SYSTEMATIC REVIEW

A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education Karen McCutcheon, Maria Lohan, Marian Traynor & Daphne Martin Accepted for publication 7 July 2014

Correspondence to K. McCutcheon: e-mail: [email protected] Karen McCutcheon MSc PGCHE RGN Senior Lecturer School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK Maria Lohan BA PhD Senior Lecturer School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK Marian Traynor BSc EdD RGN Director of Education School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK Daphne Martin BSc MSc RGN Lecturer (Education) School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK

M C C U T C H E O N K . , L O H A N M . , T R A Y N O R M . & M A R T I N D . ( 2 0 1 5 ) A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. Journal of Advanced Nursing 71(2), 255–270. doi: 10.1111/jan.12509

Abstract Aim. 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. Background. The need to adequately support and develop students in clinical skills is now arguably more important than previously considered due to reductions in practice opportunities. Online and blended teaching methods are being developed to try and meet this requirement, but knowledge about their effectiveness in teaching clinical skills is limited. Design. Mixed methods systematic review, which follows the Joanna Briggs Institute User guide version 5. Data sources. Computerized searches of five databases were undertaken for the period 1995–August 2013. Review methods. Critical appraisal and data extraction were undertaken using Joanna Briggs Institute tools for experimental/observational studies and interpretative and critical research. A narrative synthesis was used to report results. Results. Nineteen published papers were identified. Seventeen papers reported on online approaches and only two papers reported on a blended approach. The synthesis of findings focused on the following four areas: performance/clinical skill, knowledge, self-efficacy/clinical confidence and user experience/satisfaction. The e-learning interventions used varied throughout all the studies. Conclusion. The available evidence suggests that online learning for teaching clinical skills is no less effective than traditional means. Highlighted by this review is the lack of available evidence on the implementation of a blended learning approach to teaching clinical skills in undergraduate nurse education. Further research is required to assess the effectiveness of this teaching methodology. Keywords: blended learning, clinical skills, nurse education, online learning, systematic review

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Why is this research or review needed? ● There is an exponential rise in the use of online learning in higher education. ● Innovative teaching methods are required to develop clinical skills for nursing students in the academic environment to support them in clinical practice. ● Blended learning is being pursued in higher education as a means to support students and there is a need to assess its effectiveness.

What are the key findings? ● There is a wide variation in the type of online and blended learning approaches used to support students in the development of clinical skills. ● The results of this review indicate that online learning for teaching clinical skills is as effective as traditional means. ● There is a lack of available evidence on the implementation of a blended learning approach to teaching clinical skills in undergraduate nurse education.

How should the findings be used to influence policy/ practice/research/education? ● This review provides educators with valuable information to aid in the selection of the most appropriate method for teaching clinical skills. ● Technology-enhanced learning can be effective in teaching clinical skills and educators should identify areas where this can be introduced. ● Further evidence on the benefits of applying a blending learning approach in teaching clinical skills is required.

Introduction The use of online learning in higher education institutions (HEIs) has continued 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. 2006, 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 (Apps), multimedia programmes and the more established virtual learning environments such as Moodle or Blackboard. Indeed, in 2004, 459% of USA HEIs were reported to offer some component of online learning in all their undergraduate courses (Porter et al. 2014). 256

The continued global expansion in the use of online learning has encouraged a wide variety of technological innovation in clinical skills nurse education, such as simulation, digital teaching aids, online teaching and virtual learning environments (Moule et al. 2010, Dearnley et al. 2013). However, Dearnley et al. (2013) concluded that the effectiveness of these innovative approaches has yet to be proven in higher education in healthcare and that this needs to be explored further. This lack of evidence may lead educators to make poor choices in the advancement of student learning through online technologies. 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). In this study, we have systematically reviewed the evidence that is available 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. 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. Internationally, there is a recognized reduction in the opportunities available for nursing students to learn clinical skills in clinical practice, caused by resource shortages, staff turnover and the increased severity of patient comorbidities (Bloomfield et al. 2008, Traynor et al. 2010). This has challenged nurse educators to develop and implement innovative methods in HEIs that are both efficient and efficacious in educational outcome, to try and meet this change in the development of undergraduate 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, Dearnley et al. 2013). Educators are now faced with a selection of teaching methods to choose from such as online, face-to-face or blended learning. There are several literature reviews available that consider the subject of online and blended learning in higher education (Bloomfield et al. 2008, Cook et al. 2010, Means 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 vs. 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. The evidence reported on in this systematic review provides a critical evaluation of the current evidence base to support the nurse educator’s pedagogical decision on the best and most © 2014 John Wiley & Sons Ltd

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effective teaching methodology and appropriate technology resources for the instruction of clinical skills.

