Nurse Education Today 66 (2018) 166–174

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Review

E-learning and nursing assessment skills and knowledge – An integrative T

review
⁎
Ewan W. McDonald , Jessica L. Boulton, Jacqueline L. Davis
Austin Clinical School, La Trobe University, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: This review examines the current evidence on the effectiveness of digital technologies or e-based
Health assessment learning for enhancing the skills and knowledge of nursing students in nursing assessment.
E-based learning Design & Background: This integrative review identifies themes emerging from e-learning and ‘nursing assess-
Digital learning: e-pedagogy ment’ literature. Literature reviews have been undertaken in relation to digital learning and nursing education,
Clinical skills
including clinical skills, clinical case studies and the nurse-educator role. Whilst perceptions of digital learning
are well covered, a gap in knowledge persists for understanding the effectiveness of e-learning on nursing as-
sessment skills and knowledge. This is important as comprehensive assessment skills and knowledge are a key
competency for newly qualified nurses.
Data-sources: The MEDLINE, CINAHL, Cochrane Library and ProQuest Nursing and Allied Health Source elec-
tronic databases were searched for the period 2006 to 2016. Hand searching in bibliographies was also un-
dertaken.
Review Methods: Selection criteria for this review included:
(i) Published in English;
(ii) Study design included measurement or analysis of Nursing subject material which included a significant
‘nursing assessment’ component; and
(iii) Study cohort was students who were enrolled within schools of higher education or directly working in the
clinical practice setting.
Findings: Twenty articles met the selection criteria for this review, and five major themes for e-based learning
were identified (a) students become self-evaluators; (b) blend and scaffold learning; (c) measurement of clinical
reasoning; (d) mobile technology and Facebook are effective; and (e) training and preparation is vital.
Conclusions: Although e-based learning programs provide a flexible teaching method, evidence suggests e-based
learning alone does not exceed face-to-face patient simulation. This is particularly the case where nursing as-
sessment learning is not scaffolded. This review demonstrates that e-based learning and traditional teaching
methods used in conjunction with each other create a superior learning style.

1. Introduction which could potentially impact patient safety. Undertaking assessment

Undergraduate education and clinical placement experience aims to
prepare nursing student nurses with a level of competence and con-
fidence for independent practice upon professional nurse registration.
However, a great deal of criticism surrounds undergraduate nursing
programs for failing to adequately prepare students. Recent studies
report that new graduate nurses lack skills in key clinical areas (Missen
et al., 2016a). In views of experienced RNs, nearly one third of graduate
nurses are rated as “poorly or very poorly” at executing clinical skills
(Missen et al., 2016b). Additionally, a lack of confidence in inter-pro-
fessional collaboration is also identified (Pfaff et al., 2014); an issue
procedures, together with critical thinking and problem solving, were
competencies that perceivably fell short of expectation for the advanced
beginner level of the graduate registered nurse; a level outlined by
Benner's (1982) seminal framework, “From Novice to Expert” (pp
402–407).
Benner's (1982) framework, originally derived from “The Dreyfus
Model of Skill Acquisition” (Dreyfus and Dreyfus, 1980), highlights that
the advanced beginner nurse (the Graduate Nurse) should demonstrate
an acceptable level of competency for clinical practice. This level of
competency is detailed in the Registered Nurse Standards for Practice
(Nursing and Midwifery Board of Australia, 2016) and is achieved, as a

⁎
Corresponding author at: Austin Clinical School, La Trobe University, Austin Tower – Level 4, Austin Health, PO Box 5555, Heidelberg, VIC 3084, Australia.
E-mail address: ewan.mcdonald@latrobe.edu.au (E.W. McDonald).

