Computers have had a major influence on nursing practice and nursing education. Currently, computers are essential tools in hospitals, community health agencies, and other settings in which nurses function. The field of nursing education has incorporated a number of computer-based technologies into its curriculum. Computer-based instruction (CBI) includes tutorials, computer-assisted instruction (CAI), interactive video instruction, and computer simulations, as well as presentation graphics, which are used in support of traditional lecture (Cohen & Dacanay, 1994). The newest CBI technologies include Web-based courses and computer-integrated simulations (Jeffries, 2005).
Researchers have focused on three major areas related to the effects of computer technology on nursing education. The majority of studies compared CBI with traditional lecture. A meta-analysis of 29 studies by Cohen and Dacanay (1994) found CBI to be moderately more effective than conventional methods of instruction. Other studies support this finding. Ayoub et al. (1998) found higher examination scores and class participation for an interactive computer classroom versus traditional lecture discussion. Jeffries (2001) found higher student satisfaction and more cognitive gains when CD-ROM was compared with traditional lecture on oral medication administration. Jeffries, Woolf, and Linde (2003) compared lecture and demonstration with an interactive CD-ROM in the teaching of 12-lead electrocardiograms. Although no significant difference was found in cognitive gains, students using CD-ROM reported greater satisfaction and self-efficacy.
Recent studies have compared Web-based courses with traditional classroom instruction. Buckley (2003) examined a nutrition course as it transitioned from a traditional classroom to a Web-enhanced and then Web-based course during a 3-year period. No significant difference was found in student learning outcomes, but the Web-based course received the lowest course evaluation scores. When Kearns, Shoaf, and Summey (2004) compared traditional and Web-based versions of a course for second-year baccalaureate nursing (BSN) students, they found that students in the Web-based course scored significantly higher on performance measures; however, students in the traditional course expressed greater satisfaction.
The second area of study investigated how learning styles relate to the effectiveness of CBI. Yoder (1994) concluded that learners who prefer active experimenting learn better with interactive video instruction, and those who prefer reflective observing do better with linear video presentations. Walker et al. (2006) examined differences between nursing students in Generation X and Generation Y. They found no significant differences between the age groups and little preference for Web-based learning.
The third area investigated student satisfaction with CBI. Studies by McBride and Nagle (1996) and Goodman and Blake (1996) found positive attitudes toward the use of computers among nursing students. On the other hand, Baldwin, Johnson, and Hill (1994) found students dissatisfied with CAI. A majority of respondents (72%) preferred faculty demonstrations of basic nursing skills. Bloom and Hough (2003) used a questionnaire with a 5-point scale to measure student satisfaction with a variety of technology-enhanced learning tools. Satisfaction was generally high, and nursing students reported greater satisfaction with CAI than did other health science students. Feingold, Calaluce, and Kallen (2004) surveyed students who used the Laerdal™ SimMan™ computerized simulator. Most students found the experience realistic and valuable, but only half felt that those skills would transfer to a real clinical setting.
The literature revealed two major limitations. First, all but two of the CBI studies involved BSN students, although a majority of RNs are educated in associate degree programs (Nursing Datasource, 1997).
The second major limitation was the lack of qualitative studies that could guide nurse educators in an analysis of their use of CBI. One previous study provides insight into nursing student perceptions of computer technology. Thede, Taft, and Coeling (1994) interviewed nursing students who had used one of four computer programs. They then conducted a content analysis of the interviews, which revealed three overall categories of comments:
(a) the learner, (b) the learning environment, and (c) the software design, including interactive features, how the learning design uses these features to achieve learning objectives, and the content. (p. 299)
This study used a qualitative case study research approach because of the interest in the full breadth of student and faculty experiences and their perceptions within a natural setting. A holistic approach to questions and in-depth interviews of students, faculty, skills laboratory staff, and the nursing director were required.
Sample and Setting
The context or setting of this case study is an associate degree nursing program at a 2-year community college in the midwestern United States. The nursing department personnel consists of 1 director or assistant dean, 12 full-time faculty, 12 part-time faculty, and 2 part-time laboratory staff members. Approximately 100 students are enrolled in each of the 2 years of the program. Of a class of 110, 15 second-year students were interviewed.
The primary data collection technique was an interview format with second-year nursing students. Prior permission was obtained from the program director and division dean, and prior consent was obtained from the students who were interviewed. A semistructured, open-ended interview was used. This format allowed for similar information from each respondent. It also allowed for the exploration of new thoughts or ideas that arose from early interviews. The second data collection technique was a focus group with nine full-time nursing faculty, and compared faculty perceptions of CBI with those of the students. The third data collection step was interviews with the two members of the nursing laboratory staff and with the director of nursing to obtain their views on the role of CBI within the nursing curriculum.
