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Evaluation of a computer assisted instruction resource in nursing education
Article
Evaluation of a computer assisted instruction resource in nursing education Anne M. Herriot, Jacki A. Bishop, Mary Kelly, Margaret Murphy and Helen Truby
Anne M. Herriot BSc (Hons), SRD, Research Officer Jacki A. Bishop PhD, SRD, RPHNutr, Nutrition Programmes Director, Centre for Nutrition and Dietetics, School of Biomedical and Molecular Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK. Tel.: +4401483-686417 E-mail: h.truby@ surrey.ac.uk Mary Kelly RGN, BSc (Hons), SRD, Lecturer (Clinical) in Clinical Nutrition Margaret Murphy BSc (Hons), PhD, European Institute of Health and Medical Sciences, The University of Surrey, Guildford, Surrey, UK (Requests for offprints to HC) Manuscript accepted: 6 June 2003
The STEP-DIET program, a computer assisted instruction (CAI) tool, was developed to prepare dietetic students for their hospital based practical training in the academic setting. This study aimed to evaluate the potential for using the programme within nursing education. The evaluation framework of Kirkpatrick [I. Forsyth, A. Jolliffe, D. Stevens (Eds.), Evaluating a Course, second ed. Kogan Page, London, p. 5] was employed to assess student response to STEP-DIET and its effectiveness as a teaching tool, with regards to perceived learning achievements. Knowledge and attitudes towards nutrition education were also investigated. Quantitative and qualitative methodologies were employed, with nine second and six final year BSc (Adult) nursing students completing questionnaires and taking part in two focus groups, separated by year group. Students rated STEP-DIET highly in terms of design and content and reported a number of perceived learning achievements including increase in nutritional knowledge, understanding of Type 2 diabetes management and the dietitian’s role, however there was a reluctance to accept CAI as a teaching method. Students reported a poor knowledge of nutrition, but recognised its importance. This study demonstrates that multidisciplinary learning by the sharing of resources has benefits to students. However, the integration of CAI into taught programmes needs to be managed to take into account student’s reluctance to rely on this method of instruction. ª 2003 Elsevier Science Ltd. All rights reserved.
Introduction Background The need to develop a new method of teaching students about clinical practice stemmed from changes in the clinical training of dietitians (Dietitians Board 2001). A computer assisted instruction programme, entitled, ‘Student Training Education and Practice in Dietetics’ (STEP-DIET) was developed at the University of Surrey as a method of familiarising students with clinical practice whilst in the academic environment (Anthony & Bishop 2000). STEPDIET utilises multimedia technology as a medium through which dietetic students could be better prepared for their practical placement
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in hospital. Based on a case study approach, it follows a patient newly diagnosed with Type 2 diabetes from hospital admission into primary care and allows the student to follow standard procedures and practices using a variety of interactive video, sound and written information. The STEP-DIET program had a number of educational aims, including to: • Encourage autonomous learning, utilising self-directed learning principles. • Enable students to learn at their own pace and reach their full academic potential. • Help develop transferable skills which included:
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Improved computer literacy. Ability to integrate knowledge of biomedical sciences and dietetics. Ability to interpret data and solve problems. Ability to understand communication patterns and interactions and how they influence outcomes. The programme is a unique teaching tool, which allows dietetic students to learn practical skills and decision-making within a virtual setting. The theoretical background on which the content was based stems from research investigating the complex interactions and pedagogy that take place during any professional interview. The specific skills that any health professional needs to communicate with any client can be observed between the dietetic practitioner and client during the dietetic interview (Tapsell 1997). The programme allows students to observe a dietitian taking a diet history, calculating nutrient intake and using the information to advise the patient on dietary change at various stages. Understanding of the patients’ medical and social history is also acquired to ensure the dietetic intervention is appropriate. Students are able to practice skills without direct clinical consequences to real people and there is particular emphasis on the use of reflective practice as a means of personal development and improved performance. Although specifically designed for dietetics, STEP-DIET embraces a number of the core competencies specified by the UK Council of Deans (1998), such as communication/interpersonal skills (embodying interview technique), analytical and evaluation skills. The use of reflective practice techniques (of which evaluation forms a part), are also employed within the nursing profession (Reed & Procter 1993, Pierson 1998). Thus the context and content of STEP-DIET provides opportunities for crossdisciplinary learning. With diabetes affecting around 1.4 million people in the UK, 75% of which have Type 2 diabetes (Thomas 2001) it is highly likely that nurses will encounter the type of patient featured in the case study and featured. Furthermore, since following dietary advice
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has been shown to be one of patients’ main concerns during their first year of Type 2 diabetes diagnosis (Woodcock & Kinmonth 2001) it would be beneficial if nurses had some knowledge of dietary recommendations. It is important for nursing students to be able to apply theory into practice not only in terms of knowledge application, but also in their ability to communicate and educate patients (Latter et al. 2001). STEP-DIET allows students to observe examples of this application within the University setting, albeit within the context of dietetics. Information technology is becoming increasingly important within the Health Care sector, requiring nurses to become more proficient in its use (Chambers & Coates 1990; Aarvold et al. 1993; Elfrink et al. 2000). The increased use of CAI within teaching is one way in which this can be achieved (Chambers & Coates 1990). The aim of this study was to determine the effectiveness and potential for using STEPDIET within nursing education. It also aimed to assess the degree of transferability of skills that are embedded within the programme and to assess how other health professionals may benefit from CAI. This study sought the opinions of both second year and final year nursing students attending the University of Surrey. The evaluation methodology was based on the theoretical model of Kirkpatrick (1977), which outlines four levels of evaluation: level 1 – reaction, level 2 – learning, level 3 – behavioural change and level 4 results to the organisation. The first two levels were investigated in this study using both quantitative and qualitative methodologies. The study had the following objectives: • To evaluate how the students responded to the programme and its teaching methods (CAI): Kirkpatrick’s first level of evaluation, ‘reaction’. • To evaluate the effectiveness of the programme as a teaching tool for nursing students: Kirkpatrick’s second level of evaluation, ‘learning’. • Describe the potential for using the programme within nursing education.
