J O U R N A L F O R N U R S E S I N S T A F F D E V E L O P M E N T  Volume 25, Number 1, E8–E13  Copyright A 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

.. D espite the education challenges faced

.. by healthcare institutions, the use of online
.. The Perception of technology (eLearning) to demonstrate
.. competency for practicing nurses in the
..
.. Learning and Satisfaction acute care environment has only recently
.. been explored. The authors discuss the
.. of Nurses in the Online implementation of an online-based
.. nursing education competency. The results
.. demonstrate that the use of the eLearning
.. Environment
.. format provides both a satisfactory and
.. effective alternative learning medium.
.. Keri L. Gerkin, MS, RN The study provides support for the use of
.. Teri H. Taylor, BSN, RN online learning in the healthcare setting.
..
.. Francene M. Weatherby, PhD, RNC, CNE
..
..
..
..
..
..
..
.................................................

T he American Nurses Association (2002) has stated

that nurses and their employers are jointly respon-
sible for creating an environment in which competent
nurses can provide quality outcomes. Despite these
mandates, healthcare institutions are faced with the
challenges of providing stimulating, relevant, and cost-
effective continuing nursing education programs. The
explosion of available nursing knowledge and the in-
creasing need for nursing competencies through regu-
lating bodies have also contributed to the challenges
in continuing education (Belcher & Vonderhaar, 2005;
Benson, 2004; Nelson, 2003; Smith, 2005). Today’s nurses
are faced with ongoing pressure to demonstrate profi-
ciency in a variety of nursing skills. Consumer demands
and the concerns of consumer advocacy groups have also
influenced continuing education and competency devel-
opment of nurses. One of the primary reasons for this
increased interest is the Institute of Medicine’s (1999)
report, which declared that 98,000 patients die annually
from medical errors while hospitalized.
..........................................
Keri L. Gerkin, MS, RN, is Education Specialist, Saint Francis Health
System, Tulsa, Oklahoma.
Teri H. Taylor, BSN, RN, is Education Instructor, Saint Francis Health
System, Tulsa, Oklahoma.
Francene M. Weatherby, PhD, RNC, CNE, is Professor of Nursing,
University of Oklahoma College of Nursing, Oklahoma City,
Oklahoma.
Despite these obvious challenges, effective institutional-
based continuing education programs are essential to
assist staff nurses in maintaining professional compe-
tence. The traditional lecture has been the primary
educational format used in continuing nursing educa-
tion to date (Dougal & Gonterman, 1999; McAlpine,
1996). Although the lecture format can be an effective
way to deliver information to a large number of nurses,
many educational disadvantages to the live lecture
format exist (Billings & Halstead, 2005; Harrington &
Walker, 2003). Didactic lectures do not appeal to a
variety of learning styles, lack learner participation
strategies, require lengthy educator preparation, and
are costly (Dunn & Griggs, 1998).
One alternative to the traditional lecture format is
the use of online technology in continuing nursing
education, also known as eLearning. Technology has
revolutionized educators’ ability to facilitate profes-
sional nursing competence through the use of online
education. The use of eLearning in the staff develop-
ment environment has only recently been explored
(Benson, 2004; Bernhardt, Runyan, Bou-Saada, & Felter,
2003). Use of eLearning to provide continuing nursing
education has many benefits, including user conve-
nience, program design flexibility, adherence to adult
learning principles, and accommodation of multiple
learning styles. The remainder of this article will discuss
the implementation of an online nursing education

E8 January/February 2009

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
competency. Specifically, the online competency fo-
cused on the nursing care of the kidney transplant
recipient. The purpose of this article is to examine the
satisfaction and perception of learning on practicing
nurses in the online environment.
LITERATURE REVIEW
A comprehensive literature review was conducted
using both the CINAHL and ERIC databases. Major
content areas identified included the impact of the
online environment on nurses, the impact of online
learning on nursing students, and theoretical principles
of online education.
The Impact of the Online Environment on Nurses
Because of its potential benefits in staff development,
nursing researchers have explored eLearning and
computer-based instructional strategies as an educa-
tional medium (Attack, 2003; Attack & Rankin, 2002;
Korhonen & Lammintakanen, 2005). Most existing
research relates to nursing students and the online
environment; however, little research exists regarding
the impact of the online environment on practicing
nurses. As a result, this literature review includes edu-
cation research that considers both graduate nursing
students and practicing nurses.
