Nurse Education Today 34 (2014) 802–808

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Effect of web-based education on nursing students' urinary

catheterization knowledge and skills
Deniz Öztürk a,⁎, Leyla Dinç b,1
a
Gazi University, Faculty of Health Sciences, Nursing Department, Besevler, 06500 Ankara, Turkey
b
Hacettepe University, Faculty of Nursing, 06100 Ankara, Turkey

a r t i c l e i n f o s u m m a r y

Article history: Background: Nursing is a practice-based discipline that requires the integration of theory and practice. Nurse
Accepted 8 August 2013 educators must continuously revise educational curricula and incorporate information technology into the
curriculum to provide students with the necessary knowledge and skills.
Objectives: The aim of this study was to assess the effect of web-based education on students' urinary catheteri-
Keywords: zation knowledge and skills.
Nursing education
Design: A convenience sample of 111 first year nursing students enrolled at two universities in Ankara during the
Web-based education
Web-enhanced learning
academic year of 2011–2012 participated in this quasi-experimental study.
In-class instruction Method: The experimental group (n = 59) received a web-based and web-enhanced learning approach along
Fundamentals of nursing with learning and practicing the required material twice as much as the control group, whereas the control
group (n = 52) received traditional classroom instruction. A knowledge test of 20 multiple-choice questions
and a skills checklist were used to assess student performance.
Results: There was no difference between the experimental group and the control group in knowledge scores;
however, students in the web-based group had higher scores for urinary catheterization skills. The highest scores
in knowledge and skills were obtained by students who experienced web-based education as a supplement to
tradition instruction.
Conclusion: Web-based education had positive effects on the urinary catheterization skills of nursing students,
and its positive effect increased for both knowledge and skills when it supplements classroom instruction.
Based on these results, we suggest the use of web-based education as a supplement to traditional classroom
instruction for nursing education
© 2013 Elsevier Ltd. All rights reserved.

Introduction practice. Although clinical practice is an integral component of nursing

The past decade has seen rapid changes in science and technology
and technological knowledge has kept pace. Education plays a pivotal
role in preparing the individual to be an effective and constructive
participant in knowledge society (Soran et al., 2006; Turgut, 2009).
Thus, nursing curricula must continuously be revised and updated to
prepare students who can be adaptive and productive using technology.
However, nursing education faces a number of challenges, including in-
adequate infrastructure and resources, the shortage of qualified nurse
educators, and a high student/faculty ratio, which limit the effectiveness
of the teaching–learning process in the classroom (National Advisory
Council on Nurse Education and Practice, 2010; McNett, 2012). These
challenges are compounded by the realities and demands of clinical
⁎ Corresponding author. Tel.: +90 312 216 26 53; fax: +90 312 216 26 36.
E-mail addresses: deniz__genc@hotmail.com (D. Öztürk), leylad@hacettepe.edu.tr
(L. Dinç).
1
Tel.: +90 312 305 41 89; fax: +90 312 3127085.
education, the limited number of clinical sites for student placement,
shortage of nursing faculty for clinical supervision, and nurses' reluc-
tance to facilitate clinical learning of students due to staff shortages
and heavy workload, are obstacles (McNett, 2012; Fitzgerald et al.,
2012).
For students, especially during their initial clinical practice, the lack
of clinical experience, unfamiliar situations, fear of making mistakes,
and negative attitudes of professional staff can result in stress and anx-
iety, which in turn affect their clinical learning (Sharif and Masoumi,
2005; Elcigil and Sarı, 2007; Moscaritolo, 2009). Consequently, the
translation of basic knowledge into practice, particularly the develop-
ment of psychomotor skills, remains a primary concern for nurse educa-
tors and students. A further concern is that involving real patients in the
development of these skills might result in the invasion of patient
privacy and dignity.