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Materials and methods The study incorporated both quantitative (questionnaires) and qualitative (focus groups) methodology to meet the above objectives. Subject selection Second and final year BSc (Adult) nursing students were recruited through the European Institute of Health and Medical Sciences, at the University of Surrey. BSc (Adult) students were selected as opposed to Diploma, BSc (Child) or BSc (Midwifery) students because they corresponded with the academic level for which STEP-DIET was developed (BSc dietetic students) and the type of patient encountered by the nursing student (case studies with adult patients). However, this resulted in a limited number of students from which to recruit volunteers. Students were recruited directly by the researcher, during lecture breaks. Seven final year and nine second year nursing students volunteered to take part in the study. It was not possible randomly to select from the student volunteers due to insufficient numbers. All volunteers (n ¼ 16) received a letter explaining the study and a consent form and were eligible to take part once written consent had been obtained. Subjects were to be financially compensated for their time, on completion of the study. Ethical approval for the study was granted by the University of Surrey Ethics in Human Research Committee. Procedure Student nurses completed the STEP-DIET program and its associated workbook in 4–6 h within 2 h timetabled sessions working at individual computers. The workbooks were primarily developed for dietetic students and were used to lead the student through the programme via a series of questions corresponding with questions that appear in the programme itself. Nursing students were only required to complete the questions in the workbook that were considered relevant to nursing as selected by an experienced tutor. Questionnaires and semi-structured focus group interviews based on Kirkpatrick’s level 1
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and level 2 evaluations were developed following a review of the relevant literature (Forsyth et al. 1999; Oppenheim 1992; Rowntree 1985; Thorpe 1993). The questions were developed and tested in a pilot study to ensure that each question was clearly understood by participants. The questionnaires were not formally tested for reliability. Face validity was achieved by a review of the format and content of the questionnaire by a team of University educators. The questionnaires were self administered on completion of the programme. They took approximately 15 min to complete and consisted of a closed question format using a 5 point Likert scale (1- to 5-higher rating indicating positive response) to measure student attitudes towards a number of components of the programme including: • Evaluation of the computerised instruction method. • Achievement of learning objectives relative to nursing. • Attitudes towards nutrition. • Relevance of the programme to nursing students. Students also attended a focus group (one for the second years and one for the final years). The focus groups were conducted within the University and lasted approximately 1 h. The same moderator facilitated both groups employing a semi-structured interview format using open-ended questions. This type of qualitative methodology aims to ensure that the subjects are able to freely discuss their opinions whilst being directed along a predetermined path by the interviewer (Kreuger & Casey 2000). This way the interviewer is not only able to gather specific information required for purposes of the evaluation but is also able to compare discussions between the different groups by ensuring validity. A number of areas were covered including: • • • •
Instruction method. Programme content and workbook. Knowledge and attitudes towards nutrition. Usefulness of the STEP-DIET program to nursing students. • Future potential directions.
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The focus groups were audio taped and an additional observer took field notes. Data analysis For the questionnaire, student responses to each of the individual questions were collated and analysed manually to give simple numerical response frequencies as a measure of student attitude towards (reaction) and effectiveness (learning) of the STEP-DIET program. For the focus groups, all recorded tapes were transcribed verbatim by the moderator and analysed using the long table approach via computer (Krueger and Casey 2000). Quotes were allocated to questions and the results from both groups collated. The following topic areas were analysed for major and minor themes and descriptive summaries made: • Teaching evaluation, Kirkpatrick level 1: ‘Reaction’ to STEP-DIET and to CAI as a instruction method. • Nursing education, Kirkpatrick level 2: ‘Learning’ – students perceived effectiveness of STEP-DIET as a teaching tool within nursing education. • Potential future directions for STEP-DIET within nursing education. The second researcher who had been present during the focus group interviews reviewed the summaries, confirming they were an accurate assessment of subject opinions. No formal statistical tests were applied to these data.
software and screen design, programme design and content. As an instruction method, there was a mixed response with only 20% (3/15) preferring CAI to traditional lectures, with all the students reporting they would prefer to have used the programme in conjunction with traditional lectures. All the students believed nutrition to be an important feature of nursing care and that it was important for nurses to learn more about nutrition. They also considered that the programme would be a useful learning resource for nursing students with 67% (10/15) rating it 4 or more in its present form, which increased to 100% (15/15) if the programme were adapted. Learning evaluation Nursing education The majority of students believed they were able to achieve the learning objectives (see Table 1.), which included an increase in their factual knowledge of diabetes, an increase in their knowledge of nutrition and an understanding of the role of a dietitian. However, only 27% (4/15) believed using the programme had allowed them to begin to develop reflective practice skills, with 53% (8/15) unsure (rating 3 on the Likert scale). Computer literacy The majority of students already felt confident using computers with only 13% (2/15) students giving a negative rating (2 or less), one of which was the only student who felt their computer skills had been improved from using the programme.
Results Nine second year nursing students and six final year students completed the programme, workbook and questionnaire and attended a focus group. Student response from the different year groups concurred, therefore for purposes of analysis both groups were combined as one unit of analysis, unless otherwise stated. Quantitative Reaction evaluation Students rated the programme highly, in the following categories: technical aspects,
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Qualitative Reaction evaluation Computerised instruction method Students found the programme ‘easy to use’ and indicated that CAI made a ‘nice change’ from traditional lectures and added variety to the learning process. They felt that CAI was a good method for teaching this type of course since it enabled the student to observe the application of theory into practice. They were open to the suggestion of using CAI within other modules and earlier in their course, but more as an ‘additional aid’ or revision tool as opposed to a substitute for lectures. A number
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Table 1 Nursing students’ perceived learning achievements from using the STEP-DIET program Number of students (n)
Learning achievements Strongly disagree (1) Increased understanding of the role of a dietitian Increased factual knowledge of diabetes Increased knowledge of nutrition Beginning to develop reflective practice skills
Disagree (2)
1
1
of advantages and disadvantages to this mode of learning were suggested. Advantages could be separated into three categories (see Table 2) of which flexibility, especially the ability to repeat sections, was the most frequently cited. Disadvantages of CAI focussed on the instruction method, the main disadvanges being lack of social contact with peers and peer-group support, which could result in boredom and/or loneliness and lack of tutor support. The second year nurses also noted the need for self-motivation and the temptation ‘not to bother’ if they had to complete the programme in their own time (see Table 3).
Neither disagree nor agree (3)
Agree (4)
Strongly agree (5)
1
6
8
4
11
1
9
5
8
3
1
STEP-DIET program content and workbooks Students felt the content was ‘a good level and depth’ and although it was primarily designed for dietetic students they still felt they were able to understand it. Students thought the workbook was well structured and answering the questions allowed them to retain the information given in the programme. There was unanimous agreement that they would find the workbooks a useful reference source in the future particularly during clinical placement.
Table 2 Student opinions on the advantages of computer-assisted instruction (CAI) Category
Example
Quote
Flexibility
Work at own pace/speed Repeat sections
‘‘You can take it at your own pace’’ ‘‘You can go back over parts if you’re not sure’’
Instruction method
Variety
‘‘You’ve got visual things and hearing and you can actually do things as well’’ ‘‘You can stop and have a break. . .I mean in lectures you just switch off. . .’’
Concentration Content
Observation of an example of practice
‘‘But it was good to see it (the interview) between two people and see the professional doing it’’
Table 3 Nursing student opinions on the disadvantages of computer-assisted instruction (CAI) Category
Example
Quote
Instruction method
Lack of tutor support
‘‘If you don’t understand something there’s no-one there to ask, to explain it in a different way’’ ‘‘Everybody will throw in something to the lecture, they’ll bring up points that you haven’t thought about which you might not think about if you’re doing it on your own’’.
