UNLV Theses, Dissertations, Professional Papers, and Capstones

12-1-2020

The Effect of Asynchronous versus Synchronous Online Course The Effect of Asynchronous versus Synchronous Online Course

Delivery on HESI Scores and Student Engagement for Rural Pre-Delivery on HESI Scores and Student Engagement for Rural Pre-

Licensure Nursing Students Licensure Nursing Students

Susan Luke Belliston

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THE EFFECT OF ASYNCHRONOUS VERSUS SYNCHRONOUS ONLINE COURSE

DELIVERY ON HESI SCORES AND STUDENT ENGAGEMENT FOR RURAL

PRE-LICENSURE NURSING STUDENTS

By

Susan Luke Belliston

Bachelor of Science in Nursing Regis University

2004

Master of Science, Nursing Regis University

2009

A dissertation submitted in partial fulfillment of the requirements for the

Doctor of Philosophy – Nursing

School of Nursing The Graduate College

University of Nevada, Las Vegas December 2020

Copyright 2021 by Susan Luke Belliston

All Rights Reserved

ii

Dissertation Approval

The Graduate College

The University of Nevada, Las Vegas

September 9, 2020

This dissertation prepared by

Susan Luke Belliston

entitled

The Effect of Asynchronous Versus Synchronous Online Course Delivery on HESI

Scores and Student Engagement for Rural Pre-Licensure Nursing Students

is approved in partial fulfillment of the requirements for the degree of

Doctor of Philosophy - Nursing

School of Nursing

Mary Bondmass, Ph.D. Kathryn Hausbeck Korgan, Ph.D. Examination Committee Chair Graduate College Dean

Michele Clark, Ph.D. Examination Committee Member

Catherine Dingley, Ph.D. Examination Committee Member

Michael Nussbaum, Ph.D. Graduate College Faculty Representative

iii

ABSTRACT

Since nurses are the primary providers of direct patient care in the United States, a

shortage in any community can impact the quality of health care available. Rural areas were

among the first to be affected by the current nursing shortage. Further challenges to the rural

nurse supply include a lack of access to nursing education, particularly baccalaureate education.

Both distance and online education options allow for the increased reach of higher

education to rural areas. Existing nursing education literature focuses on graduate nurse

education and baccalaureate completion education. The pre-licensure nursing student is mostly

absent from the existing literature concerning nursing education in distance or online formats.

This study used social constructivism as a theoretical framework. Constructivism asserts

that learning is an active process, that students construct knowledge as they interact with

instructors, students, and content in educational settings. This study used a retrospective quasi-

experimental, two group (treatment and comparison) design. The treatment group met

synchronously online with the instructor each week and participated actively with classmates in

the synchronous online forum. The comparison groups completed the same course activities in

an asynchronous online format via discussion boards. Health Education Systems, Inc (HESI)

specialty exam scores and Online Student Engagement (OSE) scores were compared between the

two groups. A convenience sample of 132 students enrolled in a traditional Bachelor of Science

nursing program at a public university in the intermountain west region of the United States was

used.

Related to the three research questions asked, statistical analyses demonstrated that 1) no

significant difference between HESI specialty exam scores and online education delivery method

(synchronous or asynchronous) was identified; 2) no significant difference between OSE scale

iv

scores and online education delivery method (synchronous or asynchronous) was found; and, 3)

a small correlation between HESI specialty exam scores and OSE scores was identified.

The small sample size resulted in insufficient statistical power to determine conclusively

whether the online delivery method (synchronous or asynchronous) impacted HESI specialty

exam scores or OSE scores. Findings suggest that pre-licensure nursing students can learn

essential didactic content in an engaging online environment. These findings have implications

for nursing education delivery to rural or remote areas, where geography or distance limit access

to higher education. Findings are also relevant given the current need in higher education for

distancing between students during a time of pandemic.

v

ACKNOWLEDGEMENTS

I would like to acknowledge with sincere gratitude the UNLV School of Nursing Faculty

and Staff, who offered support and genuine encouragement throughout my studies. Having true

nurse scholars and scientists as faculty led me to strive harder, to become something more than I

was when I started. To Dr. Bondmass, your supportive guidance and positive attitude were a

lifesaver. Some days I relied more on your belief in me than my own. To my committee

members Dr. Clark, Dr. Candela, Dr. Dingley, and Dr. Nussbaum, thank you for your input and

support; I appreciate your expertise and your ability to hold me to the highest standards. To Dr.

Feng, Dr. Song, and the amazing Xan Goodman, your help was invaluable. Thank you.

vi

DEDICATION

To my parents, who taught me the value of work and persistence

To my husband and children, who provided love and support throughout the process and who helped with editing, reference checking, and life in general

To my brother, Glen, who taught me the values of charity and equality

And to A.S., whose sweet presence and dirty socks taught me the meaning of social justice

This work is lovingly dedicated.

vii

TABLE OF CONTENTS

ABSTRACT ................................................................................................................................... iii

ACKNOWLEDGEMENTS ............................................................................................................ v

DEDICATION ............................................................................................................................... vi

LIST OF TABLES .......................................................................................................................... x

CHAPTER 1: INTRODUCTION ................................................................................................... 1

Background ......................................................................................................................... 2

Nursing Shortage .................................................................................................... 2

Need for Nurses in the Rural Community .............................................................. 2

Rural Access to Nursing Education ........................................................................ 3

Distance and Online Education ............................................................................... 4

Online Education for Pre-Licensure Nursing Students ........................................... 5

Statement of the Problem .................................................................................................... 6

Purpose of the Study ............................................................................................... 6

Study Aims.............................................................................................................. 6

Research Questions ................................................................................................. 7

Significance of the Study .................................................................................................... 8

Definition of Terms............................................................................................................. 8

Asynchronous and Synchronous Delivery in the Online Environment .................. 8

Distance, Online, and Hybrid Education ................................................................ 9

Student Engagement ............................................................................................. 11

Interaction ............................................................................................................. 12

Rural ...................................................................................................................... 12

Chapter Summary ............................................................................................................. 12

CHAPTER 2: REVIEW OF RELATED LITERATURE ............................................................. 14

Process .............................................................................................................................. 14

Distance, Online, and Hybrid Education .......................................................................... 15

Distance Education ............................................................................................... 16

Online Education .................................................................................................. 17

Hybrid Education .................................................................................................. 18

Learning Outcome Achievement .......................................................................... 19

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Access to Higher Education .................................................................................. 23

Interaction and Engagement ................................................................................. 25

Online Course Design ........................................................................................... 28

Asynchronous and Synchronous Online Education Delivery ........................................... 29

Pre-Licensure Registered Nursing Education Delivery .................................................... 32

Chapter Summary ............................................................................................................. 36

CHAPTER 3: METHODS ............................................................................................................ 38

Theoretical Framework: Social Constructivism ............................................................... 38

Research Questions ........................................................................................................... 41

Design ............................................................................................................................... 41

Sample................................................................................................................... 42

Inclusion and Exclusion Criteria ........................................................................... 42

Setting ................................................................................................................... 43

Variables and Instrumentation .............................................................................. 43

Baseline knowledge assessment ........................................................................... 47

Ethical Considerations ...................................................................................................... 47

Study Procedures .............................................................................................................. 48

Data Collection and Management ......................................................................... 48

Data Analysis .................................................................................................................... 49

Study Limitations .............................................................................................................. 50