Urinary catheterization is a basic nursing skill that cannot be
practiced on real patients without some embarrassment or discomfort
to the patient or students, even when performed by a nurse or doctor
of the same gender as the patient. Yoo et al. (2010) argue that urinary

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.08.007
 D. Öztürk, L. Dinç / Nurse Education Today 34 (2014) 802–808
catheterization is affected by culture and often stigmatized due to the
necessity of handling sexual organs, which can limit the acquisition of
knowledge and skills. In an integrative review of literature regarding
urinary catheterization, Balduino et al. (2012) state, “the manipulation
of the genitalia brings embarrassment, because it has the idea of
invasion of privacy, something sexual and dirty” (p. 2250). Moreover,
urinary catheterization is a complex and invasive procedure that poses
serious risks to patients, including trauma to the urethra or bladder
from incorrect insertion and introduction of microorganisms into the
urinary system that can result in infection. Therefore, the procedure of
urinary catheterization requires knowledge, strict adherence to aseptic
technique, and technical skills. Hoseini et al. (2009) found a significant
difference between professors' and graduated students' opinions
about the frequency of performing skills of urinary catheterization.
The authors concluded that urinary catheterization is often performed
by interns or urology residents in educational wards due to possible
complications, leaving little practice opportunities for nursing students.
To provide safe clinical practice opportunities and reduce cultural
and practical barriers, nurse educators must use skill laboratories and
clinical simulations more effectively to enhance psychomotor skill
development. In the meantime, nurse educators must view learning as
an on-going process, not confined to classroom or skill laboratories. A
lifelong learning approach should be adopted to encourage students
to be educationally proactive. Computer-assisted instruction, e-
learning, or web-based learning supplements traditional didactic in-
struction and live clinical education and encourages students to assume
responsibility for their own learning needs (Krautscheid and Burton,
2003; Karaağaçlı, 2008). The appropriate use of multimedia, such as
self-instructional CD-ROMs and videos with visual representations of
psychomotor skills, can enrich web-based/web-enhanced learning
(Demir, 2000) and promote “meaningful learning” (Karppinen, 2005).
Although there is a large amount literature on the effects of web-
based education, few studies have investigated the effect of web-based
learning on the psychomotor skills of nursing students. Cook et al.
(2012) demonstrated a positive impact of a web-based interactive simu-
lation game (PULSE) on nursing students' life-support skills. Salyers
(2007) compared a web-enhanced lecture plus a three-hour lab session
with a three-hour traditional lecture and demonstration for teaching na-
sopharyngeal suction, catheter insertion, and wet-to-dry dressing
change, and found that the web-enhanced/demonstration group
performed significantly better on the comprehensive cognitive final
exam. A study by Lu et al. (2009) compared web-based with traditional
classroom instruction with traditional classroom instruction for teaching
intramuscular injection, and found that the web-based group had signif-
icantly higher knowledge and skill performance ratings. Results of these
studies demonstrate the value of web-based education in teaching psy-
chomotor skills to students; however, to date, no study has specifically
investigated the effect of web-based education on the urinary catheteri-
zation skills of nursing students. To address the aforementioned chal-
lenges in nursing education, the potential contribution of web-based
and web-enhanced learning to the knowledge and skills of nursing stu-
dents should be explored in empirical studies.
Background/Literature
Web-based education is an individualized education system using
computers (Manochehr, 2001). Web-enhanced learning is defined as
the “supplement of web technologies to education activities in order
to support the learning–teaching process in increasing the learning of
students in a subject” (Uzunboylu, 2002).
Web-based education and web-enhanced learning are usually used
interchangeably. In fact, the two have some common characteristics, in-
cluding incorporating all possibilities of computer-assisted education
and synchronous or asynchronous lessons. Both in synchronous and
asynchronous learning, the student and teacher are at different places;
but synchronously conducted lessons take place in real time, whereas
803
asynchronously learning takes place outside of real time. However,
web-based education and web-enhanced learning are different in that
the former can be used outside of traditional formal institutions,
whereas the latter is used to supplement traditional classroom educa-
tion. Another point of divergence is associated with the educator
conducting the lesson: in web-based education, a group composed of
different specialists may lead and regulate the learning–teaching
process, while web-enhanced education is completely controlled by
one instructor (Uzunboylu, 2002).
