Preparing nurses on-line to work off-line

Experiences gained from teaching final year undergraduate nursing students in Ireland.


Sile A. Creedon MSc (Nursing), BNS, RGN,

RM, RNT, Dip IT (Teachers)



Creedon, S.  (February, 2007).  Preparing nurses on-line to work off-line: Experiences gained from teaching final year undergraduate nursing students in Ireland. Online Journal of Nursing Informatics (OJNI), 11, (1) [Online]. Available at


The purpose of this paper is to present methodologies employed and experiences gained as a result of delivering a 12 week program to final year nursing students in Ireland.  This program aimed to prepare a cohort of student nurses (n=41) to meet challenges offered by recommendations issued by the National Health Service Executive in Ireland. These recommendations focus on managing patient related data using Information Technology.   Two pedagogical approaches were taken: web-based and classroom based.  As this was the students first experience with this type of learning, they consented to participate in a survey on their experiences during this course.  Responses were overwhelmingly positive.  Furthermore, students displayed that they had engaged with the material provided for them and developed a deep understanding of the topic being studied.  This was evident in their written formative and summative work.  Recommendations from this program include preparing nursing students throughout Ireland to meet recommendations issued by the HSE and that these types of teaching strategies may be used to facilitate students in developing a deeper understanding of a chosen subject.



Nursing Informatics, online learning, virtual learning environment, interaction, peer review.



The purpose of this paper is to present methodologies employed and experiences gained as a result of delivering a 12 week program to final year nursing students in Ireland.  The genesis for this program came from recommendations issued by the National Health Service Executive in Ireland (Irish Health system ICT Framework 2003, National Health Strategy 2001).  These recommendations guide the use of ICT (Information and Communications Technology) by all persons involved in delivering patient care in Ireland.  Specific recommendations included development of electronic patient records, telemedicine, e-health and use of PDAs.  An overriding principle is maintenance of privacy and confidentiality of patient related information.  As nurses are the largest group of healthcare workers in Ireland, these recommendations are particularly relevant to them.  However, due to a lack of preparation, most nurses feel ill-prepared to meet these recommendations (Murphy et al 2004).  Furthermore, there is a dearth of published literature in relation to this topic from Ireland except that published by Murnane (2005) and that publication related to one reform in one acute care hospital.   Therefore, the aim of this program was to begin to address the gap in both nursing knowledge and practice related to the use of ICT tools on a broader level.


Course description.

            The program objectives included (i) to examine implications for health care delivery arising from telemedicine (ii) to examine the status of information technology within Irish Healthcare (iii) to explore models of computerised healthcare services and (iv) to evaluate models of information management systems.  The course title was ‘Informatics for nurses’ and was one of four optional programs offered to fourth year nursing students.  Forty one students (from a cohort of 145) opted to take it.  In delivering this program, two pedagogical approaches were adopted:  web-based and classroom based. This led to a very different experience for both students and lecturer. 

A virtual learning environment (Blackboard, was used throughout the entire program and students worked in electronically secure groups of five.  Facilities provided to each group included file transfer, discussion board, chat room and email.  The course was delivered using a three week cycle: on week one, students attended a 2 hour lecture in a classroom (IT lab) where each student had access to a computer and shared printer.  Content was delivered using specifically designed web tools and PowerPoint presentations. At the end of the lecture, students were given a particular topic for discussion on the electronic discussion board and recommended hyperlinked reading.  On week two, students were expected to contribute to the discussion board. Clear times, dates and word limits were communicated using an electronic announcement board.  The lecturer reviewed all material submitted and gave timely feedback.  On week three, students reviewed their peers’ contributions (within their group) and were asked to provide a peer review for submission.  Again, expectations in relation to submission dates, times and word limits were clearly communicated through electronic announcement boards.  Once more, the lecturer reviewed the content and gave timely feedback.  On week four, students attended four lectures and the process recommenced.