Chapter Summary ............................................................................................................. 50

CHAPTER 4: FINDINGS ............................................................................................................ 52

Demographic Characteristics of the Sample ..................................................................... 52

Data Analysis .................................................................................................................... 54

Pre-Intervention Group Comparison..................................................................... 54

Research Question One ......................................................................................... 57

Research Question Two ........................................................................................ 58

Research Question Three ...................................................................................... 60

Chapter Summary ............................................................................................................. 60

CHAPTER 5: DISCUSSION ........................................................................................................ 62

Summary of Study Findings ............................................................................................. 62

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Demographic Characteristics ................................................................................ 62

Research Question One ......................................................................................... 62

Research Question Two ........................................................................................ 64

Research Question Three ...................................................................................... 65

Implications for Nursing Education and Research ........................................................... 66

Limitations ........................................................................................................................ 67

Summary and Conclusion ................................................................................................. 67

Appendix A ................................................................................................................................... 69

Appendix B ................................................................................................................................... 70

Appendix C ................................................................................................................................... 72

Appendix D ................................................................................................................................... 74

Appendix E ................................................................................................................................... 75

References ..................................................................................................................................... 78

CURRICULUM VITAE ............................................................................................................. 102

x

LIST OF TABLES

Table 1. Demographic Characteristics of Sample....................................................................... 53

Table 2. Expected Counts for Ethnicity Variable, Uncollapsed and Collapsed Data ................. 56

Table 3. Contingency table for Ethnicity, Collapsed Data.......................................................... 56

Table 4. Means and Standard Deviations of HESI and OSE scores with 1000

Bootstrap Samples ......................................................................................................... 59

Table 5. Correlation between HESI Specialty Exam Scores and OSE Scores by Group ........... 60

Table A1. Demographics of the Missing or Excluded Cases (n = 4) .......................................... 69

Table D1. Power Analyses for Independent t-test and Pearson Correlation ............................... 74

1

CHAPTER 1: INTRODUCTION

Nurses are the primary providers of direct patient care in the United States (American

Association of Colleges of Nursing [AACN], 2019a; U.S. Department of Health and Human

Services, Health Resources and Services Administration [HRSA], National Center for Health

Workforce Analysis, 2017). The AACN (2019a) notes that care by nurses is part of most

healthcare services. The AACN (2019b) projects a shortage of Registered Nurses (RNs), and

despite an increased need for these RNs, the capacity to meet this demand remains relatively

unchanged. The shortage of nurses is particularly apparent in rural communities (Mester, 2018).

Access to higher education, including nursing education, is greater in urban areas than in rural

areas (Finnie et al., 2015; Koricich et al., 2018; Newbold & Brown, 2015).

Increasing online education (OE) options may allow students who are challenged by

geographical distance to attend urban-based nursing education programs (Scarbrough, 2015;

Vargas-Madriz, 2018). Institutions of higher education are increasingly using OE for educational

delivery (Allen & Seaman, 2017; Seaman et al., 2018). Disciplines in the sciences, the health

sciences, and the humanities utilize OE (Abrami et al., 2011; Abuatiq, 2019; Bernard et al.,

2009; Bernard et al., 2014; Egorov et al., 2019; Hockridge, 2013; Unnisa, 2016) to teach both

didactic and also skill-related content (Borneuf & Haigh, 2010; Forbes et al., 2016; Öztürk &

Dinç, 2014; Xu, 2016).

While OE has traditionally been delivered asynchronously, advances in technology now

make synchronous delivery a possibility (Scarbrough, 2015). Evidence related to the delivery of

pre-licensure nursing education using both asynchronous and synchronous formats needs to be

examined — specifically in rural areas that must rely primarily upon online delivery to reach

students — as synchronous OE technologies become more functional and accessible.

2

The current study compared outcomes of test scores and student engagement when

students were enrolled in either a synchronous online or an asynchronous online pediatric

nursing course. The study uses the term OE when discussing courses that are web-based and

known to be delivered online. The term DE is used when considering courses offered to students

who are not local to the college or university where the offering originates, but for which the

delivery method is unknown. Chapter One presents the background information for the study,

identifies the study aims and research questions, introduces the significance of the study, and

defines terms as they are used in the study.

Background

Nursing Shortage

The AACN (2019b) projects a shortage of RNs that is expected to continue to grow over

the next 10 to 15 years. The capacity to meet this demand remains relatively unchanged (AACN,

2019b). HRSA (2018) states that over 25% of the current nursing workforce is over 55 years of

age and will likely retire in the next 15 years, while the overall demand for nurses continues to

increase. This expected nursing shortage could disrupt care delivery, access to care, and the

quality of health care nationwide (AACN, 2019a; Auerbach et al., 2015).

Need for Nurses in the Rural Community

Rural communities were among the first to be affected by the ongoing nursing shortage

(Mester, 2018). These communities have a lower number of RNs per capita. Rural communities

often struggle to recruit and retain health care providers (Becker et al., 2018; Fields et al., 2018;

Mester, 2018; Odahowski et al., in press), and filling nurse vacancies is an ongoing challenge for

rural hospitals (Mester, 2018). Sixty-five percent of rural areas are classified as health

professional shortage areas (Mester, 2018). These rural areas are further challenged by higher

3

rates of poverty and proportionally larger groups of elderly, which need skilled health care

professionals, especially nurses (Buerhaus et al., 2017; Mester, 2018; Odahowski et al., in press).

Rural areas have the highest percentage of older nurses (Odahowski et al., in press), suggesting a

more significant impact of retiring nurses on the rural RN supply (Marlow & Mather, 2017).

Rural cultures and demographics may differ substantially from those in urban areas.

Individuals from rural cultures — which value independence, self-reliance, and work ethic —

often present for health care after the need is acute or critical (Odahowski et al., in press). Health

care providers in rural areas, including nurses, must be prepared to treat or stabilize complex

health care problems until arrangements are made for access to additional critical care

(Odahowski et al., in press). The broad range of patient ages and conditions encountered by the

rural nurse suggests that rural nurses would benefit from the higher levels of education

recommended by the Institute of Medicine (IOM; 2011).

Rural Access to Nursing Education

RNs in rural areas are less likely to hold a baccalaureate degree (BSN) than are their

counterparts in urban areas, with the fewest BSN-prepared nurses available in the most rural

counties (Smith et al., 2019; Odahowski et al., in press). Higher levels of education better

prepare nurses to provide more complex patient care, to manage sophisticated care-related

technologies, and to achieve better patient outcomes with lower mortality rates (Aiken et al.

2012; 2017; Harrison et al., 2019; IOM, 2011). Increased educational program access is needed

to ensure that rural areas have a sustainable supply of RNs in the workforce (Marlow & Mather,

2017; Odahowski et al., in press; Scarbrough, 2015; Smith et al., 2019).

Kovner et al. (2011) state that 52% of RNs practice within 40 miles of where they

attended high school. Due to this lack of mobility in the profession, rural nursing education

4

programs are essential to provide an adequate supply of nurses in rural areas; many rural

residents cannot or will not move out of the area, adding further challenges to this situation

(Kovner et al., 2011). Nursing school administrators in rural areas report difficulty finding

qualified nursing faculty (Kovner et al., 2018; Li et al., 2016). Fewer faculty further limits the

availability of more advanced nursing education in rural areas, resulting in educational inequity

(Kovner et al., 2018; Yang et al., 2019). Expanding distance education (DE) and OE programs

and other educational innovations to rural areas could improve the supply of rural nurses by

increasing access to nursing education (Abuatiq, 2019; Becker et al., 2018; Butler et al. 2016;

Kovner et al., 2011). These innovative programs may use synchronous or asynchronous

technologies to reach rural students (Augestad & Lendsetmo, 2009; Butler et al., 2016; Shah,

2016).

