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Effect of web-based education on nursing students' urinary catheterization knowledge and skills
Nurse Education Today 34 (2014) 802–808
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Effect of web-based education on nursing students' urinary catheterization knowledge and skills Deniz Öztürk a,⁎, Leyla Dinç b,1 a b
Gazi University, Faculty of Health Sciences, Nursing Department, Besevler, 06500 Ankara, Turkey Hacettepe University, Faculty of Nursing, 06100 Ankara, Turkey
a r t i c l e
i n f o
Article history: Accepted 8 August 2013
Keywords: Nursing education Web-based education Web-enhanced learning In-class instruction Fundamentals of nursing
s u m m a r y Background: Nursing is a practice-based discipline that requires the integration of theory and practice. Nurse educators must continuously revise educational curricula and incorporate information technology into the curriculum to provide students with the necessary knowledge and skills. Objectives: The aim of this study was to assess the effect of web-based education on students' urinary catheterization knowledge and skills. Design: A convenience sample of 111 first year nursing students enrolled at two universities in Ankara during the academic year of 2011–2012 participated in this quasi-experimental study. Method: The experimental group (n = 59) received a web-based and web-enhanced learning approach along with learning and practicing the required material twice as much as the control group, whereas the control group (n = 52) received traditional classroom instruction. A knowledge test of 20 multiple-choice questions and a skills checklist were used to assess student performance. Results: There was no difference between the experimental group and the control group in knowledge scores; however, students in the web-based group had higher scores for urinary catheterization skills. The highest scores in knowledge and skills were obtained by students who experienced web-based education as a supplement to tradition instruction. Conclusion: Web-based education had positive effects on the urinary catheterization skills of nursing students, and its positive effect increased for both knowledge and skills when it supplements classroom instruction. Based on these results, we suggest the use of web-based education as a supplement to traditional classroom instruction for nursing education © 2013 Elsevier Ltd. All rights reserved.
Introduction The past decade has seen rapid changes in science and technology and technological knowledge has kept pace. Education plays a pivotal role in preparing the individual to be an effective and constructive participant in knowledge society (Soran et al., 2006; Turgut, 2009). Thus, nursing curricula must continuously be revised and updated to prepare students who can be adaptive and productive using technology. However, nursing education faces a number of challenges, including inadequate infrastructure and resources, the shortage of qualified nurse educators, and a high student/faculty ratio, which limit the effectiveness of the teaching–learning process in the classroom (National Advisory Council on Nurse Education and Practice, 2010; McNett, 2012). These challenges are compounded by the realities and demands of clinical
⁎ Corresponding author. Tel.: +90 312 216 26 53; fax: +90 312 216 26 36. E-mail addresses: [email protected] (D. Öztürk), [email protected] (L. Dinç). 1 Tel.: +90 312 305 41 89; fax: +90 312 3127085. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.08.007
practice. Although clinical practice is an integral component of nursing education, the limited number of clinical sites for student placement, shortage of nursing faculty for clinical supervision, and nurses' reluctance to facilitate clinical learning of students due to staff shortages and heavy workload, are obstacles (McNett, 2012; Fitzgerald et al., 2012). For students, especially during their initial clinical practice, the lack of clinical experience, unfamiliar situations, fear of making mistakes, and negative attitudes of professional staff can result in stress and anxiety, which in turn affect their clinical learning (Sharif and Masoumi, 2005; Elcigil and Sarı, 2007; Moscaritolo, 2009). Consequently, the translation of basic knowledge into practice, particularly the development of psychomotor skills, remains a primary concern for nurse educators and students. A further concern is that involving real patients in the development of these skills might result in the invasion of patient privacy and dignity. Urinary catheterization is a basic nursing skill that cannot be practiced on real patients without some embarrassment or discomfort to the patient or students, even when performed by a nurse or doctor of the same gender as the patient. Yoo et al. (2010) argue that urinary
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catheterization is affected by culture and often stigmatized due to the necessity of handling sexual organs, which can limit the acquisition of knowledge and skills. In an integrative review of literature regarding urinary catheterization, Balduino et al. (2012) state, “the manipulation of the genitalia brings embarrassment, because it has the idea of invasion of privacy, something sexual and dirty” (p. 2250). Moreover, urinary catheterization is a complex and invasive procedure that poses serious risks to patients, including trauma to the urethra or bladder from incorrect insertion and introduction of microorganisms into the urinary system that can result in infection. Therefore, the procedure of urinary catheterization requires knowledge, strict adherence to aseptic technique, and technical skills. Hoseini et al. (2009) found a significant difference between professors' and graduated students' opinions about the frequency of performing skills of urinary catheterization. The authors concluded that urinary catheterization is often performed by interns or urology residents in educational wards due to possible complications, leaving little practice opportunities for nursing students. To provide safe clinical practice opportunities and reduce cultural and practical barriers, nurse educators must use skill laboratories and clinical simulations more effectively to enhance psychomotor skill development. In the meantime, nurse educators must view learning as an on-going process, not confined to classroom or skill laboratories. A lifelong learning approach should be adopted to encourage students to be educationally proactive. Computer-assisted instruction, elearning, or web-based learning supplements traditional didactic instruction and live clinical education and encourages students to assume responsibility for their own learning needs (Krautscheid and Burton, 2003; Karaağaçlı, 2008). The appropriate use of multimedia, such as self-instructional CD-ROMs and videos with visual representations of psychomotor skills, can enrich web-based/web-enhanced learning (Demir, 2000) and promote “meaningful learning” (Karppinen, 2005). Although there is a large amount literature on the effects of webbased education, few studies have investigated the effect of web-based learning on the psychomotor skills of nursing students. Cook et al. (2012) demonstrated a positive impact of a web-based interactive simulation game (PULSE) on nursing students' life-support skills. Salyers (2007) compared a web-enhanced lecture plus a three-hour lab session with a three-hour traditional lecture and demonstration for teaching nasopharyngeal suction, catheter insertion, and wet-to-dry dressing change, and found that the web-enhanced/demonstration group performed significantly better on the comprehensive cognitive final exam. A study by Lu et al. (2009) compared web-based with traditional classroom instruction with traditional classroom instruction for teaching intramuscular injection, and found that the web-based group had significantly higher knowledge and skill performance ratings. Results of these studies demonstrate the value of web-based education in teaching psychomotor skills to students; however, to date, no study has specifically investigated the effect of web-based education on the urinary catheterization skills of nursing students. To address the aforementioned challenges in nursing education, the potential contribution of web-based and web-enhanced learning to the knowledge and skills of nursing students should be explored in empirical studies. Background/Literature Web-based education is an individualized education system using computers (Manochehr, 2001). Web-enhanced learning is defined as the “supplement of web technologies to education activities in order to support the learning–teaching process in increasing the learning of students in a subject” (Uzunboylu, 2002). Web-based education and web-enhanced learning are usually used interchangeably. In fact, the two have some common characteristics, including incorporating all possibilities of computer-assisted education and synchronous or asynchronous lessons. Both in synchronous and asynchronous learning, the student and teacher are at different places; but synchronously conducted lessons take place in real time, whereas