Audiotapes of all interviews and the focus group were transcribed to enhance accuracy. Data analysis began with a line-by-line coding of student interviews, with short descriptions written in the margins of the transcriptions to capture the essence of each comment or response. After the initial coding of all 15 student interviews, 157 different codes were identified. These codes were then clustered into two major categories: factors that enhance learning, and factors that hinder learning. Three subcategories also existed: positive and negative characteristics of CBI, student behaviors with CBI that enhance and hinder learning, and student suggestions for improving CBI. After developing the categorization scheme, similar codes were combined, reducing their number from 157 to 51.
The next step used content analysis, which involved counting the number of comments made by students and faculty for each code and the number of students or faculty who made a comment. This information was entered into Microsoft Excel®, which was used to rank order the responses by frequency of student response and to create bar charts that illustrated this rank order.
After the initial counting and charting, several smaller frequency codes were collapsed into higher frequency codes, reducing the total number from 51 to the final 42 codes. Counting and bar charts gave structure to the findings by giving more significance to more frequently mentioned responses.
Five themes emerged from the content analysis of the interviews and focus group.
Theme 1: Student Recollections of CBI Are Time Bound. The first six interview questions asked students to recall their most recent and most memorable experiences with each of the three CBI technologies used in the curriculum—interactive videos, CD-ROM, and CAI programs. Responses reflected the time period in which the questions were asked. For example, the high recollection of a CAI psychiatric nursing program could be attributed to the fact that a printout from this program was a course requirement. Students’ responses, and the amount of clarification and coaching required to elicit a response suggested that students had difficulty differentiating among the three forms of technology. Students could recall programs by content, but they could not recall the specific medium through which the program was delivered.
Theme 2: CBI Enhances Learning Under Certain Important Conditions. To investigate how CBI enhanced learning, students were asked to relay the most positive thing about their experience using CBI. The most frequently mentioned positive characteristic of CBI programs was interactive (i.e., feedback). This was mentioned 36 times by 14 of the 15 students interviewed. It was also the most mentioned positive characteristic among faculty. As one student explained:
I like when they give you options and then give you a rationale for the right answer.
The second most frequently mentioned positive characteristic of CBI programs was reinforcing class content, which was mentioned 26 times by 13 of the 15 students interviewed. The third most mentioned program positive characteristic was that they provide an opportunity for application of theory. Other positive program characteristics were, in order of number of mentions:
- It was multisensory.
- It was realistic.
- It provided new information.
- It integrated information
- It provided a new perspective.
Students also provided positive feedback on the use of CBI within the nursing curriculum. The most frequently mentioned characteristic was the combination of required and optional assignments, which was mentioned 19 times by 12 of the 15 students. The second most mentioned positive characteristic was that CBI accommodated different learning styles, which was mentioned 6 times by 4 students. Other positive characteristics regarding curriculum were the use of current technology and the integration with the modules.
Students also commented on the CBI learning environment. The most frequently mentioned positive characteristic in this area was the helpful staff, with 15 mentions by 12 of the students. Privacy and quiet was the second most mentioned characteristic, and familiarity was the third most mentioned characteristic.
Students also provided feedback on their behaviors related to CBI. The most frequently mentioned student behavior that enhanced learning was working in groups. This was mentioned 17 times by 11 of the 15 students. Working alone was second, with 13 mentions by 5 students. Reviewing for examinations was third, with 10 mentions by 7 students.
Theme 3: CBI Hinders Learning Under Certain Important Conditions. To investigate how CBI might hinder learning, students were asked to relate the most negative aspect of their CBI experiences. Their responses were categorized into negative characteristics of specific CBI programs, negatives relating to CBI use within the curriculum, and negatives relating to the CBI learning environment.
The most frequently mentioned negative characteristic of CBI programs was time pressure. This was mentioned 43 times by 14 of the 15 students. It was also the most mentioned among faculty, with 22 mentions. As one student explained:
They are long, really long. Some of them are 2.5-hours long…. People work, they have kids, they need to get home.
The second most mentioned negative characteristic was no hands-on experience. This was mentioned 14 times by 10 of the 15 students interviewed. The third most mentioned negative characteristic was the lack of rationales in some programs.
