The effect of computer-assisted learning versus conventional teaching methods on the acquisition and retention of handwashing theory and skills in pre-qualification nursing students: A randomised controlled trial

Abstract

Background

High quality health care demands a nursing workforce with sound clinical skills. However, the clinical competency of newly qualified nurses continues to stimulate debate about the adequacy of current methods of clinical skills education and emphasises the need for innovative teaching strategies. Despite the increasing use of e-learning within nurse education, evidence to support its use for clinical skills teaching is limited and inconclusive.

Objectives

This study tested whether nursing students could learn and retain the theory and skill of handwashing more effectively when taught using computer-assisted learning compared with conventional face-to-face methods.

Design

The study employed a two group randomised controlled design. The intervention group used an interactive, multimedia, self-directed computer-assisted learning module. The control group was taught by an experienced lecturer in a clinical skills room. Data were collected over a 5-month period between October 2004 and February 2005. Knowledge was tested at four time points and handwashing skills were assessed twice.

Setting and participants

Two-hundred and forty-two first year nursing students of mixed gender; age; educational background and first language studying at one British university were recruited to the study. Participant attrition increased during the study.

Results

Knowledge scores increased significantly from baseline in both groups and no significant differences were detected between the scores of the two groups. Skill performance scores were similar in both groups at the 2-week follow-up with significant differences emerging at the 8-week follow-up in favour of the intervention group, however, this finding must be interpreted with caution in light of sample size and attrition rates.

Conclusion

The computer-assisted learning module was an effective strategy for teaching both the theory and practice of handwashing to nursing students and in this study was found to be at least as effective as conventional face-to-face teaching methods.

Introduction

The acquisition of clinical skills is an essential part of learning to be a nurse and a lack of clinical skills competency can compromise patient care and safety. Debate persists about the standards of skill proficiency in newly qualified nurses and the adequacy of conventional teaching methods. Face-to-face lectures and skill demonstrations have traditionally been used to teach clinical skills to pre-qualification students. These sessions typically occur in a clinical laboratory or skills classroom and usually involve the demonstration of a skill followed by an opportunity for rehearsal. It is an expectation that further supervised practice undertaken within the clinical environment will consolidate skill acquisition.

Although conventional teaching methods have been espoused for providing an opportunity for students to learn directly from subject experts (Jeffries et al., 2002), such methods can lack flexibility, do not ensure teaching consistency nor accommodate the diverse learning needs of students (Jeffries, 2001). Furthermore, in recent years, the demands of caring for increasingly acutely ill patients, shorter hospital stays and staffing shortages have curtailed teaching opportunities in many clinical areas, potentially limiting the support available for nursing students to learn in practice. Collectively, these issues have compelled nurse educators to seek alternative methods of clinical skill instruction.

e-Learning has been described as: “learning facilitated and supported through the use of information and communications technology” (Joint Information Systems Committee, 2003) and is a term that is widely evident throughout the literature. This descriptor can be applied to a considerably broad spectrum of technologically enhanced learning strategies potentially causing confusion and ambiguity. For the purpose of this study, the less general term “computer-assisted learning” (CAL) was employed and refers specifically to the use of a computer-based teaching module.

The use of computers in nurse education is not new and studies of CAL have been reported in the nursing literature since the mid 1960s (Bitzer, 1966). e-Learning has been championed for its capacity to individualise learning by de-centralising the teaching process and facilitating learner independence and self-direction (Greenhalgh, 2001). Other recognised benefits include: flexibility and the promotion of active learning (Tegtemeyer et al., 2001), improvements in student motivation and satisfaction (Gleydura et al., 1995), cost efficiency and reductions in instructional time (Jeffries, 2001), consistency of educational delivery (Jeffries, 2001) and accessibility to information available via the World Wide Web (Washer, 2001). It has also been endorsed for its role in the development of students’ computer skills and confidence (Leasure et al., 2000).

While a number of nursing studies have compared the effects of CAL with conventional teaching methods on knowledge acquisition (Lewis et al., 2001), considerably fewer have investigated its role in clinical skills education. Of particular note is the lack of published research investigating the effect of CAL on the retention of clinical skills and knowledge. Bloomfield et al. (2008) examined 12 papers in an integrative review of papers published between 1997 and 2006 comparing the effectiveness of CAL with conventional methods for clinical skills education in nursing. The majority of studies originated from the United States of America and employed a randomised experimental or quasi-experimental design comparing CAL with conventional teaching methods such as lecture, demonstration, tutorials or printed materials.

The studies involved a variety of clinical skills including oral medication administration (Jeffries, 2001, Schneider et al., 2006); intravenous therapy administration (DeAmicis, 1997, Tsai et al., 2004); blood pressure measurement (Bauer and Huynh, 1998, Beeson and Kring, 1999, Bauer et al., 2001); electrocardiography (Jeffries et al., 2003, Jang et al., 2005); cardiotography (Wilson and Mires, 1998) and the San-Yin-Jio pressure procedure (Kim et al., 2003). Outcomes measures typically involved the evaluation of skill performance using structured checklists. In some studies, theoretical knowledge was also tested using multiple-choice tests.

Overall, generally positive findings were reported. Studies by DeAmicis (1997), Bauer and Huynh (1998), Kim et al. (2003), Jang et al. (2005) and Schneider et al. (2006) reported higher skill performance scores for students who used CAL when compared to conventional methods, however, statistically significant differences (p > 0.01) were found in only three studies. Equivalent skill performance scores were reported in three studies (Beeson and Kring, 1999, Jeffries, 2001, Jeffries et al., 2003) while lower scores were associated with CAL in two of the reviewed studies (Wilson and Mires, 1998, Bauer et al., 2001). Notably, with the exception of a study by Tsai et al. (2004), none of the reviewed studies tested knowledge or skill retention, and this remains a fundamental gap in the literature. Furthermore, a number of these studies were flawed by a lack of rigor indicating the need for more robust research designs.

Handwashing is an essential skill for all nurses and healthcare staff and is crucial not only for basic hygiene, safety and patient care but also for the prevention of potentially fatal hospital acquired infections (ICNA, 2002, RCN, 2003). As such, it is imperative that nursing students are taught handwashing effectively using methods that ensure both skill proficiency and a sound understanding of the underlying theoretical principles. While previous studies have investigated handwashing from the perspectives such as technique and rates of compliance (Pittet et al., 2000, Naikoba and Hayward, 2001), there is considerably less empirical evidence pertaining to methods by which it is taught. This paper reports on a randomised controlled trial conducted to compare a self-directed CAL module, with conventional methods for handwashing education.