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Effects of e-learning, lectures, and role playing on nursing

Effects of e-learning, lectures, and role playing on nursing
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  Original Article  Medical Journal of theIslamic Republic of Iran(MJIRI) Iran University of Medical Sciences    ____________________________________________________________________________________________________________________ 1.PhDStudent in Nursing, Student Researches Committee, Faculty Member, School of Nursing and Midwifery, Mashhad University of MedicalSciences, Mashhad, 2. ( Corresponding author ) MSc, Faculty Member, East Nursing and Midwifery Research Center, School of Nursing and Midwifery, BirjandUniversity of Medical Sciences, Birjand, Iran. 3.MSc in Biostatistics, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.  Effects of e-learning, lectures, and role playing on nursingstudents knowledge acquisition, retention and satisfaction Tayebeh Pourghaznein 1 , Hakimeh Sabeghi 2 , Keyvan Shariatinejad 3 Received: 9 January 2014 Accepted: 26 April 2014 Published: 25 January 2015 Abstract Background :Nursing education can maintain its dynamic quality when it moves toward innovation and mod-ern methods of teaching and learning. Therefore, teachers are required toemploy up to date methods in their teaching plans. This study evaluated the effects of e-learning, lectures, and role playing on nursing studentslearning, retention, and satisfaction. Methods : Sixty nursing students were selected as an experiment and control groups during two consecutivesemesters. The educational content was presented as e-learning and role playing during one semester (experi-ment group) and as lectures in the next semester (control group). A questionnaire containing three parts wasused to assess demographics, learning and satisfaction statuses. The questionnaire also included a final open-ended question to evaluate the students ideas about the whole course. Results : The mean scores of posttest were 16.13 ± 1.37 using role playing,15.50 ± 1.44 using e-learning and16.45 ± 1.23 using lectures. The differences between the mean scores of posttest and pretest were 12.84 ± 1.43,12.56 ± 1.57, and 13.73 ± 1.53 in the mentioned methods, respectively. Lectures resulted in significantly better learning compared to role playing and e-learning. In contrast, retention rates were significantly lower using lec-tures than using role playing and e-learning. Students satisfaction from e-learning was significantly lower thanlecturing and role playing. Conclusion : Due to the lower rates of retention following lectures, the teachers are recommended to use stu-dent-centered approaches in their lectures. Since students satisfaction with e-learning was lower than the other methods, further studies are suggested to explore the problems of e-learning in Iran. Keywords : E-learning, lecture, role play, nursing students. Cite this article as :Pourghaznein T, Sabeghi H, Shariatinejad K.Effects of e-learning, lectures, and role playing on nursing studentsknowledge acquisition, retention and satisfaction.  Med J Islam Repub Iran 2015(25 January). Vol. 29:162. Introduction Increasing medical knowledge and theconsequent recognition of problems alongwith the shift from teacher-centered in-struction tolearner-centered teaching inhigher educations have imposed new re-sponsibilities on both the teachers and thelearners. Among the most important issuesis choosing the best learning method(1).Most universities throughout the world areseeking appropriateteaching methods toenhance clinical decision making and pro-vide continuous, self-centered learning(2).Teaching nursing can maintain teachingdynamic quality as long as it moves towardinnovation, development, and use of mod-ern methods of teaching and learning(3).Achieving this goal requires the teachers touse up-to-date methods in their teaching plan(4). In other words, selecting the bestteaching method is one of the most im- portant steps in instructional design(5).Effective learning is in fact the result of agood teaching(6). Giving lecture is the prevailing method of teaching in medicaleducation. Despite the emergence of mod-  Traditional vs. modern methods of nursing education 2 MJIRI,Vol. 29.162.25 January 2015  ern teaching methods like problem-solvingapproach and the availability of computersand the Internet, lectures are still used toexchange information due to their numer-ous benefits including cost-effectivenessfor large populations(7). Evidence suggeststhat useful content and a good lecturer will provoke positive and reasonable outcomes(6). Although attending lectures is an inev-itable part of every persons learning expe-rience, it prevents learners from thinking asan essential element of learning. Studieshave shown that about 80% of the infor-mation acquired through lectures will beforgotten after eight weeks(8).According to educational psychologists,effective, long-lasting learning entails acti-vate