Lack of peer group input
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Potential for using STEP-DIET within nursing education Students were of the opinion that the programme would be beneficial for use with nursing students in its present form. They found the information provided ‘very relevant’ to nursing and although there was more emphasis on the professional interview and interview technique than would normally be required by nurses, it was still considered a valuable part of the learning but could always be ‘skipped’ if necessary. The main change suggested to make the programme more suitable for nurses was an increased emphasis on the nurse’s role in diabetes care. Final year students also suggested information on medical complications and the action of insulin would be useful, since these were more likely to be relevant for the types of patient they would encounter in hospital. Learning evaluation Nursing students were initially assessed as to their present knowledge of nutrition and also their potential receptiveness towards nutrition education. Knowledge of nutrition The students reported they had covered a small amount of basic nutrition education in their first year of nursing studies. Their current sources of nutritional information were limited and in the second year relied entirely on selfdirected study. Of the final year students one had completed an optional nutrition module,
therefore had some nutritional knowledge whereas the others gained their knowledge primarily from other modules in their course which resulted in it being area specific for example drug–nutrient interactions and nutrition and tissue viability. Further knowledge would have to be obtained through self-study. With regards to diabetes, students reported they were more familiar with management of Type 1 diabetes, because these patients they were more likely to be encountered in hospital, but they had little knowledge of Type 2 diabetes. Attitudes towards nutrition All the students felt strongly that nutrition was an important feature of nursing and patient care, especially in relation to its effect on wound healing. They felt that nurses should learn more about nutrition and it should be given a much higher priority in nursing education. A number of areas were identified where nutritional knowledge was required and in most cases these reflected their beliefs about the role of nurses in the nutritional management of patients (see Table 4). The most frequently mentioned role was as a support to the dietitian, primarily by reinforcing dietary advice, as well as assessing and monitoring nutritional intake and food provision. A number of students believed the nutrition module in the final year should be made compulsory. Second year students all thought they would select the nutrition module in their
Table 4 Nurses’ role in nutritional management of patients as perceived by second and final year nursing students Role
Quote
Year group
Reinforcement
‘‘Act as back up teachers. . .the constant sort of encouragement, reassurance and informing. . .’’
L2
Assessment
‘‘The percentage of people who are malnourished in hospital means that nurses really all need to know about it’’
FY
Monitoring
‘‘The dietitian says they’ve got to have these meals, it’s the nurses who are going to be walking round checking them’’
L2
Food provision
‘‘A lot of the time nurses. . .fill in the menu for the patient and they don’t really know their needs’’
FY
Referrer
‘‘Referral to the dietitian if they need it. . .’’
FY
Educator
‘‘There are a lot more nurses than dietitians so the nurse is going to have to stand in and do a bit more’’
L2
L2, second year nursing student; FY, final year nursing student.
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final year and a number of the students reported one of the reasons they had taken part in the study was because of their interest in nutrition. Perceived learning achievements The main learning achievement perceived by students was an increase in knowledge especially in the areas of diabetes, including medication, blood pressure and weight management, practical dietary advice and medical complications of diabetes. They also increased their understanding of dietetics including the dietitians’ role and nutritional assessment of patients. Two of the second year nurses stated they had already benefited from knowledge gained from using STEP-DIET whilst on clinical placement subsequent to completing the programme. One student found it had helped her when she had performed the ‘first step of the dietitians’ role’, due to patient numbers requiring dietetic advice, although what this actually involved was not determined. The other student found it had helped her when having to complete a basic nutritional screening tool required for dietetic referral. Potential future directions for using STEP-DIET within nursing education Students discussed three potential areas where STEP-DIET could be used within nursing education (see Table 5) these included, student education, use with specialist nurses and also for distance learners. With regards to specialists, students felt the programme may be too basic for diabetes nurse specialists, however they believed that it would be beneficial to all qualified nurses since they
perceived that their level of knowledge of Type 2 diabetes was generally inadequate.
Discussion The primary objectives of this study were to determine the reaction to, and effectiveness of, the STEP-DIET program and CAI in nursing education. The evaluation theory of Kirkpatrick (1977) provided a framework on which these objectives were assessed. Reaction evaluation (Kirkpatrick level 1) The results indicated an extremely positive reaction, to the STEP-DIET program, however students were reluctant to accept CAI as a total substitute for traditional lectures. Nurses have shown unfavourable attitudes toward computers in the clinical setting (Sultana 1990) and lack of confidence (Thede et al. 1994; Kenny 2002). Contrary to these findings, however, the majority of students in this study felt confident with computers and dislike of computers was not a reason stated for their desire to maintain traditional lectures. It could be argued this cohort of students volunteered to take part in the study because they liked computers, however, they had no experience with this method of teaching within their University education and therefore were representative of other nursing students on their degree programme. Barriers cited including lack of peer/tutor contact and self-motivation – may be overcome by making sure a structured and assessed programme of CAI is used in the early years of a degree programme (Lowry & Johnson 1999). With the health care service becoming more dependent
Table 5 Potential areas for STEP-DIET use within nursing education Area
Examples
Incorporation into the nursing teaching programme:
Specialist/members of the nursing profession
Diabetes nurse specialists All nurses
Distance learning
Qualified nurses-continued professional development Computers on wards
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Incorporated into other modules-especially the final year nutrition module Optional module Optional access to students on university computers Sections shown within lecture and later discussed in a focus group
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upon information technology for data management and communication (Kenny 2002) it is important nurses become more proficient in its use. Although various forms of CAI have been used in nursing (Gee et al. 1998; Elfrink et al. 2000; Mangan & van Soeren 2000; Rose et al. 2000), there has been limited use of CAI within the UK nursing curriculum (Lowry & Johnson 1999). Results from this study show that STEP-DIET has potential for use as an educational resource within nursing education. CAI often provides a passive learning environment, however, with the increased emphasis on developing critical thinking (Thede et al. 1994) and clinical decision-making skills (Lowry & Johnson 1999) in nursing, tools such as the STEP-DIET program may help achieve these objectives. Learning evaluation (Kirkpatrick level 2) Although nurses recognise the importance of their role in the nutritional management of patients (Perry 1997; Rawlinson 1998), studies have shown that nurses have a poor knowledge of nutrition (Buttriss 1997; Perry 1997; Barratt 2001). This study confirms these findings and also indicates that knowledge of Type 2 diabetes is also inadequate. General dissatisfaction in the quality of training in nutrition both pre- and post-registration has been reported by practice nurses (Buttriss 1997). Students in this study believed that nutrition education should receive more emphasis within nursing education, supporting recommendations from previous researchers (Perry 1997; Rawlinson 1998; Barratt 2001). CAI has been shown to be an effective means of knowledge acquisition and application in nursing education (Belfry & Winne 1988). In this study, nursing students were able to increase their knowledge in a number of areas which had already been shown to benefit students in the clinical setting. A number of transferable skills specified in the STEP-DIET program objectives were specific for dietetic students, so it was not surprising learning achievements of the nursing students centred on knowledge acquisition as opposed to skill development. However, students did not report any increase in communication skills from using the programme. Communication
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skills have become an important part of the nursing curriculum (Chant et al. 2002). Although the STEP-DIET program provides a description of fundamental communication processes this study indicates it needs to be related more specifically to nursing practice. Study limitations Learning achievements were those perceived by the students themselves and were not formally assessed. This study relied on student volunteers and therefore, as always, there is a risk of selection bias. Indeed in the case of the second years one of the reasons they took part in the study was due to their interest in nutrition. However this was not the case for the final year students, only one of which had chosen to take the nutrition module in the final year. This study was conducted to assess the potential for using STEP-DIET and CAI within nursing education; it was not anticipated that it would be suitable for all nursing students but that there may be areas where it could be a valuable educational tool. Furthermore, with government policy favouring multidisciplinary learning (Department of Health 2000), programmes such as STEP-DIET may perform a useful role in the future.