Distance and Online Education

While DE and OE are not precisely synonymous (see Definition of Terms for further

explanation), both can increase the reach of higher education to rural areas (Abrami et al., 2011;

Bowen et al., 2013; Marlow & Mather, 2017). Both DE and OE models allow for increased

enrollment in courses without requiring a corresponding increase in physical space at the

offering institution (Bowen et al., 2013; Kozlowski-Gibson, 2018). With the availability of

computer-based materials, simulations, mobile learning, and other forms, online methods are an

effective alternative to face-to-face (FTF) lectures (Kang & Seomun, 2018). Many authors use

the terms DE and OE interchangeably; however, this study differentiates the two conceptually

based on geographical location and delivery method (see Definition of Terms).

In nursing education, DE by various delivery methods can facilitate outcomes

comparable with on-campus nursing classes (Anderson & Tredway, 2009; Becker et al., 2018;

5

Graber, 2019; Lu et al., 2009; Männistö et al., 2020; Shachar & Neumann 2003, 2010). Course

content is accessible at a distance through videoconferencing, learning management systems

(LMS), streaming videos, podcasts, and other methods. Combining these opportunities with

applied learning via case studies, virtual hospital simulations, discussions, or clinical

environments may help students engage in real-world critical thinking and problem-solving

(Anderson & Tredway, 2009; Graber, 2019; Lu et al., 2009). A systematic review by

McCutcheon et al. (2014) showed the effectiveness of OE for teaching clinical skills but noted a

distinct need for additional study in OE innovation. Graber (2019) identified presentation and

discussion in the asynchronous online format as equivalent to that found in FTF instruction for

pre-licensure students studying mental health nursing interventions. Online course delivery also

allows for ease in evaluating course effectiveness (Kozlowski-Gibson, 2018).

Online Education for Pre-Licensure Nursing Students

Initial studies regarding OE in nursing students almost exclusively pertain to

baccalaureate completion programs or to graduate students (Cleary et al., 2009; Smith et al.,

2009; Wells & Dellinger, 2011). Both completion and graduate groups consist of students who

are already licensed as RNs. More recent research addresses hybrid or blended course delivery

for undergraduate (McCutcheon et al., 2014) and graduate programs (Zydney et al., 2020). Kang

and Seomun (2018) find that current research concerning “web-based nursing education”

evaluated mostly satisfaction, knowledge level, effectiveness, or clinical performance, but failed

to identify underlying patterns (p. 1678).

Evidence suggests that successful delivery of nursing education curricula is possible in

the OE format; however, the pre-licensure nursing student is mostly absent from the literature.

Scarbrough (2015) discusses this scarcity of evidence concerning OE for the pre-licensure

6

nursing student in a pilot study that investigated the pedagogical application of synchronous

technology for teaching nursing didactic content. Scarbrough’s research may be the only

published data addressing the use of synchronous technology in teaching pre-licensure nursing

students. Voutilainen et al. (2017) also note the absence of “meta-analytically generated

knowledge regarding the comparisons between conventional and e-learning specifically in the

education of nursing students” (p. 98) in the nursing education literature. Further evidence is

needed to demonstrate the most effective means of delivering OE content to the pre-licensure

nursing student.

Statement of the Problem

There is minimal to no data on the best delivery method for OE, yet OE is needed to

deliver educational content to rural communities. Traditionally, OE content was delivered in an

asynchronous format. Advances in technology and infrastructure now allow for synchronous

delivery. Data are needed to evaluate both methods’ influence on specific outcomes related to

pre-licensure education in rural communities.

Purpose of the Study

The purpose of this study was to determine if the method of OE delivery — synchronous

or asynchronous — affected selected learning indicators for pre-licensure nursing students.

These indicators included Health Education Systems, Inc (HESI) specialty exam scores and

student engagement scores.

Study Aims

This retrospective study had three primary aims:

7

A1: The study compared pre-licensure baccalaureate nursing student learning, as

measured by HESI specialty exam scores when content was delivered synchronously versus

asynchronously in the online educational environment.

A2: The study compared pre-licensure baccalaureate nursing student engagement, as

measured by the Online Student Engagement Scale (OSE), when content was delivered

synchronously versus asynchronously in the online educational environment.

A3: The study explored the possible association between pre-licensure baccalaureate

nursing student engagement and student learning as measured by HESI specialty exam score

when content was delivered synchronously versus asynchronously in the online educational

environment.

Research Questions

The study asked three research questions to achieve its primary aims:

1. Is there a difference in pre-licensure baccalaureate nursing students’ HESI specialty

exam scores when content is delivered synchronously versus asynchronously in the

online educational environment?

2. Is there a difference in pre-licensure baccalaureate nursing students’ OSE scores

when content is delivered synchronously versus asynchronously in the online

educational environment?

3. Is there an association between pre-licensure baccalaureate nursing students’ HESI

specialty exam scores and OSE scores when content is delivered synchronously

versus asynchronously in the online educational environment?

8

Significance of the Study

Consideration for access to education is of particular importance in geographic areas that

must rely upon OE to meet the demand for nursing education (Yang et al., 2019). Better distance

access to quality nursing education may help increase the number of nurses who work in rural

communities (Marlow & Mather, 2018; Roberge, 2009). However, studies concerning the

achievement of learning outcomes by the pre-licensure nursing student in OE are missing from

nursing education literature. Further evaluation supporting the learning outcomes of the pre-

licensure student in the online environment is warranted, given the current and predicted demand

for pre-licensure nursing education. Nursing education literature fails to address the learning

outcomes of pre-licensure nursing students taught in the online environment; specifically,

whether synchronous or asynchronous instruction or interaction occurs (Scarbrough, 2015). This

retrospective study’s findings may serve to guide future course design in pre-licensure nursing

programs, to facilitate effective, accessible, pre-licensure nursing instructional design while

maintaining the quality of nursing education.

Definition of Terms

Terms defined for use in this study were as follows:

Asynchronous and Synchronous Delivery in the Online Environment

Education literature defines the term “asynchronous” online course delivery as

educational interactions between content, instructors, and peers, that occur outside of a

designated time. Students connect with the course content, instructors, or peers at a time which is

most convenient for the individual student.

9

The term “synchronous” denotes an occurrence that happens at precisely the same time

(Merriam-Webster, n.d. “synchronous”). However, the use of the term in education literature has

evolved as technology has changed to include the following situations:

• Traditional FTF course delivery, which occurs in real-time, but is not at a distance or

online.

• Emulated traditional classroom by video conference or teleconference (Giesbers et al.,

2014a; Rapchak, 2017) that may not be online.

• Online office hours in which one student at a time interacts with an instructor (Carver et

al., 2013; Swart & MacLeod, 2020).

• Online chat hours in which one or several students interact with an instructor with

specific questions or concerns about content.

• Online practice for completing homework assignments (Carver et al., 2013).

• Student-student interaction in online digital alternative worlds such as Second Life

(Boling et al., 2012).