engagement of the leaner. Therefore,education professionals are currently em- phasizing modern, active, learner-centeredmethods(9). Baghaei writes in his articlequoting Noules: that adults learn efficient-ly only via self-directed methods(6). Sev-eral teaching and learning approaches, in-cluding e-learning, have been derived fromthis theory. The e-learning enables learnersto reach their educational goals based ontheir talents and learn how to learn, whichis from educational aims(10).E-learning is a self-learning activitywhich has been newly employed in manyuniversities and education centers. It alsohelps achieving a main objective of formaleducation, i.e. preparing learners for activeand independent learning(11,12). Withthe rapid development of informationcommunication technologies (ICT), Inter-net technologies and web-based applica-tions have created unprecedented opportu-nities for conducting learning, and this phenomenon has led to the exponentialgrowth of electronic learning (e-learning)in recent years(13). This method has infact provided a new paradigm of teachingand learning which enables everyone tolearn anything anywhere and at any timethroughout their lives(14). This is of par-ticular importance and necessity in nursing profession as nurses need access to updatedinformation on diseases, treatments, drugs,and thus, new skills(15). Studies on theadvantages of teaching with computershave shown positive and promising resultscompared to other methods(16). Changetal. reported that compared to traditionalteaching methods, computer-based teachingsaves 25-60% of the learners time(15).However, this method is not common innursing education in Iran(17).Role playing is another approach for teaching and learning. It has been especial-ly designed to analyze individual valuesand behaviors, establish solutions to inter- personal (and personal) problems, and de-velop empathy with others. In medical edu-cation, role playing can be a practice for learners to communicatewith patients, dis-cover emotions involved in various behav-iors, and practice new behaviors and atti-tudes in a safe situation that resembles realconditions(18,19). Role playing assiststhe students to enhance their understandingof their own and otherpeoples feelings,develop new behaviors, and improve their  problem solving skills. However, due to theamazing nature of role playing, it maysometimes be disregarded as a context for developing educational content. The bene-fits of role playing depend onthe quality of its practice and more importantly on itsanalysis. To be precise, instead of being agoal, role playing is a means to help stu-dents show values, feelings, attitudes andsolutions and finally listen to their teachersevaluations(18).Chan(2012), considered role playing asan effective learning strategy which facili-tates independent learning and is hoped to be used by nursing teachers(20).Despite the repeated emphasis on usingmodern teaching methods, the teachers still prefer traditional methods. Implementationof modern and active methods of learningwill undoubtedly require an approach toresearch-based education. Therefore, thisstudy evaluated the effects of e-learning,lectures, and role playing on learning, re-tention, and satisfaction of nursing stu-dents.  T.Pourghaznein, et al.3 MJIRI,Vol. 29.162.25 January 2015  Methods In a quasi-experimental study, 60 nursingstudents in their fourth semester were se-lected from the School of Nursing andMidwifery (Mashhad University of MedicalSciences, Iran). Using census method, indi-viduals who werestudying their fourth se-mester during the first and second halves of 2011-12 academic year were selected as anexperiment (n=31) and control groups(n=29), respectively. The inclusion criteriawere picking Medical-Surgical nursing-IIcourse, for the firsttime and not having oc-cupations related to nursing.A three-part author-made questionnairewas used to collect data. It evaluated de-mographic information, theoreticalknowledge (20 MCQ), and satisfaction (12questions on a five-point Likert scale fromvery much to very little). The final itemwas an open-ended question that asked thestudents opinion about the entire course.Content validity was used to validate thesatisfaction questionnaire. The designedquestionnaire was distributed among 32undergraduate nursing students to identifytheir ideas about factors affecting educa-tional satisfaction. Afterward, the resultswere presented to ten faculty members of the mentioned university and the question-naire was revised based on their recom-mendations. The internal reliability of thetool was also confirmed (Cronbachs alpha= 0.82).Data were collected at baseline and oneweek and one month after the end of thecourse. All exams were extracted from thequestions bank and matched in terms of difficulty. Thetests were performed onkidney and urinary tract diseases (taughtduring Medical-Surgical Nursing-IIcourse). In the experiment group, the con-tents were divided to two parts and in-structed through e-learning and