https://doi.org/10.1016/j.nedt.2018.03.011
Received 22 May 2017; Received in revised form 16 February 2018; Accepted 13 March 2018
0260-6917/ © 2018 Elsevier Ltd. All rights reserved.
E.W. McDonald et al.
novice (an undergraduate nurse), through a process of attaining theo-
retical knowledge (by university study) and by following guidelines
(such as outlined in hospital protocols, policies and procedures) which
are supported by experiential learning (on clinical placements and/or in
clinical simulations) prior to registration as a Registered Nurse.
Achieving clinical competency for new graduate nurses includes
developing the skills and knowledge to conduct systematic health as-
sessments of patients in their undergraduate degrees. Conducting
comprehensive health assessments of patients is a core competency for
standards of practice in nursing (Nursing and Midwifery Board of
Australia, 2016). Focused patient assessments using a body systems
approach (cardiac, respiratory etc.), head-to-toe assessment and func-
tional health assessment are cornerstone foci introduced early in un-
dergraduate programs.
Prior to clinical exposure, theory components of undergraduate
degrees address the need for understanding systematic health assess-
ments. Practical patient simulations offer the unique and necessary
opportunity for undergraduates to practice the implementation of these
skills with no risk to live patients. Practical patient simulations, com-
monly used in other health disciplines as well, traditionally include
demonstrations by educators, student role-plays, patient actors, use of
anatomic models (for instance to practice injections or insertion of a
nasogastric tube or an indwelling urinary catheter) and, more recently,
the use of digital technology and high fidelity human manikins
(Durham and Alden, 2008).
Student nurses are then required, in a clinically supported en-
vironment, to apply acquired assessment and procedural skills during
clinical learning in their degrees across acute and subacute, primary
care and mental health settings.
At the completion of their degree, nursing students are expected to
have transitioned from the novice (the student), who functions largely
via compartmentalised context-free rules and clear guidelines, to the
advanced beginner (the graduate nurse) who is more able to transpose
learned skills and acknowledge context and meaning in dynamic clin-
ical situations (Benner, 1982; Dreyfus and Dreyfus, 1980).
As well as the challenge of preparing suitably competent graduates
for clinical practice, nursing education providers must integrate e-
learning into curricula, particularly in view of preparation for the ‘di-
gital age’ of health care. E-learning is a widely accepted term to de-
scribe educational material that utilises Information and
Communications Technology (ICT) for learning purposes and can in-
clude web-based or computer or digital or online learning. Compared to
face-to-face study, e-learning is often seen as attractive to universities
and training providers because of its cost-effectiveness in accom-
modating large cohorts of students (Thorne et al., 2015). E-learning is
also widely perceived as beneficial by students in offering flexible and
self–paced studying (Cook et al., 2008; Farrell et al., 2007). Some nurse
education providers foresee digital technology as transforming —
stating that it can enhance teaching quality, equip graduate nurses in
‘practice-readiness’ and ultimately build a stronger health-care work-
force (School of Nursing - George Washington University, 2016).
Evidence from educational research, however, is not equivocal on
enhancement of teaching quality and improvement of learning out-
comes. Systematic and meta-analyses have identified equivalent and
improved learning outcomes for e-learning packages vis-à-vis face-to-
face learning in health education (for both professionals and students)
though there are limitations in this body of research (Chumley-Jones
et al., 2002; Cook et al., 2008; McCutcheon et al., 2015; Thorne et al.,
2015). Firstly, only a limited number of studies, particularly in nursing,
collect student data across nursing campuses/schools. Many studies are
limited by sample size and may not be representative. Secondly, subtler
indications of learning, such as decision-making and clinical reasoning,
are rarely captured in the measurement of learning outcomes (Finn,
2010). Thirdly, Koch (2014) argues that the question of how to teach
clinical skills in e-learning is not discussed in literature — an ‘e-peda-
gogy’ unique to nursing is urgently needed. For example, although
167
Nurse Education Today 66 (2018) 166–174
digital clinical case-studies engage procedural, attitudinal and cognitive
learning (Hara et al., 2016) psychomotor skill development may be
neglected without face-to-face interaction between a professional ‘role
model’ nurse educator and the student nurse. Experiential and social
learning in the psycho-motor domain may also be restricted with the
use of ‘impersonal’ digital technology (Koch, 2014).
Teaching health assessment in nursing in the digital age is a for-
midable didactical challenge. It encompasses cognitive, procedural and
psychomotor learning and is a subject which is failing to develop
‘practice-readiness’. The purpose of this integrative review is to sum-
marise evidence on the use of digital technologies or e-based learning to
enhance the skills and knowledge of students and registered nurses in
clinical assessments. An integrative review can offer a more compre-
hensive understanding of a healthcare phenomenon as studies with
diverse methodologies (quantitative and qualitative) are included
(Whittemore and Knafl, 2005). Whilst literature and systematic reviews
have been completed on online clinical case studies (Hara et al., 2016),
online learning to enhance clinical skills (Bloomfield et al., 2008) and
overall nursing student knowledge (Lahti et al., 2014), we wish to focus
specifically on e-learning and improving clinical health assessment
skills and knowledge.
Studies which evaluate clinical competencies and knowledge may
include assessment skills as part of their measurement or understanding
of student learning. We are interested in various forms of digital tech-
nologies, including e-portfolios, Wikis, online quizzes, interactive tools,
iPad devices, video and social media. Conducting an integrative review
will provide a greater understanding of this emerging area of education
and offer directions for future research. The review will incorporate
both experimental and non-experimental studies and focus on peda-
gogical knowledge and observational findings.
2. Method
A PICO (Population, Intervention, Comparison, Outcome) Model
was used to define the research question to ensure that the literature
search was relevant. The key search terms used combinations of words
including (i) students and nurs*, undergraduate, baccalaureate and
clinician; (ii) e-based technology, computer assisted instruction, e-*
simulation, elec* # simulation, wiki*, blog*, online quiz*; and (iii)
clinical assessment* and clinical competenc*, knowledge and skills.
