by Abdul Shokoya, BSc Geo, BSN St,

Charlene Zheng, BA Econ, BSN St,

Harrison Mortimer, BSc Hort,

Shaban Gondal, BA Psych, BSN St,

Soraya Bellou, BSc Bio,

Vanessa Mensah-Wilson, BSc Bio, BSN St

Citation: Shokoya, A., Zheng, C., Mortimer, H., Gondal, S., Bellou, S. & Mensah-Wilson, V. (2023). A Systematic Review on Nursing Students’ Experiences with eLearning. Canadian Journal of Nursing Informatics, 18(3).  https://cjni.net/journal/?p=12219

Abstract

The aim of this systematic review was to explore nursing students’ experiences and satisfaction with e-learning in post-secondary institutions. Keywords, inclusion, and exclusion criteria were selected to guide the search strategy from 141 to 22 articles. Then, the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to refine the review down to the 17 articles identified that met the criteria set for the study. A thematic analysis of the articles was conducted, and four themes were identified: online learning enhances and strengthens students’ abilities; lacking the 4 C’s – connection, communication, caring, and clarity; impacts on students’ mental health; and the benefits of supportive peers and clear feedback. Issues discussed related to e-Learning included ambiguity in course objectives or assignments, syllabus inconsistencies, absent instructors, and unclear or unknown course expectations. Suggestions for further research and improvement were noted such as exploring blending online and in-person and implementing a monitoring system for training, teaching, assessment, and quality purposes.

Background

Over the last decade, educational institutions around the world have been increasingly adopting learning methods conducted through digital resources in the form of electronic media. eLearning involves the delivery of diverse formats of content such as image patterns, texts and videos over electronic media systems (Sánchez & Karaksha, 2022). The combination of education and the internet has provided students with the opportunity to learn new skills with ease of access, while supporting variability in course content and different learning situations (Langegård et al., 2021).

Traditional face-to-face learning has been an essential component of nursing education, due to the nature of the program relying on the development of practical skills; however, this notion has been challenged since the outbreak of the COVID-19 pandemic, which caused academic institutions including nursing schools to shut down, resulting in a sudden overnight shift towards electronic learning and a more learner-centered approach rather than a teacher-centered approach (Langegård et al., 2021). Arguments made in its favour include the increased flexibility, accessibility, and affordability it provides to students, making it easy for them to partake in lifelong learning and develop new skills (Dhawan, 2020). While some nursing students consider face-to-face lectures superior in increasing knowledge, with the added benefit of social interaction and increased motivation, a literature review concluded that when it comes to nursing education, online learning, or eLearning is as effective as traditional face-to-face on campus learning (Langegård et al., 2021).

Most studies regarding nursing students’ use of online learning systems report high satisfaction rates, with approach and advantage being the primary factors. These advantages include being self-paced, cheaper, and quicker with the ability to skip already known topics. In addition, for nursing students particularly, it helps in continuing professional development, along with providing a better hold and conservation of topics, and it can simultaneously be accessible to large groups of students (Sánchez & Karaksha, 2022). With some previous studies reporting negative and contradictory results for nursing students’ experiences with eLearning, and the acceleration of the use of technology in nursing education, it is important to further investigate the experiences students have, to develop effective strategies for future nursing programs.

eLearning can take learning beyond the classroom. This systematic review takes a qualitative approach and focuses on the experiences and levels of satisfaction of nursing students with regards to eLearning. Based on previous research, the study authors chose to investigate two main research questions:

• How do nursing students describe their experiences with eLearning in post-secondary institutions?

• How do nursing students rate their satisfaction with eLearning in post-secondary institutions?

Method

Inclusion and Exclusion Criteria

To answer the research questions, the inclusion criteria encompassed qualitative publications that were about or included students in a nursing program. All types of nursing programs (LPN, RN, ADN, MSN, etc.) were considered, if the programs were from a recognized post-secondary institution. To be included in the search criteria, the papers had to contain information about the students’ experiences with eLearning. The studies must have provided a firsthand eLearning experience as a part of the inclusion criteria. Only studies published on or after 2012 were considered. The rationale for this exclusion was because more recent experiences with eLearning were considered a better fit. Review articles were also excluded as original research was desired. Studies in English were only considered. Finally, quantitative studies were excluded as this study is based on qualitative approaches to research.

Search Strategy

The first step was to identify keywords used for the search. The search terms used were:

• Nurses OR nursing students
• AND eLearning or online learning or web-based learning
• AND experiences OR eLearning experiences
• AND qualitative

The second step was to complete an extensive search using the Cumulative Index of Nursing and Allied Health (CINAHL) database using the keywords, inclusion, and exclusion criteria.