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 vs. face-to-face learning of clinical skills in undergraduate nursing students? The primary objective was 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 & 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 period from 1995–2013 was identified as an applicable starting point to use when searching all databases. Specific search terms were used and the descriptors included 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 (see Supporting Information Table S1). Successive database search terms originated from the MEDLINE strategy and were adapted for each database. The search was limited to English language publications. 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:

• • • •

http://www.campbellcollaboration.org/ http://www.clinicalstudyresults.org http://eppi.ioe.ac.uk/cms/ http://www.joannabriggs.edu.au/pubs/systematic_reviews

Inclusion/exclusion criteria 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-1990s. Hence, a © 2014 John Wiley & Sons Ltd

All articles were assessed against the inclusion criteria identified in the systematic review protocol and listed below. Types of studies Included in this review were studies that evaluated the impact of online learning and/or blended learning for undergraduate nursing students. Experimental design studies such as randomized controlled trials (RCTs) and quasi-controlled trials (QCT) were considered, as are observational studies, cohort studies and surveys. Qualitative studies that detailed the nursing students’ perceptions on the impact or effect of online learning were included such as case reports and action research studies. Systematic reviews that reported on the impact of online learning and blended learning for teaching clinical skills in undergraduate nursing were included. Pilot studies of new educational resources/interventions that have a powered sample size and report on effect are included. Pilot studies that are based on intervention refinement and have small sample size were excluded. 257

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Types of participants Studies included involved nursing students who received learning through an online learning modality. This review includes nursing students at any stage of their undergraduate training. Studies that involved postgraduate and postregistration students were excluded. Studies that reported only on instructor/teacher experience were excluded. Studies that are not primarily about nursing students were excluded. Types of intervention Studies that explored the effect of either a bleded or an online learning teaching strategy for the development of a clinical skill were included. Online learning is recognized as a mode of learning that is technology based and is primarily conducted through the Internet and is exclusive of faceto-face contact with a lecturer. Online learning strategies that are web based stand-alone educational software, pure computer screen simulation and internet discussion forums were included in this review. Simulation studies were excluded as this type of education occurs mainly in simulation laboratories with instructor supervision. E-learning strategies that are purely print based correspondence, video conferencing, broadcast, television or radio was excluded. Excluded also were studies where the online learning teaching strategy used is for the primary development of theoretical knowledge in nursing and not clinical skills. Types of outcome measures Outcome measures of significance for this review were those that explore impact on the development of clinical skills, actualization of learning and assessment of knowledge. All outcome measures that investigated student learning, student attendance, professionalism and student satisfaction and any other non-learning outcome measures as described by the author were also included. All outcomes that investigated the impact and effect of supplementary face-to-face instruction including student responsiveness, knowledge, engagement in the learning activity and skill development have been reported. All outcomes that are teacher/instructor focused were not considered in this review.

Search outcome A total of 197 citations were retrieved. The titles and abstracts were then independently reviewed by two

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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).

Quality appraisal All of the 31 studies identified as meeting the inclusion criteria established in the review’s 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 study’s 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. Both of these appraisal tools are available from the JBI SUMARI User guide version 5 (JBI 2013). The questions asked in the critical appraisal tools have four possible responses. Yes (the criteria are clearly identifiable through the report description or have been confirmed by the primary author); Unclear (the criteria are not clearly identified in the report and it was not possible to acquire clarification from the author); No (the criteria failed to be applied appropriately); N/A (This differentiates between experimental and observational studies). Each study was then classified into one of the following categories:

• • •

Low risk of bias: all criteria met Moderate risk of bias: one or more criteria unclear High risk of bias: one or more criteria not met

There were no exclusions made on the basis of a minimum quality threshold (see Supporting Information Table S2). However, nine studies were excluded because they failed to meet the specified inclusion criteria (Figure 1).

