Article Text

Randomised controlled trial
Computer-assisted module for nursing students provides similar improvements in handwashing knowledge and may improve handwashing practice compared with face-to-face teaching
  1. Mary Chambers1,2
  1. 1Kingston University, London, UK
  2. 2St George's, University of London, Faculty of Health and Social Care Sciences London, UK
  1. Correspondence to Mary Chambers
    6th Floor Hunter Wing, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK; m.chambers{at}

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This paper addresses two key components of nurse education: the acquisition of clinical skills, and the use of computer-assisted learning (CAL). Also emphasised is the importance of clinical-skills acquisition in nursing, with particular reference to handwashing. It states how high levels of competency in hand washing are essential to ensure patient safety and prevent hospital acquired infections. The second important element addressed is the potential use of CAL in the teaching of clinical skills in nursing with particular reference to both the theory and skills of handwashing. Additionally, the paper refers to the lack of empirical evidence regarding the effectiveness of CAL in the teaching and learning of nursing skills. What is reported in the paper adds to the limited body of knowledge in this area.

CAL versus traditional approaches

Traditionally, a considerable proportion of clinical-skills acquisition took place in the clinical environment through ‘sitting next to Nellie’ and based on an apprenticeship model. Today the healthcare climate is very different; patients are more acutely ill, with shorter periods of hospitalisation and reduced numbers of registered nurses to provide student supervision. These factors indicate a need to find alternative teaching methods that are equally effective, if not more.

In an effort to do this and test the usefulness of CAL, this study used a randomised, controlled, trial aiming to compare the effects of a self-directed CAL module with conventional face-to-face classroom teaching on the acquisition of students' handwashing knowledge and skills. The theoretical content and duration (90 min) for both modules were identical but with differences in the delivery methods.

From a total of 420 first-year student nurses enrolled on the Common Foundation Programme of a 3-year undergraduate nursing course at a London university, 245 were recruited for the study. Students were randomly assigned to either the CAL group (intervention) or the conventional-teaching-method group (control). Data were collected at four points in the study, between October 2004 and February 2005. Baseline data consisted of a participant questionnaire and handwashing-knowledge test. The handwashing-knowledge test was also given immediately on completion of the teaching session and again at 2- and 8-week follow-ups. Additionally, a handwashing-skills performance test was carried out at both week 2 and week 8 follow-ups. This test was designed to assess students' ability to perform the recommended handwashing procedure; it was conducted under Objective Structured Clinical Examination conditions and by trained examiners blinded to the study conditions.

Is CAL better than traditional methods?

Of the 245 students recruited to the study, at week 8 follow up this number had decreased; 85 students completed the skills performance test and 96 the knowledge test.The reasons for withdrawal were not explored. In terms of managing the data analysis and reporting the results, the authors were diligent in their efforts to eliminate bias and state that the findings at week-8 follow-up must be considered with caution.

The study participants were a heterogeneous group with variation across age, gender, education, English as a first language, computer skills and experience of using CAL. At baseline, and immediately on completing the teaching session, there were no significant differences between the groups on the handwashing-knowledge-test scores, though significantly higher scores were obtained by both groups after the respective teaching sessions. A similar picture emerged at week-2 follow-up. When at week 8, a smaller group (n=86) completed the knowledge test, the scores were significantly higher than at baseline but not significant when compared between the groups.

For the handwashing-skills-performance test at week 2, there was no significant difference between the groups; however, at the week-8 follow-up, the scores for the intervention group were higher but not statistically significant. The results of this study suggest that the use of a self-directed CAL module is an alternative to a face-to-face teaching session. These results would support that of other studies whose findings were inconclusive. However, the results do offer evidence that CAL is at least as effective as traditional teaching methods when used for teaching handwashing.

Food for thought

Though this study led to some interesting findings, it still has some points requiring clarification and some areas of concern. The overall methodology is appropriate as is the statistical analysis. However, the numerical system used to determine the scores for the handwashing-skill performance seems incorrect. For example, it states that two marks were allocated to each of the eight items that involved two hands and one mark assigned to each of the remaining 11 items resulting in a maximum score of 25 marks. This would make a total score of 27 not 25 – perhaps this is a typing error.

The participant questionnaire is not described but would appear to relate to biographical data, computer competency and previous experience of using CAL.

It is not clear why the handwashing-skill-performance test was not carried out at baseline along with the other tests, as this would have given a more comprehensive picture of skills acquisition.

A more serious concern is that the study findings could be considered out of date in today's parlance because the study was conducted more than 5 years ago; Recently there have been considerable advances the application of technology to the acquisition of clinical skills, such as computer-aided simulation and the use of virtual patients.1 2 Thus, what is discussed here has shortcomings and could still be considered a little out of date.

It would have helped the reader, had an illustration of the intervention been available to gain an understanding of how it appears to the student, for example, a still from the animation or a photograph.


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  • Competing interests None.

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