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asynchronously learning takes place outside of real time. However, web-based education and web-enhanced learning are different in that the former can be used outside of traditional formal institutions, whereas the latter is used to supplement traditional classroom education. Another point of divergence is associated with the educator conducting the lesson: in web-based education, a group composed of different specialists may lead and regulate the learning–teaching process, while web-enhanced education is completely controlled by one instructor (Uzunboylu, 2002). The findings of several studies suggest positive effects of web-based education in the training of nursing students (Woo and Kimmick, 2000; Kearns et al., 2004; Dwyer and Searle, 2009; Cooke et al., 2010). For example, Woo and Kimmick (2000) found that students who took nursing lessons via the Internet were more satisfied with and enthusiastic about their lessons. Kearns et al. (2004) investigated the effect of web-based education and web-enhanced education on the achievement and satisfaction of second-year nursing students in the USA. The achievement scores of the students receiving web-based education were higher than those of students receiving traditional classroom education with web-enhanced supplements. However, there have been few studies focusing on the psychomotor skills of nursing students. Nursing is a practice-based discipline, and skilled and competent nurses are a requirement of quality health care. Therefore, developing the psychomotor skills of nursing students is important to the quality and safety of care. The aim of the present study was to evaluate the effect of three modes of education—web-based education, web-enhanced education, and traditional in-classroom education—on the urinary catheterization knowledge and skills of nursing students. The following hypotheses were tested in this study: H1. There are differences between web-based education and traditional in-classroom education in increasing urinary catheterization knowledge. H2. There are differences between web-based education and traditional in-classroom education in increasing urinary catheterization skills. H3. There are differences between web-based education and webenhanced education in increasing urinary catheterization knowledge. H4. There are differences between web-based education and webenhanced education in increasing urinary catheterization skills.
Methods Study Design and Sample A quasi-experimental design was used in this study. A convenience sample of 160 first-year nursing students was recruited from the health sciences areas of two universities. At the time of this study, students were enrolled in the Fundamentals of Nursing course during the spring semester of the academic year 2011–2012. Students who had easy access to computers and the Internet were assigned to the experimental group, while those who had limited access formed the control group. The experimental group received web-based and web-enhanced learning while the control group experienced traditional classroom learning. Five students who had continuous absenteeism and 18 students taking the course again due to failure were not included in the study. In addition, five students who had graduated from vocational health school and transferred vertically to higher education were excluded due to their previous urinary catheterization knowledge and skills. Twentyone students dropped out due to incomplete laboratory practice. Hence, the investigation was carried out with 111 students (59 students in the experimental group and 52 students in the control group). The rate of participation in the study was 69.4%.
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Ethical Considerations Written permission and approval were obtained from the Hacettepe University ethics committee and the Deans of Faculty of Health Sciences in both universities. Students who were participating in the study were informed about the aim and method of the study, and written informed consent was obtained. Instruments and Pilot Study In the present study, the data were collected using the urinary catheterization knowledge test and urinary catheterization skill checklist prepared by the researcher based on the relevant literature and consultations with experts. The instruments were developed after the preparation of teaching content regarding urinary catheterization. The goal of content preparation was to provide students with theoretical knowledge of urinary catheterization and enable them to perform urinary catheterization on a mannequin or patient accurately and safely. Specific learning objectives for students were (a) describe the anatomy and physiology associated with the performance of urinary catheterization, (b) describe the indications and contraindications for performing urinary catheterization, (c) identify the materials necessary for performing urinary catheterization, (d) perform the insertion procedure competently on a male and female mannequin, and (e) care for a patient with a urinary catheter. After preparing the teaching content, the researcher generated a pool of questions and a checklist of urinary catheterization procedures for the assessment of students' knowledge and skills. The pool of questions was modified by a panel of three experts with experience teaching the Fundamentals of Nursing. After review, questions were selected based on comprehensiveness and relevance and the final knowledge test consisted of 20 multiple-choice questions with four answer choices. The first six questions referred to anatomy–physiology of urinary system, the seventh question referred directly to the indications for indwelling urinary catheter, while the subsequent question related to the positioning of female patients during catheterization. Questions 9 and 10 referred to catheter type, length, and size for female patients, while the eleventh question related to aseptic cleaning of the genital area and urinary opening. Questions 12–14 referred to the insertion technique of a urinary catheter in a female, such as advancing it approximately from 7.5 to 10 cm and inflating the balloon of the catheter, while the last six questions were related to measures that should be taken for the care of patients with urinary catheters and the need to maintain a closed drainage system. Incorrect answers were scored “0” and correct answers were scored “1”; thus, the lowest possible score was zero and the highest 20. A pilot administration, conducted with 20 second-year nursing students, indicated no need for further revisions. The initial checklist of urinary catheterization procedure was modified to facilitate judgments on the proficiency of each student performing urinary catheterization on a mannequin. The same panel of three experts reviewed the list for content validity. Based on their suggestions, the number of items on the checklist was reduced from 51 to 26, and critical steps were highlighted. This checklist was also reviewed by a Measurement and Evaluation faculty member in the education department of the university for format and measurement properties. According to his recommendations, the steps of each observed procedure were arranged in one column, and numeric values were assigned to each of the steps to indicate the degree of achievement. Steps of performance were scored as 0 if the skill was not observed, 0.5 if incorrect, 1 if it was correct, or 2 if the skill was deemed as critical. Eight items of the urinary catheterization checklist, including positioning the female patient, sterile gloving, checking the balloon of indwelling catheter, applying lubricant to the catheter tip, aseptic cleaning of the genital area, inserting and advancing the catheter through meatus approximately from 7.5 to 10 cm, inflating the balloon of the catheter, and maintaining the closed drainage system