Related literature

In preparing to deliver this program and in order to facilitate students’ knowledge development, I reflected on my own objective as lecturer which is to engage students/learners with:


Thurmond (2003) describes these types of engagement as ‘interaction’ and defines it as ‘…a reciprocal exchange of information which enhances knowledge development in the learning environment.  The goal of interaction is to increase understanding of the course content or mastery of the defined goals’.   Four types of interaction are cited frequently in the literature: learner-content, learner-learner, learner-lecturer, and learner-interface.  (Chen 2002, Crawford 1999, Ehrlich 2002, Swan 2001).  The first three forms of interaction can be found in both traditional lecture theatres and on Web-based courses.  The last type of interaction, learner-interface, may be present or totally absent in the traditional lecture theatre.  However, Hillman, Willis and Gunawardena (2004) conclude that learner-interface interaction can have a tremendous bearing on students learning the content.  Nevertheless, the four types are not mutually exclusive.

Consequently, these theoretical underpinnings are used as a framework for this paper:


  1. Learner-content interaction:

Moore & Kearsley (1996) suggest that learner-content interaction results from students examining/studying the course content and from participating in class activities.  The literature related to learner-content interaction suggests that variables that affect this type of interaction include continuous availability of the content (Leasure, Davis & Thievon 2000), clarity of course design (Swan 20010, time (Atack and Rankin 2002), participation in online discussions (Jiang & Ting 1999) and mode of delivery of course content (Faux and Black-Hughes 2000). 

In relation to continuous interaction with the course content, Swan (2001) suggests that a Web-based format may encourage deeper immersion with the content than the traditional course format.  In this program, course statistics revealed a weekly average of 200 ‘hits’ to the program content area.  This represents an average of 5 hits / week per student.  This is in contrast to teaching other programs where students attend/not weekly lectures and complete their assignments a couple of days prior to the submission date.  Moreover, Leasure et al (2000) found that extensive contact with course content (Web-based course) increased enthusiasm for the course and may have resulted in improved grades. 

In terms of course design, Swan (2001) suggests that in a web-based course, students may perceive learning easier if the material is consistently presented in a similar format.  In this program, content was repeatedly presented using MS PowerPoint and hyperlinked web-tools.  Core content was delivered using PowerPoint format and subsequent required reading was then presented using hyperlinked web-tools. 

A major concern expressed by these students prior to engaging in this program was that lack of time to assimilate content in other courses led to a superficial knowledge in those areas. This was due to a school policy which requires high attendance at lectures (80%) and students’ apparent difficulty in sourcing recommended course reading.  In this program, much of the reading was provided (hyperlinked) and time required to read was realistically identified.  Engagement in this reading was required for submission to discussion boards. 

The medium used to deliver course information included both traditional lecture format (but using web-tools) and web-based format (lectures and reading provided, electronic discussion boards, email and chat rooms).  The literature reflects students’ differing views on preferred methods of course delivery. For example, students interviewed by Sole & Lindquist (2001) preferred the traditional classroom setting while Faux and Black-Hughes (2000) reported that students preferred more than one medium.  This was reflected in this course with more than one medium being used.  Mavarro and Shoemaker (2000) compared results achieved by students in a traditional class format with students using a web-based format.  Students engaged in a web based format course (n=48) performed significantly (p<.01) better than those exposed to traditional format (n=145).  As there was only one cohort of students in this course such comparisons were not possible.  However, on grading their assignment, the majority of students achieved either a first or second class honour indicating that they closely engaged with the question set or indicating a mastery of the subject citing relevant literature.  This was not the case in grades achieved in other programs.  


2.0. Learner-learner interaction.

The interaction that occurs among students in a Web-based course and a traditional lecture theatre is extremely dissimilar.  Beard & Harper (2002) suggest that in order for effective learning to occur in a web-based course, three types of peer behaviour are necessary: participation, response and provision of feedback.  In this program, students were required to periodically submit their reflections (discussion boards) and then review their peers’ submissions (peer review).  Students were divided into electronically secure groups of five members. Facilities for file transfer, email and chat were provided for each group.  Despite this being their final year in a four year program, this was the first experience of peer review for this group (or these students).  Non submission was not an option and dates / times of expected submissions were given.  Protected time was allocated for each submission.  Students firstly made their own submission to their allocated group and then reviewed their peers’ submissions (within their allocated group).  A further submission, which reflected their peer review was then required.  Dates and time of expected submissions were clearly displayed through the use of electronic bulletin boards.

The literature suggests that properly designed forms of interactions between students on Web-based courses may have more depth (McGinn 2000, Muirhead 2001) and this was certainly my experience.  Student’s submissions reflected engagement with the course content and recommended reading.  On evaluation of the program, many students (n=21) reflected that this form of interaction was the most effective learning methodology experienced by them in the entire program to date.  This confirms findings from a study of eight experienced teachers in online learning who rated the learner-learner interaction as the most important form of interaction (Soo & Bonk, 1998).  


