Human-to-human interactions are the core of caring science. A discipline based on values, relationships, knowledge, and connectedness in support of the health experience of an individual makes a case for caring as nursing's metaparadigm (Newman, Smith, Pharris, & Jones, 2008). According to Watson (2008), “Caring science is a moral-philosophical-theoretical-foundational starting point for nursing education, patient care, research, and even administrative practices” (p. 16). Therefore, the relational aspects of nursing need to be foundational and threaded through all aspects of nursing education. An understanding of how students become conscious of the core aspects of caring science (Caritas Processes™, transpersonal caring moment, caring as consciousness, and caring-healing modalities) will support a professional practice centered on the health experience of an individual and on caring (Newman et. al., 2008; Watson, 2008).
The number of online education programs has increased exponentially in the past decade as nursing programs attempt to balance access with utility (Allen & Seaman, 2013, 2015; Kentnor, 2015). In 2014, overall student enrollment in higher education programs exceeded 20 million, with 7 million of these students enrolled in at least one online course (Allen & Seaman, 2015). Online education programs have been instrumental in the development of quality professional nurses (American Academy of Colleges of Nursing [AACN], 2015). Degree-completion nursing programs available in the United States include 679 RN-to-baccalaureate and 209 RN-to-master's programs (AACN, 2015). According to the AACN (2015) report “Amid Calls for a More Highly Educated RN Workforce,” many of the degree-completion nursing programs are offered completely online. Consideration needs to be given to how values associated with the nursing profession—caring, compassion, and integrity—are modeled as part of the online learning process. This premise generates the question, How does technology influence the development of interpersonal relationships between the student and faculty in a virtual learning environment for nursing education?
Current qualitative research focused on nursing faculty–student interactions within an online learning environment revealed four contributing factors: student expectations of learning, use of caring language, student engagement, and identified barriers to a positive educational experience in the absence of face-to-face learning (Mastel-Smith, Post, & Lake, 2015; Sitzman, 2015, 2016). Qualitative studies by Sitzman (2015, 2016) explored faculty–student interaction from the perspective of the faculty as part of an online educational environment. Participants from 13 nursing programs indicated “caring in the online environment was possible, important, and could be actively cultivated” (Sitzman, 2015, p. 25). Emergent themes associated with the creation of a caring online learning environment from the faculty perspective in Sitzman's (2015) work included sensing (a need for a caring intervention from faculty to student), connecting (a need for faculty to reach out or communicate individually with the student), and facilitating (guiding the student forward in the learning process).
Sitzman's (2016) study included faculty from 20 nursing programs who identified specific cues from students in an online learning environment, which faculty perceived to indicate a need for individualized caring. The six cues uncovered by Sitzman (2016) included academic struggles, the student asking for help, concerning student behaviors, lack of responses or withdrawal from participation, personal concerns, and students seeking positive acknowledgment related to course activity.
Mastel-Smith et al. (2015) conducted a qualitative study of six online nursing faculty describing their active participation in an online discussion. Active participation was described by the faculty as “participation in their discussions to the extent that they know I'm there” (p. 149). Mastel-Smith et al. (2015) described that a perceived increase in student participation, as well as a sense of heightened academic success, was reported by the faculty associated with the faculty's active participation in online discussions. Faculty online teaching experience, feelings toward online teaching, and faculties understanding of similarities as well as differences associated with teaching online versus teaching face-to-face were revealed (Mastel-Smith et al., 2015).
Studies suggest that faculty can develop, facilitate, and influence caring behaviors as part of online nursing education programs (Mastel-Smith et al., 2015; Sitzman, 2015, 2016). However, these studies were exclusively focused on the interactions between the faculty and the student, rather than the goals or learning needs of the student. As such, this qualitative meta-synthesis aims to go a step further to understand how technology influences the development of interpersonal relationships between the student and faculty as part of a virtual learning experience within the context of nursing education.
An established approach to interpretive qualitative metasyn-thesis study design (Lundvigsen et al., 2016; Magid et al., 2016; Morrow, Gustavson, & Jones, 2016) was used to answer the question, How does technology influence the development of interpersonal relationships between the student and faculty in a virtual learning environment for nursing education? Despite emerging critique of this approach as being too structured or limiting data to themes (Thorne, 2017), the study design allows us to access context variation and provide concrete and pragmatic applications to study findings across settings, thus tapping into the dynamic and rich tapestry of knowledge associated with the utilization of technology, online education, and caring.