Conclusion Although STEP-DIET had been developed in response to the need to prepare dietetic students for their practical training, it has some use within a multidisciplinary environment. Nursing students reacted favourably to the programme and a number of perceived learning achievements were accomplished. It is recognised nursing students do not require the depth of nutritional knowledge of dietetic students. However, STEP-DIET has been shown to be a potential valuable source of both nutrition and Type 2 diabetes education for nursing students who wish to increase their knowledge in these areas. In addition, use of CAI has enabled a multidisciplinary learning to occur and the fostering of greater partnerships between the disciplines of nursing and dietetics. The need for greater computer literacy and self-directed learning will
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probably lead to the greater use of CAI. However, students reactions to this learning method needs to be taken into consideration and the perceived requirement for peer and tutor support within the learning environment maintained. This may be achieved by interspersing CAI with tutorial discussions to enable students to feel supported during the learning experience. Acknowledgements We would like to thank Jon Maslin and Ms Vicki Simpson, Learning Systems, University of Surrey for technical support. Mrs Deborah David (DD), for assistance with the focus groups, Ms Denise Thomas and A/Professor Linda Tapsell for assistance with the development of STEP-DIET and all the students who took part in this study. References Aarvold J, Heyman B, Bell B 1993 An information technology package. In: Reed J, Procter S (eds). Nurse Education. A Reflective Approach. Arnold, London, pp. 71–87 Anthony H, Bishop J 2000 Student Training Education and Practice (STEP DIET) – The development of a multi media resource. In: Proceedings of the 13th International Congress of Dietetics, Edinburgh, O118 Barratt J 2001 Diet-related knowledge, beliefs and actions of health professionals compared with the general population: an investigation in a community trust. Journal of Human Nutrition and Dietetics 14(1): 25–32 Belfry MJ, Winne PH 1988 A review of the effectiveness of computer-assisted instruction in nursing education. Computers in Nursing 6: 77–85 Buttriss J 1997 Food and nutrition: attitudes, beliefs, and knowledge in the United Kingdom. American Journal of Clinical Nutrition 65: 1985S–1995S Chambers M, Coates VE 1990 Computer training in nurse education: a bird’s eye view across the UK. Journal of Advanced Nursing 15: 16–21 Chant S, Jenkinson T, Randle J, Russell G, Webb C 2002 Communication skills training in healthcare: a review of the literature. Nurse Education Today 22(3): 189–202 Department of Health 2000 Meeting the challenge: a strategy for the Allied Health Professions: 26–28 www.doh.gov.uk/pdfs/meetingthechallenge.pdf Dietitians Board 2001 Pre-registration and Training of Dietitians, Vol.1: 7 www.cpsm.org.uk/dietitians/ download/BDAVolume1.pdf Elfrink V, Davis LS, Fizwater E, Castleman J, Burley J, Gorney-Moreno MJ, Sullivan J, Nichols B, Hall D, Queen K, Johnson S, Martin A 2000 A comparison of teaching strategies for integrating information technology into clinical nursing education. Nurse Educator 25(3): 136–144
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Forsyth I, Jolliffe A, Stevens D 1999 Evaluating a Course, 2nd edn. Kogan Page, London Gee PR, Peterson GM, Martin JLS, Reeve JF 1998 Development and evaluation of a computer-assisted instruction package in clinical pharmacology for nursing students. Computers in Nursing 16(1): 37–44 Kenny A 2002 Online learning: enhancing nurse education? Journal of Advanced Nursing 38(2): 127–135 Kirkpatrick DL 1977 Evaluating training programmes: evidence vs proof. In: Forsyth I, Jolliffe A, Stevens D (eds). Evaluating a Course, 2nd edn. Kogan Page, London, p. 5 Kreuger RA, Casey MA 2000 Focus Groups: A Practical Guide for Applied Research, 3rd edn. Sage, London Latter S, Rycroft-Malone J, Yerrell P, Shaw D 2001 Nurses’ educational preparation for a medication education role: findings from a national survey. Nurse Education Today 21(2): 143–154 Lowry M, Johnson M 1999 Computer assisted learning: the potential for teaching and assessing in nursing. Nurse Education Today 19: 521–526 Mangan JM, van Soeren MH 2000 Development and evaluation of a pathophysiology CD-ROM for nurse practitioner distance education. Computers in Nursing 18(2): 87–92 Oppenheim AN 1992 Questionnaire Design, Interviewing and Attitude Measurement, 2nd edn. Pinter, London Perry L 1997 Nutrition: a hard nut to crack. An exploration of the knowledge, attitudes and activities of qualified nurses in relation to nutritional nursing care. Journal of Clinical Nursing 6: 315–324 Pierson W 1998 Reflection and nursing education. Journal of Advanced Nursing 27: 165–170 Rawlinson D 1998 Audit of nutritional practice and knowledge. Professional Nurse 13(5): 291–294 Reed J, Procter S 1993 Nurse Education: A Reflective Approach. Arnold, London Rose MA, Frisby AJ, Hamlin MD, Jones SS 2000 Evaluation of the effectiveness of a web-based graduate epidemiology course. Computers in Nursing 18(4): 162–167 Rowntree D 1985 Developing Courses for Students, 2nd edn. Chapman, London Sultana N 1990 Nurses attitudes towards computerization in clinical practice. Journal of Advanced Nursing 15: 696–702 Tapsell L 1997 Client-centred practice: an interactional case study of dietary counselling. Health, Vol. 1(1). Sage, London. pp. 107–120 Thede LQ, Taft S, Coeling H 1994 Computer-assisted instruction: a learner’s viewpoint. Journal of Nursing Education 33(7): 299–305 Thomas B 2001 Diabetes mellitus. In: Thomas B (ed). Manual of Dietetic Practice, 3rd edn. Blackwell Science, Oxford, pp. 443–462 Thorpe M 1993 Evaluation Open and Distance Learning, 2nd edn. Longman, Essex UK Council of Deans and Heads of Nursing, Midwifery and Health Visiting 1998 Breaking the boundaries. UK CoD, Manchester Woodcock A, Kinmonth AL 2001 Patient concerns in their first year with Type 2 diabetes: patient and practice nurse views. Patient Education and Counselling 42(3): 257–270
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Evaluation of a computer assisted instruction resource in nursing education Anne M. Herriot, Jacki A. Bishop, Mary Kelly, Margaret Murphy and Helen Truby
Anne M. Herriot BSc (Hons), SRD, Research Officer Jacki A. Bishop PhD, SRD, RPHNutr, Nutrition Programmes Director, Centre for Nutrition and Dietetics, School of Biomedical and Molecular Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK. Tel.: +4401483-686417 E-mail: h.truby@ surrey.ac.uk Mary Kelly RGN, BSc (Hons), SRD, Lecturer (Clinical) in Clinical Nutrition Margaret Murphy BSc (Hons), PhD, European Institute of Health and Medical Sciences, The University of Surrey, Guildford, Surrey, UK (Requests for offprints to HC) Manuscript accepted: 6 June 2003
The STEP-DIET program, a computer assisted instruction (CAI) tool, was developed to prepare dietetic students for their hospital based practical training in the academic setting. This study aimed to evaluate the potential for using the programme within nursing education. The evaluation framework of Kirkpatrick [I. Forsyth, A. Jolliffe, D. Stevens (Eds.), Evaluating a Course, second ed. Kogan Page, London, p. 5] was employed to assess student response to STEP-DIET and its effectiveness as a teaching tool, with regards to perceived learning achievements. Knowledge and attitudes towards nutrition education were also investigated. Quantitative and qualitative methodologies were employed, with nine second and six final year BSc (Adult) nursing students completing questionnaires and taking part in two focus groups, separated by year group. Students rated STEP-DIET highly in terms of design and content and reported a number of perceived learning achievements including increase in nutritional knowledge, understanding of Type 2 diabetes management and the dietitian’s role, however there was a reluctance to accept CAI as a teaching method. Students reported a poor knowledge of nutrition, but recognised its importance. This study demonstrates that multidisciplinary learning by the sharing of resources has benefits to students. However, the integration of CAI into taught programmes needs to be managed to take into account student’s reluctance to rely on this method of instruction. ª 2003 Elsevier Science Ltd. All rights reserved.