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.

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Total Citations = 197 Rejected at Title = 166 Total Papers Primary Inclusion = 31 Rejected at Critical Appraisal Stage = 9 Total Papers Following appraisal = 22 Rejected at Data Extraction Phase = 3 Final Agreed Primary Study Papers = 19

Quantitative = 14

Qualitative =1

Mixed Methods =3

Integrative Review =1

Figure 1 Flow chart of systematic review results. Both reviewers met following independent data extraction to obtain agreement on all included studies and resolve any disagreements. Three papers used a mixed methods approach; data from these papers were extracted using both the qualitative and quantitative data extraction forms (Supporting Information Table S3).

Synthesis Data synthesis was initially conducted by the primary reviewer, but discussed regularly with the review team. The included papers from the systematic search were analysed using a narrative synthesis approach. 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 (Table 1). The synthesis of the studies is designed to address the key learning outcomes of clinical skills education, which included knowledge, performance, self-efficacy and student satisfaction.

Results There were 19 published studies included in the review, 14 quantitative (13 with a comparison group and one observa© 2014 John Wiley & Sons Ltd

tional with no comparison), one qualitative paper, three mixed methods paper and one integrative review (Table 1). 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 generalizability 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 259

260 Adapted version of Ferrel and McCaffreys Knowledge and attitude survey regarding pain management

40-item clinical decisionmaking tool 50 MCQ to test knowledge OSCE to assess performance in pre- and post-operative care

15-item scenario questions to test knowledge 15-item performance checklist observed by assessors to test skill 10-item competency questionnaire 27-item validated stress tool 20-item perception questionnaire

Drug calculation test Self-efficacy test Satisfaction questionnaire

N = 42 intervention N = 164 control

N = 41 Intervention N = 41 control

N = 42 Intervention N = 42 control

Intervention N = 150 Control N = 79

The effectiveness of an e-learning intervention on pain management

The effect of screen-based computer simulation vs. traditional skill laboratory training in pre- and postop surgical care

The effect of web-based learning vs. traditional teaching methods for intrapartum care

The effect of an e-drug calculations package vs. traditional handout learning

Quantitative Quasi-experimental Summative evaluation

Quantitative RCT

Quantitative Quasi-experimental

Quantitative Cluster RCT

Keefe and Wharrad (2012) UK

Durmaz et al. (2012) Turkey

Gerdsprasert et al. (2011) Thailand

McMullan et al. (2011) UK

Outcome measure/ instruments

Sample

Study aims

Method and research design

Author (s)/ year

Table 1 Overview of included studies.

Students undertaking e-learning improved knowledge highly significant (SD = 94, P < 0001). Knowledge increased with year of study pre-intervention (F (3,38)9048, Eta₂ = 042, P < 005). No significant difference between cohorts after intervention (F (3,206)0567, P > 005). No significant differences found in knowledge or decision-making (SD = 821, t = 081, P = 0421). Significant difference reported in skill in the area of patient admission for students in the intervention group (SD = 1330, t = 209, P = 004). No significant difference reported in other OSCE assessed skills (SD = 1055, t = 1874, P = 0065). Experimental group had significant higher scores in knowledge (SD = 21, t = 241, P < 005) and competency (SD = 138, t = 208, P < 0001). Performance means were significantly higher in the experimental group. (SD = 029, t = 611, P < 0001) Ignorance-related stress highly significant result (SD = 285, t = 025, P < 005). Experimental group more able to perform drug calculations than those receiving handouts. Significant difference in ability (SD = 147, t = 234 P = 0027) and Satisfaction (SD = 61, z = 365, P = 0001). No significant difference in confidence (SD = 189, t = 085, P = 0400).

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Method and research design

Mixed methods RCT Pre- and posttest design

Quantitative RCT

Mixed methods RCT

Author (s)/ year

Gerdsprasert et al. (2010) Thailand

Bloomfield et al. (2010) UK

Kaveevivitchai et al. (2009) Thailand

Table 1 (Continued).

