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Abstract
The authors examined education records of 1,661 registered nurses from four affiliated hospitals who attended either a 1-hr face-to-face instructor-led training program, an instructor-facilitated Web-based training program, or an independent Web-based training program to fulfill a training requirement concerning patient education. The authors compared post-test results, course evaluation results, and costs and also developed a demographic profile of nurses' preferences for Web-based and face-to-face learning options. There was no significant difference in course effectiveness or satisfaction between the training methods studied; however, because of the large number of nurses who selected Web-based training, it was the most cost-effective alternative.
Innovations in technology such as Web-based instruction have enhanced the knowledge acquisition of nurses by providing interactive content in a flexible learning environment. The proliferation of computer-facilitated learning options, such as continuing education offerings and online degree programs, suggests increased demand by nurses for this method of learning. Nurses at Norton Healthcare in Louisville, Kentucky, have been increasingly exposed to Web-based training (WBT) opportunities since 2005 when the corporation hired two eLearning developers and purchased high-end authoring software for developing interactive WBT. The technology was presented to nurses first with learning the electronic documentation system, then with required safety and corporate compliance training, and finally with occurrence reporting, process improvement, and some clinical competency topics.
When faced with the need to provide a mandatory education offering for approximately 3,000 employees at all four hospitals in the system, the authors immediately thought of WBT as a practical and cost-effective teaching option. However, there was still some skepticism among members of the project team about whether nurses would embrace this method of learning and adequately grasp the content and required competencies. The authors decided to offer nurses the options of independent WBT, instructor-facilitated Web-based training (FWBT), or face-to-face classroom experience and study the effectiveness and efficiency of each option. Post-test results, course evaluation results, and costs were analyzed, and a demographic profile of nurses' preferences for each type of learning activity was developed. The outcomes provided valuable information for future decision making regarding teaching methodology and allayed fears that nurses might not be ready for Web-based learning.
REVIEW OF LITERATURE
Web-based instruction has the potential to enhance knowledge acquisition of students or at least be a viable alternative to traditional face-to-face instruction. The achievement of learning objectives with Web-based instruction has been reported to be similar with that of traditional face-to-face instruction for equivalent participants (Atack, 2003). A key component of the effectiveness of Web-based instruction was believed to be support, particularly from online contact with peers and the instructor. Maki and Maki's (2002) study indicated that students achieved higher grades on Web-based instruction but that the level of learning was linked to motivation and expectations of the individual student. Part of this enhanced achievement comes from self-directed learning, including a number of interactive methods, providing choices in mechanisms of acquiring the instruction (Billings, Connors, & Skiba, 2001) and using problem-based activities (Maki & Maki, 2002). Koeckeritz, Malkiewicz, and Henderson (2002) suggested matching the student's preference for content delivery with the mechanism by which the content is delivered. However, matching multiple mechanisms of content delivery with the variety of student preferences is only useful if flexibility of delivery is available. One way of ensuring flexibility is to provide opportunities for tutorials or to incorporate traditional face-to-face methods with Web-based teaching (Kozlowski, 2002).
There is limited evidence concerning the characteristics of staff nurses in determining their preferred mechanism of instruction and whether matching this preference with the method of instruction can have a significant effect on achievement of learning objectives, satisfaction with the instruction, and cost of content delivery (Hewitt-Taylor, 2001).
Providing Web-based learning resources challenges staff educators to develop their own technological proficiency, which may be overly time consuming (Larsen, Logan, & Pryor, 2003). Using information technologists may make course design easier and more efficient. The time required for course design is variable, with some reports of at least 30 hr of design for each hour of online course content (Christianson, Tiene, & Luft, 2002).
PURPOSE AND HYPOTHESES
The purpose of this study was to compare three different mechanisms of staff instruction concerning patient education in the inpatient setting. The three methods included independent study using a WBT module, FWBT, and a face-to-face instructor-led training (ILT) with Web-based practice. The study compared competency with the content area, satisfaction with the mechanism of instruction, and labor costs associated with each mechanism of instruction. This purpose was addressed through the following hypotheses:
Hypothesis 1: Nurses who independently complete a Web-based instruction module concerning patient education will demonstrate greater competency with the content area as compared with nurses who complete an instruction module concerning patient education administered through FWBT support or face-to-face instructor-led class.
Hypothesis 2: Nurses who complete a Web-based instruction module concerning patient education will demonstrate greater satisfaction with the mechanism of instruction as compared with nurses who complete an instruction module concerning patient education administered FWBT support or face-to-face instructor-led class.
Hypothesis 3: The labor costs associated with a Web-based instruction module concerning patient education will be less than labor costs associated with patient education administered through FWBT support or face-to-face instructor-led class.
The study also sought to answer the question, are the demographic characteristics different between nurses who choose to complete a 1-hr face-to-face education program and those who choose to complete a Web-based education program to fulfill an educational requirement?