Study Screening

All six reviewers screened the papers found from the literature search. Among the papers found, only papers which contained a relevant title and abstract were fully reviewed. Any disagreements were discussed and resolved among all reviewers. We found 17 papers which fit the selection criteria (Figure 1). Figure 1 is a flow chart that illustrates the systematic review process utilized by the reviewers.

Figure 1

Study screening process

Assessment of Methodological quality

The 17 qualitative papers chosen were distributed among the six-person review team. Five reviewers assessed three papers each while one reviewer assessed two papers. The methodological quality was analyzed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research (Joanna Briggs Institute, 2017). Any differences were resolved through discussion, and the review team found all 17 papers had an appropriate methodological quality.

Data Extraction and Synthesis

The relevant data in the papers was in the form of quotations, paraphrases, and researcher interpretation. The following information was extracted from the papers by all six reviewers: author name(s), publication country, year, study design, purpose, recruitment and participants, and main findings. The data was extracted into a literature review matrix (Table 1.).

Table 1

Characteristics of the Studies

(click table for larger view)

Two reviewers (C. Z. & V. M-W.) read through each article in full detail, several times, and further analyzed the findings. Using a thematic analysis approach, several finding categories were identified in Table 2. The data synthesis involved a comparison of themes, results, and conclusions presented by the authors.

Table 2

Synthesized Study Findings

Themes of Synthesis Findings

The four themes included are: online learning enhances and strengthens students’ abilities; lacking the 4 C’s – connection, communication, caring, and clarity; impacts on students’ mental health; and the benefits of supportive peers and clear feedback. Each theme is further examined below.

Theme 1: Online learning enhances and strengthens students’ abilities

Many studies emphasized the flexibility, self-directedness, and motivation students experienced when choosing to study nursing online. It granted them the opportunities to find balance in the many roles they held within their lives from parent to student, employee, and caregiver, for example. Others found that online learning helped them discover a sense of self-directedness and motivation they lacked from in-person classes. Although the transition to online learning was a steep learning curve, some students noted it helped develop a sense of resilience and improved their ability to adapt, which was particularly beneficial in the fast-paced and dynamic profession of nursing. The following statements shared by nursing students in the studies help illustrate the theme:

“Online learning fits me and other working students to manage our work and our study”

(Bdair, 2021, p. 222).

“It’s really flexible, I can log-on and work at my own pace. In the beginning I was a little skeptical, but now I feel that I learn a lot through online. I think it’s really effective for the adult learner. We are adults, we have work, family, and school. We can log in at whatever time, day or night. I really like the options online learning provides.”

(Smith et al., 2021, p. 90)

Theme 2: Lacking the 4 C’s – Connection, Communication, Caring, and Clarity

This theme included several categories that address the aspects of online learning that are lacking. Several studies noted participants were frustrated with the lack of care from both instructors and other students during online lectures and assignments. Students complained of delayed response times to clarifying questions, impersonalized and uncaring responses, and disorganized and often rigid course materials. They described having challenges establishing rapport, lathered with technical issues, and struggled to connect and maintain relationships with instructors and peers. Below are two passages that illustrate this theme:

“[T]he digital platform may be a little messy just on those things, that you have to somehow. first you have to click there and then you have to click there […] then you will discover when you have browsed down completely that wow, I’m in the wrong subject. So, it’s a little messy, it’s too much information in one place”

(Meum et al., 2021, p. 4).

“Online courses are far less personal and less effective; everyone is faceless, so it is difficult to make personal connections and to have a relationship with the instructor”

(Smith et al., 2021, p. 790).

Theme 3: Impacts on students’ mental health

Students expressed concern for their mental well-being. They noted that online learning felt faceless, impersonalized, and isolating. Although some felt encouraged to engage more because of the depersonalization, others stated they felt more alone in their studies and saw a decrease in their mental health. Communication in online learning was described as lacking depth, uncomfortable, and anxiety inducing. Moreover, students indicated challenges in interpreting communication because it lacked nonverbal cues, such as body language, and opportunities to build meaningful rapport. The excerpt listed below illustrates the findings of the theme:

“[…] a month, two months, three months went by, and I stayed only at home. This will never end, and it seems to only get worse, and it was giving me stress, anxiety, which I had never felt before because it became something permanent that should have been temporary”

(Rodrigues et al., 2021, p. 5).