The most mentioned negative characteristic regarding how CBI was used in the curriculum was too many assignments. This was mentioned 9 times by 5 of the 15 students.
The most frequently mentioned negative characteristic of the CBI learning environment was noise. This was mentioned 13 times by 11 of the students, and 7 times by faculty. One student stated:
When you have five other people whose computer[s are] as loud as yours is, it is very loud in there.
Overcrowding was the second most mentioned negative, with 11 mentions by 9 students. Equipment malfunctions was third, with 11 mentions by 5 students.
Students also identified student behaviors related to CBI that hinder learning. The most frequently mentioned was rushing through or skipping parts. This was mentioned 11 times by 7 of the 15 students interviewed. As one student recalled:
There were five required programs. Some were 45 minutes long. I did not have 5 hours to spend, so I rushed to complete them.
The second most mentioned negative student behavior was cutting corners. One student admitted, “people just photocopy the printout and hand it in.” Another explained:
When we viewed 5 or 10 programs, we got four people together. One person does one, one does the other. Then we would all write our names on it.
Theme 4: Effective Application of CBI Depends on a Variety of Conditions. Students were asked for suggestions to improve the effectiveness of CBI. One group of suggestions was directed at CBI in the nursing curriculum. The most frequent suggestion in this area was to use the CBI programs in the classroom. This was mentioned 8 times by 8 of the 15 students. The second most frequent suggestion was fewer optional assignments. The third most frequent was fewer required assignments.
Another group of suggestions focused on the CBI learning environment. Improved access to programs was the most frequent suggestion, with 13 mentions by 11 students. Increased privacy in the laboratory was second, with 4 mentions by 3 students. Increasing laboratory hours was third.
Theme 5: CBI Benefits Nursing Education in Certain Important Areas. To investigate the areas in which CBI most benefits nursing education, students were asked whether CBI was helpful in understanding nursing theory, learning new nursing skills, and preparing for clinical experiences. Thirteen of the 15 students and all faculty agreed that computer experiences were helpful in the understanding of nursing theory. One student stated, “It reinforces the nursing process and also the theory behind it.” Another said, “It puts it together more than the book or the lecture.”
Twelve of the students and all but one faculty member agreed that computer experiences were not helpful in learning nursing skills. Nine of the students and less than half the faculty stated that computer experiences were helpful with clinical preparation. One student explained:
It helped a lot with clinical. It gives you scenarios to identify problems, what is important and how to prioritize.
Three metapolicies have been interpreted from the data. These were created by searching for patterns and structures that could connect the research themes with the coded findings.
Metapolicy 1: CBI Should Be Applied to Appropriate Content Areas. Most nursing curriculums have three major components:
- Class, where the emphasis is on theory.
- Laboratory, where nursing skills are demonstrated and practiced.
- Clinical experiences, where theory and skills are applied.
When asked about the content areas in which CBI was helpful, both students and faculty made a clear distinction. They were nearly unanimous in the view that CBI was helpful in learning nursing theory (i.e., class content) and not helpful in learning nursing skills (i.e., laboratory content). The view on CBI helpfulness in preparing for clinical experiences (i.e., application of theory and skills) was evenly split.
Support for the proposition that CBI is helpful in learning nursing theory includes student perceptions that these programs reinforce class content, provide new information, and bring a new perspective to previously covered contents. Student behaviors that support this proposition include using CBI or program printouts to review for examinations. Students also suggested that CBI programs be used during class sessions.
The proposition that CBI is not helpful in learning nursing skills is supported by the single but compelling perception that these programs lack hands-on experience. Complex psychomotor skills can be visually demonstrated by CBI, but mastery requires hands-on practice and feedback from a knowledgeable observer.
Metapolicy 2: CBI Should Make Reasonable Demands on Students. This metapolicy did not arise from any direct questions, but this issue permeated the discussion of all aspects of the CBI experience. Time demands were perceived as unreasonable by the students in this study. Characteristics of CBI programs that students perceived as hindering learning and increasing time demands were the length of time needed to complete most programs and the lack of flexibility that would allow bypassing redundant sections of the programs. Characteristics of CBI within the curriculum that increased time demands were too many assignments. Most students favored a mix of required and optional programs, but they felt that too many were assigned in both categories. The factor in the learning environment that increased time demands was equipment malfunction. Students used a variety of behaviors to address time demands, including rushing through programs, skipping parts of programs, and cutting corners. Student suggestions to reduce time demands included fewer assignments, improved access to computer programs, and longer laboratory hours.