• Web-based live classrooms where students interact with instructors and other students in

real-time by talking, listening, and writing (Boling et al., 2012).

For this study, “synchronous” online course delivery is defined as the delivery of course

content that involves active communicative processes such as talking, listening, writing, and

creating with both instructors and students in an online environment in real-time through

technology.

Distance, Online, and Hybrid Education

The terms ‘online education’ and ‘distance education’ are often used interchangeably in

scholarly literature, which is not necessarily accurate. DE includes the following characteristics:

10

• The quasi-permanent separation of teacher and learner throughout the length of the

learning process (this distinguishes it from conventional face-to-face education);

• The influence of an educational organization both in the planning and preparation of

learning materials and in the provision of student support services (this distinguishes it

from private study and teach-yourself programs);

• The use of technical media — print, audio, video or computer, or the worldwide web, to

unite teacher and learner and carry the content of the course;

• The provision of two-way communication so that the student may benefit from or even

initiate dialogue (this distinguishes it from other uses of technology in education); and

• The quasi-permanent absence of the learning group throughout the length of the learning

process so that people are usually taught as individuals rather than in groups, with the

possibility of meetings, either face-to-face or by electronic means, for both didactic and

socialization purposes. (Keegan, 1996, as cited by Keegan, 2002 and Peck et al. 2018)

Simonson et al. (2011) define DE as formal education where learners and instructors are

separated geographically and where interactive telecommunications systems connect the

involved parties. Thus, OE may fall within this definition of DE. In some settings, all DE

courses are offered online, making the terms “distance” and “online” interchangeable. In other

contexts, courses may be available at a distance without being online, and online courses may be

available for local students.

An online course has at least 80% of the course content delivered online (Allen &

Seaman, 2016). OE is web-based and uses digital technologies in conjunction with other

educational materials to deliver “personalized, learner-centered, open, enjoyable, and interactive

learning environment supporting and enhancing the learning processes” (Rodrigues et al., 2019,

11

p. 95). Voutilainen et al. (2017) use the term “e-learning” to refer to nursing student learning that

takes place in an online environment, regardless of whether the entire course is partially or fully

online. Vargas-Madriz (2018) uses the term “virtual learning environments” for any education

system accessed via internet, regardless of form (p. 16).

The current study uses the term OE when discussing courses that are web-based and

known to be delivered online. The term DE is used when considering courses offered to students

who are not local to the college or university where the offering originates, but for which the

delivery method is unknown. Blended educational offerings, which combine OE and FTF

learning, with or without DE, are identified as hybrid education.

Student Engagement

This study focuses on student engagement in the online course rather than engagement

within the undergraduate university community. Dixson (2010; 2015) defines engagement as

involving the students’ use of both time and energy in learning the course content, demonstration

of that learning, meaningful interaction with other individuals in the course (both instructors and

students), and emotional involvement with their learning. Engagement includes the students’

interest in and effort towards learning and understanding the material presented; it involves

interacting with the content, student peers, and instructors (Bolliger & Halupa, 2018). Dixson’s

(2015) OSE instrument measures factors, including skills, emotions, participation, and

performance (Bolliger & Halupa, 2018). It gages what students do and how they feel about their

learning and the connections they make with the content, the instructors, and other students

(Dixson, 2015).

12

Interaction

Interaction is a “mutual or reciprocal action or influence” (Merriam-Webster, n.d.

“interaction”). This exchange includes communication, information transfer, student

engagement, and collaborative learning (Carter & Rukholm, 2008; Cole et al., 2018): interaction

requires a mutual imparting of knowledge and trust that nourishes a learning environment (Hung,

2013). Effective communication is an essential component of interaction (Pennings et al., 2014;

Ragusa & Crampton, 2018).

Rural

The U.S. Census Bureau (2015) identifies two types of urban areas: urbanized areas of

50,000 or more people and urban clusters of between 2,500 and 50,000 people. All other areas

are considered rural. The U.S. Census Bureau uses population density to determine rural or urban

status at the state level. The 10 states with the lowest population density in the United States are

as follows: Alaska, Idaho, Kansas, Montana, Nebraska, Nevada, New Mexico, North Dakota,

South Dakota, and Wyoming (World Population Review, 2020; U.S. Census Bureau, 2018).

Chapter Summary

To meet the current and expected need for nurses in rural communities, educators must

find effective means of delivering nursing education to learners in rural areas (Kovner et al.,

2011; Scarbrough, 2015). Both theoretical content (Abrami et al., 2011; Allen & Seaman, 2016;

Bowen et al., 2013) and critical thinking skills (Hewitt et al., 2015) can be taught using OE

delivery. The literature does not currently indicate whether synchronous versus asynchronous OE

delivery influences test scores or student engagement for pre-licensure nursing students. The

purpose of this study was to determine if the method of OE delivery — synchronous or

asynchronous— affected selected learning indictors for pre-licensure nursing students. These

13

indicators included HESI specialty exam scores and OSE scores. The following three aims were

implemented to accomplish this study’s purpose: (a) a comparison of student learning as

measured by HESI specialty exam scores, (b) a comparison of student engagement as measured

by the OSE scale, and (c) an exploration of the association between student engagement and

HESI specialty exam scores in synchronous versus asynchronous online learning environments.

14

CHAPTER 2: REVIEW OF RELATED LITERATURE

This chapter presents a comprehensive review of literature related to online education

(OE) in nursing and information concerning synchronous and asynchronous OE delivery. The

chapter also defines distance education (DE), hybrid education, and spotlights the contributions

of OE to nursing education. The chapter also reviews information on pre-licensure registered

nurse (RN) education delivery.

Process

The review process involved a search of the nursing and education literature for evidence

related to OE in nursing education and information concerning synchronous and asynchronous

OE delivery. Keywords used include the following in various combinations: learning, training,

online education, e-learning, distance learning, distance education, higher education, skill

acquisition, skill development, nursing, nursing education, pre-licensure nursing, pre-registration

nursing, classroom engagement survey, student engagement measurement instrument,

synchronous, and asynchronous. Search limits identified articles published in or translated into

the English language. Narrowing limits specified that articles be classified as scholarly, peer-

reviewed, and published from 2000 to present, excepting specific seminal works, which were

older. These searches utilized the following databases: Academic Search Premier, CINAHL,

Education Full Text, and ERIC. Interlibrary Loan afforded access to any sources without the full

text available online.

Due to the length of time involved in completing this dissertation, literature was again

reviewed specific to the 2015 to 2020 dates, using the same keywords and databases. The

subsequent literature search included these additional databases: Education: A Sage Collection,

ProQuest Dissertations and Theses Global, and Google Scholar. Citation tracking also offered a

15

wealth of updated information; publicly available government data resources provided access to

workforce and rural classification data.

Distance, Online, and Hybrid Education

The terms OE and DE are often used interchangeably in scholarly literature. However,

there are unique differences between the two terms. DE has the following characteristics:

learners and instructors are separated geographically throughout the learning process; interactive

telecommunications or technical media systems connect the involved parties; two-way

communication is available for students to initiate dialogue; learning involves the individual

more than a learning group, which may be absent (Keegan, 1996, as cited by Keegan, 2002 and

Peck et al., 2018; Simonson et al., 2011). Simonson et al. (2011) include electronic

communication in their definition of “telecommunications systems.” Thus, OE may fall within

this definition of DE. In some settings, all DE courses are offered online, making the terms

“distance” and “online” interchangeable. In other settings, courses may be available at a distance

without being online, such as a face-to-face (FTF) class session via two-way videoconferencing

without any online component. Conversely, online courses may be made available for local

students (Murphy & Stewart, 2017), which disqualifies them from the definition of DE.