role play-ing. The control group received all the con-tent via lectures.E-learning was facilitated by having un-limited password protected access to thevirtual education system of Mashhad Uni-versity of Medical Sciences. The studentswere also allowed to email or visit their in-structors in case of any problems. The ex- periment group first attended a briefing ses-sion in which all stages of education wereexplained. Informed consents were thenobtained from eligible students. The select-ed individuals filled out the pretest ques-tionnaires and were taughthow to accessthe Internet and use the available infor-mation. After they had asked all their ques-tions, a unique password was provided toeach subject. Although the same contentwas supplied by both lectures and e-learning, the latter presented the material inthe form of slides, flash videos, and audiofiles (recorded in the teachers voice).During the five sessions of role playing,the scenario was developed by the instruc-tor (the researcher) and a nursing studentwith experience in theater. It was then per-formed by four nursing students in the roleof doctor, nurse, patient, and his/her com- panion. This scenario had been performedin three previous semesters along with ap- plied recommendations from performersand students. One week after the comple-tionof each teaching method, a written testwas taken to examine the students learn-ing. A satisfaction assessment form wasalso distributed among the participants. Af-ter one month, a second exam was heldwithout previous notice to determine theretention ofthe content.During the next term, the same contentwas provided to the control group throughlectures. The effects of lectures on learning,retention and satisfaction of the studentswere separately compared to the results ob-tained from role playing ande-learning.Using SPSS for Windows 11.5 (SPSS Inc.,Chicago, IL, USA), the collected data wereanalyzed by descriptive statistics as well ast-test, paired t-test, and Kruskal-Wallis,Mann-Whitney with Bonferroni correctionas Post Hoc test, Wilcoxon, andSpear-mans tests. Results The results of this study indicated thatthere was no significant difference between  Traditional vs. modern methods of nursing education 4 MJIRI,Vol. 29.162.25 January 2015  the two groups in terms of age, gender, and baseline level of knowledge. Most partici- pants were female (65%), single (88.3%),and with little interest in their study field(61.7%) and medium knowledge of com- puters (65%). The mean age of the subjectswas 20.91 ± 1.19 years old and their grade point average (GPA) until the time of studywas 16.24 ± 1.16 (on a 20 scale).The mean posttest scores were 16.13 ±1.37 in the role playing group, 15.50 ± 1.44in e-learning group, and 16.45 ± 1.23 in thelecture group. They were all significantlyhigher than pretest scores (12.84 ± 1.43,12.56 ± 1.57 and13.73 ± 1.53, respective-ly; p< 0.001). Moreover, lectures weremore effective on learning, i.e. the differ-ence between posttest and pretest scoresusing lectures was significantly greater thanthose using role playing (p= 0.024) and e-learning (p= 0.005).However, there was nosignificant difference in learning betweenrole playing and e-learning (p=0.381).After one month, the scores had signifi-cant reductions in all three methods (Table1). Lectures resulted in significantly lower retention rate comparedto role playing (p=0.001) and e-learning (p= 0.013). In addi-tion, although no significant difference inretention was observed between e-learningand role playing (p= 0.134), reductions inscores were less using the latter method.Students satisfactionwith e-learning wasless than the other two methods (Table 2).According to Mann Whitney test with Bon-ferroni correction results, the students sat-isfaction from e-learning was significantlylower than lectures (p< 0.001). Satisfactionrates from role playing and lectures werenot significantly different. However, MannWhitney test with Bonferroni correctionresults showed signficiantly higher satisfac-tion after role playing compared to e-learning (p < 0.001). While most partici- pants were moderately satisfied with lec-tures (40%) and role playing (35%), 31.7%of the subjects had little satisfaction from e-learning.Answers to the final open-ended questionrevealed major reasons for dissatisfactionwith e-learning included lack of access tohigh-speed Internet services, the habit of having face to face relationships, reducedinteraction between the students and theteacher, the habit of attending classes andstudying only during exams, and teachersmethods of lecturing and giving clinicalexamples.There was a significant positive correla-tion between the GPA during the past threesemesters and satisfaction from e-learning(p< 0.001; r: 0.606). Conversely, there wasno significant relation between the GPAand satisfaction from the other two meth-ods. None of other demographic character-istics was significantly correlated with sat-isfaction from different teaching methods. Discussion We found lectures to