© 2014 John Wiley & Sons Ltd on vital signs skills

The effect of Computer-Assisted Learning (CAL) vs. CAL/lecture and demonstration or lecture and demonstration only

20-item MCQ to test knowledge OSCE to assess performance

30-item MCQ to test knowledge 29-item performance checklist observed by assessors Semi-structured interviews to assess satisfaction Intervention 1 N = 37 Intervention 2 N = 40 Control N = 40

20-item MCQ to test knowledge 20-item satisfaction questionnaire Student interviews conducted to evaluate programme

Outcome measure/ instruments

Intervention N = 118 Control N = 113

Intervention N = 42 Control N = 43

The effect of web-based learning vs. traditional teaching methods in the mechanism of labour

The effect of computerassisted learning vs. conventional teaching on hand washing

Sample

Study aims

No significant difference pre-test (SD = 5, t = 0267, P > 005). No significant difference between groups after chapter 1 (foetal and placenta development) (SD = 087, t = 1619, P > 005). Chapter 2 (factors affecting process of labour) reported a significant difference (SD = 287, t = 8699, P < 0001) and chapter 3 (process and mechanisms of labour) reported a significant difference (SD = 283, t = 14185, P < 0001). High level of satisfaction of web-based units (r = 0828, P < 0001). Knowledge no significant difference between groups immediately posttest. (u = 5951, P = 0578). No significant difference between groups at 2 weeks (u = 3324, P = 0149). No significant difference at 8-week follow-up (u = 828, P = 0201). Performance no significant difference between groups immediately posttest (u = 3077, P = 0415). At 8 weeks significant difference reported in hand washing skill with higher scores reported in the intervention group (u = 6495, P = 0024). No significant difference noted between the groups for knowledge (F2, 114 = 1802, 1529, 3028, P > 005). Performance significant difference noted with both CAL-supplemented groups (SD 981, F2, 114 = 10447, P < 0001). Higher satisfaction noted from CAL groups reported qualitatively.

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SYSTEMATIC REVIEW

A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education Karen McCutcheon, Maria Lohan, Marian Traynor & Daphne Martin Accepted for publication 7 July 2014

Correspondence to K. McCutcheon: e-mail: [email protected] Karen McCutcheon MSc PGCHE RGN Senior Lecturer School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK Maria Lohan BA PhD Senior Lecturer School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK Marian Traynor BSc EdD RGN Director of Education School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK Daphne Martin BSc MSc RGN Lecturer (Education) School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, UK

M C C U T C H E O N K . , L O H A N M . , T R A Y N O R M . & M A R T I N D . ( 2 0 1 5 ) A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. Journal of Advanced Nursing 71(2), 255–270. doi: 10.1111/jan.12509

Abstract Aim. 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. Background. The need to adequately support and develop students in clinical skills is now arguably more important than previously considered due to reductions in practice opportunities. Online and blended teaching methods are being developed to try and meet this requirement, but knowledge about their effectiveness in teaching clinical skills is limited. Design. Mixed methods systematic review, which follows the Joanna Briggs Institute User guide version 5. Data sources. Computerized searches of five databases were undertaken for the period 1995–August 2013. Review methods. Critical appraisal and data extraction were undertaken using Joanna Briggs Institute tools for experimental/observational studies and interpretative and critical research. A narrative synthesis was used to report results. Results. Nineteen published papers were identified. Seventeen papers reported on online approaches and only two papers reported on a blended approach. The synthesis of findings focused on the following four areas: performance/clinical skill, knowledge, self-efficacy/clinical confidence and user experience/satisfaction. The e-learning interventions used varied throughout all the studies. Conclusion. The available evidence suggests that online learning for teaching clinical skills is no less effective than traditional means. Highlighted by this review is the lack of available evidence on the implementation of a blended learning approach to teaching clinical skills in undergraduate nurse education. Further research is required to assess the effectiveness of this teaching methodology. Keywords: blended learning, clinical skills, nurse education, online learning, systematic review

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Method and research design

Quantitative Observational Study Pre- and posttest design

Quantitative Quasi-experimental Pre- and posttest design

Quantitative RCT

Quantitative Quasi-experimental Pre-/posttest design

Qualitative

Author (s)/ year

McConville and Lane (2006) UK

Jang et al. (2005) Korea

Kim et al. (2003) Korea

Jeffries et al. (2003) USA

Kenny (2002) Australia

Table 1 (Continued).

