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Table of Contents
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 104-111

Online Classes for Nursing Fraternity: A Systematic Review of the Impact on Attitude, Knowledge, and Skills

1 Department of Nursing, GTB Hospital, Government of NCT, Delhi, India
2 Amity College of Nursing, Amity University, Haryana, India

Date of Submission05-Jul-2020
Date of Decision13-Jul-2020
Date of Acceptance29-Sep-2020
Date of Web Publication08-Feb-2021

Correspondence Address:
Ms. Prerna Sharma
D-467, Near Mandir Marg Police Station, Gol Market, New Delhi-110 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IOPN.IOPN_18_20

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Owing to COVID-19, there has been a lot of emphasis on online classes among educational institutes. Online classes have their own merits and demerits as compared to traditional classes. COVID-19 crisis changed the teaching–learning pedagogy dramatically and pushes the learning platform from conventional methods to more use of online or electronic methods. This objective of the study was to review the effect of online classes on attitude, knowledge, and skill among nursing fraternity (nursing students, staff nurses, and nursing faculty) so that measures can be planned to deliver online education to students in a more efficient and acceptable manner. The studies included were published between January 2010 and March 2020 using the following databases: CINAHL, ERIC, Medline, EMBASE, Dissertation, and Theses. The experimental study (randomized controlled trial) and nonexperimental study designs were included. Thirty-three studies were found eligible for inclusion in the analysis. The review demonstrates that the nursing fraternity has positive attitude toward online classes. There is a significant change in knowledge scores also, but limited data could be found regarding skill improvement after the online classes. Data were extracted using a narrative synthesis. There was significant improvement in nurses' attitude and knowledge between groups who attended online classes and the ones who participated in traditional learning.

Keywords: Attitude, e-learning, knowledge, nurses, online classes, skill

How to cite this article:
Sharma P, Arora S. Online Classes for Nursing Fraternity: A Systematic Review of the Impact on Attitude, Knowledge, and Skills. Indian J Psy Nsg 2020;17:104-11

How to cite this URL:
Sharma P, Arora S. Online Classes for Nursing Fraternity: A Systematic Review of the Impact on Attitude, Knowledge, and Skills. Indian J Psy Nsg [serial online] 2020 [cited 2023 Mar 21];17:104-11. Available from: https://www.ijpn.in/text.asp?2020/17/2/104/308827

  Introduction Top

The concept of online education is relatively new. Earlier, there used to be correspondence courses where teachers used to send lessons and receive student's responses or assignments by mail. The online courses of today are modern versions of distance learning. The benefits of online education are decrease mail transit time.

In a present scenario, the use of online learning has grown as technology is used everywhere in education and training. As per the scholar, “e-learning” is defined as the teaching method which is delivered via multimedia platforms.[1]

Whether online classes are fruitful to modify the students' attitude, knowledge, and skills is a concern. Academicians view that though knowledge, critical thinking, and attitude can be altered by virtual classes, developing clinical skills needs real-time interaction with students. For example, the skills such as administering injections and performing oral or endotracheal suctioning need practice in real hospital settings. Typing on keyboards or scrolling with the mouse will not make a pair of skillful hands which can work upon patients.

Some researchers believed that curriculum of any course challenges or motivates students. Their concern in their study was to identify the best tools for successful learning in online courses.[2] Scholars suggested that lack of experience regarding online course among teaching faculty and students is a major drawback for its successful implementation.[3]

Pew Research Centre reported that many colleges and universities preferred courses that are fully online or blended online.[4]

National Centre for Education Statistics reported that the flexible schedules, easy access of college for students, more courses available, and increasing student enrolments factors are the important markers for universities to offer online courses.[5]

In one of the studies, there was improvement in learner–teacher interaction which was important in increasing student satisfaction.[6]

A systematic study was done by the US Department of Education[7] from 1996 to July 2008. They compared an online to traditional class and measured outcomes of students in terms of their learning. They concluded that the results of online classes were not significantly effective in terms of learning.