Both DE and OE delivery models allow for increased access to education for students at a

distance from the institution of origin (Butler et al., 2016; Kozlowski-Gibson, 2018). Increased

availability of alternative teaching and learning tools, such as computer-based materials, virtual

simulation resources, and mobile learning, ensure that education in the OE format is as effective

as traditional FTF instruction (Kang & Seomun, 2018).

For this study, the term OE is used when discussing courses that are web-based and

known to be delivered online. The term DE is used when discussing courses which are delivered

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to students who are not local to the college/university where the offering originates, but for

which the delivery method is unknown. Blended educational offerings, which combine OE and

FTF learning, with or without DE, are identified as hybrid education.

Distance Education

There is consensus regarding the effectiveness of DE (compared with FTF classroom

instruction) through individual studies and multiple meta-analyses (Bernard et al., 2004; 2009;

2014; Butler et al., 2016; Lai & Bower, 2020; Lou et al. 2006; Shachar & Neumann 2003; 2010;

Voutilainen et al., 2017). Shachar and Neumann (2003; 2010) demonstrate the effectiveness of

DE courses in two meta-analyses of data comparing the academic performance of students

enrolled in DE courses with the academic performance of students in traditional (in a classroom)

face-to-face (FTF) settings. Data from over 15,000 students demonstrated that student in DE

courses outperformed their traditionally enrolled counterparts in 66% of cases (2003). In 2010,

Shachar and Neumann reviewed 20 years of research on academic performance differences, over

20,000 students, and found that students in DE settings outperformed their student counterparts

in FTF settings in 70% of cases. Butler et al. (2016) noted similar findings; distance students

outperformed those in the traditional classroom.

Successful DE involves three types of interaction: learner-content, learner-instructor, and

learner-learner (Bernard et al., 2009; Peck et al., 2018). Peck et al. (2018) state that distance

learners must be actively engaged in their learning processes to maximize student-content

interaction. Since distance learning is more individual, due to the “quasi-permanent absence of

the learning group” (Keegan, 2002, p. 19), DE students must apply consistent, sustained effort

over time to achieve educational success (Peck et al., 2018).

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Butler et al. (2016) found that distance delivery generally does not include synchronous

or face-to-face instruction. They note that improvements in technology allow for synchronous

teaching and learning with students who are at a distance from the instructor. Distance video

conferencing began in the 1960s to increase the geographic reach of surgical expertise to rural

areas (Augestad & Lendsetmo, 2009). It continues to be utilized for surgical education,

consultation, telementoring, and telemedicine surgical follow-up (Augestad & Lendsetmo, 2009;

Shah, 2016). A logical extension is to expand conferencing delivery to online education.

Online Education

Advances in e-learning technology allow many methods of instruction to be made

available to students online (Butler et al., 2016; Chan et al., 2016). This technology includes

video lectures, written discussion forums, group assignments, and online quizzing, among others.

Many institutions adopted online delivery methods for instruction and program expansion due to

its many advantages (Peck et al., 2018).

Advantages of OE include reduced time and expense on travel (Chan et al., 2016),

flexibility in time management for students and instructors (Abuatiq, 2019), and increased ease

of assessing student participation (Chan et al., 2016). OE also provides high levels of structure

for group discussions. OE can assist learners of varying learning styles, improving the overall

quality of education for a wider variety of students (Bolliger & Inan, 2012; Cooper et al., 2015;

Panzarasa et al., 2016). Student satisfaction in OE groups is comparable to that in traditional,

classroom groups (Chan et al., 2016). There is a consensus that OE is as effective as both DE and

FTF course delivery (Bernard et al., 2014).

OE is not without challenges. Some students find the online environment to be

impersonal and disengaging (Chan et al., 2016). Others cite problems with the required

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technologies. Technology problems may include faculty competence, or lack thereof (Coose,

2010), unreliability or poor performance of the technology (Chan et al., 2016), or insufficient

technical support for students (Mancuso-Murphy, 2007).

Nursing colleges are among those who have responded to increased demand for

accessible quality education by developing more online-based courses (Abuatiq, 2019; Butler et

al., 2016; Coose, 2010; Mancuso-Murphy, 2007). Online nursing courses may be part of

baccalaureate, master’s, or doctoral programs. As students often enter these programs with high

levels of technologic literacy, digital learning resources available online can be integrated into

coursework, thereby increasing institutional capacity without a corresponding increase in the

need for clinical training facilities (Abuatiq, 2019).

Scarbrough (2015) notes that nursing education adopted the use of asynchronous OE,

using written assignments, discussions, and group projects, for postgraduate training before the

widespread availability of high-speed internet. It is now realistic to expand OE use to

undergraduate, pre-licensure nursing education (Scarbrough, 2015). In addition, the widespread

availability of high-speed internet connections makes it possible to deliver content

synchronously as well as asynchronously to students in remote areas (Bernard et al., 2014;

Scarbrough, 2015).

Hybrid Education

Hybrid education refers to educational settings in which some, but not all, of the FTF

content, is delivered by virtual learning experiences or technology (Mancuso-Murphy, 2007).

Other titles for hybrid education include “blended” learning (Bernard et al., 2014) or “computer-

supported” learning (Hernández-Sellés et al., 2019). Hybrid education seeks to combine the

advantages of both FTF and distance instruction, allowing for increased equity in access to

19

education while maintaining the personal component of an instructor and class environment

(Yang et al., 2019).

The ‘synchronous hybrid’ format combines online and on-campus students in the same

classroom via internet technologies (Butz & Stupnisky, 2017), similar to the way video

conferencing via older telecommunications technology was accomplished previously. One goal

of the synchronous hybrid format is to connect disparate groups (online and on-campus) in the

same course. Butz and Stupnisky (2017) explain how threaded asynchronous discussion can help

online students connect with on-campus students in synchronous hybrid learning environments.

They identify that student feelings of connectedness to others are essential for success in

technology-rich learning environments. Their study focused on connecting disparate students in

planned asynchronous discussions to improved relatedness between students. Butz and Stupnisky

fail to identify the fully synchronous online course as an OE option; synchronous OE creates a

single community of learners rather than learners who perceive interaction as limited due to

“divergent attendance modes” (2017, p. 118). The current study does not address the hybrid or

synchronous hybrid education paradigms.

Learning Outcome Achievement

Students receiving OE have similar educational outcomes as those receiving FTF

instruction, hybrid education, or DE via offline means (Allen & Seaman, 2016; Bernard et al.,

2014; Keefe & Wharrad, 2012; Li et al., 2019; McCutcheon et al., 2018; Shachar & Neumann,

2003; 2010). These outcomes include increases in critical-thinking skills, complex systems

analysis, team processes, theoretical knowledge, formational learning, and the performance of

hands-on skills (Hockridge, 2013; Lu et al., 2009; Öztürk & Dinç, 2014; Silveira & Cogo, 2017).

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Allen and Seaman (2016) report that 71.4% of chief academic officers identified OE as either the

same, or superior, in quality as FTF instruction.