© 2014 John Wiley & Sons Ltd 27-item MCQ test 22-item assessor-rated competency skills checklist Satisfaction Questionnaire

Focus groups and individual interviews

Intervention N = 45 Control N = 32

N = 21

Compares the effect of CAL CD-ROM 12lead ECG with traditional teaching to evaluate satisfaction, performance and knowledge

Explore the experiences of students following an online learning course

Performance observed by assessors using performance checklist Self-administered Knowledge and Satisfaction questionnaire

Intervention N = 36 Control N = 39

CD-ROM vs. printed material for teaching San-Yin-Jiao pressure procedure for pain relief in labour

6-item pre-test self-efficacy questionnaire posttest 12-item self-efficacy questionnaire

45-item learning achievement tool measuring knowledge 15-item ECG interpretation tool 18-item satisfaction tool

N = 145

Assessing the effectiveness of video clip material for enhancing students’ self-efficacy when communicating with potentially difficult patient groups Compares web-based ECG programme with traditional face-to-face teaching

Outcome measure/ instruments

Intervention N = 54 Control N = 51

Sample

Study aims

No significant difference following videos or lectures in self-efficacy. (Wilks Lambda = 091, P > 005, partial Eta₂ = 008) Overtime significant effect in improved self-efficacy scores (Wilks Lambda = 096, P < 005, partial Eta2 = 004). Experimental group more able to interpret highly significant (SD = 31, t = 2839, P = 0005). No significant difference in motivation (SD = 201, t = 0779, P = 0438). No significant difference in satisfaction (SD = 142, t = 0484, P = 0630). There were no significant differences observed in knowledge (SD = 16, t = 0216, P = 0830) or performance (SD = 35, t = 1804, P = 0750). Student satisfaction scored higher with CD-ROM (SD = 47, t = 436, P < 005). Significant differences from pre- and posttest groups Knowledge the intervention pre-test (mean = 136 compared to posttest mean 203, P < 00001). No significant differences between the groups in satisfaction (Mean = 176, cronbach’s alpha = 092, P > 005)) or skill performance (mean = 269, P > 005) Analysis of the interviews produced 4 themes: Computer confidence Flexibility Active learning Practicalities of teaching.

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Method and research design

Quantitative Randomized experimental

Quantitative Quasi-experimental Pre-/posttest design

Quasi-experimental RCT

Quantitative RCT

Author (s)/ year

Bauer and Huynh (2001) Australia

Jeffries (2001) USA

Beeson and Kring (1999) USA

De Amicus (1997) USA

Table 1 (Continued).

Significantly higher posttest knowledge in CAL group (SD = 23%, Kuder Richardson test = 024, P = 001). No significant difference regarding performance (statistics not reported). Satisfaction higher in CAL group (Mean 183, Cronbach’s alpha = 083, P = 001). Significance in knowledge higher with traditional group (M = 9243, F(1,102), P < 001). Performance showed no difference between groups (M = 9311, t = 145, P < 015). Although IVDI scored higher on skill performance, it was not significantly higher (effect estimates not reported, P > 005). Both groups reported satisfaction with teaching methods. 40-item Knowledge test Performance observed by assessors using performance checklist Satisfaction questionnaire

14-item MCQ test for knowledge assessment 20-item Performance checklist

Performance observed by assessors using performance checklist Satisfaction questionnaire

Intervention N = 25 Control N = 24

Sample sizes not reported total population N = 104

Sample sizes not available N = 32

Compares the effectiveness of interactive videodisc instruction (IVDI) vs. a lecture demonstration for teaching IV therapy

Explores the use of an interactive video vs. a traditional lecture and video

Greater adherence to recommended procedure demonstrated by conventional group and the supplemented CAL group. Poor skill acquisition in CAL only group with only 2 out of 16 steps adhered to (v2 = 197–004, P = 100–04)

