Web-based education and computer-assisted instruction have become common teaching and learning strategies in the nursing curriculum. The World Health Organization recommends the use of e-learning and simulation methods in nursing education.1 Web-based education is an e-learning method, a type of distance learning in which training or educational material is delivered electronically to a remote learner via the Internet or intranet.2 Web-based education abolishes the distance factor of a campus-based learning environment so that students can obtain information whenever they choose and may retrieve information repeatedly in many forms of Web-based education. Web-based education allows students to openly communicate with others, participate in self-paced learning, take responsibility for their own learning, and manage their time on their own.3 Moreover, the cost of distance or online Web-based education is lower than other methods.4-7 The advantages of this method have increased its use in education.8-13
LITERATURE REVIEW
Web-based education is sometimes also called online learning or e-learning. Because of its advantages, it has become an important alternative to classroom education.2 Researchers have examined the effects of this educational method on knowledge and skill in numerous studies, with differing results.9-11 One quasi-experimental study assessing the efficacy of an e-learning (Web-based) cardiac disease program among second-year nursing students found that the overall cardiovascular knowledge scores of the students were lower than, and central venous pressure and electrocardiogram skill scores were similar to, those of students in traditional classroom lectures.9 No significant difference was found in the pediatric medication management knowledge scores of undergraduate nursing students in a historical comparison study assessing the efficacy of e-learning education methods in pediatric medication administration safety.10 An experimental study examining the effects of e-learning methods on nursing students in acquiring intravenous therapy and drug administration skills found that the total scores of students receiving e-learning education on the intravenous therapy and drug administration skill checklist were significantly higher.11 No significant difference was found in a systematic review between the knowledge, skills, and satisfaction of nursing students through e-learning and traditional learning methods.12 Despite the results of these studies, there have been no studies evaluating the knowledge, skills, clinical practice performance, or clinical decision-making skills of nursing students trained using Web-based education. Another systematic review found Web-based e-learning to be as efficient as traditional education methods.13 According to the results of this systematic review, there is a lack of systematically conducted randomized controlled trial studies comparing the effects of e-learning and traditional learning methods in nursing education.12,13 Well-designed randomized controlled trials showing the effect of educational methods on knowledge, skill, clinical practice, and decision making are needed.
Preoperative and postoperative patient care management is the primary subject of surgical nursing. The goal of preoperative care management is to define risk factors that might lead to postoperative complications for the patient. Nurses should be alert for signs of complications. Postoperative care management focuses on reestablishing the patient's physiological equilibrium and preventing complications. Nurses make a careful assessment and provide interventions to assist the patient in returning to optimal functioning.14 It is a complex and complicated process for nursing students, who have difficulty in preoperative and postoperative patient care management and in combining knowledge, skills, and attitudes in patient care in clinical settings. Equally important in this educational challenge is the insufficient number of instructors combined with an increasing number of students in Turkey. In addition, there is a lack of studies examining the effects of Web-based education on the clinical learning results of undergraduate nursing students. The purpose of this study was to evaluate the effect of Web-based preoperative and postoperative patient care education on the knowledge, skills, decision making, and clinical performance of undergraduate nursing students.
The following hypotheses were tested in this study:
H1. There is a significant difference between the knowledge scores of students receiving Web-based education and those who received traditional education.
H2. There is a significant difference between the skill scores of students receiving Web-based education and those who received traditional education.
H3. There is a significant difference between the clinical practice scores of students receiving Web-based education and those who received traditional education.
H4. There is a significant difference between the clinical decision-making scores of students receiving Web-based education and those who received traditional education.
METHODS
Design
This was an experimental, randomized, controlled, double-blind study. Randomization of participants was ensured using Research Randomizer (Social Psychology Network, Wesleyan University, Middletown, CT).15 One of the researchers created a randomization list of participants before the study began. The total number of participants was entered into Research Randomizer, and the program automatically created the experimental and control groups.
The experimental group received Web-based preoperative and postoperative patient care education, while the control group received traditional education using PowerPoint presentations (Microsoft, Redmond, WA), case discussions, and question-and-answer sessions.
Participants
The research was conducted between February and May 2017 in a nursing program that applies an integrated curriculum program in Western Turkey. The study sample comprised sophomore students (N = 314) taking a surgical nursing course in the 2016-2017 academic year and included students taking preoperative and postoperative care management for the first time. Students who had failed after receiving education on preoperative and postoperative care management the preceding year were not included in the study (n = 5). The aim of the study was explained to all students (n = 309), and all agreed to participate. Of the sample of 309 participants, 155 were randomly assigned to the experimental group and 154 to the control group. Four participants left the control group before taking the Preoperative and Postoperative Care Knowledge Test (Knowledge Test). The study was thus completed with 155 participants in the experimental group and 150 in the control group.