The purpose of this metasynthesis was to gain an understanding of how technology influences the development of interpersonal relationships between the student and faculty in a virtual learning environment for nursing education. A search was completed using the following databases: PubMed®, EBSCO, CINAHL®, MEDLINE®, ProQuest®, Ovid Nursing®, and Google™ Scholar. Search key words included education, online learning, virtual spaces, nursing, caring, and technology. Articles were filtered to include English language publications and those published from 2000 to 2016, to coincide with the growth of online education programs occurring in the late 1990s. The population of focus included either graduate or undergraduate online nursing programs, faculty facilitating or developing online nursing courses, and nursing students participating in online courses.
Inclusion and Exclusion Criteria
For the purpose of this study, virtual spaces were defined as a cyber-learning environment in which computer associated technology is the interface between the educator and the student (Sitzman & Watson, 2017; Watson, 2005). Caring is defined as a moral, ethical, and scientific center of relationships that allows for actualization of human potential in times of health and illness (ANA, 2015; Watson, 2008). Inclusion criteria for this study consisted of scholarly and peer-reviewed articles using a qualitative approach. Each study contained primary data with a focus on caring and interpersonal aspects of online distance learning. Articles were excluded from consideration if they were identified through a key word search associated with simulation, three-dimensional learning programs, patient education, were not a research study (e.g., editorial), non-English language, non-education focused, or with a focus on education in the classroom or clinical setting. Journal manuscripts are widely accessible and have become the vehicle utilized by the discipline to share knowledge; thus, books, editorials, and dissertations were excluded.
An abstract review was completed on all articles considered relevant by title. Following the abstract review, chosen articles were read in their entirety. A team of reviewers (L.M.G., M.K.H., E.T., J.J.) were presented with the final sample of articles for review and discussion. Reviewers discussed the article selections on multiple occasions until consensus on the final sample of articles was reached.
Methodological Critical Review
The McMaster University Tool (Letts et al., 2007) was the methodological rating tool used to guide the critical appraisal process as a first step in interpretive immersion. The decision to use this tool was influenced by the comprehensive criteria, rigor, and objective nature (Letts et al., 2007). Four reviewers (L.M.G., M.K.H., E.T., J.J.) independently reviewed each article and then discussed methodological ratings on multiple occasions (i.e., by telephone, written feedback, and face-to-face web conference). Each study was examined in relation to study purpose, background literature reviewed, study design, appropriateness of study design, design type, sampling, data collection, data analysis, and overall rigor (Letts et al., 2007).
Emden and Sandelowski (1999) suggested that the depth of qualitative research and its implicit goodness can be determined based on the criteria used by the researcher during the research process. Goodness, as discussed by Emden and Sandelowski (1999), refers to the reliability and validity of qualitative research. For this study, reliability and validity are supported by relevance of the research question, article selection process, reflexivity, authentic contribution of authors, and richness of interpretations. The McMaster University Tool allowed the review team to carefully consider and assess overall rigor of selected studies based on credibility, transferability, dependability, and confirmability (Letts et al., 2007).
A metasynthesis is a rigorous, time-intensive process (Ludvigsen et al., 2016; Sandelowski & Barroso, 2007) intended to illuminate new knowledge from existing studies. This process is a reflective practice (Ludvigsen et al., 2016) of interpretation and a reassessment of all chosen studies as a whole (Sandelowski & Barroso, 2007). Answers to new questions are derived from a deepened review, not intended toward replication (Sandelowski & Barroso, 2007). Instead, the aim of a metasynthesis is to move current research into a realm of revealing a new perspective (Richards & Morse, 2013).
As a whole, selected articles for this study were reviewed by a team of researchers focused on interpretation, reinterpretation, and reintegration (Sandelowski & Barroso, 2007). A reciprocal translation process (Noblit & Hare, 1988) was used as an audit trail in support of the team's interpretations, as well as a means to honor each individual study (Noblit & Hare, 1988; Sandelowski & Barroso, 2007). It involves a toolkit of interpretive analytic strategies, including theme analysis and dynamic interplay of inductive, deductive and abductive reasoning, reflection, and back translation (Morrow et al., 2016).