were deemed critical. Thus, the total possible score for the entire set of skill checklist ranged from 0 to 34. Video Recording and Web Design Process Our intention was to simulate the procedure of urinary catheterization as close to reality as possible because, with web-based education, where there is no actual face-to-face contact between the teacher and the students. The issue of copyright and cost of existing instructional video materials and lack of appropriate video specific to urinary catheterization procedure in Turkish language compelled us to produce our own video. The principal investigator performed urinary catheterization on a mannequin, which was recorded by a professional using a digital video recorder with a built in microphone. Important parts of catheterization, particularly the insertion of the catheter, were filmed in closeup and at a distance simultaneously using two separate cameras. The video data was transferred from the digital video recorder to the computer for editing and the edited version was reviewed by two nurse educators who had experience in teaching the Fundamentals of Nursing. Their comments and recommendations were acknowledged and amalgamated into the final product. Following the video material, the investigator purchased a web domain and a website was created with the help of a professional web designer. The web designer used MySQL database management system (MySQL, 2013). The intra-site algorithms, interfaces and dynamic page content of the website were generated using PHP (Hypertext PreProcessor) programming language because it was available at no cost with documentation in many languages. The teaching content regarding urinary catheterization, converted to PowerPoint slides, and accompanied by a summative text, static pictures, and pre-recorded video, was uploaded to the website; this formed the basis of web-based education procedures. A list of student IDs was imported to the database to authenticate students creating user accounts. The home page of the website included a welcome message, contact information, including a phone number and a “mailto:” feature at the bottom of the page, and a user account form. Students could access the online course after their ID and password were verified. The website included the online knowledge test and answers were recorded automatically. The last slide included a dialog box containing two radio buttons: a return to the online course and online knowledge test. However, entrance to the online test was closed until a preset date. The functionality, usability, and compatibility of the website with popular browsers were tested before being launched on the Internet. Implementation of the Study Implementation in the experiment group The students in the experiment group were informed in detail about the registration procedure and use of the website. The website was activated in March 2012 and kept open for two weeks. Students who wanted to enter the website had to register by typing their name or school number and a predetermined code number, which had been sent to them previously. After registering, they could enter the system by clicking the box next to “I agree to participate in the study” in the lower part of the registration page. They could access the course via Internet at any time within the two-week period. At the end of the two-week period the system was automatically and temporarily closed. Following the web-based education, the online test link of the website was activated and knowledge tests were administered online in a computerized classroom under the supervision of a researcher. Answers were recorded on the MySQL database automatically, graded on completion, and students were provided with immediate feedback. To assess the skills of the experimental group on urinary catheterization, students were divided into small groups and they practiced performing urinary catheterization on mannequins in the simulation laboratories of the nursing departments. Immediately after the
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laboratory practice, the urinary catheterization skill of each student was observed by two independent observers who had PhD degree in Fundamentals of Nursing simultaneously using the skills checklist. Implementation in the Control Group After the web-based education was completed, urinary catheterization was taught to both experimental and control group students by the researcher in the classroom using the methods of lecturing via PowerPoint presentations, question-and-answer sessions, discussions, and demonstration on a mannequin. The video was not used. Immediately after the lecture, a knowledge test was administered to all students. Then, all students, including both the experimental group and control group students, were divided into small groups and practiced the urinary catheterization procedure on mannequins in the simulation laboratory. Following the laboratory practice of all students, the skill performance of each student was observed and rated by two independent observers in the laboratory. Thus, the date of the in-classroom education control group and data of the web-enhanced education experimental group (web-based as a supplement to traditional classroom instruction) were collected (Flow chart 1). After the implementation of the study, the website was opened for the use of the students in the control group without any test or additional practice. Evaluation of Data Data regarding the knowledge assessment of the experimental group were stored in the database of the website in CSV (Comma Separated Values) format, which could be transferred to Excel format and
Experiment Group (n= 59)
Web-based education
805
imported to SPSS. Data obtained by using the checklists and paper and pencil format knowledge test was entered manually into SPSS (17.0) program (SPSS Inc., 2007) and analyzed using descriptive statistics. The mean scores of each student on knowledge test and skill performance were computed and used as a dependent variable, whereas “modes of instruction” (web-based education, web-enhanced learning and in class-instruction) were considered as independent variables. Since the data were not normally distributed, differences between the scores of the experimental and control groups were analyzed using the Mann–Whitney U test. Data of the experimental group regarding the web-based education and web-enhanced education were analyzed using the Wilcoxon signed rank test. Inter-rater reliability between observers was assessed using Cohen's kappa coefficient. A p value of 0.05 was set for statistical significance. Results The study sample (N = 111) consisted of two groups of students categorized by mode of instructional format: the experimental group experienced web-based education, and then in-classroom instruction (web-enhanced education) (n = 59) and control group experienced only in-class instruction (n = 52). Descriptive statistics revealed that the experimental group had slightly higher mean scores in knowledge (M = 15.0; SD = 2.4) than the control group (M = 14.1; SD = 3.2). However, the Mann–Whitney U test showed no significant difference between the experimental and control groups in knowledge scores (p = 0.153), indicating that H1 was rejected.
Control Group (n= 52)
Traditional, in-classroom
Knowledge test Web-based lecturing Skill observation in laboratory Web-based knowledge test
Skill observation in laboratory
Web-enhanced education
Evaluation of data, testing of hypotheses
Flow chart 1. Steps of the research.
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Table 1 Comparison of knowledge and skill scores between web-based education and in-class instruction. Variables Dependent variables Knowledge test
Skill performance
Scores
Independent variables Experimental group (web-based education) Control (in-class instruction) Total Experimental group (web-based education) Control (in-class instruction) Total
Mann Whitney U Test
n
Mean
Min
Max
SS
Mean rank
U
p
59 52 111 59 52 111
15.0 14.1 14.6 27.9 23.7 25.9
10 6 6 14 9 9
19 20 20 34 33.5 34
2.4 3.2 2.9 4.4 6.3 5.7
60.1 51.4
1294
0.153
66.9 43.6
888.5
0.000⁎
⁎ p b 0.05.
The mean score on skill performance of the experimental group was 27.9 (SD = 4.4), while the control group had a mean score of 23.7 (SD = 6.3). The Mann–Whitney U test revealed significant difference between the mean scores of two groups (p N .001.). Thus, the H2 was confirmed. Based on these results, we concluded that there was no difference between the web-based education and traditional in-classroom education groups in the knowledge of urinary catheterization; however, webbased education had positive effects on the urinary catheterization skills of students (Table 1). To identify differences in skill areas, we examined individual items of the skill checklist, particularly the eight critical items. Results indicated that students receiving web-based education obtained higher scores for some steps of the urinary catheterization procedure during performance observations. These steps were “assisting the patient to the dorsal recumbent position,” “checking and inflating the balloon of indwelling catheter,” “cleaning the genital area using aseptic technique,” and “maintaining a closed drainage system by attaching the end of catheter to the collecting tube of the drainage system.” In contrast, there was no significant difference between experimental and control group students' performance for some critical skills, including “donning sterile gloves using aseptic technique,” “applying lubricant to the catheter tip,” and “inserting the catheter through meatus and advancing it approximately 7.5 to 10 cm.” In addition to the analyses of differences between web-based education and in-class instruction, we assessed the effect of web-based education as a supplement to classroom instruction (web-enhanced education) on students' scores of knowledge and skills and compared it with the web-based education itself. As expected, the knowledge score of students after web-enhanced education increased from 15.0 to 17.3, while the score of skill performance increased from 27.9 to 30.9. The Wilcoxon signed rank test revealed significant differences between web-based education and web-enhanced education groups, indicating that students obtained the highest scores when web-based education was used as a supplement to traditional classroom instruction. Thus, hypotheses H3 and H4 were accepted (Table 2).