METHODS
As a requirement of continued employment at the four Norton Healthcare hospitals (Kosair Children's Hospital, Norton Suburban Hospital, Norton Audubon Hospital, and Norton Hospital), approximately 3,000 staff members, consisting of nurses and non-nurse professionals, were required to complete an education program during the first 2 months of 2007. This education program included how to provide and document patient education. Two methods were offered through which the staff could complete this educational requirement: WBT or face-to-face ILT. Nurses from the four hospitals self-selected one of these methods of education. Nurses who selected the ILT option received one of two methods of instruction, depending on the location of the class and the preference of the educator (see Figure 1). Some attended a traditional ILT course with lecture and Web-based activities, whereas others completed the Web-based instruction with an instructor/facilitator in the room to assist and answer questions. After the education session, participants from all groups were required to complete a proficiency test and an evaluation form which included demographic information. Educational records were deidentified and aggregated, and permission for record review was obtained from the Institutional Review Board and the Norton Healthcare Research Office prior to data analysis. The Institutional Review Board approved the study as expedited with no consent required for review of existing data.
 | FIGURE 1 Breakdown of how education method was selected and offered. WBT = Web-based training; ILT = instructor-led training; FWBT = instructor-facilitated web-based training. |
INTERVENTIONS AND PROCEDURES
The authors reviewed records of 1,661 registered nurses who completed the training via one of the following methods:
* ILT classes presented in computer classrooms at prescheduled times by instructors using a PowerPoint presentation and portions of the WBT module on the computer for practice. The class lasted 1 hr, and participants were paid for that hour.
* WBT delivered through a self-directed format accessible on a Web site from any PC, 24 hr a day for 6 weeks. The module required approximately 1 hr to complete, and participants were paid 1 hr of base pay upon proof of completion of the module and competency test.
* FWBT conducted at specified times in a classroom setting using the WBT module. A trained facilitator was present in the classroom to guide participants in logging onto the site, assist with any technical problems, answer content questions, and provide other feedback related to the course. As with the other methods, participants were paid 1 hr of base pay upon completion.
Nurses registered for the class or WBT module using a computer-based enrollment system. Staff educators used the same learning objectives, content, examples, and practice scenarios in developing the three types of courses that were provided.
After the instruction, each participant completed two instruments. First, they completed a course evaluation, including demographic questions which documented their gender, education, years of professional service, and previous experience with computers. The course evaluation also requested participants to rate their level of satisfaction on a 5-point Likert scale (very dissatisfied, dissatisfied, neutral, satisfied, and very satisfied). Next, participants completed a proficiency examination which measured their competency with the content included in the patient education instruction. A score of 85% was required to pass the competency test. Nursing staff who did not achieve 85% competency were required to repeat the proficiency examination until able to achieve a grade of 85%. They were allowed to review the module as often as necessary. Staff received payment for 1 hr, at their regular hourly rate, once they completed the proficiency examination, regardless of how much time they needed to complete the course.
Educators who developed the content for each of the three methods of instruction documented the number of hours they spent developing each of the specific presentation formats. The researchers spread the time that was spent developing the content, including case examples and practice scenarios, over all three methods of instruction. In addition, for the WBT, educators documented time spent with the eLearning developer writing, reviewing, and revising the module. The eLearning developer's time dedicated to the project was also documented. For the ILT classes, the time required to prepare the audiovisual aids and train the trainers was added to the actual face-to-face class time. For the FWBT, the facilitator's time to be present in the classroom was documented. These times were multiplied by standard rates for developers and staff educators then divided by the number of attendees for each method to arrive at a total cost per student for each method of instruction.
ANALYSIS
Preliminary analysis of the data consisted of comparing demographics between the nurses in the three groups of instruction. To address the hypotheses, these three groups were compared on their competency scores on their first attempt to complete the proficiency examination, pass rate score of 85% or greater on the first proficiency examination, their satisfaction with the method of instruction, and the total cost per participant relative to the method of instruction. Chi-square statistics were employed for group comparisons involving categorical data, and one-way analysis of variance statistics were calculated to address comparisons between the groups on continuous variables. Statistical significance was set at p < .05. For each statistical model addressing the study hypotheses, the participant's self-selected group was the independent variable. To address Hypothesis 1, the individual's initial competency score was employed as the dependent variable. Individuals were categorized as passing the proficiency examination on the first attempt if they scored 85% or higher on the proficiency examination. If individuals scored below 85%, they were categorized as failing on the first attempt to complete the proficiency examination. Analyses addressing Hypothesis 2 employed satisfaction with the mechanism of instruction as the dependent variable. The 5-point satisfaction scale was collapsed into not satisfied, neutral, and satisfied by combining the satisfied and very satisfied scores into the satisfied category and the very unsatisfied and unsatisfied scores into the unsatisfied category. Finally, total labor cost and cost per individual were used as the dependent variables to address Hypothesis 3.