Critical thinking and complex systems analysis can be taught successfully using OE

interventions (Hewitt et al., 2015; Kalelioğlu & Gülbahar, 2014). Hewitt et al. (2015) report that

a problem-based learning series of short digital recordings was effective in teaching an

interdisciplinary, systems approach to safe medication administration as well as generating

student understanding of those systems and processes. The intervention by Hewitt et al. did not

target the skill of medication administration, but rather the critical thinking involved in the

process and the extrinsic system factors required. Kalelioğlu and Gülbahar (2014) find that using

varied instructional techniques encourages students to think diversely. This variety helps develop

enhanced critical thinking processes. Kalelioğlu and Gülbahar assert that using a variety of

teaching methods, such as brainstorming, role-playing, problem-based learning, or Socratic

seminar, in the online environment is beneficial to students’ learning. They specify that planned

instructional methods are essential if students are to learn higher-order thinking and problem-

solving skills (Kalelioğlu & Gülbahar, 2014).

Ajabshir (2019) provides evidence for student learning of complex processes online.

They evaluated the acquisition of interlanguage pragmatic competence when discussing the

impact of synchronous and asynchronous computer-mediated communication instruction.

Ajabshir finds that both synchronous and asynchronous online interventions supported

collaborative dialogue between learners, serving as “cognitive amplifiers” for students in

achieving learning outcomes (p.175). Carbonaro et al. (2008) describe learners studying complex

interprofessional team process skills in a blended environment using both synchronous and

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asynchronous online delivery. Learners in both studies achieved outcomes comparable to those

reached by learners in the FTF classroom setting (Ajabshir, 2019; Carbonaro et al., 2008).

Campbell et al. (2008) observe that OE is effective in teaching research. Their study

demonstrated that online asynchronous discussions achieved comparable results with FTF

discussions in a postgraduate research methods course for nursing and health care students.

Thomas (2013) also notes the effectiveness of online asynchronous discussions, specifically the

components involving interaction and instructor feedback, in developing student ability to reflect

and analyze issues critically. Campbell et al. also maintain that increased student use of online

resources correlates with higher student achievement. This finding is corroborated by Wang

(2017), who noted a correlation between the use of online problem-solving activities and higher

student achievement.

Hockridge (2013) evaluates the appropriateness of fully online and blended course

delivery methods for preparing students for formational learning in the relational professions,

such as theology, social work, nursing, and medicine. Hockridge suggests that formational

education “shapes individuals’ capacities, choices, and characteristics” (p. 143) and should

include both affective and cognitive learning. Benner et al. (2010) state that formation is the

“shaping of the habits and dispositions for [the] use of knowledge and skilled-know-how” (p.

104). This change at the core of the individual is a complex process and not easily achieved

regardless of the mode of educational delivery (Hockridge, 2013, p. 158). The study finds that

purposeful attention by the educator “to the relational and affective components of learning” (p.

144) supports and helps develop formational learning in the student, regardless of whether the

education occurs in the OE, hybrid, or FTF setting.

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Egorov et al. (2019) further evaluate Hockridge’s assessment concerning formational

learning. They identify the importance of cognitive, social, and teaching presences for students to

be successful in achieving deep, meaningful learning in an online environment. In their

ethnographic review, Egorov et al. note that obtaining knowledge alone does not necessarily

result in the education of the whole person, including spiritual and character formation. DE or

OE must include a systematic means for two-way communication between the instructor and

students and between students to achieve formational learning effectively; i.e., the social and

teaching presences must be part of any successful distance or online program (Egorov et al.,

2019).

Salter et al. (2014) present their systematic review of the literature concerning OE in

pharmacy education. Of the 17 studies meeting the criteria for review, 14 (82%) delivered online

instruction in more than one format. Learning effectiveness was measured using both objective

and subjective assessments such as pre-post knowledge tests, mock patients, rating scales,

written or online surveys, and others. Eleven of the reviewed studies assessed knowledge

change; all reported a significant improvement in knowledge following the OE offering. Salter et

al. find that OE is effective in significantly increasing knowledge, improving attitudes, and

building confidence related to task performance. However, they note that the evidence is weak as

to whether OE is effective in actually improving or changing either pharmacy skills or

professional practice. Thus, they recommend translational research to evaluate the benefits of OE

at the patient and organizational levels (Salter et al., 2014).

While consensus exists regarding comparable learning outcome achievement, there is a

need for more research comparing different types of DE and OE (Abrami et al., 2011; Bernard et

al., 2004; 2014; Simonson et al., 2011). There is a lack of rigorous evidence on learning

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outcomes for students enrolled in OE; a majority of existing studies lack rigorous design,

randomization, or sample sizes sufficient to generalize findings (Bernard et al., 2014; Bowen et

al., 2013; Salter et al., 2014). To advance theory and strengthen the evidence base for educational

practice, Bernard et al. (2009; 2014) recommend additional studies to compare the effectiveness

of differing types of interaction treatments in DE or OE.

Access to Higher Education

Allen and Seaman (2017) report that over 6 million students in the United States enrolled

in online and distance courses in the fall of 2015. Both DE and OE can increase the reach and

quality of education without a corresponding increase in cost (Abrami et al., 2011; Bowen et al.,

2013; Salter et al., 2014). Distance and online models allow for increased enrollment in some

courses without requiring a corresponding increase in physical space (Bowen et al., 2013). This

increased enrollment permits institutions to expand access to students who may otherwise be

unable to advance their education (Allan & Aldebron, 2008; Bolliger & Halupa, 2018; Butler et

al., 2016; Peck et al., 2018). DE and OE can also provide equitability in access to education for

remote students (Butler et al., 2016; Egorov et al., 2019; Hockridge, 2013).

Butler et al. (2016) identify distance as a significant barrier to nursing education in rural

and remote communities. When investigating the discrepancy between the number of Indigenous

people in nursing and social work and the number of Indigenous people in the rest of the

workforce in that region, it became clear that access to higher education was the primary barrier.

Butler et al. developed a distance program to support learners where they lived, regardless of

geography. This program increased access to quality education, improved health care delivery in

the region, and provided additional opportunities and career choices for the local people.

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Bryan-Green (2015) also identifies the need to increase access to nursing education to

meet the projected demand for nurses. They note that OE can deliver the didactic component of

nursing education successfully. Bryan-Green finds that nursing students educated in an online

competency-based program were as prepared for clinical experiences as were their traditional

nursing student counterparts. Their study supports the development of online programs for

purposes of increasing student access to nursing education without the need for additional

physical space. Bryan-Green also calls for further research about online nursing students’

preparedness for the clinical environment.

Both DE and OE options increase students’ ability to schedule their education time

around other responsibilities, such as work or family obligations; this allows some institutions to

increase access to education for distance students in higher numbers (Bowen et al., 2013;

Murphy et al., 2011; Peck et al., 2018; Roh & Park, 2010). Consideration for access is of

particular importance in geographic areas that must rely upon OE to meet the demand for

education (Butler et al., 2016; Scarbrough, 2015).

However, to support access to online education, a variety of tools are necessary. These

tools include learning management systems (e.g., WebCTTM, MoodleTM, or BlackBoardTM),

email, media (e.g., podcasts, webcasts), social media (e.g., blogs or Facebook), discussion

forums, and other content-specific material (Butler et al., 2016; Murphy et al., 2011; Scarbrough,

2015). Online education also requires access to high-speed internet, which is increasingly

available worldwide (Scarbrough, 2015). OE is technology-dependent. Both instructors and

learners must have access to the required technology and be competent in its use for the content

to be delivered.