Table 2 Comparison of knowledge and skill scores between web-based education and the supplement of web-based education to in-classroom instruction. Dependent variables
Knowledge test (web-based education) Knowledge test (web-based education + class instruction) Skill performance (web-based education) Skill performance (web-based education + class instruction) ⁎ p b 0.05.
Scores
Wilcoxon sign test
n
Mean
Min
Max
SS
Z
p
59
15.0
10
19
2.4
−5.316
0.000⁎
59
17.3
13
20
1.8
59
27.9
14
34
4.4
−5.203
0.000⁎
59
30.9
23.5
34
2.3
To gain some understanding about the students' online learning activity, we tracked the number of logins on the website. Students accessed the course materials one to 12 times per week, with an average of six times. Nevertheless, no significant correlation was found between the number of logins to the website and the students' knowledge scores after web-based education (p N 0.05). However a moderately significant positive relation was found between the frequency of logins to the website and the mean score of skill performance after web-basededucation (r = 0.270) (p b 0.05).
Discussion The present study, which investigated the effect of web-based education in teaching urinary catheterization, was carried out among 111 first-year nursing students enrolled in Fundamentals of Nursing. In this present study, we found no significant difference between web-based education group and classroom instruction group in knowledge of urinary catheterization. This finding is contradictory to the literature, suggesting that web-based learning provides flexibility for students in time, place, and access to teaching content (Buckley, 2003; Wilkinson et al., 2004; Farrell et al., 2007) and enhances the learning capacity of students by enabling them to progress at their own speed (Koch et al., 2010). A possible explanation of our finding might be the limitations of interaction between teachers and students. Students in the web-based group had no opportunity to ask questions or discuss the teaching content, and they were unable to receive immediate feedback from the teacher, whereas those in the classroom instruction group had the opportunity for face-to-face interaction during the course. The results of this study support our hypothesis that web-based education is effective in increasing the skills of students in the experimental group. In addition, some critical steps of the urinary catheterization procedure were performed better by the students of the web-based group. Despite the fact that web-based learning includes a virtual learning environment for students rather than real life context for practicing the skills, the use of video and pictures, which could be viewed by students repeatedly without any limitations of time and place, might have influenced their performance positively. Our result is consistent with the results of other studies. For example, Beeckman et al. (2008) conducted a study to detect problems when classifying pressure ulcers and to examine whether an e-learning program was able to increase the skills of qualified nurses and nursing students. They found that nursing students achieved better results when using the e-learning program. As stated in the introduction, Lu et al. (2009) assessed the effectiveness of supplementing conventional classroom teaching with web-based learning when teaching intramuscular injection nursing skills. They reported that participants achieved higher skill performance scores with web-based learning compared to conventional learning methods. In contrast, Bloomfield et al. (2010) investigated the effect of computerassisted learning versus conventional teaching methods on the acquisition and retention of hand washing theory and skills in pre-qualification nursing students. Their mode of instruction for the experimental group
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included computer-assisted instruction instead of web-based education, and they found no significant differences between the groups. Results of this study indicated that the use of a web-based education as a supplement to traditional classroom education (web-enhanced education) increased both the knowledge and skill performance scores of students on urinary catheterization. The highest scores of knowledge and skill performance were obtained for the web-enhanced group. This result suggests that student learning is boosted when students are incorporated interactively in the process through multiple learning methods, and this approach is used to support face-to-face classroom education. Consistent with our result, Salyers (2007) compared a webenhanced lecture plus a three-hour lab session with a three-hour traditional lecture and demonstration of some basic nursing skills and reported positive effects of the web-enhanced demonstration group. Gerdprasert et al. (2010) used the web-based learning unit to supplement traditional conventional lectures and assessed students' achievements by using the pre- and post-test scores on factual knowledge and semi-structured interviews. The group receiving supplementation with web-based materials had significantly higher scores than the traditional lecture group. The study by Cooke et al. (2010) suggested that students participating in a web-enhanced classroom environment were able to study lessons at their own pace and repeat the content of lessons whenever they wanted. The American Association of Colleges of Nursing (2005) also reported that supplementing classroom education with web technologies is an effective method of increasing student achievement. However, our finding conflicts with some other studies, which found no significant difference between the learning outcomes of the web-enhanced group and traditional classroom education group (Dwyer and Searle, 2009), or higher scores of students in the web-based group when compared to the web-enhanced group (Kearns et al., 2004). Limitations of the Study Several limitations of this study must be acknowledged. First, the study was based on a nonprobability convenience sample, which increases the risk of bias. However, the sample was consistent with educational level of the students (all were first year nursing students) and curriculum of the schools. Second, our results regarding the significantly higher scores of the students in the web-enhanced group should be interpreted with caution because the experimental group had easy access to computers, and internet and two opportunities to take the knowledge test and perform the skills. Third, the use of video in the web-based group might have positively influenced the scores and performances of students. Fourth, during the observations of student skills, inter-observer consistency was at a moderate level in some steps. Repeated observational measures within a short time interval (15 min per student) were tiring for observers, and they had to complete all observations within a few days. Such a tiring and long-lasting process of observation might have decreased the vigilance of observers and influenced inter-rater reliability. Finally, due to concerns of safety and privacy, we used a female mannequin for demonstration during lectures and observation of students' skill performances. Conclusion Together with the challenges of rapid changes in science and technology and difficulties faced by nurse educators in imparting the appropriated knowledge and skills required for the integration of theory and practice, there is a growing trend of incorporating information technology into the nursing education curriculum. Computerassisted instruction, web-based education, web-enhanced education, and distance education have the potential to contribute to the effectiveness and quality of nursing education. The results of this study indicated that web-based education has positive effects in increasing the urinary catheterization skills of nursing students; however, supplementing