The initial search generated 205 articles. The Figure displays the steps associated with the article selection process. Following a title screening and abstract review, 177 articles did not meet the inclusion criteria. The majority of articles excluded from the study were associated with patient education (n = 47), had a non-education focus (n = 34), or focused on simulation (n = 28). A yield of 14 studies underwent a full article review. After the full article review, a final yield of 10 articles met all inclusion criteria and these were determined to be of relevance to the current study.
Search flow diagram.
Study and Participant Characteristics
A summary including authors, publication year, study purpose, study design, country, methods, participants, and study findings of the 10 articles is presented in Table A (available in the online version of this article). This type of retrospective yet newly interpretive study is a way to tap into the context variation of the participant's world from across the world and across 191 people.
Two of the 10 studies used multiple qualitative data collection methods. The most frequently used data collection method was open-ended interview questions as part of an online survey (n = 5), followed by focus groups (n = 2), with observation, journal writings (n = 1), discussion posts (n = 1), document review, blog entries, and written narrative (n = 1). In studies that identified gender, the predominate gender identified was female (n = 102). Participants' ethnicity was not disclosed. Level of online nursing education explored as part of the 10 chosen studies was evenly distributed: graduate (n = 4) and undergraduate (n = 4). One study included both levels of online nursing education (graduate and undergraduate), and one study did not specify the level of online nursing education.
Methodological Critical Review
The McMaster University 17 criteria review tool was used to critically appraise each study (Letts et al., 2007), the results of which are summarized in Table B (available in the online version of this article). All included studies clearly stated the study purpose and an appropriate literature review was present. Table C (available in the online version of this article) reflects the theoretical perspectives identified in nine of the 10 studies. Sampling methods for all 10 studies were identified as appropriate, and three of the studies articulated a connection between saturation and sample size (Mastel-Smith et al., 2015; Sitzman, 2015, 2016). Only one study lacked an audit trail (Hyde & Murray, 2005). Three studies had elements of all four components of rigor: dependability, credibility, transferability, and confirmability (Gallagher-Lepak, Reilly, & Killion, 2009; Mastel-Smith et al., 2015; Sitzman, 2016). Dependability and credibility were achieved by eight of the studies. Transferability was recognized in seven of the 10 studies. Confirmability was identified in only five studies.
Critical Review of the Identified Studies
Study Theoretical Perspective:
Themes and subthemes that emerged from the metasynthesis of the chosen studies are presented in Table D (available in the online version of this article). A manual naming and coding process identified meanings, features, and relationships. Patterns were grouped and interpreted within each individual study and then across the 10 studies. The overarching synthesized ideal identified from the 10 studies was that technology alters communication, positioning the educator at the heart of interpersonal relationship development supported by the following three themes:
- Virtual learning community formation.
- Intentionality of the educator.
- Students' perceived or experienced gap.
Primary studies identified in Table A are referenced and linked to the themes and subthemes through the reciprocal translation process illustrated in Table D.
Theme 1: Virtual Learning Community Formation. Technology is the interface of online nursing education. Co-creation of this learning environment is necessary for the student in the realization of career and personal goals. This theme speaks to the attributes of an online course that contribute to personal connections. There was a common understanding across all studies of a conscious awareness toward the atmosphere of an online learning environment where “faculty create the environment” Woodard Leners & Sitzman, 2006, p. 318) and that an online atmosphere should be reciprocal where “frequent feedback creates an online environment of caring between the student and instructor” (Sitzman et al., 2006, p. 256). The ability of the educator was another attribute considered to be essential, with instructors describing “a need for competencies beyond traditional classroom learning” (Paulus et al., 2010, p. 14) and “expertise of educator and strong online presence” (Edwards, Perry, & Janzen, 2011, p. 111). Hyde et al. (2005) stated, “Dialogue between the provider and recipient of education is at a minimum and the scope of exchange of ideas in a two-way process is limited” (p. 89), and Mastel-Smith et al. (2015) stated that “feedback through diverse strategies, phone, email, Skype, synchronized chat” (p. 147) gave voice to the need for student–faculty connection points. Use of language and etiquette in the formation of a virtual learning community emerged, with respondents reflecting that “faculty choose and craft communication language carefully” (Woodard Leners & Sitzman, 2006, p. 317), and “non-verbal communication, involved lack of face-to-face communication which at times required extra effort to know classmates and understand communications” p. 317). Technology emerges as the means in creating a virtual community for learning: “technology enhances learning” (Mastel-Smith et al., 2015, p. 147), and “teachers who once taught in traditional face-to-face classrooms are now challenged to adapt their strategies to use technology and remain effective in this new educational environment” (Edwards et al., 2011, p. 102). Therefore, the importance of community is realized by both the student and the educator as part of an online educational environment.