3.0 Learner-Instructor interaction:

The interaction that transpires between students and lecturers is intended to reinforce student understanding of the course content or clarify meanings.  The pedagogical role of the lecturer in a Web-based format is a dramatic change from the one in the traditional lecture theatre.  In the traditional format, the lecturer often takes centre stage while in the Web-based format; the lecturer becomes more of a facilitator (Gutierrez 2000). In traditional classroom settings, interaction can occur face to face while in a Web-based course, interaction must be transmitted electronically by email or chat discussions. Using survey data collected from 287 students in 78 Web-based courses, Jiang and Ting (1999) concluded that learner-instructor interaction was the most significant predictor of perceived learning. 

In this course, students frequently emailed me or participated in discussion boards related to content material.  When students were required to make submissions and peer review in their secure groups, I reviewed each submission made to each group.  I commented on the strengths / limitations of each student’s submission in a timely manner.   The time required to undertake this work is not to be underestimated and is a crucial factor to be considered if further courses / programs are to be delivered in the manner that this one was.  However, on evaluation, students commented on the importance of this interaction in relation to their learning and satisfaction with the program.  This confirms findings by Leong, Ho and Saromines (2002).


4.0 Learner-interface interaction

Findings from the literature show that students’ prior experience with computers, computer skills and access to computers can affect their learning in a web-based course (Leasure et al 2000, Wilson & Weiser 2001, Kenny 2002).  For the purposes of this course, students interacted with Blackboard and the Internet.  Students possessed varying degrees of computer literacy – many were novices.  However, the simplicity of design and user-friendliness of Blackboard facilitated many students to overcome any concerns initially felt. Use of two pedagogical mediums also helped as I was physically present for various sessions and any difficulties could be resolved.




As this was the first time this program had been conducted, students consented to participate in an online survey of their experiences related to this program.  A questionnaire was developed following an extensive review of related literature.  The questionnaire consisted of 15 open-ended questions in five sections. Questions related to demographics comprised section one.  Questions in sections two, three and four related to the Virtual learning environment, student – student interaction, and student – lecturer interaction respectively. There were 41 students in the cohort and all were invited to participate in the survey and given the opportunity to decline. The survey was conducted online using Mark class software.  Anonymity and confidentiality was assured.  Data was analysed using thematic analysis.



Thirty one (31) questionnaires were returned (75% response rate).  No follow up reminders (letters, emails) were used to prompt any further replies.  In hindsight, it might have benefited the study and further boosted the response rate if one prompt had been used. 

Ninety eight per cent (98%) of participants were female (n=30) with only one male respondent.  Most, 60% (n=19) were aged between 20 – 29 years.  Eight participants (25%) were aged between 30 and 39 and 15% (n=5) between 40 and 49 years.  When asked how they viewed their expertise in relation to using computers, 30% (n=10) categorised themselves as ‘expert’, 40% (n= 12) ‘comfortable’ and 30% (n=10) as ‘novice’. 


Questions relating to students’ views on using a VLE to facilitate online discussion, electronic group membership, email facilities and peer review were positively responded to.  All respondents (100%) felt their learning was positively enhanced by using a VLE.  Some students (40%) said they preferred to email the lecturer rather than telephone.  Participation in an online discussion board and electronic group membership were new experiences to all students and all evaluated both as an ‘excellent’ method of facilitating their learning. Direct comments included:

In relation to participation in online discussions

            ‘it was a new experience for me and forced me to practice and improve my computer skills.  It made me read the literature in preparation for the next discussion’.


            ‘I found this way of learning very good.  It should be used on other programs in the future.  I hadn’t done anything like it before and I found it very simple and very effective’.

            ‘it made the assignment interesting.  I put more effort into my assignment because I knew my friends would be reading it and as a result I did a better essay’.


            ‘it was a valuable learning experience, it makes you work harder when you know your peers are going to be reading your work.  It was a good incentive to get a better grade’.


Student to student interaction:

Questions relating to how students interacted with each other again received positive responses from all participants (n=31). 


‘My experience was very positive! Working as a group was really good.  I have never done peer review before and I have to say it raised the standard for all of us and encouraged us to put in more work’.