Studies were located using the following online research databases:
MEDLINE, CINAHL, Cochrane Library and ProQuest Nursing and Allied
Health Source. Manual hand-searching was also undertaken based on
the reference list of retrieved articles. Inclusion criteria for studies were
(i) Single research study or Systematic Review (ii) Study design in-
cluded measurement or analysis of Nursing subject material which in-
cluded a significant ‘nursing assessment’ component; (iii) English lan-
guage; (iv) Published between 2006 and 2016; (iv) study cohort were
student nurse from Australia, North America, South America, Europe,
Asia and Africa who were enrolled within schools of higher education
or directly working in the clinical practice setting. Studies which solely
included Registered Nurses as the experimental cohort or group of in-
terviewees were excluded.
The original series of searches resulted in a total of 268 articles. The
citation from each article was reviewed, and 157 articles were regarded
irrelevant as they did not meet the inclusion criteria. The abstracts of
the remaining 111 articles were then reviewed and 33 articles were
found to be applicable. Following this, the full text of each of the 33
articles was reviewed. 16 articles were excluded and three new articles
were sourced from a manual search. This left a total of 21 articles re-
levant for review.
3. Findings
Table 1 displays each identified study including the research pur-
pose, design, the learning of ‘nursing assessment’ component, sample/
 Table 1
Summary of studies.
Author(s), year, Purpose
country
Chan et al. (2016), To examine the Case-Based Web
China Learning (CBL) experience of
students using both traditional
classroom and web-based
approaches
Watson et al. (2016) To understand student experience of
Australia using Facebook to build confidence
in clinical skills
Bogossian et al. To measure and investigate
(2015), students' learning and virtual
Australia clinical performance in response to
an e-simulation of a deteriorating
patient (FIRST2ACT)
168
Cooper et al. (2015), To evaluate the performance of
Australia student satisfaction of an e-
simulation program of a
deteriorating patient with
traditional face-to-face teaching
Brown and To explore the impact of tablet
McCrorie technology, in the form of Apple
(2015) iPads, on students' learning
Australia outcomes
Rosenkoetter et al. To implement and evaluate the use
(2014) U.S.A. of the Video Analysis Tool (VAT)
online system to capture video
evidence of students clinical
performance
McCutcheon et al. To review and evaluate evidence of
(2015) United online or blended learning programs
Kingdom for teaching of clinical skills in
undergraduate nursing
Design Learning of ‘Nursing Assessment’
component
Quasi-experimental - e- (i) Education setting - Medical and
learning intervention Surgical Nursing & Paediatric
Mixed-methods Nursing courses
(ii) Clinical reasoning ability
measured
Phenomenological (i) Student enrolled in Clinical
approach – semi-structured Health Assessment course
interviewing (ii) Interview question on
confidence in clinical skills
Pre-post intervention - (i) Skills measured include
multi-center ‘recognizing a deteriorating patient’
and ‘managing emergency
priorities’
(ii) Clinical knowledge tested is of a
deteriorating patient
Quasi-experimental-pre- (i) Skills measured include
post intervention ‘recognizing a deteriorating patient’
and ‘managing emergency
priorities’
(ii) Clinical knowledge tested is of a
deteriorating patient
Case study: survey (i) Use of iPad for accessing clinical
guides on collapse and chest pain
during Clinical Laboratory
Pre-post intervention – (i) Geriatric Nursing content
multi site including Nursing Assessment
Systematic review (i) Teaching of clinical
competencies in nursing which
includes assessment skills
Sample/group
Third-year undergraduate
nursing students
Quant. survey n = 122
Three focus groups, 18
participants
First-year nursing students.
10 participants
Final year nursing students
across 3 universities and 2
vocational colleges
n = 367
Final year nursing students
n = 97 (Face-to-Face teaching)
n = 30 (e-simulation)
First-year and third-year
nursing students.
n = 45
Undergraduate Nursing
students in Geriatric subject
across 4 Universities
n = 80
18 primary studies and one
secondary study identified and
reviewed
Outcome measures/themes
Self-developed questionnaire (5
point Likert) with three domains -
self-learning ability, clinical
reasoning ability and student
satisfaction with CBL
Focus groups - five themes emerged:
structure, environment, critical
thinking and problem solving,
influence of culture, technological
concerns
Themes – enhanced social
connectedness, perceived
benchmarking with other students,
short and long term ambitions,
familiarity and immediacy
Self-assessed clinical knowledge and
skills using 11 item 5 point Likert
scale. Objective assessment of
clinical knowledge on deteriorating
patient using 11 item multiple
choice questionnaire. Clinical
performance measured using ‘click’
data aligned to an Objective
Structured Clinical Examination
(OSCE) score sheet. Used for all 3
scenarios – Cardiac, Shock,
Respiratory
Objective assessment of clinical
knowledge on deteriorating patient
using 11 item multiple choice
questionnaire. Clinical performance
measured using ‘click’ data aligned
to an Objective Structured Clinical
Examination (OSCE) score sheet.
Used for all 3 scenarios – Cardiac,
Shock, Respiratory
Online survey of 6 items on student
satisfaction including open
comments
Questionnaire of 15 item 5-point
Likert scale - student perception of
the effectiveness of the VAT on their
learning.
10 questions on Geriatric Nursing
knowledge
Systematic review with inclusion/
exclusion criteria and quality
appraisal criteria – low, moderate,
high bias risk
Resultsa/findings & implications
E.W. McDonald et al.
(=)
No difference between the face-to-
face and web-based approaches for
self-learning ability and clinical
reasoning
Real-time e-discussion and progress
tracking online recommended.
Greater teacher interaction online to
suit Chinese culture (i.e. teacher
respect)
Students' sense of confidence in
clinical skills was increased e.g. ‘I
can do this’. The Facebook page
provided a means to discuss, reflect,
clarify, consolidate learning and
develop collegial relationships
(+, =)
Significant increase in mean clinical
knowledge score from 7.63 pre-
simulation to 8.68 post-simulation
(p < 0.01). Knowledge the main
predictor of clinical performance
(R2 = 0.090, p < 0.001) i.e.
university students performed
significantly better. Only 38.1%
achieved a clinical performance pass
across all three scenarios
(=)
Significant improvements in clinical
performance scores for both e-
simulation and traditional face-to-
face teaching
Students reported favourably on use
of iPads. No statistical significance
testing. Descriptive tables shown
with percentages of responses
(=)
No significant difference was found
for pre and Geriatric Nursing
knowledge other than for medication
and nutrition knowledge
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Nurse Education Today 66 (2018) 166–174
 Table 1 (continued)