Theme 2: Intentionality of the Educator. Educators are essential for online course implementation, as stated by Paulus et al. (2010), and “need to think about teaching…[and] need to think about learning” (pp. 6–8). This theme speaks to the traits of an online educator that allow for personal connections. An awareness of students' needs emerged as an essential trait, as stated by Sitzman et al. (2015): “…notice, sense circumstances” (p. 25) and by Woodard Leners and Sitzman (2006) “…sensing student overload from a distance” (p. 317). Intentionality of the educator, who can “create a personal touch” (Sitzman, 2016, p. 257) by “sharing of personal stories and photos” (Mastel-Smith et al., 2015, p. 150) and “being authentic” (Edwards et al., 2011, p. 112), endorses the looked-for trait of self-sharing. Modeling caring behaviors emerged as an essential trait in the facilitation of a personal student-faculty connection, described as “empathy, participation in discussions, trust, respect” (Sitzman et al., 2006, p. 257), “presence engenders trust” (Gallagher-Lepak et al., 2009, p. 141), and “active presence, extending beyond the virtual environment (Edwards et al., 2011, p. 112). Thus, the intentional use of technology by the educator allows for a shared connection with the student.
Theme 3: Students Perceived or Experienced Gap. Technology can enhance connectedness or create a virtual gap for individuals engaged in this environment. This theme speaks to the virtual gap that hinders the development of a personal connection, as reflected in the words of a student: “aloneness, trepidation, disconnected, and an unknown” (Gallagher-Lepak et al., 2009, p. 137). Student feelings associated with a virtual learning environment emerged, and they wanted an online course to reflect student–faculty and student–student connections as experienced within a face-to-face learning environment. Students verbalized this loss of connectivity in an online environment as feeling “alone and not the priority” (Sitzman et al., 2006, p. 258), experiencing “isolation, bounded = self-contained” (Hyde et al., 2005, p. 92), and “not receiving feedback, students have dropped courses” (Woodard Leners & Sitzman, 2006, p. 317). A strong assertion toward individuality emerged from all studies, emphasizing the importance of “valuing students as individuals” (Edwards et al., 2011, p. 108), “how much personal information to share” (Gallagher-Lepak et al., 2009, p. 137), “lack of individuality, consider[ing] individual learning needs” (Hyde et al., 2005, p. 92), and “understand[ing] them as people, and not just as a computer entries” (Woodard Leners & Sitzman, 2006, p. 318). Personal and academic growth emerged as the student's primary purpose for participating in an online course “…need challenged, recognize their academic as well as personal potential and insist that they reach it” (Edwards et al., 2011, p. 108) and “…online faculty caring helps me to be the best I can be” (Woodard Leners & Sitzman, 2006, p. 317). The students' experience of an online learning environment being an obstacle in achievement of personal and professional goals emerged: “spending time with technology glitches distract from learning” (Gallagher-Lepak et al., 2009, p. 140). Hence, an educator's awareness of how student learning is experienced in an online environment is essential for reducing the perceived gap articulated by students, as well as the necessity to utilize technology, toward enhancing the student–faculty and the student–student relationship.
Findings from all 10 studies offered a meaningful and authentic representation of the phenomena under study. Online nursing education has become a predominate modality for learning and degree completion (AACN, 2015; Allen & Seaman, 2013, 2015; Kentnor, 2015). Through this metasynthesis of existing qualitative literature, a perception of how technology alters the dynamics of communication in an online educational environment was discovered across all studies. Insight into the understanding of the educator being the heart of how technology can best facilitate a caring, quality virtual learning environment, and a learning environment that enhances personal connections was outlined by the three themes that emerged: (a) Virtual Learning Community Configuration, (b) Intentionality of the Educator, and (c) Students Perceived or Experienced Gap.
Support of a framework for online educators, including course development, technological competency, and a caring consciousness was highlighted through this metasynthesis. This new knowledge is essential for the growth of educators, as well as nursing programs in the understanding that virtual learning spaces need virtually trained educators. Faculty need to become conscious of the altered ways of thinking and methods for educating students that are necessary to meet the expectations of a virtual learning environment.