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Interaction and Engagement

Student-student, student-instructor, and student-content interaction are essential

components in OE (Bernard et al., 2009; Hampton et al., 2017; Moore, 1989, as cited in Peck et

al., 2018). Other considerations for student success include student characteristics, motivation,

and course design (Bernard et al., 2009; Bolliger & Halupa, 2018; Giesbers et al., 2014b;

Hampton et al., 2017; Iqbal et al., 2011; Joksimović et al., 2015; Moore, 1989, as cited in Peck et

al., 2018; Ravenna et al., 2012; Song et al., 2003). Active involvement in the learning process is

necessary for students to associate new information with previously learned material (Peck et al.,

2018).

Lu et al. (2009) observe that DE and OE bridge the physical separation between teachers

and students and thereby expand opportunities for teaching and learning by allowing for

meaningful interaction to occur. OE provides students the opportunity to interact with a more

diverse peer group than might otherwise be available (Bolliger & Inan, 2012). Innovative

instructional technologies also allow options for expanded interaction (Bolliger & Inan, 2012).

Because of the primarily asynchronous nature of online communications (Bolliger & Inan, 2012;

Bolliger & Halupa, 2018), some students find personal interaction to be lacking in the online

environment. Interactive OE is now possible due to recent advances in technology and internet

speed (Bolliger & Halupa, 2018; Cant & Cooper, 2014; Scarbrough, 2015). Boling et al. (2012)

state that creating an interactive learning community in the online environment is challenging but

essential for maximizing student learning.

Revere and Kovach (2011) note that the integration of technology in course activities can

promote learner-centered education. They indicate that the highest quality OE engages students

in learning exercises. Instructors use a variety of technologies in the online learning

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environment; when these instructors successfully integrate the technology in supportive learning

activities, they can expect to achieve enhanced student engagement (Revere & Kovack, 2011).

Martin and Bolliger (2018) reviewed various engagement strategies for OE. Positive,

engaging activities may include collaborative group work, student-facilitated presentations or

discussions, sharing learning resources, case studies, and reflections. Student engagement

decreases learner isolation and improves retention and graduation rates in online learners (Martin

& Bolliger, 2018). Martin and Bolliger found that participants valued strategies that provided

student-instructor interaction.

Bodily et al. (2017) observe that instructors in a traditional FTF classroom adapt in real-

time to variations in student engagement but are unable to monitor engagement outside of the

classroom. They note that technology-mediated instruction, such as OE, can capture data related

to student learning outside of the FTF classroom, allowing teachers to adjust instruction if

students are not engaged fully. However, Bodily et al. identify that the time-intensive nature of

collecting engagement data usually means that it is only collected at the course level, rather than

identifying specific activities for which engagement is high or low. This course-level data is

collected retrospectively, making it useful for subsequent courses, but not providing instructors

the opportunity for immediate correction. Bodily et al. discuss potential technologic solutions for

getting engagement data to stakeholders in a timely, useful fashion.

Active participation is one form of engagement. O’Flaherty and Laws (2014) found

evidence of student participation in their study of online classes; they explored students’

utilization and the perceived benefits of participating in a web-based virtual classroom.

O’Flaherty and Laws (2014) studied voluntary attendance in the virtual classroom. Seventy-five

percent of students participated in over 50% of the virtual classes, and 53% participated in over

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75% of the virtual classes. The overall voluntary attendance in the virtual classroom was 89% (p.

657). Student satisfaction and exam pass rates increased for those participants who engaged in

virtual classrooms (O’Flaherty & Laws, 2014).

In addition to active student participation, student engagement involves interaction in the

intellectual community (Bond et al., 2020; Dixson, 2015; Dixson et al., 2017; Hrastinski, 2009).

Engagement entails “the energy and effort that students employ within their learning community,

observable via any number of behavioral, cognitive, or affective indicators across a continuum”

(Bond et al., 2020, p. 3). In online coursework, students may interact with others in quantifiable

ways to learn course content and skills, to demonstrate that learning, and to value the learning

acquired (Dixson, 2015). This engagement and interaction may occur either synchronously,

asynchronously, or in both formats (Hampton et al., 2017). Students work collaboratively to

complete assignments and analyses, providing opportunities for interaction, discussion,

reflection, and knowledge creation (Ashcraft et al., 2008; Hampton et al., 2017). Interaction is

essential in all types of learning formats, including FTF classroom-based, synchronous and

asynchronous online or distance models, and hybrid or blended courses (Woo & Reeves, 2007).

Increasing quality interaction in online learning environments provides students with improved

opportunities to learn collaboratively and to be integrated into a learning community (Banna et

al., 2015; Bond et al., 2020; Joksimović et al., 2015; Woo & Reeves, 2007).

Dixson (2010) presents an in-depth discussion of the methods of tool development and

reliability and validity testing for the Online Student Engagement Scale (OSE). Dixson holds that

effective online instruction requires active learning for students and strong instructor presence in

the online course. Using tools previously validated for student engagement in FTF courses,

Dixson utilized focus groups of online instructors to provide input on what constitutes student

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engagement in online course work. Reliability was strong (0.95) in the pilot with 31 online

students. The scale “correlated strongly with two global items on engagement with the course (r

= 0.73; p < 0.01) and two global items of social presence (getting to know other students and

your instructor) (r = 0.38; p < 0.05), thus supporting face validity” (Dixson, 2010, p. 4).

Online Course Design

OE has changed and expanded in educational settings as digital technologies have

evolved since the year 2000 as a result of new devices, smaller batteries, and other innovative

applications (Bramer, 2020; Gagnon et al., 2013; Smart et al., 2020). Online course design and

delivery vary widely from one institution or one instructor to another. Computers, networks, and

mobile technologies connect teachers, learners, and course content (Bernard et al., 2004; Lee,

2015; Raman, 2015). Courses may use web-based resources as well as computer-mediated

learning opportunities, which include self-directed learning modules, podcasts, and video-

enhanced programs (Bernard et al., 2004; Cant & Cooper, 2014; Öztürk & Dinç, 2014;

Scarbrough, 2015). Educators design courses to maximize both student engagement and student

learning to meet the desired educational and professional outcomes (Scarbrough, 2015; Smart et

al., 2020). With technological improvements, simulation in the online environment can now

immerse students in realistic contexts that facilitate learning (Cant & Cooper, 2014; Lean et al.,

2014; Powers et al., in press). New and emerging videoconferencing technology allows

instructors the ability to include simultaneous interactions between teachers and students who are

at a distance from one another (Borokhovski et al., 2016; Butler et al., 2016; Scarbrough, 2015).

Effective instructional design is essential in online learning environments (Lawton et al.,

2012; Song et al., 2003). While learning outcomes may relate to online course design, the

general practices and principles that are effective in FTF education are often applicable to OE as

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well (Lawton et al., 2012; Simonson et al., 2011). Technology alone does not result in improved

learning (Silveira & Cogo, 2017). Sound pedagogical practices are required. These practices

include quality instruction, interaction, teacher and student training in the media used, and

teamwork that includes instructional designers, media specialists, and instructors (Bernard et al.,

2009; Reime et al., 2008; Simonson et al., 2011).