Author(s), year, Purpose Design Learning of ‘Nursing Assessment’ Sample/group Outcome measures/themes Resultsa/findings & implications
country component

Nineteen primary studies were

E.W. McDonald et al.

identified. The available evidence

Carlson-Sabelli et al. To examine leaner perception of
(2011), U.S.A. benefits and challenges associated
with the Neighborhood (NBH) - a
virtual community
Heinrich et al. To assess content knowledge of
(2012) U.S.A. students participating in MicorSim
virtual case studies, in the classroom
setting.
Wilson et al. (2014) To examine student performance
U.S.A. and the diagnostic skills used in
Case study – survey (inc. (i) Virtual ‘Neighborhood
open comments) Community’ involves student
nurses examining health status,
symptom emergence and medical
records
Pre-post intervention – Patient scenario tested includes
experimental acting on assessment data (ABG and
pathology)
Quasi-experimental Sepsis scenario using diagnostic
crossover reasoning skills
1st year First-semester
undergraduate nursing
students.
Survey: n = 280
Third-year undergraduate
nursing students
n = 56
Final year nursing students
enrolled in high acuity course
Quantitative: 19 item survey with
four constructs: perceived learner
utility, perceived benefits and
challenges, learner engagement,
and cultural awareness
Qualitative: 1 open ended question
to describe more about learning
experiences. Content analysis used
(i) Cognitive knowledge using MCQ
- 9 questions on diabetic
ketoacidosis and 8 questions on
pulmonary embolism.
(ii) Student perception of their
‘virtual lab’ experience - 10 item 5
point Likert survey
Crossover between human patient
simulation and computer-based
suggests that online learning for
teaching clinical skills is no less
effective than traditional means.
Lack of evidence is available on the
implementation of blended learning
Students reported that the virtual
community enlarged their view of
factors that impact on health;
increased their understanding and;
allowed them to identify with the
patient.
Challenges included: (i) Keeping up
with so much information, (ii)
Ineffective use of time
(+,=)
Mean difference between pre and
post-test scores was significant for
both scenarios. All students agreed
the MicroSim had increased their
knowledge
(−)
Only significant improved post test