Convenience and flexibility have been cited by
nursing researchers as contributing to nurses’ satisfac-
tion with the online learning environment (Attack, 2003;
Attack & Rankin, 2002; Billings, Connors, & Skiba, 2001).
Although multiple studies claim flexibility as an advantage
to online courses, Korhonen and Lammintakanen (2005)
found contradictory results when studying the impact
of online learning and nurse managers. According to
their qualitative study, the degree of satisfaction with the
flexibility and convenience of online learning was directly
related to certain time- and place-dependent conditions.
For example, online courses were considered flexible and
convenient only if the nurse manager had adequate
home computer access and time at work and home to
devote to studying online. Similar findings were reported
by Attack (2003), who found that the convenience and
flexibility offered in an online course were dependent
on the nurse’s ability to become more disciplined in
overall study habits. Current literature demonstrates
that nurses cite convenience and flexibility as advan-
tages to online learning. However, adequate computer
access, development of disciplined study habits, and
adequate time spent studying all affect the nurses’ sat-
isfaction with online courses.
Self-paced learning has also been studied as it
relates to the success and satisfaction of nurses in the
online environment. Grant (1993) studied the re-
JOURNAL FOR NURSES IN STAFF DEVELOPMENT
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
sponse of nurses to self-paced learning modules during
a nursing orientation program compared with a
traditional lecture format. The self-paced learning
modules were the method of choice for most nurses,
although the authors noted that many nurses selected
a blend of both self-paced learning and lecture as their
preferred teaching strategies. Andrusyszyn, Cragg, and
Humbert (2001) and Kozlowski (2002) found that self-
direction, self-paced learning, and flexibility were cited
by nurses as important advantages to the online learn-
ing environment.
Although there are advantages for nurses using the
online environment, the literature review did uncover
some barriers to implementation and use of online
learning. Lack of computer access and insufficient
computer skills are the most frequently cited barriers
(Attack & Rankin, 2002; Billett, 1992; Criddle, 1995;
Khoiny, 1995; Nowicki, 1996; Schmitt, Titler, Herr, &
Ardery, 2004). Attack (2003) and Smith (2005) also
reported that lack of computer skills negatively affects
nurses’ satisfaction in the online learning environment.
The Impact of Online Learning on
Nursing Students
Bloom and Hough (2003) studied nursing and allied
health students and found that they were highly
satisfied with the use of technology in learning.
Additional nursing student studies have demonstrated
satisfaction with the use of the online environment
(Parker, Riza, Tierney, & Barrett, 2005; Ryan, Carlton, &
Ali, 1999; Soon, Sook, Jung, & Im, 2000; Thurmond,
Wamback, Connors, & Frey, 2002). Similar to results
reported regarding practicing nurses, nursing students
often cite convenience and access as the primary
reasons to choose online courses (Billings, 1999; Soon
et al., 2000).
Theoretical Principles of Online Staff Education
Learning theories and educational frameworks are
the philosophical foundations that guide the selec-
tion of instructional strategies and learning activities.
Andragogy (Knowles, 1980) and adult learning theory
are commonly used as theoretical foundations for on-
line course design both for nursing students and prac-
ticing nurses. Adult education literature reports that
adult learners, including nurses, value online course
designs based on andragogical principles (Ausburn,
2004; Bernhardt et al., 2003; Dyck, 1986).
The Constructivist Learning Theory is also com-
monly used as a theoretical basis for online course
design (Moallem, 2001). The Constructivist Learning
Theory evolved from both psychology and philoso-
phy and holds that assimilation, accommodation, and
E9
construction are the basic components of learning
(Billings & Halstead, 2005; Ryan, Carlton, & Ali, 2005).
According to Constructivism, learners construct their
knowledge by actively participating in the learning
process and constructing their own meanings and un-
derstanding. Concepts that are central to the Construc-
tivist Learning Theory include collaboration, learner
autonomy, reflection, and experiential learning (Huang,
2002; Moallem, 2001). Huang (2002) and Ali, Carlton,
and Ryan (2004) discussed Constructivist-based instruc-
tional principles for successful online adult learning.
These instructional principles include providing an
interactive learning environment through online dis-
cussion, critical thinking, reflection, timely positive feed-
back, establishment of collaborative learning projects,
facilitation of meaningful learning experiences, and ap-
plication of real-world knowledge. The Constructivist
Learning Theory, along with the Adult Learning Theory,
is the theoretical framework used for the development
and implementation of the online staff nursing educa-
tion programs discussed in this article.