The findings of several studies suggest positive effects of web-based
education in the training of nursing students (Woo and Kimmick, 2000;
Kearns et al., 2004; Dwyer and Searle, 2009; Cooke et al., 2010). For ex-
ample, Woo and Kimmick (2000) found that students who took nursing
lessons via the Internet were more satisfied with and enthusiastic about
their lessons. Kearns et al. (2004) investigated the effect of web-based
education and web-enhanced education on the achievement and satis-
faction of second-year nursing students in the USA. The achievement
scores of the students receiving web-based education were higher
than those of students receiving traditional classroom education with
web-enhanced supplements. However, there have been few studies
focusing on the psychomotor skills of nursing students. Nursing is a
practice-based discipline, and skilled and competent nurses are a re-
quirement of quality health care. Therefore, developing the psychomo-
tor skills of nursing students is important to the quality and safety of
care.
The aim of the present study was to evaluate the effect of three
modes of education—web-based education, web-enhanced education,
and traditional in-classroom education—on the urinary catheterization
knowledge and skills of nursing students. The following hypotheses
were tested in this study:
H1. There are differences between web-based education and traditional
in-classroom education in increasing urinary catheterization knowledge.
H2. There are differences between web-based education and tradition-
al in-classroom education in increasing urinary catheterization skills.
H3. There are differences between web-based education and web-
enhanced education in increasing urinary catheterization knowledge.
H4. There are differences between web-based education and web-
enhanced education in increasing urinary catheterization skills.
Methods
Study Design and Sample
A quasi-experimental design was used in this study. A convenience
sample of 160 first-year nursing students was recruited from the health
sciences areas of two universities. At the time of this study, students
were enrolled in the Fundamentals of Nursing course during the spring
semester of the academic year 2011–2012. Students who had easy ac-
cess to computers and the Internet were assigned to the experimental
group, while those who had limited access formed the control group.
The experimental group received web-based and web-enhanced learn-
ing while the control group experienced traditional classroom learning.
Five students who had continuous absenteeism and 18 students taking
the course again due to failure were not included in the study. In addi-
tion, five students who had graduated from vocational health school
and transferred vertically to higher education were excluded due to
their previous urinary catheterization knowledge and skills. Twenty-
one students dropped out due to incomplete laboratory practice.
Hence, the investigation was carried out with 111 students (59 students
in the experimental group and 52 students in the control group). The
rate of participation in the study was 69.4%.
804 D. Öztürk, L. Dinç / Nurse Education Today 34 (2014) 802–808
Ethical Considerations
Written permission and approval were obtained from the Hacettepe
University ethics committee and the Deans of Faculty of Health Sciences
in both universities. Students who were participating in the study were
informed about the aim and method of the study, and written informed
consent was obtained.
Instruments and Pilot Study
In the present study, the data were collected using the urinary cath-
eterization knowledge test and urinary catheterization skill checklist
prepared by the researcher based on the relevant literature and consul-
tations with experts.
The instruments were developed after the preparation of teaching
content regarding urinary catheterization. The goal of content prepara-
tion was to provide students with theoretical knowledge of urinary
catheterization and enable them to perform urinary catheterization on
a mannequin or patient accurately and safely. Specific learning objectives
for students were (a) describe the anatomy and physiology associated
with the performance of urinary catheterization, (b) describe the indica-
tions and contraindications for performing urinary catheterization,
(c) identify the materials necessary for performing urinary catheteriza-
tion, (d) perform the insertion procedure competently on a male and
female mannequin, and (e) care for a patient with a urinary catheter.
After preparing the teaching content, the researcher generated a
pool of questions and a checklist of urinary catheterization procedures
for the assessment of students' knowledge and skills. The pool of ques-
tions was modified by a panel of three experts with experience teaching
the Fundamentals of Nursing. After review, questions were selected
based on comprehensiveness and relevance and the final knowledge
test consisted of 20 multiple-choice questions with four answer choices.
The first six questions referred to anatomy–physiology of urinary
system, the seventh question referred directly to the indications for
indwelling urinary catheter, while the subsequent question related to
the positioning of female patients during catheterization. Questions 9
and 10 referred to catheter type, length, and size for female patients,
while the eleventh question related to aseptic cleaning of the genital
area and urinary opening. Questions 12–14 referred to the insertion
technique of a urinary catheter in a female, such as advancing it approx-
imately from 7.5 to 10 cm and inflating the balloon of the catheter,
while the last six questions were related to measures that should be
taken for the care of patients with urinary catheters and the need to
maintain a closed drainage system. Incorrect answers were scored “0”
and correct answers were scored “1”; thus, the lowest possible score
was zero and the highest 20. A pilot administration, conducted with
20 second-year nursing students, indicated no need for further
revisions.