Procedure
All participants took the Knowledge Test before starting education (n = 305). Participants were notified of group assignment after completing the pretest.
Participants in the experimental group were given specific user IDs and passwords created by the researcher to log in to the Web-based education. The researcher presented 2 hours of information to the experimental group on how to access and use the Web-based education material. Participants agreed to keep their individual log-in information private until the assessment was completed.
Participants were given Knowledge Test 1 (posttest 1) 2 weeks after receiving education and Knowledge Test 2 (posttest 2) after clinical practice. Posttest 1 was taken by 148 (95.48%) of the participants in the experimental group and 141 (94%) in the control group; similarly, 149 (96.12%) in the experimental group and 142 (94.66%) in the control group took posttest 2. Participants were assessed in clinical practice using the Preoperative and Postoperative Care Skill Control List (Skill Control List). Their clinical performance was assessed by the Nursing Student Clinical Performance Evaluation Scale (Clinical Performance Scale). All participants completed the skill and performance assessments. After clinical practice, 150 (96.77%) from the experimental group and 139 (92.66%) from the control group completed the Clinical Decision Making in Nursing Scale (CDMNS). Table 1 shows the measurement tools applied to the groups and sampling losses in detail.
Web-Based Education
The educational content provided to the experimental group was prepared according to preoperative and postoperative care standards. Preoperative care management includes five parts: general preoperative nursing interventions and patient education (deep breathing, coughing, leg exercises), as well as psychosocial (fear, anxiety) and physiological assessments (respiratory status, cardiovascular status, endocrine function, drug or alcohol use), pain management, and the diet, skin, and bowel preparation of the patient.
Postoperative care management includes three parts: potential intraoperative complications (hypoxia, hypothermia, malignant hyperthermia), postoperative patient assessment and interventions (nursing management in the postanesthesia care unit, care of hospitalized postoperative patients), and observations for potential complications (atelectasis, pain, shock, delirium, hemorrhage, deep vein thrombosis). The content of the education module was used in a study by Durmaz et al15 and was revised according to preoperative and postoperative information. The content was evaluated by two instructors with doctorates in surgical nursing. The Web-based education for preoperative and postoperative patient care included specific textual information, images, flowcharts, tables, reminders, sample case studies, videos, and a feedback section for participant questions.
Participants were given access to Web-based education content on smartphones as well as computers. All experimental group participants accessed the Web education more than once; many repeatedly accessed the Web education for clinical practice.
Traditional Education
In the control group, the instructors explained the course content using PowerPoint presentations, case discussions, and question-and-answer methods in the classroom, and participants viewed presentations after the lesson. The content and objectives of the traditional education and Web-based education were the same.
The instructors explained preoperative and postoperative care to the control group for 4 hours, and the experimental group received Web-based education for the same period.
Ethical Considerations
This study was approved by the institutional review board of the University Ethics Committee (3343-GOA, 2017/18-31). The aim and content of the study were explained. Written and oral consent was obtained from study participants. The interventions that participants could not do/discontinued were given or completed by the clinical educator or clinical nurse. All patients received necessary care before and after the surgery.
Instruments
The Knowledge Test, Skill Control List, CDMNS, and Clinical Performance Scale were used to assess knowledge levels in terms of preoperative and postoperative care and skills in clinical practice, clinical decision making, and clinical performances, respectively.
Preoperative and Postoperative Care Knowledge Test
This test comprises 20 multiple-choice questions on preoperative and postoperative care. The questions were prepared by an instructor from real-life patient scenarios aligned with the literature. Prior to use, two instructors with doctorates in surgical nursing evaluated the questions according to the content and objectives of education, and the test was developed according to the instructors' opinions. The [kappa] statistic was used to test interrater reliability,16 the level of agreement between the two instructors. A value of Cohen's [kappa] coefficient of 0.64 was found, showing a good level of agreement between the two instructors.
The Knowledge Test was taken by participants before and after their education sessions. Each correct answer is worth 5 points, so scores ranged between 0 and 100 on the Knowledge Test.
Preoperative and Postoperative Care Skill Control List
This test comprises 11 psychomotor skills: four psychomotor skills for preoperative care (teaching coughing and deep breathing exercises, removing jewelry) and seven psychomotor skills for postoperative care (taking vital signs, observing drainage and bleeding). The psychomotor skill control list was prepared by an instructor who is a specialist in the field and was evaluated prior to application by two instructors with doctorates in surgical nursing. Interrater reliability was tested with Cohen's [kappa] coefficient,16 for which a value of 0.62 was found in this study, showing a good level of agreement between the two instructors.