DESCRIPTION OF PROJECT
Online Program Description
Nurses who care for kidney transplant recipients are
required by Saint Francis Health System policy to
complete an initial kidney transplant certification
course and an annual recertification class to maintain
their competence in the care of this complex patient
population (Saint Francis Health System, 2005a). The
annual kidney transplant competency course, originally
several hours in length, was taught in a traditional
classroom lecture-based format. In the spring of 2006,
the traditional annual competency course was con-
verted to an entirely online format. Prior to content
development, a needs assessment of the transplant
nurses was conducted.
Instructional Design Principles, Program Design,
and Implementation
MC Strategies Webinservice1 was the application used
to complete the design and execution of this online
competency. Saint Francis Health System chose this
application because of its simplicity and ease of
use. This application also allows nursing educators to
easily modify content in order to meet the learn-
ers’ needs.
Course access, hierarchical organization, flexibility,
and self-pacing are some of the learning strategies
included in the course design that were based on the
theoretical underpinnings of Constructivism and Adult
E10
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Learning Theory. The developed module is accessed
from the Internet, allowing the nurse to complete the
lesson from either the home or work environment.
Internet access was provided to allow staff to obtain
the course material from their home because studies
have reported that the noisy stressful nursing work
milieu can hamper online learning (Knapp, 2004; Rick,
Kearns, & Thompson, 2003). Nurses at Saint Francis
Health System have ready access to computer termi-
nals for electronic documentation and Internet access
to professional resources. The online course format of
this competency is self-paced and will allow staff to
learn in their preferred environment. Studies demon-
strate that students retain a higher percentage of the
information when they are allowed to learn at their
own pace (Nelson, 2003).
The course content was organized hierarchically,
with the least complicated material covered first
followed by the higher level cognitive domains. The
hierarchical organization and depth of the course
content are based on Constructivist learning models
and focus on the Constructivist instructional concepts
of problem-based learning, solving of real-world prob-
lems, layering of information, and conceptual interre-
latedness (Moallem, 2001).
Critical thinking skills are essential for a nurse prac-
ticing in a complex healthcare system. Case studies and
problem-solving opportunities were included in the
course content to appeal to adult learners’ desire for im-
mediate real-world application of knowledge (Knowles,
1980). Case studies also followed Constructivist learning
principles of real-world problem application and knowl-
edge linkage to everyday practice (Ali et al., 2004; Twibell,
Ryan, & Hermiz, 2005). Specifically, the case studies were
included to assist the learner in obtaining critical thinking
and problem-solving skills for common complications
after kidney transplantation.
Additional module features included animation and
graphics to emphasize important content. Graphics
and animation were used in balance with static text to
stimulate visual learners and maintain the learners’
interest (Belcher & Vonderhaar, 2005; Cuellar, 2002;
Peterson & Berns, 2005). Item validation (questions
throughout the module that required answering before
the learner could continue), positive reinforcement,
functional links to Internet resources and hospital
policies and procedures, and a printable summary of
key points were also included in the course design.
Resource links and printable handouts were included
to improve learner–content interactions (Merriam &
Caffarella, 1999; Thurmond, 2003).
Program development and content were approved
by the Director of Education. After content devel-
opment, a pilot test was conducted, and the results
were used in continuing program development. The
January/February 2009
module was assigned to the appropriate nurses, who the perceived learning and satisfaction of nurses. The
were given 90 days for completion. After Institutional authors found that most surveyed nurses perceived
Review and Ethics Board approval, a written survey that learning took place in the online educational
was developed and distributed to the 20 nurses after environment. In addition, the nurses reported satisfac-
the completion of the module. Since implementa- tion with the online format and commented that
tion, 20 kidney transplant nurses have completed the online learning was convenient, flexible, and useful.
module along with a 20-question, multiple-choice on- These findings are consistent with the education
line posttest. literature, which reports that nurses are satisfied
with a Web-based format particularly because the on-
line environment provides convenience and flexibility
EVALUATION OF OUTCOMES (Fearing & Riley, 2005; Harrington & Walker, 2003;
Irons, Jung, & Keel, 2002; Phillips, 2006).