The initial checklist of urinary catheterization procedure was modi-
fied to facilitate judgments on the proficiency of each student performing
urinary catheterization on a mannequin. The same panel of three experts
reviewed the list for content validity. Based on their suggestions, the
number of items on the checklist was reduced from 51 to 26, and critical
steps were highlighted. This checklist was also reviewed by a Measure-
ment and Evaluation faculty member in the education department of
the university for format and measurement properties. According to his
recommendations, the steps of each observed procedure were arranged
in one column, and numeric values were assigned to each of the steps to
indicate the degree of achievement. Steps of performance were scored as
0 if the skill was not observed, 0.5 if incorrect, 1 if it was correct, or 2 if the
skill was deemed as critical. Eight items of the urinary catheterization
checklist, including positioning the female patient, sterile gloving,
checking the balloon of indwelling catheter, applying lubricant to the
catheter tip, aseptic cleaning of the genital area, inserting and advancing
the catheter through meatus approximately from 7.5 to 10 cm, inflating
the balloon of the catheter, and maintaining the closed drainage system
were deemed critical. Thus, the total possible score for the entire set of
skill checklist ranged from 0 to 34.
Video Recording and Web Design Process
Our intention was to simulate the procedure of urinary catheteriza-
tion as close to reality as possible because, with web-based education,
where there is no actual face-to-face contact between the teacher and
the students. The issue of copyright and cost of existing instructional
video materials and lack of appropriate video specific to urinary cathe-
terization procedure in Turkish language compelled us to produce our
own video. The principal investigator performed urinary catheterization
on a mannequin, which was recorded by a professional using a digital
video recorder with a built in microphone. Important parts of catheter-
ization, particularly the insertion of the catheter, were filmed in close-
up and at a distance simultaneously using two separate cameras. The
video data was transferred from the digital video recorder to the
computer for editing and the edited version was reviewed by two
nurse educators who had experience in teaching the Fundamentals of
Nursing. Their comments and recommendations were acknowledged
and amalgamated into the final product.
Following the video material, the investigator purchased a web
domain and a website was created with the help of a professional web
designer. The web designer used MySQL database management system
(MySQL, 2013). The intra-site algorithms, interfaces and dynamic page
content of the website were generated using PHP (Hypertext Pre-
Processor) programming language because it was available at no cost
with documentation in many languages.
The teaching content regarding urinary catheterization, converted to
PowerPoint slides, and accompanied by a summative text, static
pictures, and pre-recorded video, was uploaded to the website; this
formed the basis of web-based education procedures. A list of student
IDs was imported to the database to authenticate students creating
user accounts. The home page of the website included a welcome mes-
sage, contact information, including a phone number and a “mailto:”
feature at the bottom of the page, and a user account form. Students
could access the online course after their ID and password were verified.
The website included the online knowledge test and answers were
recorded automatically. The last slide included a dialog box containing
two radio buttons: a return to the online course and online knowledge
test. However, entrance to the online test was closed until a preset
date. The functionality, usability, and compatibility of the website with
popular browsers were tested before being launched on the Internet.
Implementation of the Study
Implementation in the experiment group
The students in the experiment group were informed in detail about
the registration procedure and use of the website. The website was ac-
tivated in March 2012 and kept open for two weeks. Students who
wanted to enter the website had to register by typing their name or
school number and a predetermined code number, which had been
sent to them previously. After registering, they could enter the system
by clicking the box next to “I agree to participate in the study” in the
lower part of the registration page. They could access the course via
Internet at any time within the two-week period. At the end of the
two-week period the system was automatically and temporarily closed.
Following the web-based education, the online test link of the
website was activated and knowledge tests were administered online
in a computerized classroom under the supervision of a researcher. An-
swers were recorded on the MySQL database automatically, graded on
completion, and students were provided with immediate feedback.