The instructors observed participants in surgery clinics according to the skill checklist as they provided preoperative and postoperative care to patients. The instructors marked the skills in the control checklist as "done" or "not done."
Clinical Decision Making in Nursing Scale
Jenkins17 developed the CDMNS to describe the perceptions of students' clinical decision making. The scale is a 5-point Likert-type scale consisting of 40 items with six subscales. Cronbach's [alpha] was found to have a value of .83 in the original study. A validity and reliability study for Turkish was conducted by Durmaz et al,18 who found an acceptable scale model goodness-of-fit in the confirmatory factor analysis, with Cronbach's [alpha] of .78. The total mean score and total-subscale correlation coefficients were 0.74 and 0.82, respectively.18 Participants completed the scale independently, and scores ranged between 40 and 200, with no cutoff point. A high score on the scale indicates that decision-making perception is high, and a low score indicates that it is low.
Clinical Performance Evaluation Scale
The Clinical Performance Scale used to assess the clinical performance of study participants was developed by Karayurt et al.19 Cronbach's [alpha] for the internal consistency of the scale was .97. Three subscales of nursing process, professionalism, and ethical principles were determined using descriptive factor analysis as having factor loads between 0.58 and 0.89. The scale comprises 26 items scored from 1 to 10 points. The performance score was calculated by dividing the obtained score by the number of items. The highest possible score is 100, and the lowest is 1, and scores 85 to 100, 75 to 84, 60 to 69, 50 to 59, and 49 and below were categorized as excellent, satisfactory, average, passing, and failing, respectively.19
Data Collection
A knowledge pretest was used to assess knowledge scores before the instruction. All participants received preoperative and postoperative care education after the pretest was administered. In the traditional education, preoperative and postoperative care slide presentations were discussed. Following the traditional education, lecture materials prepared by the instructors were given to the control group. Educational content prepared on the Web was introduced the experimental group, who were informed how to use the educational content and given specific log-in information to access the Web-based education. Participants then answered questions on the topic. Participants in the experimental group were observed from the database they entered on their computers and smartphones during Web-based education.
Knowledge Test 1 (posttest 1) was administered to both groups 2 weeks after completing the course. Their preoperative and postoperative skills were assessed using the Skill Control Test in clinical application 2 weeks after posttest 1, after which their clinical skills were put into practice in surgical clinics. Each participant was required to observe at least one patient in the preoperative and postoperative period in a clinical setting. Participants were not assessed in the first 2 days of clinical practice in order to allow them to adapt to the clinical setting.
During clinical practice, participants were assessed by instructor nurses who had at least a master's degree in surgical nursing and had experience with students in a clinical environment. The instructor nurses were given an orientation about participant assessments and the skill checklist before clinical practice. The instructor nurses then observed each participant giving preoperative and postoperative care to at least one patient in the clinical setting. The instructor nurses used the skill checklist to assess whether participants had "done" or "not done" a given item and then assessed their clinical performance on the Clinical Performance Scale. During the clinical practice, the instructor nurses did not know to which group participants were assigned. Knowledge Test 2 (posttest 2) and the CDMNS were administered the day after the clinical practice.
Data Analysis
Data were analyzed using IBM SPSS Statistics version 20 (IBM, Armonk, NY). An intention-to-treat analysis was conducted because of losses in sampling during the research. For participants without a posttest score, the mean of the participant's column was used as the posttest score. For participants who did not have a CDMNS score, the mean score of the group was used. After these corrections, a Student's t test was used to analyze whether there was a difference between the knowledge levels of the experimental and control groups, as well as clinical performance and clinical decision-making scores in independent groups. A [chi]2 test was used to examine skill levels.
A double-blind method was used in the study. The instructors who assessed participants in the clinical setting were blind to their group membership, different researchers performed the data input and analysis, and the researcher making the data analysis was blind to the participant groups.
RESULTS
The mean age of participants was 20.74 +/- 1.16 years; 75.4% (n = 230) were female and 24.6% (n = 75) were male, and the experimental and control groups were similar in terms of age and sex (P > .05). Mean pretest knowledge scores of the experimental and control groups were 63.85 +/- 0.80 and 64.05 +/- 0.88, respectively. There was no significant difference between the scores before intervention (t = -0.31; P = .75 > .05) (Table 1).