Theme 4: The Benefits of Supportive Peers and Clear Feedback

Many of the studies emphasized how nursing students collectively bonded and supported one another through the hardships of online nursing courses by sharing their experiences, validating their peers’ feelings, and providing emotional and academic support. Likewise, some students found instructors of online courses provided more personalized feedback on assignments that helped better guide their learning through the rest of the course and improve their motivation to continue working hard. Here are two quotes from students that exemplified the theme:

“I think it was very good that we got individual assignments and feedback from the teacher (.) because then you got a better overview of how it should be”

(Meum et al., 2021, p. 3).

“We communicated back and forth about whatever we were struggling with so there was a lot of group interaction that kind of helped to keep the sanity I guess and help each other out through some of the more difficult content we had to go through”

(Jones, 2015, p. 53).
 

Discussion

Implications of Research

Our review into the effectiveness of online learning was focused on 17 different studies from various countries across multiple continents. Each study resulted in their unique themes based on the facts that they gathered but when compiled together, a correlation between studies appeared. Participants preferred the traditional face-to-face learning citing that they found it more engaging and interactive (Farley, 2018). Many students found the absence of face-to-face practical sessions predisposed them to feel incompetent and unconfident when it came to practicing their skills with patients once clinical practices were to restart (Hu et al., 2022).

Another research paper noted that their students, while doing online courses, felt like they were alone and missing a sense of connection with their cohort and teachers, trepidations including timidity and fear of making mistakes due to the lack of experiences they received and that there were issues with the way the courses were presented. The course issues were summed up as an ambiguity in course objectives or assignments, syllabus inconsistencies, absent instructors, and unclear or unknown course expectations (Reilly et al., 2012).  Other studies paralleled these statements by acknowledging that in some cases there was a lack of instructor commitment to offering guidance or feedback or that the instructor was just uninvolved in the entire process (Farley, 2018).  Issues with online learning also arose around people’s personal lives which is described best by one participant: “to study at home has been challenging, because when I walk out that door, I’m able to go to school [University] and forget that I’m a mum and a wife, but here I’m juggling all three hats” (Godbold et al., 2021).

Not everything was negative in the reported findings. A theme from one of the studies noted that the participants chose to proceed with online studies because of family or work obligations that would have stifled their ability to do in-person courses. Enough participants agreed that they found the online learning not challenging enough that it also became a theme in the same study (Farley, 2018). Advantages to online learning also included the ability to have a flexible learning environment, academic achievement, and student-centered learning (Bdair, 2012).

Implications for Practice

In accordance with the studies noted in this research paper, there is room for improvement in current online courses and considerations to be taken when designing any new courses in the future. The first aspect that can easily be implemented to improve courses for the students taking them is to provide access to recorded lectures. The participants stated that this would give them the feeling of being in a classroom (Farley, 2018). The notion of recordings was further mentioned by another study which confirmed the added benefit of these lectures is that they would provide convenience and flexibility to review them at their preferred time, location, and pace (Hu et al., 2022). While the latter is a recurring benefit for taking online courses; recorded lectures have the added benefit of simplifying the necessary information for the students to learn. Because online courses are primarily chosen by students juggling a work/life balance at the same time, this streamlined learning will allow them to reduce the frustrations and anxiety that goes along with being a student. Further recommendations are to implement a monitoring system for training, teaching, assessment, and quality purposes (Bdair, 2012).

One study performed in 2012 indicated that the best form of education would be a blended course of online and in-person. There were four main themes in this study that were identified in favor of this style of course. The positives of blending online and in-person are that it enhances thinking ability, improves problem-solving skills, gives greater opportunity to reflect in and on practice, encourages active learning and identifies the value of nursing. The participants went further to state that blended learning experiences were overall positive experiences (Hsu, 2012).

Limitations

This review that we have prepared comes with some limitations. First, we chose to only use studies that were available on CINAHL. While this choice was made to help focus our research, it also hindered our resource pool for data collection. The studies that we did choose were all in English which reduces the amount of information we could have gathered; however, the studies came from multiple countries from across the world which helped reduce our English-only bias. Another limitation this study has is that it is dependent on the quality and interpretations of the original research teams, but this is a fact that all synthesized review studies suffer from. The final limitations that this research paper has is that it was created by first year students of a Bachelor of Science in Nursing Advanced Entry program. This limitation was softened though since all students already had a degree in another discipline. Time constraints and experience in writing research papers were the largest limiting factors for this research study.

Conclusion

This study was conducted to explore how nursing students view their experiences and overall satisfaction with eLearning in post-secondary institutions. Students had mixed responses about eLearning. Four themes were identified in the study. While most students choose to study online for the flexibility to learn at their own pace, a blended experience holds the potential for maximizing the benefits while reducing students’ frustrations. Overall, the review highlighted students’ diverse experiences in eLearning and provides a foundation for further research on how to improve eLearning for nursing students.

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