Realized through the current study are the proficiencies required by the online educator in the use of technology (Edwards et al., 2011; Gallagher-Lepak et al., 2009; Mastel-Smith et al., 2015; Paulus et al., 2010; Sitzman & Woodard Leners, 2006). This discovery corresponds to studies completed in clinical settings related to the use of technology as part of nursing care from the perspective of the patient and the nurse (Kongsuwan & Locsin, 2011; Locsin & Kongsuwan, 2013; McGrath, 2008). These clinical studies support the perception of competency in technology as part of nursing, allowing for the creation of a personal connection (student–educator), as well as a modality to demonstrate caring to the individual (Kongsuwan & Locsin, 2011; Locsin & Kongsuwan, 2013). Further, these studies also reflect how technology can be an obstacle in the creation of a personal connection when a caring intention is not coupled with the use of technology (Kongsuwan & Locsin, 2011; Locsin & Kongsuwan, 2013; McGrath, 2008). This metasynthesis gave voice to the importance of intentional use of technology toward co-creation of a caring online experience that reflects a personal connection between the student and the educator.
Caring is the foundation of nursing (ANA, 2015; Watson, 2008). The three themes that emerged from this study support new knowledge about the creation of a unique human-to-human learning experience as part of an asynchronous virtual educational environment. An educator who is open to the possibility of change, meeting the needs of the other, the individuality that all participants bring to the learning environment, and the use of technology coupled with a caring intention will support the development of interpersonal relationships between the student and the faculty in a virtual learning environment.
Information identified through this study endorses the development of a framework for online nursing courses, the need for continuing education of nursing faculty, and an educator with a caring intention. This study supports future research into the use of technology and promotion of a caring intention in a virtual learning environment, such as the Caritas Processes or the Caritas Coach Education Program, as a foundation for online educator development. Sitzman and Watson (2017) implied that caring does occur within an online environment: “Caritas Consciousness transforms the question of whether or not it is possible to care in digital settings into a quest for excellence in conveying and sustaining caring despite the absence of physical or temporal proximity” (p. 19). A quest for excellence and the development of educated, caring practitioners places the onus on nursing education programs to generate new knowledge regarding how technology is used in nursing education and how faculty are prepared to co-create a caring practice in a virtual learning environment.
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Summary of Included Studies
|Study||Study Purpose||Country||Study Design||Methods||Participants||Summary of Findings|
|Edwards et al. (2011)||Students' perspectives of the qualities of an exceptional online educator||Canada||Narrative Inquiry||Sent questions asked to write a story of their experience||23 graduate students from online Maters; Health Studies, Nursing, Nurse Practitioner programs||*Themes from student stories imply and exemplary educator is the following: (a) challenger, (b) affirmers, and (c) persons of influence
*Online experience is positive when faculty are partnered in the learning with the student|
|Gallagher-Lepak et al. (2009)||Students' perceptions of community in online learning environments||United States||Phenomenology Framework||Focus Groups||18 RN-BSN online nursing student ages 25 to 54||*Fifteen themes which added to or took away from a sense of community in an online course
*Structural themes: class structure, required participation, teamwork, and technology
*Emotional factors: aloneness, trepidations, unknown, anonymity, and communication
*Processual factors: becoming, commonalities, disconnects, mutual exchange, and online etiquette|
|Hyde et al. (2005)||An exploration of the experience of nurses participating in a “distance education program”||Ireland||Grounded Theory||Semi-structured in-depth interviews||15 students ages 26 to 54 who completed a distance education program at diploma level or higher||*Conceptualization of Lifeworld categories
*Students experience isolation in distance education
* “Packaged” limited scope of learning
*Critical thinking limited by decreased interactions
*Program content personalized to meet the learning needs of the student|