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traditional classroom teaching with web-based learning enhanced both knowledge and skill performances of nursing students. Based on these results, we recommend the integration of web-based education into traditional teaching methods. However, more studies are needed to provide additional evidence regarding the effects of web-based curriculum on students' academic and skill performance and the advantages and disadvantages for nursing education. References American Association of Colleges Of Nursing, 2005. Faculty shortages in baccalaureate and graduate nursing programs: scope of the problem and strategies for expanding the supply. Retrieved December 26, 2012, from http://www.aacn.nche.edu/publications/whitepapers/facultyshortage.pdf. Balduino, L.S.C., de Vasconcelos Torres, G., de Oliveira e Araújo, R., de Almeida Quithé de Vasconcelos, O.L.D., Germano, R.M., de Menezes, R.M.P., 2012. 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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Effect of web-based education on nursing students' urinary catheterization knowledge and skills Deniz Öztürk a,⁎, Leyla Dinç b,1 a b
Gazi University, Faculty of Health Sciences, Nursing Department, Besevler, 06500 Ankara, Turkey Hacettepe University, Faculty of Nursing, 06100 Ankara, Turkey
a r t i c l e
i n f o
Article history: Accepted 8 August 2013
Keywords: Nursing education Web-based education Web-enhanced learning In-class instruction Fundamentals of nursing
s u m m a r y Background: Nursing is a practice-based discipline that requires the integration of theory and practice. Nurse educators must continuously revise educational curricula and incorporate information technology into the curriculum to provide students with the necessary knowledge and skills. Objectives: The aim of this study was to assess the effect of web-based education on students' urinary catheterization knowledge and skills. Design: A convenience sample of 111 first year nursing students enrolled at two universities in Ankara during the academic year of 2011–2012 participated in this quasi-experimental study. Method: The experimental group (n = 59) received a web-based and web-enhanced learning approach along with learning and practicing the required material twice as much as the control group, whereas the control group (n = 52) received traditional classroom instruction. A knowledge test of 20 multiple-choice questions and a skills checklist were used to assess student performance. Results: There was no difference between the experimental group and the control group in knowledge scores; however, students in the web-based group had higher scores for urinary catheterization skills. The highest scores in knowledge and skills were obtained by students who experienced web-based education as a supplement to tradition instruction. Conclusion: Web-based education had positive effects on the urinary catheterization skills of nursing students, and its positive effect increased for both knowledge and skills when it supplements classroom instruction. Based on these results, we suggest the use of web-based education as a supplement to traditional classroom instruction for nursing education © 2013 Elsevier Ltd. All rights reserved.
Introduction The past decade has seen rapid changes in science and technology and technological knowledge has kept pace. Education plays a pivotal role in preparing the individual to be an effective and constructive participant in knowledge society (Soran et al., 2006; Turgut, 2009). Thus, nursing curricula must continuously be revised and updated to prepare students who can be adaptive and productive using technology. However, nursing education faces a number of challenges, including inadequate infrastructure and resources, the shortage of qualified nurse educators, and a high student/faculty ratio, which limit the effectiveness of the teaching–learning process in the classroom (National Advisory Council on Nurse Education and Practice, 2010; McNett, 2012). These challenges are compounded by the realities and demands of clinical
⁎ Corresponding author. Tel.: +90 312 216 26 53; fax: +90 312 216 26 36. E-mail addresses: [email protected] (D. Öztürk), [email protected] (L. Dinç). 1 Tel.: +90 312 305 41 89; fax: +90 312 3127085. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.08.007
practice. Although clinical practice is an integral component of nursing education, the limited number of clinical sites for student placement, shortage of nursing faculty for clinical supervision, and nurses' reluctance to facilitate clinical learning of students due to staff shortages and heavy workload, are obstacles (McNett, 2012; Fitzgerald et al., 2012). For students, especially during their initial clinical practice, the lack of clinical experience, unfamiliar situations, fear of making mistakes, and negative attitudes of professional staff can result in stress and anxiety, which in turn affect their clinical learning (Sharif and Masoumi, 2005; Elcigil and Sarı, 2007; Moscaritolo, 2009). Consequently, the translation of basic knowledge into practice, particularly the development of psychomotor skills, remains a primary concern for nurse educators and students. A further concern is that involving real patients in the development of these skills might result in the invasion of patient privacy and dignity. Urinary catheterization is a basic nursing skill that cannot be practiced on real patients without some embarrassment or discomfort to the patient or students, even when performed by a nurse or doctor of the same gender as the patient. Yoo et al. (2010) argue that urinary
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catheterization is affected by culture and often stigmatized due to the necessity of handling sexual organs, which can limit the acquisition of knowledge and skills. In an integrative review of literature regarding urinary catheterization, Balduino et al. (2012) state, “the manipulation of the genitalia brings embarrassment, because it has the idea of invasion of privacy, something sexual and dirty” (p. 2250). Moreover, urinary catheterization is a complex and invasive procedure that poses serious risks to patients, including trauma to the urethra or bladder from incorrect insertion and introduction of microorganisms into the urinary system that can result in infection. Therefore, the procedure of urinary catheterization requires knowledge, strict adherence to aseptic technique, and technical skills. Hoseini et al. (2009) found a significant difference between professors' and graduated students' opinions about the frequency of performing skills of urinary catheterization. The authors concluded that urinary catheterization is often performed by interns or urology residents in educational wards due to possible complications, leaving little practice opportunities for nursing students. To provide safe clinical practice opportunities and reduce cultural and practical barriers, nurse educators must use skill laboratories and clinical simulations more effectively to enhance psychomotor skill development. In the meantime, nurse educators must view learning as an on-going process, not confined to classroom or skill laboratories. A lifelong learning approach should be adopted to encourage students to be educationally proactive. Computer-assisted instruction, elearning, or web-based learning supplements traditional didactic instruction and live clinical education and encourages students to assume responsibility for their own learning needs (Krautscheid and Burton, 2003; Karaağaçlı, 2008). The appropriate use of multimedia, such as self-instructional CD-ROMs and videos with visual representations of psychomotor skills, can enrich web-based/web-enhanced learning (Demir, 2000) and promote “meaningful learning” (Karppinen, 2005). Although there is a large amount literature on the effects of webbased education, few studies have investigated the effect of web-based learning on the psychomotor skills of nursing students. Cook et al. (2012) demonstrated a positive impact of a web-based interactive simulation game (PULSE) on nursing students' life-support skills. Salyers (2007) compared a web-enhanced lecture plus a three-hour lab session with a three-hour traditional lecture and demonstration for teaching nasopharyngeal suction, catheter insertion, and wet-to-dry dressing change, and found that the web-enhanced/demonstration group performed significantly better on the comprehensive cognitive final exam. A study by Lu et al. (2009) compared web-based with traditional classroom instruction with traditional classroom instruction for teaching intramuscular injection, and found that the web-based group had significantly higher knowledge and skill performance ratings. Results of these studies demonstrate the value of web-based education in teaching psychomotor skills to students; however, to date, no study has specifically investigated the effect of web-based education on the urinary catheterization skills of nursing students. To address the aforementioned challenges in nursing education, the potential contribution of web-based and web-enhanced learning to the knowledge and skills of nursing students should be explored in empirical studies. Background/Literature Web-based education is an individualized education system using computers (Manochehr, 2001). Web-enhanced learning is defined as the “supplement of web technologies to education activities in order to support the learning–teaching process in increasing the learning of students in a subject” (Uzunboylu, 2002). Web-based education and web-enhanced learning are usually used interchangeably. In fact, the two have some common characteristics, including incorporating all possibilities of computer-assisted education and synchronous or asynchronous lessons. Both in synchronous and asynchronous learning, the student and teacher are at different places; but synchronously conducted lessons take place in real time, whereas