The educational program was evaluated using the Web-
As discussed in the literature review, drawbacks to
based course outcome assessment framework pro-
using online learning include lack of computer access,
posed by Billings (2000). The framework has five major
lack of dedicated time for learning, and insufficient
concepts which should be evaluated within the online
computer skills. Although the authors did not experi-
education format. The evaluation categories include
ence these issues in this project, other institutions may
outcomes, educational practices, faculty support,
encounter these difficulties when implementing online
learner support, and the use of technology (Billings,
learning. In addition, some institutions might have
2000). Sixteen of the 20 surveys were returned, for a
nurses who lack sufficient computer skills. Limitations
response rate of 80%. The time to complete the lesson
of this study were similar to other educational re-
ranged from 2 to 45 minutes, with an average com-
search studies in that a small convenience sample was
pletion time of 23 minutes. The average online posttest
used; therefore, the results are not generalizable to all
score was 94.8%, with all learners passing the exami-
nursing environments.
nation with a score of 80% or better. A score of 80% or
According to Adult Learning and Constructivist
better was required to demonstrate competency (Saint
principles, direct application and association of real-
Francis Health System, 2005b).
world principles and knowledge are essential to a
A five-question Likert scale survey was administered
successful learning experience (Forrest, 2004; Huang,
after completion of the lesson. The overall evaluation
2002; Knowles, 1980; Moallem, 2001). This is particu-
of the lesson was cited as very good or above average
larly significant in the profession of nursing, where the
by 100% of the nurses surveyed. All of the nurses also
critical test of learning is the application of knowledge
reported that the content level was appropriate for
to clinical practice (Sheridan & LeGros, 1995). Unfor-
their job activities, and most nurses (87.5%) found the
tunately, a paucity of research exists regarding the
lesson very helpful for enhancing their job perfor-
direct translation of online knowledge into nursing
mance related to the care of the kidney transplant
practice (Attack & Rankin, 2002; Beitz & Snarponis,
recipient. According to the course evaluations, 87.5%
2006). Only one study that examined the ability of
of the nurses agreed that the online format facilitated
nurses to transfer knowledge learned in the online
learning, and the remaining nurses somewhat agreed
environment to practice was found. Therefore, future
that the online format facilitated learning. Thirteen
nursing education research should be directed at
nurses (81%) perceived that learning took place in
understanding both the impact of online learning on
the online environment and were able to list specific
practicing nurses and the nurse’s ability to translate
learned concepts.
knowledge into clinical practice.
Written evaluation comments included the follow-
In summary, nurse educators are faced with the
ing: ‘‘it was a great refresher,’’ ‘‘liked the use of
challenge of providing relevant and effective educa-
the computer and eLearning because it can be done
tion programs in an increasingly complex health-
at a time that is convenient for me,’’ ‘‘quick and
care environment. This study demonstrated that the
useful resource,’’ ‘‘I enjoyed the questions through-
eLearning format provided a satisfactory and effec-
out to make sure the information is retained,’’ and
tive alternative for nurses in practice. In addition, this
‘‘good review.’’
study provides further support for existing literature
that states nurses can learn in an online environment
CONCLUSIONS, LIMITATIONS, AND if specific barriers are overcome. The challenge of
ensuring competency for practicing nurses is com-
IMPLICATIONS FOR PRACTICE plex. Educational programs that are designed using an
This descriptive study examined the impact of an online format provide a positive educational medium
online kidney transplant nurse competency module on for learning.

JOURNAL FOR NURSES IN STAFF DEVELOPMENT E11

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
REFERENCES
Ali, N. S., Carlton, K. H., & Ryan, M. (2004). Students’ perceptions
of online learning: Implications for teaching. Nurse Educator,
29(3), 111–115.
American Nurses Association. (2002). Continuing professional nurs-
ing competence: Nursing’s agenda for the 21st century. Silver
Springs, MD: Author. Retrieved October 29, 2006, from http://
nursingworld.org/practice/sgcommittee/contcompetence2002rev.
pdf
Andrusyszyn, M. E., Cragg, C. E., & Humbert, J. (2001). Nurse
practitioner preferences for distance education methods
related to learning style, course content, and achievement
[Electronic version]. Journal of Nursing Education, 40(4),
163–170.
Attack, L. (2003). Becoming a Web-based learner: Registered
nurses’ experiences. Journal of Advanced Nursing, 44(3),
297–298.
Attack, L., & Rankin, J. (2002). A descriptive study of registered
nurses’ experiences with Web-based learning. Journal of
Advanced Nursing, 40(4), 457–465.