Introduction Background The need to develop a new method of teaching students about clinical practice stemmed from changes in the clinical training of dietitians (Dietitians Board 2001). A computer assisted instruction programme, entitled, ‘Student Training Education and Practice in Dietetics’ (STEP-DIET) was developed at the University of Surrey as a method of familiarising students with clinical practice whilst in the academic environment (Anthony & Bishop 2000). STEPDIET utilises multimedia technology as a medium through which dietetic students could be better prepared for their practical placement
0260-6917/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0260-6917(03)00095-9
in hospital. Based on a case study approach, it follows a patient newly diagnosed with Type 2 diabetes from hospital admission into primary care and allows the student to follow standard procedures and practices using a variety of interactive video, sound and written information. The STEP-DIET program had a number of educational aims, including to: • Encourage autonomous learning, utilising self-directed learning principles. • Enable students to learn at their own pace and reach their full academic potential. • Help develop transferable skills which included:
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Improved computer literacy. Ability to integrate knowledge of biomedical sciences and dietetics. Ability to interpret data and solve problems. Ability to understand communication patterns and interactions and how they influence outcomes. The programme is a unique teaching tool, which allows dietetic students to learn practical skills and decision-making within a virtual setting. The theoretical background on which the content was based stems from research investigating the complex interactions and pedagogy that take place during any professional interview. The specific skills that any health professional needs to communicate with any client can be observed between the dietetic practitioner and client during the dietetic interview (Tapsell 1997). The programme allows students to observe a dietitian taking a diet history, calculating nutrient intake and using the information to advise the patient on dietary change at various stages. Understanding of the patients’ medical and social history is also acquired to ensure the dietetic intervention is appropriate. Students are able to practice skills without direct clinical consequences to real people and there is particular emphasis on the use of reflective practice as a means of personal development and improved performance. Although specifically designed for dietetics, STEP-DIET embraces a number of the core competencies specified by the UK Council of Deans (1998), such as communication/interpersonal skills (embodying interview technique), analytical and evaluation skills. The use of reflective practice techniques (of which evaluation forms a part), are also employed within the nursing profession (Reed & Procter 1993, Pierson 1998). Thus the context and content of STEP-DIET provides opportunities for crossdisciplinary learning. With diabetes affecting around 1.4 million people in the UK, 75% of which have Type 2 diabetes (Thomas 2001) it is highly likely that nurses will encounter the type of patient featured in the case study and featured. Furthermore, since following dietary advice
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has been shown to be one of patients’ main concerns during their first year of Type 2 diabetes diagnosis (Woodcock & Kinmonth 2001) it would be beneficial if nurses had some knowledge of dietary recommendations. It is important for nursing students to be able to apply theory into practice not only in terms of knowledge application, but also in their ability to communicate and educate patients (Latter et al. 2001). STEP-DIET allows students to observe examples of this application within the University setting, albeit within the context of dietetics. Information technology is becoming increasingly important within the Health Care sector, requiring nurses to become more proficient in its use (Chambers & Coates 1990; Aarvold et al. 1993; Elfrink et al. 2000). The increased use of CAI within teaching is one way in which this can be achieved (Chambers & Coates 1990). The aim of this study was to determine the effectiveness and potential for using STEPDIET within nursing education. It also aimed to assess the degree of transferability of skills that are embedded within the programme and to assess how other health professionals may benefit from CAI. This study sought the opinions of both second year and final year nursing students attending the University of Surrey. The evaluation methodology was based on the theoretical model of Kirkpatrick (1977), which outlines four levels of evaluation: level 1 – reaction, level 2 – learning, level 3 – behavioural change and level 4 results to the organisation. The first two levels were investigated in this study using both quantitative and qualitative methodologies. The study had the following objectives: • To evaluate how the students responded to the programme and its teaching methods (CAI): Kirkpatrick’s first level of evaluation, ‘reaction’. • To evaluate the effectiveness of the programme as a teaching tool for nursing students: Kirkpatrick’s second level of evaluation, ‘learning’. • Describe the potential for using the programme within nursing education.