Need of the review

Online classes have become the new normal in the field of nursing education amid lockdown due to COVID-19. In Indian scenario, conducting and working through online classes are quite challenging owing to limited availability of infrastructure, workforce, skill, and other facilities. There is a constant debate whether skills can be taught online as nurses are dealing with real human beings where “touch” is very important.

In spite of the volume of literature, a quick review revealed that there is a variation in the attitude and perception of nursing students and teachers toward an online method of education. At present, only a limited Indian studies are available related to the use of online classes; this review was done to synthesize the evidence. This systematic review was done and evaluate to examining effect of online classes on attitude, knowledge, and skill among the nursing fraternity.

  Methods Top

Search strategy

The studies included were published between january 2010 to march 2020 by using the following databases CINAHL, ERIC, Medline, EMBASE, Dissertation and theses. The primary search terms were online classes, attitude, knowledge, skills, nursing students, nurses, and nursing faculty. Reference lists of relevant topics were also searched.

Inclusion and exclusion criteria of the review

  1. Study design: Experimental studies (randomized controlled trial [RCT]) and non-RCTs [Table 1].
  2. Participants: we have included nursing students (diploma, undergraduate, and postgraduate), staff nurses involved in healthcare, and nursing faculty who are involved in nursing education. Participants must have exposure of online classes during the study
  3. Intervention: we defined online classes as any nursing course or programs aimed at its effect on attitude, knowledge, skills, and challenges in online classes and other factors affecting online classes in undertaking the completion of online courses or syllabus. Although online classes include different diploma courses in the nursing curriculum, certificate courses were excluded from the study
  4. Outcomes: studies included were reported outcomes related to attitude, knowledge, skills, and challenges in online classes and other factors affecting online classes in undertaking the completion of online classes or syllabus.
Table 1: Inclusion and exclusion criteria of the review

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Data extraction

Researchers read titles and abstract of all the articles. Then, they were assessed that whether they met the inclusion criteria. Apparently potential eligible articles were retrieved full for systematic review. The researcher synthesized the data narratively. Based on the full articles, data were used regarding study design, participants, setting, intervention, control group, and outcome using a self-developed data extraction sheet by the researcher.

Risk bias assessment

Researcher assessed studies for all the biases such as selection, participation, attrition, detection, reporting, and any other bias. The bias and judgment about their presence were based on the Cochrane collaboration risk of bias assessment tool in the Cochrane handbook for systematic reviews of intervention.[8]

Risk of bias

The selection bias was not clear in RCTs as information provided on random sequence was insufficient. The risk of attrition and outcomes were excluded from the study.

For non-RCT studies, all studies were evaluated to assess the risk of performance bias as group allocation was not done.

Statistical analyses

All the data set of included studies was analyzed. The full texts of 65 articles were assessed for inclusion. The total numbers of studies excluded in the study were 32, most commonly on the basis of intervention and participants, and finally, 33 were included in the review as shown in [Figure 1]. The participants ranged from 1st-year students to staff nurses in healthcare and faculty members. The sample sizes were ranged from 16 to 1041. Most studies evaluated the effects on online classes on attitude, knowledge, and skill, while fewer evaluated the comparison of online classes with traditional educational effect. Outcome measures included changes in attitude (n = 17, 51.5%), changes in knowledge (n = 6, 18.18%), changes in skill (n = 6, 18.18%), factors affecting online class success (n = 2, 6.06%), and challenges faced during online classes (n = 2, 6.06%).
Figure 1: PRISMA flowchart

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  Results Top

Attitude of nursing students, staff nurses, and nursing faculty toward online classes

The outcomes of the included studies are shown in [Table 2].[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] There was evidence that nurses have positive attitude toward online classes. Thirteen of the 17 studies showed that there is favorable attitude of nursing students, staff nurses, and nursing faculty toward online classes,[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] one study[22] has shown that there is unfavorable attitude toward online classes, and remaining three studies[23],[24],[25] demonstrated that there is no significant difference in the attitude toward online classes among nursing students, staff nurses, and nursing faculty members.
Table 2: Effect of online classes on attitude among nursing students, staff nurses, and nursing faculty (n=17)