|Loke et al. (2013)||To gain an understanding of the political forces at play during online learning within a university context||United Kingdom||Grounded Theory Framework||890 online text-based messages from course discussion boards||13 master's students||*Themes identified: (a) nurses led and dominated discussions, (b) nurses' messages resembled written text for one-way communication, (c) nurses text responses supported by an evidenced based discussion, and (d) nursing text discussions resembled “documentation”
*Online spaces are environments can support a power struggle|
|Mastel-Smith et al. (2015)||Concept development and field study connected to the definition: “Online caring presence is the faculty's feelings of concern for and resulting connection with students in the online environment” using the Caritas Processes™||United States||Grounded Theory Framework||Observation and in-depth interviews||6 doctoral-prepared nursing faculty ages 50 to 67 who taught 100% online and had a working knowledge of the Caritas Processes||*Four major themes: (a) online teaching experience, (b) similarities and differences between online and face-to-face teaching, (c) online presence, and (d) online caring presence
*Communication focused on the student
*Recognizing students' online personality
*Computer alters communication
*Students need to be taught how to respectfully communicate
*Creation of safe spaces for open communication|
|Paulus et al. (2010)||“Describes the experience of faculty at one institution as they participated in a grassroots effort to learn about online teaching”||United States||Case Study||Online discussions, focus groups, and blogging activities||25 nursing faculty||“Six themes related to faculty development emerged”: (a) plugging in, (b) peer sharing, (c) multidimensional learning, (d) paradigm shift, (e) sustaining momentum, and (f) role shifting
*Faculty positive associated with the relational ability technology provides in an online environment
*Faculty perceive online learning can overwhelm students|
|Sitzman et al. (2006)||RN-BSN students' perception of how instructors convey caring in online education||United States||Phenomenology Framework||E-mailed 6 questions||11 RN-BSN online nursing students ages 24 to 48||*Eight themes emerged: (a) frequent feedback, (b) timeliness, (c) caring online is reciprocal, (d) personal connection and empathy, (e) clarity, (f) multiple contact opportunities, (g) commitment to learning, and (h) second-fiddle worries|
|Sitzman (2015)||Nurse educators experience of caring online through Watson's lens||United States||Phenomenological Inquiry||Online survey||24 nursing faculty who teach online ages 32 to 72 in undergraduate and graduate nursing programs||*There themes uncovered: (a) sensing circumstances (b) connecting through reaching out, and (c) facilitating growth
*Educators confident in ability to sense and meet students' needs|
|Sitzman (2016)||“What student cues prompt online instructors to offer caring interventions?”||United States||Phenomenological Inquiry||Online survey||56 nursing faculty ages 26 to 72||*Six categories of student “cues”: (a) academic struggle, (b) appeal for help, (c) concerning behaviors, (d) withdrawal, (e) personal issues, and (f) positive events
*Instructor responses to “student cues”: a.) reaching out, b.) concrete academic support, c.) intentional caring comportment
*Student responses to faculty caring: a.) gratitude, b.) find voice, and c.) improvement
*Study reflects relationship between the student and the instructor|
|Woodard Leners et al. (2006)||An exploration of graduate nursing students' perceptions of caring in online classes||United States||Phenomenology Framework||Open-ended questions through an online survey||39 graduate nursing students consisting of 36 females and 3 males||*Six themes identified: (a) empathetic perspective, (b) timeliness of communication, (c) tone of appreciation, (d) being the best I can be, (e) finding a chord of harmony, and (f) feeling the passion of caring online
*Caring is perceived through attention to quality and relational interactions
*A need for awareness of faculty presence
*Prompt communication as well as constructive communication is expected|
Critical Review of the Identified Studies
|Edwards et al. (2011)||Gallagher-Lepak et al. (2009)||Hyde & Murray (2005)||Loke et al. (2013)||Mastel-Smith et al. (2015)||Paulus et al. (2010)||Sitzman & Woodard Leners (2006)||Sitzman (2015)||Sitzman (2016)||Woodard Leners & Sitzman (2006)|
|Was the purpose and/or research question stated clearly?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Was relevant background literature reviewed?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Was a theoretical perspective identified?||Yes||Yes||Yes||Yes||Yes||Yes||No||Yes||Yes||Yes|