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Materials and methods The study incorporated both quantitative (questionnaires) and qualitative (focus groups) methodology to meet the above objectives. Subject selection Second and final year BSc (Adult) nursing students were recruited through the European Institute of Health and Medical Sciences, at the University of Surrey. BSc (Adult) students were selected as opposed to Diploma, BSc (Child) or BSc (Midwifery) students because they corresponded with the academic level for which STEP-DIET was developed (BSc dietetic students) and the type of patient encountered by the nursing student (case studies with adult patients). However, this resulted in a limited number of students from which to recruit volunteers. Students were recruited directly by the researcher, during lecture breaks. Seven final year and nine second year nursing students volunteered to take part in the study. It was not possible randomly to select from the student volunteers due to insufficient numbers. All volunteers (n ¼ 16) received a letter explaining the study and a consent form and were eligible to take part once written consent had been obtained. Subjects were to be financially compensated for their time, on completion of the study. Ethical approval for the study was granted by the University of Surrey Ethics in Human Research Committee. Procedure Student nurses completed the STEP-DIET program and its associated workbook in 4–6 h within 2 h timetabled sessions working at individual computers. The workbooks were primarily developed for dietetic students and were used to lead the student through the programme via a series of questions corresponding with questions that appear in the programme itself. Nursing students were only required to complete the questions in the workbook that were considered relevant to nursing as selected by an experienced tutor. Questionnaires and semi-structured focus group interviews based on Kirkpatrick’s level 1
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and level 2 evaluations were developed following a review of the relevant literature (Forsyth et al. 1999; Oppenheim 1992; Rowntree 1985; Thorpe 1993). The questions were developed and tested in a pilot study to ensure that each question was clearly understood by participants. The questionnaires were not formally tested for reliability. Face validity was achieved by a review of the format and content of the questionnaire by a team of University educators. The questionnaires were self administered on completion of the programme. They took approximately 15 min to complete and consisted of a closed question format using a 5 point Likert scale (1- to 5-higher rating indicating positive response) to measure student attitudes towards a number of components of the programme including: • Evaluation of the computerised instruction method. • Achievement of learning objectives relative to nursing. • Attitudes towards nutrition. • Relevance of the programme to nursing students. Students also attended a focus group (one for the second years and one for the final years). The focus groups were conducted within the University and lasted approximately 1 h. The same moderator facilitated both groups employing a semi-structured interview format using open-ended questions. This type of qualitative methodology aims to ensure that the subjects are able to freely discuss their opinions whilst being directed along a predetermined path by the interviewer (Kreuger & Casey 2000). This way the interviewer is not only able to gather specific information required for purposes of the evaluation but is also able to compare discussions between the different groups by ensuring validity. A number of areas were covered including: • • • •
Instruction method. Programme content and workbook. Knowledge and attitudes towards nutrition. Usefulness of the STEP-DIET program to nursing students. • Future potential directions.
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The focus groups were audio taped and an additional observer took field notes. Data analysis For the questionnaire, student responses to each of the individual questions were collated and analysed manually to give simple numerical response frequencies as a measure of student attitude towards (reaction) and effectiveness (learning) of the STEP-DIET program. For the focus groups, all recorded tapes were transcribed verbatim by the moderator and analysed using the long table approach via computer (Krueger and Casey 2000). Quotes were allocated to questions and the results from both groups collated. The following topic areas were analysed for major and minor themes and descriptive summaries made: • Teaching evaluation, Kirkpatrick level 1: ‘Reaction’ to STEP-DIET and to CAI as a instruction method. • Nursing education, Kirkpatrick level 2: ‘Learning’ – students perceived effectiveness of STEP-DIET as a teaching tool within nursing education. • Potential future directions for STEP-DIET within nursing education. The second researcher who had been present during the focus group interviews reviewed the summaries, confirming they were an accurate assessment of subject opinions. No formal statistical tests were applied to these data.
software and screen design, programme design and content. As an instruction method, there was a mixed response with only 20% (3/15) preferring CAI to traditional lectures, with all the students reporting they would prefer to have used the programme in conjunction with traditional lectures. All the students believed nutrition to be an important feature of nursing care and that it was important for nurses to learn more about nutrition. They also considered that the programme would be a useful learning resource for nursing students with 67% (10/15) rating it 4 or more in its present form, which increased to 100% (15/15) if the programme were adapted. Learning evaluation Nursing education The majority of students believed they were able to achieve the learning objectives (see Table 1.), which included an increase in their factual knowledge of diabetes, an increase in their knowledge of nutrition and an understanding of the role of a dietitian. However, only 27% (4/15) believed using the programme had allowed them to begin to develop reflective practice skills, with 53% (8/15) unsure (rating 3 on the Likert scale). Computer literacy The majority of students already felt confident using computers with only 13% (2/15) students giving a negative rating (2 or less), one of which was the only student who felt their computer skills had been improved from using the programme.
Results Nine second year nursing students and six final year students completed the programme, workbook and questionnaire and attended a focus group. Student response from the different year groups concurred, therefore for purposes of analysis both groups were combined as one unit of analysis, unless otherwise stated. Quantitative Reaction evaluation Students rated the programme highly, in the following categories: technical aspects,
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Qualitative Reaction evaluation Computerised instruction method Students found the programme ‘easy to use’ and indicated that CAI made a ‘nice change’ from traditional lectures and added variety to the learning process. They felt that CAI was a good method for teaching this type of course since it enabled the student to observe the application of theory into practice. They were open to the suggestion of using CAI within other modules and earlier in their course, but more as an ‘additional aid’ or revision tool as opposed to a substitute for lectures. A number
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Table 1 Nursing students’ perceived learning achievements from using the STEP-DIET program Number of students (n)
Learning achievements Strongly disagree (1) Increased understanding of the role of a dietitian Increased factual knowledge of diabetes Increased knowledge of nutrition Beginning to develop reflective practice skills
Disagree (2)
1
1
of advantages and disadvantages to this mode of learning were suggested. Advantages could be separated into three categories (see Table 2) of which flexibility, especially the ability to repeat sections, was the most frequently cited. Disadvantages of CAI focussed on the instruction method, the main disadvanges being lack of social contact with peers and peer-group support, which could result in boredom and/or loneliness and lack of tutor support. The second year nurses also noted the need for self-motivation and the temptation ‘not to bother’ if they had to complete the programme in their own time (see Table 3).
Neither disagree nor agree (3)
Agree (4)
Strongly agree (5)
1
6
8
4
11
1
9
5
8
3
1
STEP-DIET program content and workbooks Students felt the content was ‘a good level and depth’ and although it was primarily designed for dietetic students they still felt they were able to understand it. Students thought the workbook was well structured and answering the questions allowed them to retain the information given in the programme. There was unanimous agreement that they would find the workbooks a useful reference source in the future particularly during clinical placement.
Table 2 Student opinions on the advantages of computer-assisted instruction (CAI) Category
Example
Quote
Flexibility
Work at own pace/speed Repeat sections
‘‘You can take it at your own pace’’ ‘‘You can go back over parts if you’re not sure’’
Instruction method
Variety
‘‘You’ve got visual things and hearing and you can actually do things as well’’ ‘‘You can stop and have a break. . .I mean in lectures you just switch off. . .’’
Concentration Content
Observation of an example of practice
‘‘But it was good to see it (the interview) between two people and see the professional doing it’’
Table 3 Nursing student opinions on the disadvantages of computer-assisted instruction (CAI) Category
Example
Quote
Instruction method
Lack of tutor support
‘‘If you don’t understand something there’s no-one there to ask, to explain it in a different way’’ ‘‘Everybody will throw in something to the lecture, they’ll bring up points that you haven’t thought about which you might not think about if you’re doing it on your own’’.