No statistically significant difference was found between knowledge levels (P = .63; P = .26), clinical performance assessments (P = .30), or scores on the clinical decision-making scale (P = .80) in the experimental and control groups after the education (P > .05). A difference was found regarding the time when pretest, posttest 1, and posttest 2 knowledge levels were assessed (time; F = 181.57, P = .00), such that knowledge levels in the two groups increased with time.
In clinical practice, the skills in preoperative and postoperative care were assessed, and a statistically significant difference was found between the groups for the skills of "check patient's documents and prophylactic antibiotics when going to surgery" ([chi]2 = 4.88; P = .02), "controls the surgical safety checklist (before surgery) before going to surgery" ([chi]2 = 10.41; P = .00), and "observes surgical site/dressing" ([chi]2 = 7.77; P = .00). Participants in the experimental group were found to perform these skills more often (Table 2). No significant difference between the two groups was found for other skills.
DISCUSSION
No statistically significant difference was found between the posttest 1 and posttest 2 knowledge scores of participants who received Web-based and traditional preoperative and postoperative care management education in this study. There have been different research results regarding Web-based education on knowledge, such that no statistically significant difference was found in the knowledge scores of students who received e-learning or Web-based education in respiratory medicine, pediatric medicine safety, urinary catheterization skills, and airway obstruction.10,20-22 On the other hand, the knowledge scores of students who received Web-based education in postpartum care and cardiovascular diseases were found to be significantly higher.9,23 The differences in the research results might be due to differences in the topics examined in the studies. No significant difference was found in knowledge scores by educational method in our study, perhaps because it was a sample case of the education given in class; the question-and-answer method was used to provide educational content. The experimental and control groups were in the same environment and therefore might have shared knowledge and discussed course materials with each other. A significant difference was found between the knowledge scores over time because posttest 2 was assessed after clinical application. This result showed that clinical practice was effective for all participant learning abilities.
This study assessed the skills of participants who received preoperative and postoperative care management through Web-based and traditional education. Among preoperative patient care skills, those who received Web-based education were found to have statistically significantly higher scores on "check patient's documents and prophylactic antibiotics when going to surgery," "controls the surgical safety checklist (before surgery) before going to surgery," and "observes surgical site/dressing," but the two groups were similar in their performance of other skills. We did not find any previous studies that assessed the skills examined in our study. Other studies assessing different skills found positive results from Web-based education. The scores of nursing students who received Web-based education were found to be higher in studies assessing medication administration, urinary catheterization, and care in airway obstruction skills.11,20,21,24 We found a significant difference in only one postoperative care skill and two preoperative care skills among participants who received Web-based education. The visual education methods (video, flow scheme, reminders) and accessibility of Web-based education, including mobile phones, may have made a difference in these skills. Moreover, the literature indicates that visual education was more effective and permanent for these skills.23,25
As previously noted, the scores for the other skills of the experimental and control groups were similar. As all skills were evaluated in clinical application, participants may have experienced stress at that time that might have affected their ability to demonstrate the requisite skills.
No statistical difference was found between the scores on the clinical decision-making scale and the subscale scores of experimental and control groups (P > .05). Similarly, no difference was found in nursing students' clinical decision making in a study assessing the effect of Web-based simulations.15 We found no other studies assessing decision making as examined in our study, and thus we have no basis for comparison for our results. As the clinical decision-making scale was administered after clinical practice, it is possible that observing and experiencing the same situations in clinical environments may have led participants in different groups to make similar decisions.
No difference was found in clinical performance assessment scores between experimental and control groups. As we have not found any study of the effects of Web-based education on clinical performance in the literature, this result cannot be compared with those of other studies. There are several possible reasons for our result. Exposure to inhibiting and triggering factors in the clinical environment may have affected participant performance. In addition, heavy patient loads in surgical clinics and the experience of observing critically ill patients might have negatively affected participant performance in clinical settings. Finally, the idea of doing no harm to the patient may have inhibited participants and negatively affected their performance.
Limitations of the Study
One limitation of the study is that as the experimental and control groups were in the same environment (school, hospital), they might have interacted with each other. Another limitation is that participants who received face-to-face instruction in the control group were able to ask more questions in real time.
CONCLUSION
This study examined the effect of e-learning on the knowledge, skills, clinical decision making, and clinical performance of nursing students. We have found no similar study in the literature. We recommend that e-learning methods be used as an alternative to other learning methods in undergraduate education, even though we found no difference in the two groups in many skills. Significant differences were found between groups in some skills, although no difference was found in knowledge, clinical decision making, or clinical performance. Web-based education is easily accessible to students for clinical practice, and it contributes to skill development by providing visual content. More well-designed studies are needed to investigate the use of mobile-assisted software, Web-based education, and e-learning in skills applications.
References