169
human patient and computer-based
simulations
Stephens et al. To report and reflect on students'
(2013) United evaluations of a learning activity
Kingdom which employed a Wiki
Iverson et al. (2016) To identify current use of mobile
U.S.A. device technology amongst nursing
faculty staff and students
Beers and Gurdak To compare perceptions of students
Berry (2015) who use traditional resources with
U.S.A. those who use electronic resources
in the clinical setting
Morente et al. To evaluate the effectiveness of
(2014) Spain information and communication
technologies in pressure ulcer
training as a learning tool,
compared with traditional teaching
methods
Case study: online survey Scenario based on stroke, acute care
and CT imaging
Case study: survey Use of technology in the clinical
setting
Comparative case-study Student utilised on-line and
traditional resources for evidence-
based guidelines and ‘other
information’ in clinical nursing
course
Randomised control study E-learning tool includes
- e-learning intervention integumentary assessment and
classification of wound stage
Comparative case-study
n = 60 simulation. Score given of quality of
SBAR report post-scenario.
Coding of use of diagnostic
reasoning processes using video and
audio records
Nursing and radiography Online questionnaire – qualitative
students comments focused on learning from
n = 41 student's perspective
Nursing students – n = 105 Survey included item responses and
Faculty staff – n = 31 open comments. No detailed
description of survey instrument.
No statistical review
Nursing students Students' perception of the benefits
n = 98 of using electronic resources was
measured using open-ended
question and scale questions
73 Bachelor of Nursing (30 in Pre and post-test questionnaire to
experimental group 45 in evaluate a-priori and acquisition of
control) knowledge on pressure ulcer
evaluation. Student's observation of
pressure ulcer image in both. 6 item
categories (inc. wound
classification, tissue classification
detection, skin, dressing, wound
care)
scores were for human patient
simulation
Enhanced knowledge of roles,
communication skills and trust
between two professions
Students referred to mobile devices
in clinical placement (outwith the
clinical area) as learning tools that
made them more knowledgeable and
prepared to care for patients
Students perceived electronic
resources to be easily accessible,
quick and easy to use. Students
perceived traditional resources to be
more time-consuming when trying to
search for information
(+)
Significant improvement in
knowledge with e-learning pressure
ulcer tool (p = 0.01). Non-significant
improvement in knowledge form
traditional classroom teaching. Small
sample sizes
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Nurse Education Today 66 (2018) 166–174
 Table 1 (continued)
Author(s), year, Purpose
country
Klaassen et al. To evaluate student satisfaction and
(2013) U.S.A. learning outcomes for rural nurses
of a ‘live’ health assessment in a
virtual classroom
Winters and Winters Evaluate effectiveness of video-
(2007) U.S.A. conferencing and tele-heath
technologies through three pilot
studies comparing face-to-face, low
bandwidth and high bandwidth
approaches
Hessler and To investigate effectiveness of an e-
Henderson learning interactive case study
(2013) compared to traditional hand-
written paper in learning outcomes
and acquired knowledge for nursing
students
170
Kaveevivitchai et al. To evaluate the effectiveness of
(2009) computer assisted learning (CAL)
media for vital sign measurement
amongst nursing students
Hoffman et al. To evaluate design of an interactive
(2011), computerised decision support
Australia framework as strategy to improve
nursing student clinical reasoning
skills
Beeckman et al. To investigate whether an e-
(2008), Belgium learning program compared with a
lecture can increase classification
skills of pressure ulcers for nursing
students and Registered Nurses
Weatherspoon et al. To examine whether, an e-
(2015), USA simulation over 2 weeks, compared
with a paper based case study,
increases critical thinking and
clinical judgement skills for nursing
students
a
Experimental studies: (+) E-learning group sig. improved result compared to classroom. (−) Classroom group sig. improved result to e-learning. (=) No difference. (+, =) E-learning significantly improved result
but not compared to classroom.
Design Learning of ‘Nursing Assessment’
component
Students enrolled in Health
Assessment for Clinical Practice
subject in Bachelor of Nursing
Comparative case study Cohorts included (i) undergraduate
students conducting neurological
examinations and (ii) postgraduate
(advanced practitioner) students
performing cardio-pulmonary
assessments
Quasi-experimental – e- Powerpoint interactive program
learning intervention includes assessment of heart and
lung sounds and patient's physical
and mental abilities
Quasi-experimental –e- Performance of vital sign
learning intervention. measurement by second year
Semi-structured interviews undergraduate students
Case-study survey Clinical Reasoning focus – including
clinical scenarios to recognise
patient deterioration and use
clinical decision-making
Repeated measure: pre-test Pressure ulcer classification (4
and three post-tests stages) and assessment of difference
of moisture lesions
Randomised control trial. Scenario: student playing role of
E-simulation triage nurse in an emergency
(intervention) and department – assign lower and
traditional paper-based higher acuity levels
study (control)
Sample/group Outcome measures/themes
Online students undertook live For both online and onsite students
health assessment in virtual Survey of student satisfaction and
class using Learning Exchange perception of achievement of
Reverse Demonstration (LERD) learning outcomes
model n = 23
Students on traditional onsite
course.
n = 38
Undergraduate nursing Students completed ‘2 satisfaction/
students evaluation instruments’ for cohort
n = 34 (i) and participant satisfaction
Advanced practitioner students forms for cohort (ii)
n = 20
1st year undergraduate Student's quiz score of clinical
nursing students knowledge and student's evaluation
n = 95 of perception of cognitive load,
opinions on e-learning program
functionality. Item and Likert not
described
Second year nursing students 30 item MCQ on vital signs
n = 117 assessment. 29 item checklist to
evaluate student's ability to measure
and interpret vital signs. User
satisfaction survey – 20 items 5-
point Likert scale. 10 semi-
structured interviews
Undergraduate Nursing 18 item/5 point Likert scale student
students satisfaction questionnaire
n = 320
Final year students from two 1 pre-test -participants asked to
undergraduate schools of classify (4 categories/stages) 1 set
nursing of 20 photographs. Each of 3 post-
n = 204 tests – classify set of 40 photographs
Final year Nursing students 75 item test - California Critical
n = 117 Thinking Disposition Inventory
(CCDTI). Triage Acuity Instrument
(TIA) to measure clinical judgement
and efficiency of decision making
Resultsa/findings & implications
Descriptive review of survey results
E.W. McDonald et al.
(no significance testing)
Students reported increased
satisfaction with on-line course as
less travel and ‘time-off’ expenses.
Student learning perceived as greater
or equal to the tradition onsite
course
Empirical data not presented.
Students reported satisfaction
irrespective of level of technology
(=)
No significant difference between
experimental and control group on
students' perception of cognitive load
and quiz scores. Student's showed a
preference for the e-learning
intervention - significantly difference
in responses for experimental group -
helpful to their learning (p = 0.02)
and helped to integrate case study
(p = 0.00)
(=)
No significant difference in pre and
post scores for both experimental
and control groups. E-learning
students gained significantly higher
post-test item checklist scores
compared with traditional lecture
students. High student satisfaction
expressed for CAL in both survey and
interviews
84% of students agreed that clinical
scenarios were useful to their
learning including 81% agreeing that
they helped to recognise clinical
deterioration
(+,=) Significant improvement in
scores for both e-learning and lecture
groups. Better scores in post-tests for
e-learning groups though not
statistically significant difference
with control
(+)
Significantly improved CCDTI score
for experimental e-simulation group
and significant difference to ‘paper-
based’ control
Nurse Education Today 66 (2018) 166–174
 Table 2
Data Reduction of identified studies.
Qualitative studies of student experience

Study authors Cohort Analysis Trustworthiness

E.W. McDonald et al.