Lack of peer group input
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Potential for using STEP-DIET within nursing education Students were of the opinion that the programme would be beneficial for use with nursing students in its present form. They found the information provided ‘very relevant’ to nursing and although there was more emphasis on the professional interview and interview technique than would normally be required by nurses, it was still considered a valuable part of the learning but could always be ‘skipped’ if necessary. The main change suggested to make the programme more suitable for nurses was an increased emphasis on the nurse’s role in diabetes care. Final year students also suggested information on medical complications and the action of insulin would be useful, since these were more likely to be relevant for the types of patient they would encounter in hospital. Learning evaluation Nursing students were initially assessed as to their present knowledge of nutrition and also their potential receptiveness towards nutrition education. Knowledge of nutrition The students reported they had covered a small amount of basic nutrition education in their first year of nursing studies. Their current sources of nutritional information were limited and in the second year relied entirely on selfdirected study. Of the final year students one had completed an optional nutrition module,
therefore had some nutritional knowledge whereas the others gained their knowledge primarily from other modules in their course which resulted in it being area specific for example drug–nutrient interactions and nutrition and tissue viability. Further knowledge would have to be obtained through self-study. With regards to diabetes, students reported they were more familiar with management of Type 1 diabetes, because these patients they were more likely to be encountered in hospital, but they had little knowledge of Type 2 diabetes. Attitudes towards nutrition All the students felt strongly that nutrition was an important feature of nursing and patient care, especially in relation to its effect on wound healing. They felt that nurses should learn more about nutrition and it should be given a much higher priority in nursing education. A number of areas were identified where nutritional knowledge was required and in most cases these reflected their beliefs about the role of nurses in the nutritional management of patients (see Table 4). The most frequently mentioned role was as a support to the dietitian, primarily by reinforcing dietary advice, as well as assessing and monitoring nutritional intake and food provision. A number of students believed the nutrition module in the final year should be made compulsory. Second year students all thought they would select the nutrition module in their
Table 4 Nurses’ role in nutritional management of patients as perceived by second and final year nursing students Role
Quote
Year group
Reinforcement
‘‘Act as back up teachers. . .the constant sort of encouragement, reassurance and informing. . .’’
L2
Assessment
‘‘The percentage of people who are malnourished in hospital means that nurses really all need to know about it’’
FY
Monitoring
‘‘The dietitian says they’ve got to have these meals, it’s the nurses who are going to be walking round checking them’’
L2
Food provision
‘‘A lot of the time nurses. . .fill in the menu for the patient and they don’t really know their needs’’
FY
Referrer
‘‘Referral to the dietitian if they need it. . .’’
FY
Educator
‘‘There are a lot more nurses than dietitians so the nurse is going to have to stand in and do a bit more’’
L2
L2, second year nursing student; FY, final year nursing student.
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final year and a number of the students reported one of the reasons they had taken part in the study was because of their interest in nutrition. Perceived learning achievements The main learning achievement perceived by students was an increase in knowledge especially in the areas of diabetes, including medication, blood pressure and weight management, practical dietary advice and medical complications of diabetes. They also increased their understanding of dietetics including the dietitians’ role and nutritional assessment of patients. Two of the second year nurses stated they had already benefited from knowledge gained from using STEP-DIET whilst on clinical placement subsequent to completing the programme. One student found it had helped her when she had performed the ‘first step of the dietitians’ role’, due to patient numbers requiring dietetic advice, although what this actually involved was not determined. The other student found it had helped her when having to complete a basic nutritional screening tool required for dietetic referral. Potential future directions for using STEP-DIET within nursing education Students discussed three potential areas where STEP-DIET could be used within nursing education (see Table 5) these included, student education, use with specialist nurses and also for distance learners. With regards to specialists, students felt the programme may be too basic for diabetes nurse specialists, however they believed that it would be beneficial to all qualified nurses since they
perceived that their level of knowledge of Type 2 diabetes was generally inadequate.
Discussion The primary objectives of this study were to determine the reaction to, and effectiveness of, the STEP-DIET program and CAI in nursing education. The evaluation theory of Kirkpatrick (1977) provided a framework on which these objectives were assessed. Reaction evaluation (Kirkpatrick level 1) The results indicated an extremely positive reaction, to the STEP-DIET program, however students were reluctant to accept CAI as a total substitute for traditional lectures. Nurses have shown unfavourable attitudes toward computers in the clinical setting (Sultana 1990) and lack of confidence (Thede et al. 1994; Kenny 2002). Contrary to these findings, however, the majority of students in this study felt confident with computers and dislike of computers was not a reason stated for their desire to maintain traditional lectures. It could be argued this cohort of students volunteered to take part in the study because they liked computers, however, they had no experience with this method of teaching within their University education and therefore were representative of other nursing students on their degree programme. Barriers cited including lack of peer/tutor contact and self-motivation – may be overcome by making sure a structured and assessed programme of CAI is used in the early years of a degree programme (Lowry & Johnson 1999). With the health care service becoming more dependent
Table 5 Potential areas for STEP-DIET use within nursing education Area
Examples
Incorporation into the nursing teaching programme:
Specialist/members of the nursing profession
Diabetes nurse specialists All nurses
Distance learning
Qualified nurses-continued professional development Computers on wards
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Incorporated into other modules-especially the final year nutrition module Optional module Optional access to students on university computers Sections shown within lecture and later discussed in a focus group
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upon information technology for data management and communication (Kenny 2002) it is important nurses become more proficient in its use. Although various forms of CAI have been used in nursing (Gee et al. 1998; Elfrink et al. 2000; Mangan & van Soeren 2000; Rose et al. 2000), there has been limited use of CAI within the UK nursing curriculum (Lowry & Johnson 1999). Results from this study show that STEP-DIET has potential for use as an educational resource within nursing education. CAI often provides a passive learning environment, however, with the increased emphasis on developing critical thinking (Thede et al. 1994) and clinical decision-making skills (Lowry & Johnson 1999) in nursing, tools such as the STEP-DIET program may help achieve these objectives. Learning evaluation (Kirkpatrick level 2) Although nurses recognise the importance of their role in the nutritional management of patients (Perry 1997; Rawlinson 1998), studies have shown that nurses have a poor knowledge of nutrition (Buttriss 1997; Perry 1997; Barratt 2001). This study confirms these findings and also indicates that knowledge of Type 2 diabetes is also inadequate. General dissatisfaction in the quality of training in nutrition both pre- and post-registration has been reported by practice nurses (Buttriss 1997). Students in this study believed that nutrition education should receive more emphasis within nursing education, supporting recommendations from previous researchers (Perry 1997; Rawlinson 1998; Barratt 2001). CAI has been shown to be an effective means of knowledge acquisition and application in nursing education (Belfry & Winne 1988). In this study, nursing students were able to increase their knowledge in a number of areas which had already been shown to benefit students in the clinical setting. A number of transferable skills specified in the STEP-DIET program objectives were specific for dietetic students, so it was not surprising learning achievements of the nursing students centred on knowledge acquisition as opposed to skill development. However, students did not report any increase in communication skills from using the programme. Communication
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skills have become an important part of the nursing curriculum (Chant et al. 2002). Although the STEP-DIET program provides a description of fundamental communication processes this study indicates it needs to be related more specifically to nursing practice. Study limitations Learning achievements were those perceived by the students themselves and were not formally assessed. This study relied on student volunteers and therefore, as always, there is a risk of selection bias. Indeed in the case of the second years one of the reasons they took part in the study was due to their interest in nutrition. However this was not the case for the final year students, only one of which had chosen to take the nutrition module in the final year. This study was conducted to assess the potential for using STEP-DIET and CAI within nursing education; it was not anticipated that it would be suitable for all nursing students but that there may be areas where it could be a valuable educational tool. Furthermore, with government policy favouring multidisciplinary learning (Department of Health 2000), programmes such as STEP-DIET may perform a useful role in the future.
