects making it impossible to comment on whether these aspects had an effect on student satisfaction. Therefore the results of this review are inconclusive as to which teaching method is best supported by student satisfaction.

One of the main difficulties faced by this review in terms of study comparison was the wide variation of intervention used in each study. This variety of interventions used can trace the trends and development of technology through the last two decades. The older papers explored the use of interactive video discs (De Amicis 1997, Beeson & Kring 1999) and CD-ROMs (Jeffries 2001, Bauher & Huynh 2001, Jeffries et al. 2003, Kim et al. 2003) whilst the most recent papers explore the use of screen based computer simulation (Durmaz et al. 2012) and e-learning packages using multimedia books (Keefe & Wharrad 2012). This variety in technology limits the ability to make comparisons over time between studies, but shows the trajectory and development of online learning in clinical skills nurse education.

This review was undertaken because of the exponential rise in online and blended learning and its application to the acquisition of undergraduate clinical nursing skills. In relation to online learning versus traditional learning the result of this review would show that online learning appears at least as effective as traditional learning approaches. With reference to blended learning versus traditional learning there was limited evidence available to enable conclusive opinion to be made. However, the two studies, Bauher & Huynh (2001) and Kaveevivitchia et al (2010), reported a significant difference in the blended approach for performance and skill acquisition compared to online learning alone. This limited evidence would suggest that there may be potential benefits to the further development and evaluation of a blended learning approach to clinical skills education in the undergraduate nursing curriculum.

Conclusion

The strengths of this review include the systematic and replicable search strategy which has been used to explore the evidence available on online learning and blended learning for teaching clinical skills in undergraduate nursing. This review builds on previous reviews and has used a contemporary mixed methods approach to increase the reportable evidence base available on the subject. It highlights a developing body of evidence in the area of online learning in teaching clinical skills in undergraduate nurse education. The evidence that is available here suggests that online learning for teaching clinical skills is no less effective than traditional means, with the exception of three studies where better outcomes were reported with the control group (Beeson & Kring 1999, Bauer & huynh 2001, Jang et al. 2005). This has implications for the future direction of nurse education and the teaching of clinical nursing skills.

The data explored in this review highlights the lack of available evidence internationally on the implementation of a blended learning approach to teaching clinical skills in undergraduate nurse education. Whilst the two blended learning studies considered in this review showed promise in relation to the positive impact of a blended learning approach in teaching clinical skills the evidence available is lacking in both quantity and quality. Dearnley et al. (2013) reported that this gap in evidence may be due to lack of research and publication in higher education innovation. There is an absolute need for the future design of online and blended learning innovations to include a robust methodologically strong study in their implementation process to help close this gap and encourage future development. Further exploration in this area is necessary before any assumptions can be made regarding the usefulness of employing an online or blending learning approach in teaching clinical skills in undergraduate nurse education.

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