Watson et al. (2016) First year U/G students Thematic - hermeneutic approach Thorough verification during interviews of participant's views/experience. Same single researcher
during all ten interviews
Carlson-Sabelli et al. (2011) First year U/G students Content analysis (qualitative component to Mixed Methods study and diamond Coding of open-ended questions from self-completed survey. Analysis by two researchers
of opposites analysis) independently

Descriptive and comparative surveys of student experience

Study authors Single case or comparative (e-tech vs traditional) Measurement

Brown and McCrorie (2015) Single case Student satisfaction

Hoffman et al. (2011) Single case Student satisfaction
Carlson-Sabelli et al. (2011) Single case Perceived learner utility, perceived benefits and challenges, learner engagement and cultural awareness
Iverson et al. (2016) Single case Understanding of technology used, perception of usefulness of technology
Stephens et al. (2013) Single case Perception of learner benefit of technology (as ‘process’ and ‘product’). Perception of learner experience
Beers and Gurdak Berry (2015) Comparative Perception of usefulness of technology, perception of impact on performance and patient care
Klaassen et al. (2013) Comparative Student satisfaction, perception of achievement of learning outcomes
Winters and Winters (2007) Comparative Student satisfaction

Experimental studies with Clinical Reasoning and Clinical Performance (non-psychomotor skills) outcome measure

Study authors Result Sample/cohort Measurement Validated tool?

171
Weatherspoon et al. (2015)
Heinrich et al. (2012)
Bogossian et al. (2015)
Beeckman et al. (2008)
Chan et al. (2016)
Cooper et al. (2015)
Wilson et al. (2014)
(+) Senior baccalaureate nursing 75 item test - California Critical Thinking Disposition Inventory (CCDTI). Triage Acuity Yes – internally tested for reliability. Face/content validity validated
students Instrument (TIA) to measure clinical judgement and efficiency of decision making through multiple screenings by local college level educators
(+,=) Final year U/G students Student scores from ‘multilogical’ MCQs (in effect Clinical Reasoning) Content validity with panel of experts – not externally validated tool
(+, =) Final year U/G students Calculation of ‘click’ data aligned to an Observed Structured Clinical Examination (OSCE) No
scoresheet
(+,=) Final year U/G students 1 pre-test and 3 post-test scores of number of photographs correctly classified Yes – inter and intra reliability using median Cohen's coefficient
(=) Final year U/G students Student self-evaluation Clinical Reasoning ability – 5-point Likert Internal reliability and face validity – not external validated tool
(=) Final year U/G students Experimental group - calculation of ‘click’ data aligned to an Observed Structured Clinical No
Examination (OSCE) scoresheet
Control group – 3 expert observers using OSCE checklist
(−) Final year U/G students Assessment by educator of completeness and correctness of a student's SBAR report Inter-rater reliability for SBAR reports – not externally validated tool
Review by educator from video and audio tape. Coding sheet of diagnostic reasoning

Experimental study with Clinical Performance (Psycho-motor) outcome measure

Study authors Result Sample/cohort Measurement Validated tool?

Kaveevivitchai et al. (2009) (=) 2nd year U/G Students Observation by educator - 29-item, 4 point, performance checklist for vital signs assessment Internal reliability – not externally validated tool

Experimental studies with Clinical Knowledge as outcome measure

Study authors Result Cohort Measurement Validated tool?