Metapolicy 3: CBI Should Occur in an Environment with Minimal Distractions. The nursing laboratory used for CBI experiences at this college was also used for nursing skill practice and instruction. As a result, most students described the environment as noisy and overcrowded. According to Saranto, Leino-Kilpi, and Isoaho (1997):
A basic requirement for positive learning outcomes is that the learning environment be at least pleasant and secure. (p. 324)
A Model for Optimizing the Application of CBI to Education Programs
A diagram that shows the relationship between the three metapolicies has been prepared (Figure). The areas within the three circles represent appropriate content area, reasonable demands on students, and a low distraction environment. When all three metapolicies are met, all three circles overlap and an optimal fit is achieved between CBI and the program. This model can be used in the application of other teaching strategies in any discipline. The issues of content, learning environment, and demands on students must be addressed by every program planner.
Figure. Three Metapolicies Helped to Optimize the Application of Computer-Based Instruction to Nursing Education Programs.
Computer-based instruction is a relatively new teaching tool whose full potential has not been realized. Currently, most progress has come from advances in technology rather than from advancements in the ways educators are using the technology. The specific findings of this study are limited to a single nursing program during a particular 2-year period. However, I would recommend that the issues identified by the three metapolicies (i.e., appropriate content, reasonable demands on students, a low distraction learning environment) should be carefully considered whenever CBI is being planned, implemented, and evaluated. I would also encourage other nurse educators to seek student feedback on how well their use of CBI is meeting their students’ needs. A simple, structured questionnaire tailored to your individual course or program can be used instead of the open-ended interview technique in this study. However, questions regarding content, time demands on students, and the learning environment all should be included. A better understanding of student perceptions of CBI can motivate and direct educators toward improving those perceptions.
- Ayoub, JL, Vanderbroom, C, Knight, M, Walsh, K, Briggs, R & Grekin, K1998. A study of effectiveness of an interactive computer classroom. Computers in Nursing, 16, 333–338.
- Baldwin, D, Johnson, J & Hill, P1994. Student satisfaction with classroom use of computer-assisted instruction. Nursing Outlook, 42, 188–192.
- Bloom, KC & Hough, MC2003. Student satisfaction with technology-enhanced learning. Computers in Nursing, 21, 241–248. doi:10.1097/00024665-200309000-00011 [CrossRef]
- Buckley, KM2003. Evaluation of classroom-based, web-enhanced and web-based distance learning nutrition courses for undergraduate nursing. Journal of Nursing Education, 42, 367–370.
- Cohen, P & Dacanay, LS1994. A meta-analysis of computer-based instruction in nursing education. Computers in Nursing, 12, 89–97.
- Feingold, CE, Calaluce, M & Kallen, MA2004. Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43, 156–163.
- Goodman, J & Blake, J1996. Multi-media courseware transforming the classroom. Computers in Nursing, 14, 287–296.
- Jeffries, PR2001. Computer versus lecture: Two methods of teaching oral medication administration in a nursing skills lab. Journal of Nursing Education, 40, 323–329.
- Jeffries, PR2005. Technology trends in nursing education: Next steps. Journal of Nursing Education, 44, 3–4.
- Jeffries, PR, Woolf, S & Linde, B2003. Technology-based vs. traditional instruction: A comparison of two methods for teaching the skill of performing a 12-lead ECG. Nursing Education Perspectives, 24, 70–74.
- Kearns, LE, Shoaf, JR & Summey, MB2004. Performance and satisfaction of second-degree BSN students in web-based and traditional course delivery environments. Journal of Nursing Education, 43, 280–284.
- McBride, SH & Nagle, LM1996. Attitudes toward computers: A test of construct validity. Computers in Nursing, 14, 164–170.
- Nursing Datasource. 1997. Trends in contemporary nursing education New York: National League for Nursing Press.
- Saranto, K, Leino-Kilpi, H & Isoaho, H1997. Learning environment in information technology. The views of student nurses. Computers in Nursing, 15, 324–332.
- Thede, LQ, Taft, S & Coeling, H1994. Computer-assisted instruction: A learner’s viewpoint. Journal of Nursing Education, 33, 299–305.
- Walker, JT, Martin, T, White, J, Elliot, R, Norwood, A & Mangum, C et al. . 2006. Generation (age) differences in nursing students’ preferences for teaching methods. Journal of Nursing Education, 45, 371–374.
- Yoder, M1994. Preferred learning style and educational technology: Linear vs. interactive video. Nursing and Health Care, 15, 128–132.