To assess the skills of the experimental group on urinary catheteriza-
tion, students were divided into small groups and they practiced
performing urinary catheterization on mannequins in the simulation
laboratories of the nursing departments. Immediately after the
 D. Öztürk, L. Dinç / Nurse Education Today 34 (2014) 802–808
laboratory practice, the urinary catheterization skill of each student was
observed by two independent observers who had PhD degree in Funda-
mentals of Nursing simultaneously using the skills checklist.
Implementation in the Control Group
After the web-based education was completed, urinary catheteriza-
tion was taught to both experimental and control group students by the
researcher in the classroom using the methods of lecturing via
PowerPoint presentations, question-and-answer sessions, discussions,
and demonstration on a mannequin. The video was not used. Immedi-
ately after the lecture, a knowledge test was administered to all stu-
dents. Then, all students, including both the experimental group and
control group students, were divided into small groups and practiced
the urinary catheterization procedure on mannequins in the simulation
laboratory. Following the laboratory practice of all students, the skill
performance of each student was observed and rated by two indepen-
dent observers in the laboratory. Thus, the date of the in-classroom ed-
ucation control group and data of the web-enhanced education
experimental group (web-based as a supplement to traditional class-
room instruction) were collected (Flow chart 1). After the implementa-
tion of the study, the website was opened for the use of the students in
the control group without any test or additional practice.
Evaluation of Data
Data regarding the knowledge assessment of the experimental
group were stored in the database of the website in CSV (Comma Sepa-
rated Values) format, which could be transferred to Excel format and
Experiment Group (n= 59)
Web-based
education
Web-based
lecturing
Web-based
knowledge test
Skill
observation in
laboratory
Web-enhanced
education
Evaluation of data, testing of hypotheses
Flow chart 1. Steps of the research.
805
imported to SPSS. Data obtained by using the checklists and paper and
pencil format knowledge test was entered manually into SPSS (17.0)
program (SPSS Inc., 2007) and analyzed using descriptive statistics.
The mean scores of each student on knowledge test and skill perfor-
mance were computed and used as a dependent variable, whereas
“modes of instruction” (web-based education, web-enhanced learning
and in class-instruction) were considered as independent variables.
Since the data were not normally distributed, differences between the
scores of the experimental and control groups were analyzed using
the Mann–Whitney U test. Data of the experimental group regarding
the web-based education and web-enhanced education were analyzed
using the Wilcoxon signed rank test. Inter-rater reliability between ob-
servers was assessed using Cohen's kappa coefficient. A p value of 0.05
was set for statistical significance.
Results
The study sample (N = 111) consisted of two groups of students
categorized by mode of instructional format: the experimental group
experienced web-based education, and then in-classroom instruction
(web-enhanced education) (n = 59) and control group experienced
only in-class instruction (n = 52).
Descriptive statistics revealed that the experimental group had
slightly higher mean scores in knowledge (M = 15.0; SD = 2.4) than
the control group (M = 14.1; SD = 3.2). However, the Mann–Whitney
U test showed no significant difference between the experimental and
control groups in knowledge scores (p = 0.153), indicating that H1
was rejected.
Control Group (n= 52)
Traditional, in-classroom
Knowledge test
Skill observation in laboratory
806 D. Öztürk, L. Dinç / Nurse Education Today 34 (2014) 802–808

Table 1
Comparison of knowledge and skill scores between web-based education and in-class instruction.

Variables Scores Mann Whitney U Test

Dependent variables Independent variables n Mean Min Max SS Mean rank U p

Knowledge test Experimental group (web-based education) 59 15.0 10 19 2.4 60.1 1294 0.153
Control (in-class instruction) 52 14.1 6 20 3.2 51.4
Total 111 14.6 6 20 2.9
Skill performance Experimental group (web-based education) 59 27.9 14 34 4.4 66.9 888.5 0.000⁎
Control (in-class instruction) 52 23.7 9 33.5 6.3 43.6
Total 111 25.9 9 34 5.7
⁎ p b 0.05.