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asynchronously learning takes place outside of real time. However, web-based education and web-enhanced learning are different in that the former can be used outside of traditional formal institutions, whereas the latter is used to supplement traditional classroom education. Another point of divergence is associated with the educator conducting the lesson: in web-based education, a group composed of different specialists may lead and regulate the learning–teaching process, while web-enhanced education is completely controlled by one instructor (Uzunboylu, 2002). The findings of several studies suggest positive effects of web-based education in the training of nursing students (Woo and Kimmick, 2000; Kearns et al., 2004; Dwyer and Searle, 2009; Cooke et al., 2010). For example, Woo and Kimmick (2000) found that students who took nursing lessons via the Internet were more satisfied with and enthusiastic about their lessons. Kearns et al. (2004) investigated the effect of web-based education and web-enhanced education on the achievement and satisfaction of second-year nursing students in the USA. The achievement scores of the students receiving web-based education were higher than those of students receiving traditional classroom education with web-enhanced supplements. However, there have been few studies focusing on the psychomotor skills of nursing students. Nursing is a practice-based discipline, and skilled and competent nurses are a requirement of quality health care. Therefore, developing the psychomotor skills of nursing students is important to the quality and safety of care. The aim of the present study was to evaluate the effect of three modes of education—web-based education, web-enhanced education, and traditional in-classroom education—on the urinary catheterization knowledge and skills of nursing students. The following hypotheses were tested in this study: H1. There are differences between web-based education and traditional in-classroom education in increasing urinary catheterization knowledge. H2. There are differences between web-based education and traditional in-classroom education in increasing urinary catheterization skills. H3. There are differences between web-based education and webenhanced education in increasing urinary catheterization knowledge. H4. There are differences between web-based education and webenhanced education in increasing urinary catheterization skills.
Methods Study Design and Sample A quasi-experimental design was used in this study. A convenience sample of 160 first-year nursing students was recruited from the health sciences areas of two universities. At the time of this study, students were enrolled in the Fundamentals of Nursing course during the spring semester of the academic year 2011–2012. Students who had easy access to computers and the Internet were assigned to the experimental group, while those who had limited access formed the control group. The experimental group received web-based and web-enhanced learning while the control group experienced traditional classroom learning. Five students who had continuous absenteeism and 18 students taking the course again due to failure were not included in the study. In addition, five students who had graduated from vocational health school and transferred vertically to higher education were excluded due to their previous urinary catheterization knowledge and skills. Twentyone students dropped out due to incomplete laboratory practice. Hence, the investigation was carried out with 111 students (59 students in the experimental group and 52 students in the control group). The rate of participation in the study was 69.4%.
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Ethical Considerations Written permission and approval were obtained from the Hacettepe University ethics committee and the Deans of Faculty of Health Sciences in both universities. Students who were participating in the study were informed about the aim and method of the study, and written informed consent was obtained. Instruments and Pilot Study In the present study, the data were collected using the urinary catheterization knowledge test and urinary catheterization skill checklist prepared by the researcher based on the relevant literature and consultations with experts. The instruments were developed after the preparation of teaching content regarding urinary catheterization. The goal of content preparation was to provide students with theoretical knowledge of urinary catheterization and enable them to perform urinary catheterization on a mannequin or patient accurately and safely. Specific learning objectives for students were (a) describe the anatomy and physiology associated with the performance of urinary catheterization, (b) describe the indications and contraindications for performing urinary catheterization, (c) identify the materials necessary for performing urinary catheterization, (d) perform the insertion procedure competently on a male and female mannequin, and (e) care for a patient with a urinary catheter. After preparing the teaching content, the researcher generated a pool of questions and a checklist of urinary catheterization procedures for the assessment of students' knowledge and skills. The pool of questions was modified by a panel of three experts with experience teaching the Fundamentals of Nursing. After review, questions were selected based on comprehensiveness and relevance and the final knowledge test consisted of 20 multiple-choice questions with four answer choices. The first six questions referred to anatomy–physiology of urinary system, the seventh question referred directly to the indications for indwelling urinary catheter, while the subsequent question related to the positioning of female patients during catheterization. Questions 9 and 10 referred to catheter type, length, and size for female patients, while the eleventh question related to aseptic cleaning of the genital area and urinary opening. Questions 12–14 referred to the insertion technique of a urinary catheter in a female, such as advancing it approximately from 7.5 to 10 cm and inflating the balloon of the catheter, while the last six questions were related to measures that should be taken for the care of patients with urinary catheters and the need to maintain a closed drainage system. Incorrect answers were scored “0” and correct answers were scored “1”; thus, the lowest possible score was zero and the highest 20. A pilot administration, conducted with 20 second-year nursing students, indicated no need for further revisions. The initial checklist of urinary catheterization procedure was modified to facilitate judgments on the proficiency of each student performing urinary catheterization on a mannequin. The same panel of three experts reviewed the list for content validity. Based on their suggestions, the number of items on the checklist was reduced from 51 to 26, and critical steps were highlighted. This checklist was also reviewed by a Measurement and Evaluation faculty member in the education department of the university for format and measurement properties. According to his recommendations, the steps of each observed procedure were arranged in one column, and numeric values were assigned to each of the steps to indicate the degree of achievement. Steps of performance were scored as 0 if the skill was not observed, 0.5 if incorrect, 1 if it was correct, or 2 if the skill was deemed as critical. Eight items of the urinary catheterization checklist, including positioning the female patient, sterile gloving, checking the balloon of indwelling catheter, applying lubricant to the catheter tip, aseptic cleaning of the genital area, inserting and advancing the catheter through meatus approximately from 7.5 to 10 cm, inflating the balloon of the catheter, and maintaining the closed drainage system
