Enhancing nursing students’ skills in vital signs assessment by using multimedia computer-assisted learning with integrated content of anatomy and physiology

Computer-assisted learning 

Computer-assisted learning (CAL) is an individualized method of self-study using the computer to deliver an educational activity. It allows learners to proceed at their own pace with immediate and continuous feedback on their progress as a response to a software program. Multisensory learning with interactive CAL multimedia has been widely used and proved to be a successful educational tool to communicate the objectives and involves the student as an active participant in the learning process. The use of CAL multimedia as a supplement to traditional classroom lecture produced a significant improvement on the student’s performance than when either strategy was used alone (Rouse, 2000). In addition, most students using CAL had positive attitude toward CAL and felt more confident than those who learned by other teaching methods (Wharrad et al., 2001). There are also indirect benefits such as the development of computer and information technology (IT) skills (Lewis et al., 2005).

Learning skills 

The theory-practice gap is a complex phenomenon frequently defined as a discrepancy between what nursing students are taught in a classroom setting, the theoretical aspects of nursing, and what they experience whilst on placement in clinical areas. Better sequencing of theory and practice is a factor to be considered for their integration and for reduction of the gap. Therefore, students should receive relevant theories immediately before a clinical placement (Corlett et al., 2003). Furthermore, cognitive theorists believe that learning is an internalization event in which the information is encoded, stored and later retrieved. An information-processing model of memory illustrates how information is incorporated and retrieved in four stages, viz, paying attention to environmental stimuli, information processing by the senses, transforming the information into short-term memory after which it is either disregarded and forgotten or stored as long-term memory. The last stage involves the action or response that the individual makes on the basis of how information is processed and stored (Vandeveer and Norton, 2005).

On the other hand, the first year nursing students are taught vital signs sporadically, primarily in anatomy and physiology courses without much emphasis on the clinical issues (Saksoomboon et al., 2002). As a result, students have difficulties integrating the basic science and clinical aspects of vital signs assessment. Understanding the anatomical and physiological knowledge of vital signs is necessary for development of critical thinking skills that the nurse must use to ensure the vital signs assessment (Dwyer et al., 2007). These understandings also influence patient outcomes in nursing practice (Prowse and Heath, 2004).

Conceptual framework 

The conceptual framework of this study was based on an integration of the cognitive learning theory (Vandeveer and Norton, 2005) and the 5Es inquiry cycle (Bybee et al., 2006) to the interactive multimedia. Cognitive psychologists believe that when students take an active role in their learning, they will learn more, accumulate, assimilate the knowledge and then make sense of it. Colburn and Clough (2007) also recommend the 5Es inquiry cycle as an effective means to help students enjoy science, understand content, and apply scientific processes as well as concepts to authentic situations needed for clinical problem solving. The development of CAL multimedia in this study followed these strategies by making the instruction as interactive as possible, and using 5Es inquiry cycle approaches to encourage students to develop their own frames of thought through critical and logical thinking.

Study design 

A randomized experimental design was used in this study (Shadish et al., 2001). The subjects were 117 second-year nursing students enrolled in a fundamental nursing course. They were from two nursing schools in Thailand, both of which had similar curricula and learning facilities such as computers, skill resource centers and other equipment. Most participants (93.2%) were female, with mean age of 19.39±0.82 years and grade point average (GPA) of 2.56±0.46. There was no significant difference in age and GPA of the students (p>.05). The students were randomly assigned into three groups of different teaching methods: (1) CAL/lecture (n=37), (2) CAL/lecture/demonstration (n=40) and (3) lecture/demonstration (n=40).

Development of CAL multimedia 

The CAL multimedia was developed by integrating the necessary knowledge on anatomy and physiology for vital signs with the 5Es inquiry cycle. The content was displayed by using graphics, pictures, animation, video and simulation of experiences. This interactive CAL multimedia with the above features allowed the students to see, hear and interact during the learning process. This CAL multimedia was composed of five sections: 1. preparation for physical examination, 2. examination techniques, 3. instrumentation, 4. appearance and behavior examination and 5. vital signs assessment.

The content in “vital signs assessment” section consisted of underlying anatomy and physiology principles related to body temperature, respiration pulse and blood pressure including the Korotkoff sound. These contents were arranged in a chronological sequence for vital signs assessment, i.e., the apparatuses needed for measurement, a video demonstrating how to measure and record data and finally how to interpret the findings. Discussions on the meanings of normal or abnormal readings and documentation were also included (Figure 1, Figure 2, Figure 3, Figure 4).

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Figure 1. Illustrating interactive blood pressure measurement menu allowing learners to choose content they want to review.

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Figure 2. An interactive window that the learner can practice listening to Korotkoff sound.

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Figure 3. An interactive menu about body temperature measurement.