Performance observed by assessors using performance checklist

Intervention 1 N = 23 Intervention 2 N = 21 Control N = 23

Results

Compares three methods of instruction to teach BP: -CD-ROM only -CD-ROM and conventional -conventional only Effectiveness of CDROM vs. traditional lecture for drug administration

Outcome measure/ instruments

Sample

Study aims

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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, JBI (2008) mixed method systematic review process enabled 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. 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 methodology with qualitative aspects presented in a more ad hoc manner. Following the JBI approach to systematic reviews, the evidence abstracted from these studies was 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 were 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 (2014) Reviewers Manual, to avoid duplication and overreliance of the Bloomfield et al. (2008) review, the results from this previous research synthesis have been summarized and have not been re-synthesized in this review’s results.

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 and 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 8-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 = 0024) at 8 weeks open to bias. Power calculations to establish sample size were not reported on in any of the papers, thereby the risk of a Type II error is increased. © 2014 John Wiley & Sons Ltd

Outcome measures and results Synthesis of impact for both online and blended learning vs. face-to-face learning for undergraduate nursing students in relation to clinical skills was focused on the following four main outcomes: performance/clinical skill, knowledge, self-efficacy/clinical confidence and user experience/satisfaction (Table 2). Knowledge The outcome measures used to evaluate knowledge varied between studies. Only one study reported postintervention recall in the medium term (8 weeks) (Bloomfield et al. 2010). There were 13 papers that assessed knowledge after 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 et al. 2003, Kaveevivitchai et al. 2009, Gerdsprasert et al. 2010, 2011, Keefe & Wharrad 2012). Two papers reported on a higher level of knowledge following face-to-face teaching (Beeson & Kring 1999, Jang et al. 2005). Five papers reported no significant difference in the students’ level of knowledge between online and face-to-face learning (Kim et al. 2003, Gega et al. 2007, Reime et al. 2008, Bloomfield et al. 2010, Durmaz et al. 2012). 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, Kaveevivitchai et al. 2009, Gerdsprasert et al. 2011, McMullan et al. 2011, Durmaz et al. 2012). Durmaz et al. (2012) reported on significant difference with only one of the pre-surgical care skills (P = 004) and found that all other skills evaluated had no significant difference. Bloomfield et al. (2010) also reported no significant difference between groups at 2 weeks, but a significant difference at week eight follow-up was observed P = 0024. One study, Bauer and Huynh (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 Amicus 1997, Beeson & Kring 1999, Jeffries 2001, Jeffries et al. 2003, Kim et al. 2003, Gega et al. 2007). 265

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Table 2 Quantitative and qualitative synthesis. Outcome category

Quantitative studies’ evidence

Performance/ clinical skill

Durmaz et al. (2012) Gerdsprasert et al. (2011) McMullan et al. (2011) Bloomfield et al. (2010) Kaveevivitchai et al. (2009) Gega et al. (2007) Jang et al. (2005) Jeffries et al. (2003) Kim et al. (2003) Bauer and Huynh (2001) Jeffries (2001) Beeson and Kring (1999) De Amicus (1997) Durmaz et al. (2012) Keefe and Wharrad (2012) Gerdsprasert et al. (2011) Bloomfield et al. (2010) Gerdsprasert et al. (2010) Kaveevivitchai et al. (2009) Reime et al. (2008) Gega et al. (2007) Jang et al. (2005) Jeffries (2001) Jeffries et al. (2003) Kim et al. (2003) Beeson and Kring (1999) McMullan et al. (2011) McConville and Lane (2006) McMullan et al. (2011) Gega et al. (2007) Jang et al. (2005) Jeffries et al. (2003) Kim et al. (2003) Jeffries (2001) De Amicus (1997)

Knowledge

Self-efficacy/ clinical confidence User experience/ attitudes/ satisfaction

Qualitative evidence identified

Kenny (2002)

Kenny (2002) Reime et al. (2008) Kaveevivitchai et al. (2009) Gerdsprasert et al. (2010)

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 and Lane (2006) observed a significant increase with students’ self-efficacy scores following the use of online video clips towards dealing with difficult situations. One qualitative study, Kenny (2002), 266