Conclusion Although STEP-DIET had been developed in response to the need to prepare dietetic students for their practical training, it has some use within a multidisciplinary environment. Nursing students reacted favourably to the programme and a number of perceived learning achievements were accomplished. It is recognised nursing students do not require the depth of nutritional knowledge of dietetic students. However, STEP-DIET has been shown to be a potential valuable source of both nutrition and Type 2 diabetes education for nursing students who wish to increase their knowledge in these areas. In addition, use of CAI has enabled a multidisciplinary learning to occur and the fostering of greater partnerships between the disciplines of nursing and dietetics. The need for greater computer literacy and self-directed learning will
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probably lead to the greater use of CAI. However, students reactions to this learning method needs to be taken into consideration and the perceived requirement for peer and tutor support within the learning environment maintained. This may be achieved by interspersing CAI with tutorial discussions to enable students to feel supported during the learning experience. Acknowledgements We would like to thank Jon Maslin and Ms Vicki Simpson, Learning Systems, University of Surrey for technical support. Mrs Deborah David (DD), for assistance with the focus groups, Ms Denise Thomas and A/Professor Linda Tapsell for assistance with the development of STEP-DIET and all the students who took part in this study. References Aarvold J, Heyman B, Bell B 1993 An information technology package. In: Reed J, Procter S (eds). Nurse Education. A Reflective Approach. Arnold, London, pp. 71–87 Anthony H, Bishop J 2000 Student Training Education and Practice (STEP DIET) – The development of a multi media resource. In: Proceedings of the 13th International Congress of Dietetics, Edinburgh, O118 Barratt J 2001 Diet-related knowledge, beliefs and actions of health professionals compared with the general population: an investigation in a community trust. Journal of Human Nutrition and Dietetics 14(1): 25–32 Belfry MJ, Winne PH 1988 A review of the effectiveness of computer-assisted instruction in nursing education. Computers in Nursing 6: 77–85 Buttriss J 1997 Food and nutrition: attitudes, beliefs, and knowledge in the United Kingdom. American Journal of Clinical Nutrition 65: 1985S–1995S Chambers M, Coates VE 1990 Computer training in nurse education: a bird’s eye view across the UK. Journal of Advanced Nursing 15: 16–21 Chant S, Jenkinson T, Randle J, Russell G, Webb C 2002 Communication skills training in healthcare: a review of the literature. Nurse Education Today 22(3): 189–202 Department of Health 2000 Meeting the challenge: a strategy for the Allied Health Professions: 26–28 www.doh.gov.uk/pdfs/meetingthechallenge.pdf Dietitians Board 2001 Pre-registration and Training of Dietitians, Vol.1: 7 www.cpsm.org.uk/dietitians/ download/BDAVolume1.pdf Elfrink V, Davis LS, Fizwater E, Castleman J, Burley J, Gorney-Moreno MJ, Sullivan J, Nichols B, Hall D, Queen K, Johnson S, Martin A 2000 A comparison of teaching strategies for integrating information technology into clinical nursing education. Nurse Educator 25(3): 136–144
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Forsyth I, Jolliffe A, Stevens D 1999 Evaluating a Course, 2nd edn. Kogan Page, London Gee PR, Peterson GM, Martin JLS, Reeve JF 1998 Development and evaluation of a computer-assisted instruction package in clinical pharmacology for nursing students. Computers in Nursing 16(1): 37–44 Kenny A 2002 Online learning: enhancing nurse education? Journal of Advanced Nursing 38(2): 127–135 Kirkpatrick DL 1977 Evaluating training programmes: evidence vs proof. In: Forsyth I, Jolliffe A, Stevens D (eds). Evaluating a Course, 2nd edn. Kogan Page, London, p. 5 Kreuger RA, Casey MA 2000 Focus Groups: A Practical Guide for Applied Research, 3rd edn. Sage, London Latter S, Rycroft-Malone J, Yerrell P, Shaw D 2001 Nurses’ educational preparation for a medication education role: findings from a national survey. Nurse Education Today 21(2): 143–154 Lowry M, Johnson M 1999 Computer assisted learning: the potential for teaching and assessing in nursing. Nurse Education Today 19: 521–526 Mangan JM, van Soeren MH 2000 Development and evaluation of a pathophysiology CD-ROM for nurse practitioner distance education. Computers in Nursing 18(2): 87–92 Oppenheim AN 1992 Questionnaire Design, Interviewing and Attitude Measurement, 2nd edn. Pinter, London Perry L 1997 Nutrition: a hard nut to crack. An exploration of the knowledge, attitudes and activities of qualified nurses in relation to nutritional nursing care. Journal of Clinical Nursing 6: 315–324 Pierson W 1998 Reflection and nursing education. Journal of Advanced Nursing 27: 165–170 Rawlinson D 1998 Audit of nutritional practice and knowledge. Professional Nurse 13(5): 291–294 Reed J, Procter S 1993 Nurse Education: A Reflective Approach. Arnold, London Rose MA, Frisby AJ, Hamlin MD, Jones SS 2000 Evaluation of the effectiveness of a web-based graduate epidemiology course. Computers in Nursing 18(4): 162–167 Rowntree D 1985 Developing Courses for Students, 2nd edn. Chapman, London Sultana N 1990 Nurses attitudes towards computerization in clinical practice. Journal of Advanced Nursing 15: 696–702 Tapsell L 1997 Client-centred practice: an interactional case study of dietary counselling. Health, Vol. 1(1). Sage, London. pp. 107–120 Thede LQ, Taft S, Coeling H 1994 Computer-assisted instruction: a learner’s viewpoint. Journal of Nursing Education 33(7): 299–305 Thomas B 2001 Diabetes mellitus. In: Thomas B (ed). Manual of Dietetic Practice, 3rd edn. Blackwell Science, Oxford, pp. 443–462 Thorpe M 1993 Evaluation Open and Distance Learning, 2nd edn. Longman, Essex UK Council of Deans and Heads of Nursing, Midwifery and Health Visiting 1998 Breaking the boundaries. UK CoD, Manchester Woodcock A, Kinmonth AL 2001 Patient concerns in their first year with Type 2 diabetes: patient and practice nurse views. Patient Education and Counselling 42(3): 257–270
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