|Were the sampling methods appropriate?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Was sampling done until redundancy in data was reached?||No||No||No||NA||Yes||NA||NA||Yes||Yes||NA|
|Was procedural rigor used?||No||Yes||NA||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Clear and complete description of participants?||No||Yes||No||Yes||Yes||No||No||Yes||Yes||Yes|
|Role of researcher and relationship with participants?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Were data analyses inductive?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Were findings consistent with and reflective of data?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Was a decision trail developed?||Yes||Yes||NA||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Was the process of analyzing the data described adequately?||No||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Did a meaningful picture of the phenomenon under study emerge?||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Do the descriptions and interpretations of the participants appear to capture the phenomenon?||Yes||Yes||No||Yes||Yes||Yes||No||Yes||Yes||Yes|
|Can the findings be transferred to other situations?||No||Yes||No||Yes||Yes||No||Yes||Yes||Yes||Yes|
|Was there consistency between the data and findings?||Yes||Yes||No||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Were strategies employed to minimize bias?||No||Yes||No||Yes||Yes||Yes||No||No||Yes||No|
Study Theoretical Perspective:
|Theoretical Perspective Identified||Study|
|Community of Inquiry Model||Edwards et al. (2011)|
|Habermas' Dualism of System and Lifeworld||Hyde & Murray (2005)|
|Bakhtin's Theory of Intertextuality||Loke et al. (2013)|
|Caritas Processes™ from Caring Science||Mastel-Smith et al. (2015)|
|Seven Principles of Good Practice||Paulus et al. (2010)|
|Watson's Human Caring Theory||Sitzman (2015, 2016); Sitzman & Woodards Leners (2006); Woodards Leners & Sitzman (2006)|
Team Synthesis and Reciprocal Translation
Technology alters communication positioning the educator at the heart of interpersonal relationship development
|Derived Analytic Themes and Subthemes||Study||Primary Study Themes|
|Virtual Learning Community Formation|
|This theme speaks to the attributes of the online course which contribute to personal connections|
|Atmosphere||Edwards et al. (2011); Gallagher-Lepak et al. (2009); Loke et al. (2013); Mastel-Smith et al. (2015); Sitzman et al. (2006, p. 256); Woodard Leners et al. (2006, p. 318)||Educator creates the learning experience (Edwards et al., 2011); class structure (Gallagher-Lepak et al., 2009); understanding of nursing communication (Loke et al., 2013); safe environment, caring community (Mastel-Smith et al., 2015); frequent feedback creates an online environment of caring between student and instructor (Sitzman et al., 2006, p. 256); faculty create the environment (Woodard Leners et al., 2006, p. 318).|
|Educators' ability||Edwards et al. (2011, p. 111); Mastel-Smith et al. (2015); Paulus et al. (2010, p. 14); Sitzman et al. (2006)||Expertise of educator and strong online presence (Edwards et al., 2011, p. 111); online faculty need to be mentored, teaching experience (Mastel-Smith et al., 2015); need competencies beyond traditional classroom learning (Paulus et al., 2010, p. 14); clarity of course requirements (Sitzman et al., 2006).|
|Student–faculty connection points||Gallagher-Lepak et al. (2009); Hyde et al., (2005, p. 89); Loke et al. (2013); Mastel-Smith et al. (2015, p. 147); Sitzman et al. (2006); Sitzman (2015); Sitzman (2016); Woodard Leners et al. (2006, p. 317)||Informal discussions, teamwork participation, mutual exchange (Gallagher-Lepak et al., 2009); Dialogue between the provider and recipient of education is at a minimum and the scope of exchange of ideas in a two-way process is limited (Hyde et al., 2005, p. 89); communicate as accessor and educator (Loke et al., 2013); feedback through diverse strategies, phone, email, Skype, synchronized chat (Mastel-Smith et al., 2015, p. 147); timeliness, reciprocal, and frequent communications (Sitzman et al., 2006); reaching out (Sitzman, 2015); purposeful response (Sitzman, 2016); students clearly desired prompt responses from faculty as often as possible (Woodard Leners et al., 2006, p. 317).|
|Language/etiquette||Gallagher-Lepak et al. (2009, p. 137); Loke et al. (2013); Mastel-Smith et al. (2015); Paulus et al. (2010); Sitzman (2016); Woodard Leners et al. (2006, p. 317)||Non-verbal communication involved lack of face-to-face communication which at times required extra effort to know classmates and understand communications (Gallagher-Lepak et al., 2009, p. 137); rules of conduct for online communication (Gallagher-Lepak et al., 2009); nurses communicate like they document, technical terminology, text reflects evidence based (Loke et al. (2013); awareness of online tone (Mastel-Smith et al., 2015); anonymity facilitates depth of responses (Paulus et al., 2010); finding online voice (Sitzman, 2016); faculty choose and craft communication language carefully (Woodard Leners et al., 2006, p. 317).|