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. User satisfaction with online learning Satisfaction and user experience with online learning were reported on in eleven papers. Qualitative data were collected in the form of individual interviews or focus groups in four of the papers (Kenny 2002, Kaveevivitchai et al. 2009, Reime et al. 2008, Gerdsprasert 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, Kaveevivitchai et al. 2009, Gerdsprasert et al. 2010, McMullan et al. 2011). Reime et al. (2008) 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 Amicus 1997, Jeffries et al. 2003, Jang et al. 2005, Gega et al. 2007). Several outcomes were reported on in a few of the studies, which were outside 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 with a replicable search strategy based on 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. © 2014 John Wiley & Sons Ltd

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Evaluating the impact of online or blended learning vs. face-to-face learning

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, several 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 relevant research pertaining to the aim of this review. 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 The conclusion that may be drawn from 10 of the 13 studies was 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 (Gerdsprasert et al. 2010, 2011, Durmaz et al. 2012, Keefe & Wharrad 2012). The highly significant results observed in the intervention groups could be attributed to 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 (Duijin et al. 2014). The limited findings from this review would tend to support that opinion, but further research on the use of supplementary technology would be essential prior to any implementation due to the resource and cost implications. It may be concluded from the 13 papers that evaluated the impact of the students’ clinical skill or performance following online or a blended learning approach, that students obtained a higher or similar level of clinical skill when compared to education using a traditional learning method. One possible explanation for this result was highlighted by a recent study by Duijin et al. (2014), where it was shown that the students’ 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 deliv© 2014 John Wiley & Sons Ltd

ered 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 can introduce 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 the control groups to enable accurate interpretation of results. In five of 11 studies, it was reported that students had a higher level of satisfaction compared to traditional style teaching methods. This is similar to findings reported in other reviews of student satisfaction with online resources in undergraduate education (Bloomfield et al. 2008, Cook et al. 2010). However, in four of the studies included in this review a lesser satisfaction level with online resources was reported. This result is consistent with research findings on students enrolled in other degree programmes outside nursing (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 studies as affecting the student’s level of engagement and satisfaction with online learning (Tallent-Runnels 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. The wide variation of intervention used in each study under review made the synthesis of data difficult. 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 videodiscs (De Amicus 1997, Beeson & Kring 1999) and CD-ROMs (Bauer & Huynh 2001, Jeffries 2001, Jeffries et al. 2003, Kim et al. 2003) whilst the most recent papers explored the use of screen-based computer simulation (Durmaz et al. 2012) and e-learning packages using multimedia books (Keefe & Wharrad 2012). Although the variety in technology limits the ability to make comparisons over time between studies, it showcases 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 267

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relation to online learning vs. traditional learning, we may conclude on the basis of this review that online learning appears to be at least as effective as traditional learning approaches. With reference to blended learning vs. traditional learning, there was limited evidence available to enable a conclusive opinion to be made. However, in two studies, Bauer and Huynh (2001) and Kaveevivitchai et al. (2009) reported a significant difference in favour of blended learning for performance and skill acquisition compared with online learning alone. This limited evidence would suggest that there is a need to research the future development of blended learning approaches for clinical skills education in the undergraduate nursing curriculum.

Acknowledgements

Conclusion

Author contributions

The evidence reported on in this review builds on the work of previous reviews and has used a contemporary mixed methods approach to increase the reportable evidence base available on the subject of online learning and blended learning for teaching clinical skills in undergraduate nursing. The evidence made available here has suggested that, overall, 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 have highlighted the lack of available evidence internationally on the implementation of a blended learning approach to teaching clinical skills in undergraduate nurse education. While 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 was lacking in both quantity and quality. Dearnley et al. (2013) reported that this gap in evidence may be due to a 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 in the evidence base of online learning and clinical skill development. Further exploration in this area is necessary before any assumptions can be made on the usefulness of employing an online or blending learning approach in teaching clinical skills in undergraduate nurse education.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

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Acknowledgment is made to Patricia Watt, Subject librarian CPD Nursing, Queen’s University Belfast for the guidance given in the development of the search strategy.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest No conflict of interest declared by the authors.

• •

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site.

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A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education.

To determine whether the use of an online or blended learning paradigm has the potential to enhance the teaching of clinical skills in undergraduate n...
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