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Effect of online classes on knowledge of nursing students, staff nurses, and nursing faculty

There is evidence that online classes improve knowledge among nursing students, staff nurses, and faculty. Six studies [Table 3][26],[27],[28],[29],[30],[31] were reported for the effect of online classes on knowledge. Three studies[26],[27],[28] have shown that online classes have improved knowledge, and the remaining studies have shown[29],[30],[31] that there is no improvement in knowledge with the help of online classes and staff nurses have supported offline traditional education method.
Table 3: Effect of online classes on knowledge of nursing students, staff nurses, and nursing faculty (n=6)

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Effect of online classes on skill of nursing students, staff nurses, and nursing faculty

The evidence, about the effect of online classes on skill development of nursing student, staff, nurses, and faculty was limited. As the total study reported [Table 4] were six,[32],[33],[34],[35],[36],[37] of which two studies[32],[33] have shown improvement in the skill development after the online program while three studies[34],[35],[36] have shown no improvement or less improvement in skill after the online program. One study[37] has shown that there is no significant finding in the results after the online classes.
Table 4: Effect of online classes on skill of nursing students, staff nurses, and nursing faculty (n=6)

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Other outcomes

Although the challenges and factors contributing the effect of online classes were not one of the predefined outcome measures, it was noticed when the researcher collected the data. Two studies[38],[39] reported [Table 5] that communication, administration support, technology issues, time management, and cost of the program were the main challenges faced during the online classes which affect the attitude, perception, and behavior of nursing students, staff nurses, and faculty toward online classes. Two studies[40],[41] stated that the factors which affect the successful implementation of online classes were motivation, satisfaction, time management skill, self-efficacy, and increased communication.
Table 5: Studies assessing the effect of online classes on other outcomes (n=4)

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  Discussion Top

The result of the present study is reported on the effect of online classes on nursing fraternity. The study suggested that an online class does lead to changes in attitude, knowledge, and skill. The findings of the current study findings are similar to previous results of online classes review.

This systematic review included 33 primary studies reporting the effect of online classes among nursing students, staff nurses, and faculty members. Most included studies demonstrated a statistically significant effect on attitude[9],[10],[11] and knowledge.[26],[27],[28] Only limited number of studies evaluated effect of online classes on nursing skill.[32],[33],[34],[35],[36],[37] There were few studies that have shown the challenges and factors which may be associated with the successful implementation of online classes program.[38],[39],[40],[41]

The review has demonstrated that there is a consistent positive attitude of nurses toward online classes.[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] Online classes were also effective in bringing about the change in knowledge[26],[27],[28] among nursing students, staff nurses, and nursing faculty, but there were limited data that present significant changes in skill[32],[33] improvement. As included studies did not measure the complication and contraindication of online classes, the extent to which statistically significant improvement in online class's implementation is unclear.

In review, 39.39% have shown favorable attitude toward online classes, 9.09% of the studies have shown significantly improvement in knowledge, and 6.02% of the studies have shown significantly skill improvement. The result of the study applies to nursing fraternity from different universities and colleges. As per one study, nursing students are ready to adopt online learning and are able to utilize in education, but they consider the difficulties with technical support.[22]

The study has many strengths. The review was based on a thorough search of available literature. The review includes experimental studies (RCT), non-RCTs, controlled before and after the implementation of an intervention, and controlled observational studies. To ensure the quality of data, article was screened properly and data extraction was done independently by both the authors to avoid subjective bias.

Mainly, studies included in our study were published after 2010, earliest included study being published in January 2010. Performance bias is unavoidable as during the data collection the participant or the researcher was not blinded.

  Conclusion Top

The findings suggest that, in the present review, some evidence supports the provision of online class's implementation, particularly for undergraduate nursing students. The age of the nursing students also varied between the studies; hence, no conclusion can be drawn with the effect of age on online classes. Only two studies were reviewed which have included the challenges during online class's implementation, and the other two studies have included the factors effecting online classes. Thus, further research should be done regarding the factors which effect positively online class's implementation; we should also do further research on the challenges that face during the online class's implementation so that policy development and the successful implementation of online classes program can be done.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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