Morente et al. (2014)
Bogossian et al. (2015)
Beeckman et al. (2008)
Hessler and Henderson (2013)
(+) U/G Students Student scores from 6 item questionnaire on stages of evaluation for Ulcers (e.g. tissue classification, choice of dressing) No
(+, =) Final year U/G students Student scores from 11-item multiple choice questionnaire Yes - externally validated
(+, =) Final year nursing students Repeated measures – 1 pre-test and 3 post-tests. Display of photographs and classification of wound stages Yes – inter and intra reliability
(=) 1st year U/G students Aggregated quiz data from case studies (lung, neuro & cardiac) – immediately post and during learning, and re-test in later semester No
Nurse Education Today 66 (2018) 166–174
E.W. McDonald et al.
group, outcomes/themes and findings. As part of this integrative re-
view, data reduction is performed (displayed Table 2) where identified
studies are clustered according to type of study: experimental studies by
clinical performance (non-psychomotor), clinical performance (psy-
chomotor) and clinical knowledge; qualitative studies; and descriptive
and comparative surveys. A small set of generalisations can initially be
made from this collation of data. There is pre-dominantly an equiva-
lence of outcomes for e-learning/e-simulation and traditional class-
room/laboratory instruction or simulation, both for clinical perfor-
mance and clinical knowledge. An exception to this is two studies on
pressure ulcer evaluation where e-learning is significantly positively
different to traditional teaching. However, only one of these studies has
validated and reliability tested measurement. There is limited qualita-
tive research on this subject with numerous questionnaires/surveys
conducted on student satisfaction and student's perception of learning
outcomes. Some of these are limited by only descriptive statistics col-
lated from survey responses. For data comparison in our integrative
review we then identified patterns or clusters that emerged. We detail
these commonalities and themes as follows: (i) Students as Self-eva-
luators; ii) Blended and Scaffolded e-learning; (iii) Clinical Reasoning
measurement; (iv) Use of popular Communication Technology and
Platforms; and (v) Training and Preparation is vital. Each theme is
considered with occasional comment on the quality of the retrieved
evidence.
3.1. Students Become Self-evaluators
A key focus emerges from nursing education literature of the need to
move away from “instructor-centered, learner-passive” teaching to
“student-centered, integrative learning” activities (Carlson-Sabelli
et al., 2011). Self-assessment is an integral part of learning and im-
proving. When instruction is given to the student, they are directly
engaged in planning, implementation and assessment. Several re-
searchers found that various forms of digital technologies offer poten-
tial to complement traditional methods of teaching as they allow stu-
dents to evaluate oneself (Bogossian et al., 2015). In the students who
were exposed to a patient deterioration e-simulation program sig-
nificant improvements in “self-assessed knowledge, skills, confidence
and competence” were shown (Bogossian et al., 2015). Similarly, self-
assessment was facilitated when a Facebook group was introduced as a
tool to support study (Tower et al., 2014; Watson et al., 2016). The
Facebook group provided a sense of control in students, allowing them
to take responsibility for their own learning. By reading existing posts
and giving and receiving feedback to and from their peers, students
were able to identify gaps in their knowledge. Videos allowed students
to “identify with them (patients) and not see them as just a ‘case’ on
paper" (Carlson-Sabelli et al., 2011). For the Wiimali virtual community
an opportunity to replay captured video of a health case provided a way
to learn, remember and reflect (Levett-Jones et al., 2015). These studies
exhibit how students are able to identify with education technology and
take control of their learning. A further benefit is that self-assessment
and acquisition of clinical knowledge can happen without risk to a
patient. This demonstrated from a randomised trial study where an
experimental group scored significantly higher knowledge scores post
use of an e-learning pressure ulcer evaluation tool (Morente et al.,
2014). These studies exhibit how students are able to identify with
education technology and take control of their learning. In fact, such
locus of control also improves accessibility. A live health assessment
virtual class permitted rural students to stay in their own communities
(Klaassen et al., 2013). Further, an online forum from a web-based case
meant Chinese students avoided a ‘fear of losing face’ when asking
questions to an academic. Other studies in nursing education which
focus less on assessment skills also show very similar findings
(Anderson et al., 2013; Brown and McCrorie, 2015).
172
Nurse Education Today 66 (2018) 166–174
3.2. Scaffolded and Blended e-Learning
Some evidence suggests further research is required on scaffolded
and blended subject content with digital technology. More advanced
baseline knowledge for Final Year nursing students compared with ju-
nior baccalaureate student nurses may explain improved learning out-
comes in certain studies from use of digital learning. Significant also, is
that clinical performance in the Bogossian et al. (2015) study is most
improved for university than vocational college students. Evaluating
cognitive load in an Assessment subject for 1st or 2nd year under-
graduate nurses is could be a key consideration when developing e-
learning modules. More strategic thinking may be required as to when
to introduce e-learning packages across a Nursing curriculum. For
nursing assessment content in an electronic format, later in the degree
may be considered better pedagogical practice. As well as subject
content, modes of learning (e-learning, face to face) can be scaffolded.
Understanding cognitive load for students is crucial when introducing
e-learning packages (Hessler and Henderson, 2013). Further, there is
also danger in importing e-learning materials to undergraduate curri-
culum, where content is too advanced for early undergraduate level.
With multiple entrance points for Nursing curricula occurring more
often (e.g. Enrolled Nurse, Science or Arts Graduate), scaffolding of e-
learning is vital.
There is wide commentary on blended learning where an e-based
learning package can be a complementary tool to traditional teaching
method (Ilkay and Zeynep, 2014; Park and Park, 2015). Although not
stated in many of the studies the digital tools devised are most likely
part of a blended undergraduate program. However, little research
explicitly evaluates blended learning delivery. One exception is a quasi-
experimental study of vital sign measurement, which incorporated
blended modules, and found a significant improvement in knowledge
and student satisfaction for the blended learning group (Kaveevivitchai
et al., 2009). A systematic review states the need for evidence on im-
plementation of blended learning for teaching clinical skills in under-