were deemed critical. Thus, the total possible score for the entire set of skill checklist ranged from 0 to 34. Video Recording and Web Design Process Our intention was to simulate the procedure of urinary catheterization as close to reality as possible because, with web-based education, where there is no actual face-to-face contact between the teacher and the students. The issue of copyright and cost of existing instructional video materials and lack of appropriate video specific to urinary catheterization procedure in Turkish language compelled us to produce our own video. The principal investigator performed urinary catheterization on a mannequin, which was recorded by a professional using a digital video recorder with a built in microphone. Important parts of catheterization, particularly the insertion of the catheter, were filmed in closeup and at a distance simultaneously using two separate cameras. The video data was transferred from the digital video recorder to the computer for editing and the edited version was reviewed by two nurse educators who had experience in teaching the Fundamentals of Nursing. Their comments and recommendations were acknowledged and amalgamated into the final product. Following the video material, the investigator purchased a web domain and a website was created with the help of a professional web designer. The web designer used MySQL database management system (MySQL, 2013). The intra-site algorithms, interfaces and dynamic page content of the website were generated using PHP (Hypertext PreProcessor) programming language because it was available at no cost with documentation in many languages. The teaching content regarding urinary catheterization, converted to PowerPoint slides, and accompanied by a summative text, static pictures, and pre-recorded video, was uploaded to the website; this formed the basis of web-based education procedures. A list of student IDs was imported to the database to authenticate students creating user accounts. The home page of the website included a welcome message, contact information, including a phone number and a “mailto:” feature at the bottom of the page, and a user account form. Students could access the online course after their ID and password were verified. The website included the online knowledge test and answers were recorded automatically. The last slide included a dialog box containing two radio buttons: a return to the online course and online knowledge test. However, entrance to the online test was closed until a preset date. The functionality, usability, and compatibility of the website with popular browsers were tested before being launched on the Internet. Implementation of the Study Implementation in the experiment group The students in the experiment group were informed in detail about the registration procedure and use of the website. The website was activated in March 2012 and kept open for two weeks. Students who wanted to enter the website had to register by typing their name or school number and a predetermined code number, which had been sent to them previously. After registering, they could enter the system by clicking the box next to “I agree to participate in the study” in the lower part of the registration page. They could access the course via Internet at any time within the two-week period. At the end of the two-week period the system was automatically and temporarily closed. Following the web-based education, the online test link of the website was activated and knowledge tests were administered online in a computerized classroom under the supervision of a researcher. Answers were recorded on the MySQL database automatically, graded on completion, and students were provided with immediate feedback. To assess the skills of the experimental group on urinary catheterization, students were divided into small groups and they practiced performing urinary catheterization on mannequins in the simulation laboratories of the nursing departments. Immediately after the
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laboratory practice, the urinary catheterization skill of each student was observed by two independent observers who had PhD degree in Fundamentals of Nursing simultaneously using the skills checklist. Implementation in the Control Group After the web-based education was completed, urinary catheterization was taught to both experimental and control group students by the researcher in the classroom using the methods of lecturing via PowerPoint presentations, question-and-answer sessions, discussions, and demonstration on a mannequin. The video was not used. Immediately after the lecture, a knowledge test was administered to all students. Then, all students, including both the experimental group and control group students, were divided into small groups and practiced the urinary catheterization procedure on mannequins in the simulation laboratory. Following the laboratory practice of all students, the skill performance of each student was observed and rated by two independent observers in the laboratory. Thus, the date of the in-classroom education control group and data of the web-enhanced education experimental group (web-based as a supplement to traditional classroom instruction) were collected (Flow chart 1). After the implementation of the study, the website was opened for the use of the students in the control group without any test or additional practice. Evaluation of Data Data regarding the knowledge assessment of the experimental group were stored in the database of the website in CSV (Comma Separated Values) format, which could be transferred to Excel format and
Experiment Group (n= 59)
Web-based education
805
imported to SPSS. Data obtained by using the checklists and paper and pencil format knowledge test was entered manually into SPSS (17.0) program (SPSS Inc., 2007) and analyzed using descriptive statistics. The mean scores of each student on knowledge test and skill performance were computed and used as a dependent variable, whereas “modes of instruction” (web-based education, web-enhanced learning and in class-instruction) were considered as independent variables. Since the data were not normally distributed, differences between the scores of the experimental and control groups were analyzed using the Mann–Whitney U test. Data of the experimental group regarding the web-based education and web-enhanced education were analyzed using the Wilcoxon signed rank test. Inter-rater reliability between observers was assessed using Cohen's kappa coefficient. A p value of 0.05 was set for statistical significance. Results The study sample (N = 111) consisted of two groups of students categorized by mode of instructional format: the experimental group experienced web-based education, and then in-classroom instruction (web-enhanced education) (n = 59) and control group experienced only in-class instruction (n = 52). Descriptive statistics revealed that the experimental group had slightly higher mean scores in knowledge (M = 15.0; SD = 2.4) than the control group (M = 14.1; SD = 3.2). However, the Mann–Whitney U test showed no significant difference between the experimental and control groups in knowledge scores (p = 0.153), indicating that H1 was rejected.
Control Group (n= 52)
Traditional, in-classroom
Knowledge test Web-based lecturing Skill observation in laboratory Web-based knowledge test
Skill observation in laboratory
Web-enhanced education
Evaluation of data, testing of hypotheses
Flow chart 1. Steps of the research.
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Table 1 Comparison of knowledge and skill scores between web-based education and in-class instruction. Variables Dependent variables Knowledge test
Skill performance
Scores
Independent variables Experimental group (web-based education) Control (in-class instruction) Total Experimental group (web-based education) Control (in-class instruction) Total
Mann Whitney U Test
n
Mean
Min
Max
SS
Mean rank
U
p
59 52 111 59 52 111
15.0 14.1 14.6 27.9 23.7 25.9
10 6 6 14 9 9
19 20 20 34 33.5 34
2.4 3.2 2.9 4.4 6.3 5.7
60.1 51.4
1294
0.153
66.9 43.6
888.5
0.000⁎
⁎ p b 0.05.