be a significantlymore effective teaching method than role playing and e-learning. In contrast,Hezaveyie etal. reported significantlyhigher scores of nutrition-relatedknowledge after role playing than after lec-tures(21). Similarly, Erfanian et al. showedrole playing to more effectively improvelearning of communicational and counsel- Table 1. Scores of nursing students immediately after the course and one month later using different teaching methodsImmediately afterOne month laterDifferencepRole playing16.13 ± 1.3715.26 ± 1.50-0.87 ± 0.62< 0.001e-learning15.50 ± 1.4414.45 ± 1.60-1.05 ± 0.57<0.001Lecture16.45 ± 1.2314.97 ± 1.53-1.48 ± 0.73< 0.001Values are presented as mean ± SD.Table 2. Scores of satisfaction from different methods of teachingMedianThe First quartileThe ThirdquartileRole playing423675e-learning262432Lecture403644  T.Pourghaznein, et al.5 MJIRI,Vol. 29.162.25 January 2015  ing skills of students(22).This differencemight be justified by the fact that theoreti-cal topics and multiple-choice questionsdeal with cognitive aspects, but role play-ing involves emotional, mental, and motor domains. In addition, according to the re-sults of studies in this field,(23)careful de-sign and development of a scenario and providing feedback can elevate the effi-ciency of role playing(24).We also found lectures to result in signif-icantly better acquisition compared to e-learning. Contrariwise, some previous stud-ies have obtained the same levels of acqui-sition via e-learning and lectures(10,25-30). In a study by Woo and Kimmick, de-spite the absence of significant differencesin acquisition scores and satisfaction be-tween lectures and e-learning, studentswere significantly more motivated using e-learning. This method was nonetheless as-sociated with more problems with softwareand technical support(31). Another re-search on nursing students who used web- based e-books reported satisfaction andself-guided learning asimportant factorsleading to better acquisition in this method.The researchers thus concluded that highquality and effective web-based learningrequires the teachers to identify the learn-ers characteristics from the very first stepsof course design(32).Various factors might have been respon-sible for differences between our findingsand previous studies that suggested the benefits of e-learning. As our participantsstated, reading habits and problems of e-learning such as lack of access to high-speedInternet were among the barriers tothe success of this method. Likewise,Schrader and Kldiashvili indicated that possessing personal computers and havingrelevant skills facilitate students functionin e-learning(33). vanutet al. reportedthat voluntary use of virtual learning in-creases the learners acceptance. Therefore,making this course obligatory for studentsreduces its effectiveness(34).In the present study, retention of contentfollowing lectures was significantly lower than that after role playing and e-learning.Moreover, although there was not a signifi-cant difference between e-learning and role playing in this regards, the latter was asso-ciated with lower reductions in scores over time. According to previousresearch, role playing not only promotes knowledge re-tention, but also allows the students to actout real situations and reduces their anxiety(35). Maunye et al. reported role playing asa common method of teaching for nurses inMpumalanga in the easternpart of SouthAfrica(36). Other studies have also intro-duced role playing as a method to promotecommunication and counseling skills(22,37,38).Our participants were significantly lesssatisfied with e-learning than lectures androle playing. However, there was no signif-icant difference between role playing andlectures regarding satisfaction. In contrast,Woo and Kimmick did not find a signifi-cant difference between satisfaction fromlectures and role playing(31). Our partici- pants reasons for dissatisfaction from e-learning included not having access tohigh-speed Internet, being accustomed toface to face relationships, reduced interac-tions between students and teachers, habitsof attending classes and studying only dur-ing exams, and teachers methodsof lectur-ing and giving clinical examples. There-fore, the students learning methods need to be modified as they enter university or evenduring high school years. The studentsshould also be motivated and their habit of studying only for exams and scoreshas to be changed. Multiple strategies such as us-ing student-centered methods beside lec-tures and constant assessment of studentsthroughout the semester are hence indis- pensable. Furthermore, problems of low-speed Internet and inadequate computer skills must be solved as the results of other studies showed that one of the major effec-tive dimensions on using e-programs iscomputer and Internet skills(39).Finally, the significant positive correla-tion between GPA and satisfaction from e-learning emphasizes the importance of the
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