‘I found this very interactive and a great way to learn. It was helpful in that you could interact with what other people were doing and this helped to spark ideas. An enjoyable and new way to learn’.


‘I really enjoyed participating in the discussions and you had to have your reading done to do this’.


‘It was great to participate this way, exchanging ideas; it was fast and just very enjoyable. Wish we had more of it! Excellent!!’


Student – lecturer

Responses related to student / lecturer interaction were very positive.  The focus appeared to be on the importance of receiving timely feedback which confirms findings by Leong, Ho and Saromines (2002). 


‘It was such a help getting feedback after each discussion….  I really learned from this course’.


‘I have never had this type of experience before, Sile really kept the pressure on in the discussions…. it was just great!!’


‘This was such a different approach to teaching – wonderful….knowing how you were doing made such a difference’,


‘Fantastic….guidance from sile really helped me…best experience in the four years…’.


Student – content. 


Comments related to the course content and reflections on learning included:


‘I have learned such a lot about IT in the health services in Ireland. Thank you!’


‘This was a fabulous program, the content is really relevant.  I would recommend that this should be a core program.’


‘Excellent content, relevant to nursing, I really learnt a lot’


‘The material was very relevant and caused me to reflect on IT in the health sector.  I would not have done this without this program’.



Evidence of student learning


The summative assessment in this program required students to reflect on the ward/unit/care area they were most familiar with and to design a nursing information system to manage patient related data in that area.  Presentations were peer reviewed and the final grade was awarded by the lecturer. 

Student submissions focused on hardware and software required.  Details related to hardware required i.e. numbers and exact location of monitors, use of PDAs and tablets.   Functionality of software required included detailed development of electronic care planning and electronic patient records.  Much emphasis was placed on system security and confidentiality of patient related data.  Many students presented their view on how their ‘desktop’ might appear using various icons they had developed.  All students related their recommendations to relevant literature.  All students outlined the training required for ‘their’ system and many had consulted their hospitals to outline the financial implications of their proposal.  One of the main strengths of all proposed ‘systems’ was their application to nursing practice in the ward outlined.  A further strength related to how the students had integrated relevant literature and had contextualised their work to the Irish healthcare system.  Overall, many students displayed evidence that they engaged systematically with the assignment set and showed strong evidence of a comprehensive mastery of the subject matter, ably supported by relevant citations.  Furthermore, much of their work displayed a highly developed capacity for original, creative and logical thinking.  Their summative assessments were marked by two lecturers and the external examiner who all commented on the high quality of the work presented.  Most students achieved an honour in their results with many receiving first class honours. 



Experiences gained from delivering this program confirm findings from other researchers (Swan 2001) that web-based courses may facilitate a deeper understanding of the course content.  Furthermore nurses need to be prepared to engage with ICT tools.  Therefore, programs such as the one described in this paper may prove timely.  There is an urgent need to address this area, particularly in Ireland. 

In relation to providing web-based or online courses, the amount of time invested by both students and lecturers needs to be investigated and compared to traditional methods of teaching and learning.  Leasure et al (2000) and findings from this study suggest that students in web-based courses had more continuous contact with the course content because of the participation in electronic discussions than did students in the traditional classroom setting.  A comparison between study time in the traditional classroom setting and the virtual environment would be interesting for all involved in education.

Further research needs to be conducted in the area of instrument development.  Many of the studies in this area (Merisotis 2001, Wharrad et al 2005, Garde et al 2005) do not provide information on instrument reliability and validity.  Therefore, it may be useful to develop an instrument that would assess the four types of interaction discussed in this paper. 

Finally, more research is needed so that firmer conclusions might be made on web-based courses and student outcomes.  In particular quasi-experimental studies are needed where web-based and traditional pedagogical approaches might be compared. 




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Author’s Bio

Sile A. Creedon MSc (Nursing), BNS, RGN, RM, RNT,

                           Dip IT (Teachers)


Sile Creedon is a lecturer in the School of Nursing and Midwifery, University College Cork, Ireland.  Her areas of expertise are Nursing Informatics, Infection Control and Nursing Research and she lectures at both undergraduate and postgraduate level.   She is research active in both infection control and nursing informatics and has numerous publications in both areas.  She is currently studying for her PhD with London City University.