Ausburn, L. J. (2004). Course design elements most valued by
adult learners in blended online education environments:
An American perspective [Electronic version]. Educational
Media International, 41(4), 327–337.
Beitz, J. M., & Snarponis, J. A. (2006). Strategies for online
teaching and learning. Nurse Educator, 31(1), 20–25.
Belcher, J. V., & Vonderhaar, K. J. (2005). Web-delivered
research-based nursing staff education for seeking Magnet
status [Electronic version]. Journal of Nursing Adminis-
tration, 35(9), 382–386.
Benson, E. P. (2004). Online learning: A means to enhance
professional development. Critical Care Nurse, 24(1), 60–63.
Bernhardt, J. M., Runyan, C. W., Bou-Saada, I., & Felter, E. M.
(2003). Implementation and evaluation of a Web-based con-
tinuing education course in injury prevention and control.
Health Promotion Practice, 4(2), 120–128.
Billett, S. (1992). Towards a theory of workplace learning
[Electronic version]. Studies in Continuing Education, 14,
143–152.
Billings, D. M. (1999). The next generation distance education:
Beyond access and convenience. Journal of Nursing Educa-
tion, 38(6), 246–247.
Billings, D. M. (2000). A framework for assessing outcomes and
practices in Web-based courses in nursing. Journal of
Nursing Education, 39(2), 60–67.
Billings, D. M., Connors, H. R., & Skiba, D. J. (2001). Benchmark-
ing best practices in Web-based nursing courses [Electronic
version]. Advances in Nursing Science, 23(3), 41–52.
Billings, D. M., & Halstead, J. A. (2005). Teaching in nursing: A
guide for faculty (2nd ed.). St. Louis, MO: Elsevier Saunders.
Bloom, K. C., & Hough, M. C. (2003). Student satisfaction with
technology-enhanced learning [Electronic version]. Computers,
Informatics, Nursing, 21(5), 241–246.
Criddle, L. M. (1995). Computer-assisted instruction: A successful
approach to mandatory annual review education. Journal of
Nursing Staff Development, 11(4), 219–225.
Cuellar, N. (2002). The transition from classroom to online
teaching. Nursing Forum, 37(3), 5–13.
Dougal, J., & Gonterman, R. (1999). A comparison of three
E12
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
teaching methods on learning and retention [Electronic
version]. Journal for Nurses in Staff Development, 15(5),
205–209.
Dunn, R., & Griggs, S. A. (Eds.). (1998). Learning styles and the
nursing profession. New York: National League for Nursing
Press.
Dyck, S. (1986). Self-directed learning for the RN in a bac-
calaureate program. Journal of Continuing Education in
Nursing, 17, 194–197.
Fearing, A., & Riley, M. (2005). Graduate students’ perceptions of
online teaching and relationships to preferred learning styles
[Electronic version]. Medsurg Nursing, 14(6), 383–389.
Forrest, S. (2004). Learning and teaching: The reciprocal link.
Journal of Continuing Education in Nursing, 35(2), 74–79.
Grant, P. (1993). Formative evaluation of a nursing orienta-
tion program: Self-paced versus lecture-discussion [Electronic
version]. Journal of Continuing Education in Nursing,
24(6), 245–248.
Harrington, S. S., & Walker, B. L. (2003). Is computer-based
instruction an effective way to present fire safety training to
long-term care staff? [Electronic version]. Journal for Nurses
in Staff Development, 19(3), 147–154.
Huang, H. M. (2002). Toward constructivism for adult learners in
online learning environments [Electronic version]. British
Journal of Educational Technology, 33(1), 27–37.
Institute of Medicine. (1999). To err is human. Washington, DC:
Author.
Irons, L. R., Jung, D. J., & Keel, R. O. (2002). Interactivity in
distance learning: The digital divide and student satisfaction.
Educational Technology & Society, 5(3), 175–188.
Khoiny, F. (1995). Factors that contribute to computer assisted
instructional effectiveness. Computers in Nursing, 13, 165–168.
Knapp, B. (2004). Competency: An essential component of caring
in nursing. Nursing Administration Quarterly, 28(4), 285–287.
Knowles, M. S. (1980). The modern practice of adult educa-
tion: From pedagogy to andragogy (2nd ed.). New York:
Cambridge Books.
Korhonen, T., & Lammintakanen, J. (2005). Web-based learning
in professional development: Experiences of Finnish nurse
managers. Journal of Nursing Management, 13, 500–507.