|Use of technology||Edwards et al. (2011, p. 102), Gallagher-Lepak et al. (2009); Mastel-Smith et al. (2015, p. 147); Paulus et al. (2010); Sitzman et al. (2006)||Teachers who once taught in traditional face-to-face classrooms are now challenged to adapt their strategies to use technology and remain effective in this new educational environment (Edwards et al., 2011, p. 102); knowledge of computers as well as malfunctions of computers (Gallagher-Lepak et al., 2009); technology enhances learning (Mastel-Smith et al., 2015, p. 147); mastering technology, use technology effectively, alters role of faculty (Paulus et al., 2010); technology can limit an understanding of information received and transmitted (Sitzman et al., 2006).|
|Intentionality of Educator|
|This theme speaks to traits of an online educator which allow for personal connections|
|Awareness of students' needs||Edwards et al. (2011); Mastel-Smith et al. (2015); Sitzman (2015, p. 25); Sitzman (2016); Woodard Leners et al. (2006, p. 317)||Watching for clues (Edwards et al., 2011); in-tune, intuitive (Mastel-Smith et al., 2015); notice, sense circumstances (Sitzman, 2015, p. 25); academic struggle, concerning behaviors, withdrawal (Sitzman, 2016); Sense student overload from a distance (Woodard Leners et al., 2006, p. 317).|
|Self-sharing||Edwards et al. (2011, p. 112); Mastel-Smith et al. (2015); Sitzman et al., (2006); Sitzman (2015); Woodard Leners et al. (2006)||Authentic (Edwards et al., 2011, p. 112); sharing of personal stories and photos (Mastel-Smith et al., 2015); sharing about self (Sitzman et al., 2006); personal touch (Sitzman, 2015); willingness of faculty to share about themselves (Woodard Leners et al., 2006).|
|Modeling caring behaviors||Edwards et al. (2011, p. 110); Gallagher-Lepak et al. (2009, p. 141); Mastel-Smith et al. (2015, p. 149); Sitzman et al., (2006, p. 257); Sitzman (2015); Woodard Leners et al. (2006)||Active presence, extending self beyond the virtual environment (Edwards et al., 2011, p. 110); presence engenders trust (Gallagher-Lepak et al., 2009, p. 141); flexibility, holistic approach, knowing the student (Mastel-Smith et al., 2015, p. 149); empathy, participation in discussions, trust, respect (Sitzman et al., 2006, p. 257); humanizing, establishing connections (Sitzman, 2015); sensitivity, openness, responsiveness, being genuine (Woodard Leners et al., 2006).|
|Students perceived or experienced a gap|
|This theme speaks to the virtual gap which hinder the development of personal connections|
|Student feelings||Gallagher-Lepak et al. (2009); Hyde et al., (2005, p. 92); Sitzman et al., (2006, p. 258); Woodard Leners et al. (2006, p. 317)||Trepidation, aloneness, disconnected, unknowns (Gallagher-Lepak et al., 2009); isolation, bounded = self-contained (Hyde et al., 2005, p. 92); students feel alone and not the priority (Sitzman et al., 2006, p. 258); not receive necessary feedback students have dropped courses (Woodard Leners et al., 2006, p. 317).|
|Individuality||Edwards et al. (2011, p. 108); Gallagher-Lepak et al. (2009, p. 137); Hyde et al., (2005, p. 92); Mastel-Smith et al. (2015); Paulus et al. (2010); Sitzman et al., (2006); Woodard Leners et al. (2006)||Value students as individuals (Edwards et al., 2011, p. 108); how much personal information to share (Gallagher-Lepak et al., 2009, p. 137); lack of individuality, consider individual learning needs (Hyde et al., 2005, p. 92); online personalities, individualized learning (Mastel-Smith et al., 2015); awareness students are balancing learning and responsibilities (Paulus et al., 2010); value student experiences brought to the environment (Sitzman et al., 2006); know students on a personal level (Woodard Leners et al., 2006).|
|Personal/academic growth||Edwards et al. (2011, p. 108); Gallagher-Lepak et al. (2009, p. 140); Paulus et al. (2010); Sitzman (2015); Woodard Leners et al. (2006, p. 317)||Need challenged, recognize their academic as well as personal potential and insist that they reach it (Edwards et al., 2011, p. 108); spending time with technology glitches distract from learning (Gallagher-Lepak et al., 2009, p. 140); set the bar high, maintain momentum (Paulus et al., 2010); facilitate growth (Sitzman, 2015); online faculty caring helps me to be the best I can be (Woodard Leners et al., 2006, p. 317).|