The mean score on skill performance of the experimental group was 27.9 (SD = 4.4), while the control group had a mean score of 23.7 (SD = 6.3). The Mann–Whitney U test revealed significant difference between the mean scores of two groups (p N .001.). Thus, the H2 was confirmed. Based on these results, we concluded that there was no difference between the web-based education and traditional in-classroom education groups in the knowledge of urinary catheterization; however, webbased education had positive effects on the urinary catheterization skills of students (Table 1). To identify differences in skill areas, we examined individual items of the skill checklist, particularly the eight critical items. Results indicated that students receiving web-based education obtained higher scores for some steps of the urinary catheterization procedure during performance observations. These steps were “assisting the patient to the dorsal recumbent position,” “checking and inflating the balloon of indwelling catheter,” “cleaning the genital area using aseptic technique,” and “maintaining a closed drainage system by attaching the end of catheter to the collecting tube of the drainage system.” In contrast, there was no significant difference between experimental and control group students' performance for some critical skills, including “donning sterile gloves using aseptic technique,” “applying lubricant to the catheter tip,” and “inserting the catheter through meatus and advancing it approximately 7.5 to 10 cm.” In addition to the analyses of differences between web-based education and in-class instruction, we assessed the effect of web-based education as a supplement to classroom instruction (web-enhanced education) on students' scores of knowledge and skills and compared it with the web-based education itself. As expected, the knowledge score of students after web-enhanced education increased from 15.0 to 17.3, while the score of skill performance increased from 27.9 to 30.9. The Wilcoxon signed rank test revealed significant differences between web-based education and web-enhanced education groups, indicating that students obtained the highest scores when web-based education was used as a supplement to traditional classroom instruction. Thus, hypotheses H3 and H4 were accepted (Table 2).
Table 2 Comparison of knowledge and skill scores between web-based education and the supplement of web-based education to in-classroom instruction. Dependent variables
Knowledge test (web-based education) Knowledge test (web-based education + class instruction) Skill performance (web-based education) Skill performance (web-based education + class instruction) ⁎ p b 0.05.
Scores
Wilcoxon sign test
n
Mean
Min
Max
SS
Z
p
59
15.0
10
19
2.4
−5.316
0.000⁎
59
17.3
13
20
1.8
59
27.9
14
34
4.4
−5.203
0.000⁎
59
30.9
23.5
34
2.3
To gain some understanding about the students' online learning activity, we tracked the number of logins on the website. Students accessed the course materials one to 12 times per week, with an average of six times. Nevertheless, no significant correlation was found between the number of logins to the website and the students' knowledge scores after web-based education (p N 0.05). However a moderately significant positive relation was found between the frequency of logins to the website and the mean score of skill performance after web-basededucation (r = 0.270) (p b 0.05).
Discussion The present study, which investigated the effect of web-based education in teaching urinary catheterization, was carried out among 111 first-year nursing students enrolled in Fundamentals of Nursing. In this present study, we found no significant difference between web-based education group and classroom instruction group in knowledge of urinary catheterization. This finding is contradictory to the literature, suggesting that web-based learning provides flexibility for students in time, place, and access to teaching content (Buckley, 2003; Wilkinson et al., 2004; Farrell et al., 2007) and enhances the learning capacity of students by enabling them to progress at their own speed (Koch et al., 2010). A possible explanation of our finding might be the limitations of interaction between teachers and students. Students in the web-based group had no opportunity to ask questions or discuss the teaching content, and they were unable to receive immediate feedback from the teacher, whereas those in the classroom instruction group had the opportunity for face-to-face interaction during the course. The results of this study support our hypothesis that web-based education is effective in increasing the skills of students in the experimental group. In addition, some critical steps of the urinary catheterization procedure were performed better by the students of the web-based group. Despite the fact that web-based learning includes a virtual learning environment for students rather than real life context for practicing the skills, the use of video and pictures, which could be viewed by students repeatedly without any limitations of time and place, might have influenced their performance positively. Our result is consistent with the results of other studies. For example, Beeckman et al. (2008) conducted a study to detect problems when classifying pressure ulcers and to examine whether an e-learning program was able to increase the skills of qualified nurses and nursing students. They found that nursing students achieved better results when using the e-learning program. As stated in the introduction, Lu et al. (2009) assessed the effectiveness of supplementing conventional classroom teaching with web-based learning when teaching intramuscular injection nursing skills. They reported that participants achieved higher skill performance scores with web-based learning compared to conventional learning methods. In contrast, Bloomfield et al. (2010) investigated the effect of computerassisted learning versus conventional teaching methods on the acquisition and retention of hand washing theory and skills in pre-qualification nursing students. Their mode of instruction for the experimental group
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included computer-assisted instruction instead of web-based education, and they found no significant differences between the groups. Results of this study indicated that the use of a web-based education as a supplement to traditional classroom education (web-enhanced education) increased both the knowledge and skill performance scores of students on urinary catheterization. The highest scores of knowledge and skill performance were obtained for the web-enhanced group. This result suggests that student learning is boosted when students are incorporated interactively in the process through multiple learning methods, and this approach is used to support face-to-face classroom education. Consistent with our result, Salyers (2007) compared a webenhanced lecture plus a three-hour lab session with a three-hour traditional lecture and demonstration of some basic nursing skills and reported positive effects of the web-enhanced demonstration group. Gerdprasert et al. (2010) used the web-based learning unit to supplement traditional conventional lectures and assessed students' achievements by using the pre- and post-test scores on factual knowledge and semi-structured interviews. The group receiving supplementation with web-based materials had significantly higher scores than the traditional lecture group. The study by Cooke et al. (2010) suggested that students participating in a web-enhanced classroom environment were able to study lessons at their own pace and repeat the content of lessons whenever they wanted. The American Association of Colleges of Nursing (2005) also reported that supplementing classroom education with web technologies is an effective method of increasing student achievement. However, our finding conflicts with some other studies, which found no significant difference between the learning outcomes of the web-enhanced group and traditional classroom education group (Dwyer and Searle, 2009), or higher scores of students in the web-based group when compared to the web-enhanced group (Kearns et al., 2004). Limitations of the Study Several limitations of this study must be acknowledged. First, the study was based on a nonprobability convenience sample, which increases the risk of bias. However, the sample was consistent with educational level of the students (all were first year nursing students) and curriculum of the schools. Second, our results regarding the significantly higher scores of the students in the web-enhanced group should be interpreted with caution because the experimental group had easy access to computers, and internet and two opportunities to take the knowledge test and perform the skills. Third, the use of video in the web-based group might have positively influenced the scores and performances of students. Fourth, during the observations of student skills, inter-observer consistency was at a moderate level in some steps. Repeated observational measures within a short time interval (15 min per student) were tiring for observers, and they had to complete all observations within a few days. Such a tiring and long-lasting process of observation might have decreased the vigilance of observers and influenced inter-rater reliability. Finally, due to concerns of safety and privacy, we used a female mannequin for demonstration during lectures and observation of students' skill performances. Conclusion Together with the challenges of rapid changes in science and technology and difficulties faced by nurse educators in imparting the appropriated knowledge and skills required for the integration of theory and practice, there is a growing trend of incorporating information technology into the nursing education curriculum. Computerassisted instruction, web-based education, web-enhanced education, and distance education have the potential to contribute to the effectiveness and quality of nursing education. The results of this study indicated that web-based education has positive effects in increasing the urinary catheterization skills of nursing students; however, supplementing
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