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Figure 4. An interactive menu about pulse measurement.

This CAL multimedia was designed for the learners to interact with the module and tailored to their own learning pace. The interactive part included review questions for nursing interventions, case scenarios with multiple choice questions, clinical applications, practices in listening to Korotkoff sound and the sounds of abnormal respiration patterns.

In each section, the CAL content was developed based on the 5Es inquiry cycle concept as follows:

This CAL multimedia was validated by three experts in three different fields. The item objective congruence (IOC) ranged from 0.75 to 0.95.

Implementation of the CAL 

Prior to the initiation of this study, the approval was obtained through the university’s committee on human subject research. The effectiveness of CAL multimedia on student’s achievement was evaluated on the second-year nursing students by using a factual knowledge test on vital signs and a performance checklist. The user’s satisfaction, i.e., the ease of navigation, flow of content and comprehensiveness of the material was also tested by using multimedia assessment scale adapted from Tuphikron et al. (2001) and a semi-structured interview.

After the orientation, all nursing students were given the pretest on factual knowledge before the 60-minute traditional lecture. Then, the students assigned in groups 1 and 2 were allowed to study the CAL individually for 90min in a computer laboratory. On the following day, students in groups 2 and 3 were shown how to measure and record vital signs by faculty demonstration in the skill resource center. Then, the posttest on factual knowledge and a 30-min test on their abilities to measure vital signs using a performance checklist was given to all students after completing all interventions. Additionally, a 60-minute interview was conducted on ten students from the CAL group. In determining the effects of this CAL multimedia on students’ achievement and the difference between groups, descriptive statistics, t-test, analysis of variance (ANOVA) and Bonferroni posthoc test (Shadish et al., 2001) were used. Students’ achievement and factual knowledge about vital signs were assessed before and after the activities and while the performance checklist score of vital signs measurement was measured only at the end of the implementation.

The factual knowledge test on vital signs assessment: the 30-item multiple-choice questions were validated by using the item objective congruence (IOC) technique. The average scores of all items ranged from 0.5 to 0.75. The test was then tried out on 30 second-year nursing students. The reliability estimated by Kuder–Richardson 20 was 0.71 (KR-20=0.71), the difficulty and discrimination indices were 0.30–0.95 and 0.27–0.84, respectively. The possible total scores of the factual knowledge ranged from 0 to 30, one point for each correct answer.

The performance checklist: the 29-item performance checklist and Teacher Guide for Vital Signs assessment, developed by Fundamental Nursing Committee, Ramathibodi Nursing School, Faculty of Medicine Ramathibodi Hospital (2007), were used to evaluate students’ ability to measure and interpret the vital signs. The reliability test showed a Cronbach alpha coefficient of 0.81. Five points ranging from 0 to 4 were given for satisfactory performance of the vital signs measurement based on criteria for satisfactory performance in the Teacher Guide. These criteria included appropriate patient preparation, handling of apparatus, correct procedures such as exact placement of the oral thermometer, correct cuff placement, use of the stethoscope, palpation of arterial pressure, proper inflation and deflation of the cuff, blood pressure reading within stated range and documentation of findings. The possible total scores of the performance skills test ranged from 0 to 116: zero point for no performance and four for most satisfactory.

Students’ Attitude: The CAL assessment scale and a semi-structured interview were used to evaluate students’ attitude. The CAL assessment scale modified from Tuphikron et al.’s (2001) multimedia assessment form was used to evaluate for user’s satisfaction and its quality. The reliability of this CAL assessment scale showed Cronbach alpha coefficient of 0.89. The nursing students in the CAL groups (groups 1,2) were asked to rate 20 items related to clarity of instructions, ease of use and interest. Additional space was also provided for comments. The responses were rated on the 5-point Likert scale, ranging from“poor” to “excellent”. Thus the total score ranged from 20 to 100.

A semi-structured interview: students’ experience and attitude in using the CAL multimedia were explored by using a semi-structured interview. Ten participants in the CAL groups were randomly selected for a 60-minute interview which were audio-taped for further analysis. Some examples of the questions are: “How do you feel in using the CAL multimedia to supplement your learning?” “What do you like or dislike about the CAL multimedia?” and “What features in CAL multimedia would you like to change if you could?”.

Students’ achievement 

The effectiveness of computer-assisted learning (CAL) multimedia was tested by comparing its effects on the three instructional intervention strategies, i.e., (1) CAL/lecture, (2) CAL/lecture/demonstration and (3) lecture/demonstration. The results in Table 1 show that the pretest on factual knowledge of nursing students in all three groups were significantly different from those of the posttest. Analysis of t-test on gain scores of factual knowledge showed a significant gain in knowledge in the posttest for every group (t=−7.64, t=−6.25, t=−10.13; p<.001). However, there was no significant difference in the mean pretest, posttest scores, and gain scores of the factual knowledge among the CAL supplemented groups and traditional group (F2,114=1.802, 1.529, 3.028; p>.05).