The mean score on skill performance of the experimental group was To gain some understanding about the students' online learning
27.9 (SD = 4.4), while the control group had a mean score of 23.7 activity, we tracked the number of logins on the website. Students
(SD = 6.3). The Mann–Whitney U test revealed significant difference accessed the course materials one to 12 times per week, with an average
between the mean scores of two groups (p N .001.). Thus, the H2 was of six times. Nevertheless, no significant correlation was found between
confirmed. the number of logins to the website and the students' knowledge scores
Based on these results, we concluded that there was no difference after web-based education (p N 0.05). However a moderately signifi-
between the web-based education and traditional in-classroom educa- cant positive relation was found between the frequency of logins to
tion groups in the knowledge of urinary catheterization; however, web- the website and the mean score of skill performance after web-based-
based education had positive effects on the urinary catheterization skills education (r = 0.270) (p b 0.05).
of students (Table 1).
To identify differences in skill areas, we examined individual items of
the skill checklist, particularly the eight critical items. Results indicated Discussion
that students receiving web-based education obtained higher scores for
some steps of the urinary catheterization procedure during performance The present study, which investigated the effect of web-based edu-
observations. These steps were “assisting the patient to the dorsal re- cation in teaching urinary catheterization, was carried out among 111
cumbent position,” “checking and inflating the balloon of indwelling first-year nursing students enrolled in Fundamentals of Nursing.
catheter,” “cleaning the genital area using aseptic technique,” and In this present study, we found no significant difference between
“maintaining a closed drainage system by attaching the end of catheter web-based education group and classroom instruction group in knowl-
to the collecting tube of the drainage system.” In contrast, there was no edge of urinary catheterization. This finding is contradictory to the liter-
significant difference between experimental and control group students' ature, suggesting that web-based learning provides flexibility for
performance for some critical skills, including “donning sterile gloves students in time, place, and access to teaching content (Buckley, 2003;
using aseptic technique,” “applying lubricant to the catheter tip,” and Wilkinson et al., 2004; Farrell et al., 2007) and enhances the learning
“inserting the catheter through meatus and advancing it approximately capacity of students by enabling them to progress at their own speed
7.5 to 10 cm.” (Koch et al., 2010). A possible explanation of our finding might be the
In addition to the analyses of differences between web-based educa- limitations of interaction between teachers and students. Students in
tion and in-class instruction, we assessed the effect of web-based educa- the web-based group had no opportunity to ask questions or discuss
tion as a supplement to classroom instruction (web-enhanced the teaching content, and they were unable to receive immediate feed-
education) on students' scores of knowledge and skills and compared back from the teacher, whereas those in the classroom instruction
it with the web-based education itself. As expected, the knowledge group had the opportunity for face-to-face interaction during the
score of students after web-enhanced education increased from 15.0 course.
to 17.3, while the score of skill performance increased from 27.9 to The results of this study support our hypothesis that web-based ed-
30.9. The Wilcoxon signed rank test revealed significant differences be- ucation is effective in increasing the skills of students in the experimen-
tween web-based education and web-enhanced education groups, indi- tal group. In addition, some critical steps of the urinary catheterization
cating that students obtained the highest scores when web-based procedure were performed better by the students of the web-based
education was used as a supplement to traditional classroom instruc- group. Despite the fact that web-based learning includes a virtual learn-
tion. Thus, hypotheses H3 and H4 were accepted (Table 2). ing environment for students rather than real life context for practicing
the skills, the use of video and pictures, which could be viewed by stu-
dents repeatedly without any limitations of time and place, might have
influenced their performance positively. Our result is consistent with
Table 2
the results of other studies. For example, Beeckman et al. (2008)
Comparison of knowledge and skill scores between web-based education and the supple-
ment of web-based education to in-classroom instruction.