RESULTS
As Table 1 indicates, of the 1,661 nurses in the study, 1,544 (92.9%) selected the WBT method of training, whereas 50 selected the ILT method and 67 attended a FWBT class, thus indicating that nurses preferred to complete the training using the WBT method of instruction. These groups differed only in their years of experience as a nurse ([chi]2 = 12.5, p = .05). Nurses with <5 years of experience were more likely to choose WBT (94.3%) than nurses with 21+ years (91.6%), although a very high percentage of both of these groups preferred the WBT method (see Figure 2). The groups did not differ on any other demographic variables.
 | TABLE 1 Comparisons Between Three Methods of Instruction |
 | FIGURE 2 Years of experience as a factor in the selection of WBT. WBT = Web-based training. |
Similarly, nurses who participated in the study expressed a degree of satisfaction with their method of instruction that was not significantly different from the satisfaction of others. Satisfaction rates ranged from 72% in the WBT to 84% in the ILT group.
The WBT total cost was the greatest at $6,253 followed by ILT at $5,512 and FWBT at $3,953. However, due to the large number of participants who selected the WBT option, the cost per student ($4.05) was dramatically lower than the cost per student for ILT ($59.35). Because of the large investment of instructor time needed to be available for participants to do the FWBT and the low number of participants who selected this method, the cost per student was dramatically higher for this method ($110.25) than for either of the other two (see Figure 3).
 | FIGURE 3 Comparison of labor cost per student of each method. WBT = Web-based training; ILT = instructor-led training; FWBT = instructor-facilitated web-based training. |
CONCLUSIONS
The results do not support the first two hypotheses of the study. The WBT was equally as effective as the FWBT and ILT methods of instruction in terms of achieving competency with the content area and satisfaction with the mechanism of instruction. Hypothesis 3 was supported. Although the total labor cost was greater for WBT than FWBT and ILT, the cost per individual was substantially less than these other methods of instruction. This cost per person combined with the similar effectiveness of the WBT in generating similar levels of proficiency with the content and satisfaction among the participants indicates that WBT was the most cost-effective method of instruction for the large number of participants who needed the required education. A number of factors are pertinent for future decision making (see Figure 4). Consideration should be given not only to the size of the target audience, but also to the potential for future audiences to use the module. For instance, the patient education module used in this study will continue to be used for new employee orientation. Given the development cost of WBT, the key to cost effectiveness is the audience size. The more the module can be used with future audiences, with little or no maintenance, the lower the cost per participant.
 | FIGURE 4 Decision checklist. WBT = Web-based training; IT = information technology. |
During program planning, educators need to determine whether the objectives of a course can be met using a Web-based approach. Clearly, there are some topics, such as those that require hands-on practice of a technical skill, for which this method of instruction may not be ideal. However, technological advances in the field of eLearning are occurring rapidly. Some authoring programs allow for highly interactive simulations and problem-solving modules. Review of the satisfaction surveys, including written comments, provided insight into the reasons nurses overwhelmingly self-selected WBT over a scheduled class. They claimed to appreciate having the course available 24/7 on the Web and being able to schedule the course around their other life demands. They liked working at their own pace and being paid for the class whether they took it on the job or at home. Technical difficulties created frustration for a significant percentage of learners, however, and one cost not captured by the researchers was time spent on technical support after the program was launched. Whereas it is desirable to create courses that are interactive, with simulations that allow the student to practice new skills, it is important to assess in advance whether the software will be compatible with the computer systems the audience will most likely use.
The demographic instrument asked nurses to report the types of computer activities they had engaged in previously to determine if there was a correlation between previous computer experience and likelihood to select WBT. Generally, there was a trend toward greater likelihood of selecting WBT with increased experience with computers, but even nurses with little previous experience still selected WBT.
Nurse educators can save time and money by converting some of their frequently used content-stable coursework to WBT format. Nurses appreciate variety in teaching techniques and prefer learning methods that are engaging, interactive, and self-paced. The more frequently nurses are exposed to WBT, the more comfortable they become, and the more they prefer this option. When educators allow nurses to choose when and where they complete the WBT, this teaching method becomes even more appealing. Nurses are definitely ready for WBT, and educators have a great opportunity to increase their own efficiency and productivity while satisfying their customer, the nurse.
REFERENCES
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Billings, D. M., Connors, H. R., & Skiba, D. J. (2001). Benchmarking best practices in Web-based nursing courses. Advances in Nursing Science, 23(3), 41-52. [Context Link]
Christianson, L., Tiene, D., & Luft, P. (2002). Web-based teaching in undergraduate nursing programs. Nurse Educator, 27(6), 276-282. [Context Link]
Hewitt-Taylor, J. (2001). Self-directed learning: Views of teachers and students. Journal of Advanced Nursing, 36(4), 496-504. [Context Link]
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