Table 1. The pretest and posttest of factual knowledge of the CAL supplemented group and traditional group (lecture/demonstration) (n=117)

	Intervention group	Pre-test	Post-test	Difference (pre-post)	t-value
		Mean (SD) F(2,114)	Mean (SD) F(2,114)	Mean (SD) F(2,114)
	1. Lecture/CAL (n=37)	14.84 (2.82) 1.802ns	17.65 (2.06) 1.529⁎	2.81(2.06) 3.028⁎	−6.25⁎⁎
	2. Lecture/CAL/ Demonstration (n=40)	13.90 (2.59)	18.33(1.87)	4.43(2.76)	−10.13⁎⁎
	3. Lecture/Demonstration (n=40)	13.80(2.55)	17.83(2.35)	3.78(3.13)	−7.64⁎⁎

ns No significant difference. ⁎⁎ p<.001.

The performance checklist scores of the CAL supplemented groups, both with and without faculty demonstration were significantly different from those of the traditional group (Table 2: F2,114=10.447, p<.001). Bonferroni Posthoc test (Table 3) showed that students taught by supplementing with CAL (groups 1,2) gained significantly higher performance checklist scores than those taught by traditional lecture and demonstration (group 3). Nevertheless, the results showed no significant difference in performance checklist score between the two CAL supplemented groups, i.e., with and without faculty demonstration (groups 1,2).

Table 2. Comparison of the average performance checklist score between the CAL supplemented and traditional group (lecture/demonstration) (n=117)

	Intervention group	Mean	SD	F(2,114)
	1. Lecture/ CAL (n=37)	103.46	9.81	10.447⁎⁎
	2. Lecture/CAL/Demonstration (n=40)	102.10	7.99
	3. Lecture/Demonstration (n=40)	94.23	10.94

⁎⁎ p<.001.

Table 3. Posthoc test of the average performance checklist score (n=117)

	(I)Intervention group	(J)Intervention group	Mean difference (I–J)	Standard error	Significance	95% Confidence interval
						Lower bound	Upper bound
	Group 1	Group 2	1.359	2.203	1.000	−3.99	6.71
	(Lecture/CAL)	Group 3	9.234⁎⁎	2.203	0.000	3.88	14.59
	Group 2	Group 1	−1.359	2.203	1.000	−6.71	3.99
	(Lecture/CAL/Demonstration)	Group 3	7.875⁎	2.160	0.001	2.63	13.12
	Group 3	Group 1	−9.234⁎⁎	2.203	0.000	−14.59	−3.88
	(Lecture/Demonstration)	Group 2	−7.875⁎	2.160	0.001	−13.12	−2.63

⁎ p<.01. ⁎⁎ p<.001.

User’s satisfaction 

When the satisfaction and quality of CAL multimedia were evaluated using 20 items on CAL assessment scale, rating on 5-point Likert scale from poor to excellent. The higher scores indicate the higher perceived CAL multimedia quality. The evaluation results from 77 students showed the mean score of 91.20±9.18, indicating high satisfaction and quality of CAL multimedia from user’s perception. Additionally, examples of excerpts from interviews as shown in Table 4 were in favor of CAL multimedia, the only negative comment was time constraint: only 90 min was allowed for the study. The comments were grouped into three categories, i.e., learner, learning environment and software design. The well-designed interactive software of the CAL multimedia provided an independent interactive learning experience and stimulated joy of leaning. Moreover, most of them agreed that CAL multimedia provided an effective method to enhance students’ learning, understanding and knowledge retention.

Table 4. Excerpt from interview

	Categories	Examples of excerpt from interview
	1.Learner
	• Easier to understand	I prefer the CAL module as it is much easier to complete and it increases understanding
	• More interesting	CAL module is more interesting and colorful
		CAL is more informative and held my attention for a longer period of time
	2. Learning environment
	• Learning flexibility	CAL module contains a lot of information in which one can learn at one’s own pace
	3. Software designs
	• Presentation	The design of interface enhances the learner’s experience and understanding
	• Interaction	CAL module provides an independent interactive learning experience
	• Instant feedback	I like the quizzes at the end because they are immediate reinforcement of information
		CAL module tells us whether we are right or wrong

Limitations and recommendations 

The limitations in this study were the time constraint in using CAL multimedia, i.e., only 90min were given. If more time was allowed, the students could possibly have gained more factual knowledge. More research is also needed to determine the exact costs in terms of human and financial resources. A future study with an emphasis on students’ outcomes in long-term knowledge retention is also recommended.