Kozlowski, D. (2002). Using online learning in a traditional
face-to-face environment [Electronic version]. Computers in
Nursing, 20(1), 23–30.
McAlpine, L. (1996). Comparison of the effectiveness of tu-
tored videotape instruction versus traditional lecture for a
basic hemodynamic monitoring course [Electronic version].
Journal of Nursing Staff Development, 12(3), 119–125.
Merriam, S. B., & Caffarella, R. S. (1999). Learning in adult-
hood: A comprehensive guide (2nd ed.). San Francisco:
Jossey-Bass.
Moallem, M. (2001). Applying constructivists and objectivist
learning theories in the design of a Web-based course: Impli-
cations for practice [Electronic version]. Educational Tech-
nology & Society, 4(3), 113–125.
Nelson, E. A. (2003). E-learning: A practical solution for training
and tracking in patient-care settings [Electronic version].
Nursing Administration Quarterly, 27(1), 29–32.
Nowicki, C. R. (1996). Twenty-one predictions for the future of
hospital staff development. Journal of Continuing Education
in Nursing, 27, 259–266.
January/February 2009
Parker, E. B., Riza, L., Tierney, S., & Barrett, A. (2005). Inter-
disciplinary collaboration: An effective approach for devel-
oping Web-based courses [Electronic version]. Computers,
Informatics, Nursing, 23(6), 308–313.
Peterson, R., & Berns, S. (2005). Establishing standards for
intranet on-line education [Electronic version]. Nursing
Economics, 23(5), 268–270.
Phillips, J. M. (2006). Preparing preceptors through online
education. Journal for Nurses in Staff Development, 22(3),
150–156.
Rick, C., Kearns, M. A., & Thompson, N. A. (2003). The reality of
virtual learning for nurses in the largest integrated health care
system in the nation. Nursing Administration Quarterly,
27(1), 41–57.
Ryan, M., Carlton, K. H., & Ali, N. S. (1999). Evaluation of tra-
ditional classroom teaching methods versus course delivery
via the World Wide Web [Electronic version]. Journal of
Nursing Education, 38(6), 1–6.
Ryan, M., Carlton, K. H., & Ali, N. S. (2005). A model for faculty
teaching online: Confirmation of a dimensional matrix. Jour-
nal of Nursing Education, 44(8), 357–365.
Saint Francis Health System. (2005a). Kidney transplant pro-
gram: Scope of services. Tulsa, OK: Author.
Saint Francis Health System. (2005b). Human resources: Com-
petency assessment. Tulsa, OK: Author.
Schmitt, M. B., Titler, M. G., Herr, K. A., & Ardery, G. (2004).
Challenges of Web-based education in educating nurses
JOURNAL FOR NURSES IN STAFF DEVELOPMENT
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
about evidence-based acute pain management practices for
older adults. Journal of Continuing Education in Nursing,
35(3), 121–127.
Sheridan, M., & LeGros, E. (1995). Computer-assisted instruction
using electronic e-mail. Journal of Nursing Staff Develop-
ment, 11(2), 100–103.
Smith, C. M. (2005). E-orientation: A cyber approach to orienting
per diem and temporary nurses [Electronic version]. Journal
for Nurses in Staff Development, 21(5), 204–212.
Soon, K. H., Sook, K. I., Jung, C. W., & Im, K. M. (2000). The
effects of Internet-based distance learning in nursing [Elec-
tronic version]. Computers in Nursing, 18(1), 19–25.
Thurmond, V. A. (2003). Defining interaction and strategies to
enhance interactions in Web-based courses [Electronic ver-
sion]. Nurse Educator, 28(5), 237–241.
Thurmond, V. A., Wamback, K., Connors, H. R., & Frey, B. B.
(2002). Evaluation of student satisfaction: Determining the
impact of a Web-based environment by controlling for stu-
dent characteristics. American Journal of Distance Educa-
tion, 16(3), 169–189.
Twibell, R., Ryan, M., & Hermiz, M. (2005). Faculty perceptions of
critical thinking in student clinical experiences [Electronic
version]. Journal of Nursing Education, 44(2), 71–79.
ADDRESS FOR CORRESPONDENCE: Keri L. Gerkin, MS, RN,
Saint Francis Hospital, Department of Education, 6161 S. Yale,
Tulsa, OK 74136 (e-mail: klgerkin@saintfrancis.com).
E13