conducted a study to detect problems when classifying pressure ulcers
and to examine whether an e-learning program was able to increase the
Dependent variables Scores Wilcoxon sign skills of qualified nurses and nursing students. They found that nursing
test
students achieved better results when using the e-learning program. As
n Mean Min Max SS Z p stated in the introduction, Lu et al. (2009) assessed the effectiveness of
Knowledge test 59 15.0 10 19 2.4 −5.316 0.000⁎ supplementing conventional classroom teaching with web-based
(web-based education) learning when teaching intramuscular injection nursing skills. They re-
Knowledge test (web-based 59 17.3 13 20 1.8
ported that participants achieved higher skill performance scores with
education + class instruction)
Skill performance 59 27.9 14 34 4.4 −5.203 0.000⁎ web-based learning compared to conventional learning methods. In
(web-based education) contrast, Bloomfield et al. (2010) investigated the effect of computer-
Skill performance (web-based 59 30.9 23.5 34 2.3 assisted learning versus conventional teaching methods on the acquisi-
education + class instruction) tion and retention of hand washing theory and skills in pre-qualification
⁎ p b 0.05. nursing students. Their mode of instruction for the experimental group
 D. Öztürk, L. Dinç / Nurse Education Today 34 (2014) 802–808
included computer-assisted instruction instead of web-based educa-
tion, and they found no significant differences between the groups.
Results of this study indicated that the use of a web-based education
as a supplement to traditional classroom education (web-enhanced ed-
ucation) increased both the knowledge and skill performance scores of
students on urinary catheterization. The highest scores of knowledge
and skill performance were obtained for the web-enhanced group.
This result suggests that student learning is boosted when students
are incorporated interactively in the process through multiple learning
methods, and this approach is used to support face-to-face classroom
education. Consistent with our result, Salyers (2007) compared a web-
enhanced lecture plus a three-hour lab session with a three-hour tradi-
tional lecture and demonstration of some basic nursing skills and re-
ported positive effects of the web-enhanced demonstration group.
Gerdprasert et al. (2010) used the web-based learning unit to supple-
ment traditional conventional lectures and assessed students' achieve-
ments by using the pre- and post-test scores on factual knowledge
and semi-structured interviews. The group receiving supplementation
with web-based materials had significantly higher scores than the tradi-
tional lecture group. The study by Cooke et al. (2010) suggested that
students participating in a web-enhanced classroom environment
were able to study lessons at their own pace and repeat the content of
lessons whenever they wanted. The American Association of Colleges
of Nursing (2005) also reported that supplementing classroom educa-
tion with web technologies is an effective method of increasing student
achievement. However, our finding conflicts with some other studies,
which found no significant difference between the learning outcomes
of the web-enhanced group and traditional classroom education
group (Dwyer and Searle, 2009), or higher scores of students in the
web-based group when compared to the web-enhanced group
(Kearns et al., 2004).
Limitations of the Study
Several limitations of this study must be acknowledged. First, the
study was based on a nonprobability convenience sample, which
increases the risk of bias. However, the sample was consistent with
educational level of the students (all were first year nursing students)
and curriculum of the schools. Second, our results regarding the signif-
icantly higher scores of the students in the web-enhanced group should
be interpreted with caution because the experimental group had easy
access to computers, and internet and two opportunities to take the
knowledge test and perform the skills. Third, the use of video in the
web-based group might have positively influenced the scores and
performances of students. Fourth, during the observations of student
skills, inter-observer consistency was at a moderate level in some
steps. Repeated observational measures within a short time interval
(15 min per student) were tiring for observers, and they had to com-
plete all observations within a few days. Such a tiring and long-lasting
process of observation might have decreased the vigilance of observers
and influenced inter-rater reliability. Finally, due to concerns of safety
and privacy, we used a female mannequin for demonstration during
lectures and observation of students' skill performances.
Conclusion
Together with the challenges of rapid changes in science and
technology and difficulties faced by nurse educators in imparting
the appropriated knowledge and skills required for the integration
of theory and practice, there is a growing trend of incorporating in-
formation technology into the nursing education curriculum. Computer-
assisted instruction, web-based education, web-enhanced education,
and distance education have the potential to contribute to the effective-
ness and quality of nursing education. The results of this study indicated
that web-based education has positive effects in increasing the urinary
catheterization skills of nursing students; however, supplementing
807
traditional classroom teaching with web-based learning enhanced both
knowledge and skill performances of nursing students. Based on these
results, we recommend the integration of web-based education into tra-
ditional teaching methods. However, more studies are needed to provide
additional evidence regarding the effects of web-based curriculum on
students' academic and skill performance and the advantages and disad-
vantages for nursing education.
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