graduate education (McCutcheon et al., 2015). For example, further
evaluations could compare different weighting of e-learning content in
subjects.
3.3. Measurement of Clinical Reasoning
Although clinical reasoning is used as a measure for learning out-
comes, many studies have not performed thorough validation of such
instruments. One study sought student views on whether an interactive
clinical decision module helped them to recognise clinical deterioration
(Hoffman et al., 2011). Lack of validation of clinical reasoning mea-
surement is surprising given critique of new graduate nurses lack of
confidence in clinical decision-making. Online ‘click’ data (as the stu-
dent's selected response) was used in the Bogassian study. In a study on
Registered Nurses not included in this review, observed clinical per-
formance used a ‘Responding to a Deteriorating Patient’ (RAPIDS) tool.
Both studies demonstrated a significant increase in ‘virtual’ clinical
performance. Further studies might include use of clinical reasoning
measurement tools, such as RAPIDS, and could be adapted according to
knowledge base and undergraduate level (1st vs 3rd year). For example,
in an early curriculum design a less-complex case study involving re-
sponses to abnormal vital signs could be adopted. This compares with
management of a deteriorating patient later in a degree and simulations
that are more challenging. Measurement and testing of clinical rea-
soning skills in the educational-setting could be aligned with introdu-
cing ‘management of a deteriorating patient’ earlier in students' degrees
(Bogossian et al., 2015).
3.4. Mobile Technology and Facebook Are Effective
Four studies report on student perception of use of digital and social
media technology, including use of mobile phones during the clinical
E.W. McDonald et al.
placement period (Beers and Gurdak Berry, 2015; Iverson et al., 2016;
Tower et al., 2014; Watson et al., 2016). All of these conclude that their
use contributes positively to student learning. Caution should be ex-
ercised with two of these studies; however, as statistical significance of
survey response differences are not calculated. Importantly though, the
Watson et al. (2016) qualitative study elucidates on a communal re-
flection on clinical skills and the collegial relationships that develop.
Observation of growth of an on-line community during clinical skills
acquisition and greater inter-professional engagement is also reported
(Stephens et al., 2013). Digital technology may have capacity to be
‘impersonal’ (Koch, 2014) in a learning environment, however, op-
portunities can arise for strengthening group learning. Nursing educa-
tors should also consider that students might be more likely to use
common social media tools, such as Facebook rather than discussion
boards on university platforms.
3.5. Training and Preparation Is Vital
Optimal training and preparation was a consistent theme in many of
the identified studies. Researchers concur that for an e-based program
to be integrated into curriculum, staff and students require training.
When mobile device technology was introduced into nursing education,
faculty identified it was difficult to teach and support students, parti-
cularly when a faculty member was not familiar with aspects of the
software (Iverson et al., 2016). Particular problems include the up-
loading of video recordings, accessing systems and time lags
(Rosenkoetter et al., 2014). When students felt they did not have the
required IT skills, they did not fully engage with the program (Stephens
et al., 2013). A relationship between application skill level and age was
consistent throughout studies. Tuominen et al. (2014, p. 4) state that,
“younger students (age < 26 years) have better skills to use social
media applications”.
Health-care organisations also managed similar issues, with staff
requiring extensive training in e-documentation. Input of admission and
assessment data and a ‘mix’ of paper of digital documents are key
challenges. For preparing student nurses, integration of Nursing
Informatics content into curricula is therefore fundamental for the di-
gital age in health care. Registration bodies may consider a clinical
competency for newly qualified nurses of managing patient e-doc-
umentation.
4. Conclusion
Despite, the level of theory and practical components of under-
graduate nursing programs, which are currently augmented by digital
technologies, education providers have recently reaped some criticism
for failing to adequately equip nursing students with the clinical as-
sessment skills necessary to meet the expectations of the clinical com-
petencies required by the graduate nurse.
This review consequently offers a number of ‘prompts’ for poten-
tially improving e-learning of nursing assessment subjects. An im-
portant limitation, however, is that our review has not scrutinised, in
detail, the procedural, cognitive and psychomotor models of learning
relevant to a nursing assessment subject. We also emphasise the di-
versity of methods, student groups, measurement tools and e-learning
interventions amongst the studies. For future scholarship, in developing
Koch's concept of e-pedagogy, a better understanding of these models in
a nursing assessment context would be opportune. For example, this
could take the form of a realist review, where a more theoretical ap-
proach in interrogating the literature is adopted.
Educators are grappling with the most effective way to integrate e-
based learning into nursing curricula. This review shows that for
teaching of nursing assessment, e-based programs can supplement tra-
ditional teaching methods. Careful thought is needed for scaffolding
and blending e-learning into ‘nursing assessment’ courses. Evaluation
studies of e-based programs used to enhance students' clinical skills and
173
Nurse Education Today 66 (2018) 166–174
knowledge find high levels of satisfaction in students. However, caution
should be exercised with such findings as often the quality of mea-
surement and analysis of such data can be variable. Findings show that
e-based learning facilitates a sense of control in students, encouraging
them to reflect and self-correct their actions. However, for e-based
programs to be effective in learning it is important that education
providers spend a significant amount of time planning the program and
training staff and students. Consideration also needs to be made of
greater Nursing Informatics content in nursing studies. Finally, e-based
learning offers an excellent tool to complement face-to-face teaching in
enhancing clinical skills and knowledge, although more targeted re-
search on the modes and weighting of blended learning is further re-
quired.
Acknowledgements
The project was funded through an internal grant at the School of
Nursing & Midwifery – La Trobe University for JB (Bachelor of Nursing
student) to draft initial manuscript. EM conceived review, revised
content and completed further drafts. The authors wish to acknowledge
Stav Hillel for assistance with library searching.
The authors declare they have no actual or potential competing fi-
nancial interests.
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