Online instructional design that is effective should focus on both the technological

aspects of the course and also on well-defined learning goals, objectives, and expectations for

learners (Reime et al., 2008; Silveira & Cogo, 2017; Song et al., 2003). Student success is also

influenced by learning motivation, time management, comfort with online technologies, and a

sense of community in the online environment (Peck et al., 2018; Song et al., 2003).

Online and hybrid courses use similar design principles. (Lean et al., 2014; Wood et al.,

2013). Online simulation can stimulate students’ critical thinking and decision-making (Lean et

al., 2014; Powers et al., in press; Silveira & Cogo, 2017). Wood et al. (2013) identify the hybrid

components as beneficial in enhancing student understanding of the content and the nature of

interprofessional teamwork. Additional research in both OE and hybrid course delivery is

warranted (Gagnon et al., 2013; McCutcheon et al., 2014).

Asynchronous and Synchronous Online Education Delivery

Asynchronous online education (AOE) involves students working with course material

under the guidance on an instructor, but on their own time rather than on a schedule (Bramer,

2020; Lowenthal et al., 2017; Malik et al., 2017; Murphy et al., 2011; Öztürk & Dinç, 2014).

AOE is free from geographic limitations and offers students to work at a time that is convenient

for them (Butler et al., 2016). Butz and Stupnisky (2017) note that the education “anytime,

anyplace flexibility” is the defining characteristic of asynchronous course delivery. They state

30

that asynchronous attendance is “the only option for students who are place-bound or bound by

demanding personal or professional schedules” (p. 119). Butz and Stupnisky assessed student

self-efficacy in developing relatedness with individuals who attended online.

Thrane (2020) suggests the asynchronous online format for nursing students studying

palliative and end of life care. They find that the time allowed by the asynchronous discussion

format to be beneficial in allowing students the opportunity for thoughtful reflection on the

challenging subject.

Synchronous online education (SOE) connects instructors and students temporally but not

geographically (Becker et al., 2018; Marlow & Mather, 2017; Murphy et al., 2011; Öztürk &

Dinç, 2014). Instructors and learners may be thousands of miles apart but must be online in the

agreed-upon format at the specified time. As a result, SOE offers a reduced amount of

scheduling flexibility, but more closely simulates a classroom environment and offers increased

access to the instructor in real-time (Banna et al., 2015; Bernard et al., 2004; Bramer, 2020;

Marlow & Mather, 2017). SOE allows geographically isolated individuals to connect to a

broader community for scholarly exchange (Musits & Mannix, 2019). When the geographic

spread is wide, synchronous participation may be limited by variations in time zones (Musits &

Mannix, 2019). Also, similar to the framework used in a live classroom, SOE is less amenable to

self-paced education.

A combination of synchronous and asynchronous communication supports learner

engagement and learning quality (Giesbers et al., 2014b; Green et al., 2017; Hampton et al.,

2017; May, 2019). Asynchronous communication allows students time for reflection and

discussion of complex ideas; whereas, synchronous communication accommodates fluid

conversations, allows for immediate feedback, and builds community (Hrastinski et al., 2010;

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Molnar & Kearney, 2017). Facilitators identify observable student learning as a positive measure

of OE in both synchronous and asynchronous situations.

Synchronous communication tools, such as web-conferencing, allow for more direct

interaction and feedback between online teachers and learners (Giesbers et al., 2014b; Hrastinski

et al., 2010; Molnar & Kearney, 2017; Oztok et al., 2013; Scarbrough, 2015). Molnar and

Kearney (2017) suggest that these synchronous communication tools may lead to higher levels of

cognitive presence, essential in fostering critical thinking skills. Oztok et al. (2013) support this

view; that sustaining social, teaching, and cognitive presences is more likely to occur when

synchronous communication options are available to students. Learners may be less engaged in

online courses if only asynchronous communication is utilized (Bramer, 2020; Giesbers et al.,

2014b; Oztok et al., 2013). Current findings with synchronous communication warrant further

research (Giesbers et al., 2014b). Hrastinski (2008) calls for more study regarding the benefits

and limitations of developing types of asynchronous, synchronous, and hybrid e-learning.

Scarbrough (2015) notes that historical precedent for online nursing education includes heavy

use of asynchronous methodologies, including written assignments, discussion posts, group

projects, and online quizzes.

AOE has been more commonly used to date than SOE (Lowenthal et al., 2017; Murphy

et al., 2011; Molnar & Kearney, 2017). However, synchronous online interaction may increase

student success (Carver et al., 2017). Synchronous communications can enhance the quality of

experiential education that students receive (Cant & Cooper, 2014). Iqbal et al. (2011) also

support the belief that this type of interaction in synchronous learning has positive effects on

student achievement in distance learners. Scarbrough (2015) evaluated student satisfaction with

online course delivery involving synchronous videoconferencing. Scarbrough’s study found

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significantly higher scores in the domains of Instructor Support and Interaction. Other domains

concerning learning quality, satisfaction, and social presence were not different between the

synchronous and asynchronous groups (2015, pp. 70-71). Individual student motivation is also

associated with student engagement in both asynchronous and synchronous course

communication (Bond et al., 2020; Giesbers et al., 2014b).

Academic leaders rate hybrid courses, which offer more real-time interaction than

courses that are entirely online, as superior to both online and FTF courses in achieving learning

outcomes (Allen & Seaman, 2016). As synchronous technologies become more powerful and

more accessible, it becomes possible to create course offerings that are entirely online and also

increase the amount of real-time student-student and student-teacher interaction. While e-

learning was initially limited to asynchronous communication, current technology provides the

capacity for “authentic experiential learning” in a synchronous online environment (Cant &

Cooper, 2014, p. 1436; Yang et al., 2019; Zydney et al., 2020)

Pre-Licensure Registered Nursing Education Delivery

Today’s RNs are active participants in interdisciplinary health care teams and are

responsible for making complex, high stakes decisions based on sound clinical judgment

(Wilkinson et al., 2016). Thus, nursing educators must train students to be able to perform

essential functions to deliver safe health care when they reach the practice setting. Pre-licensure

nursing education integrates theory and knowledge, so that the newly educated nurse may apply

the information to complicated, real-life situations (Bramer, 2020; Thrane, 2020).

Nurses are educated through one of several pathways. RN education occurs in diploma

programs, associate degree (AD) programs, or baccalaureate degree (BS or BSN) programs.

Diploma programs are typically 3-year programs, are hospital-based, and follow an

33

apprenticeship model (Wilkinson et al., 2016). Diploma programs focus on direct patient care.

AD programs are usually 2-year programs offered through community colleges. These programs

require general education instruction in the liberal arts and sciences but also focus primarily on

direct patient care (Wilkinson et al., 2016).

BS/BSN programs include a liberal education in the humanities and sciences before

extended focus on nursing study. These students are also prepared to provide direct patient care

and to address complex care situations. Additionally, they are equipped to work in leadership or

community health roles, and to evaluate and incorporate research into practice (Wilkinson et al.,

2016). AD and BS/BSN programs may be delivered via FTF classroom instruction, by DE or

OE, and will also include clinical experiences in a variety of settings. Some schools offer

master’s level entry to nursing for students who have a baccalaureate degree in another field.

Doctoral entry is also available in some areas but is uncommon.

Curricula are similar in various types of nurse preparation programs, although teaching

approaches may differ (Anderson & Tredway, 2009; Gooder & Cantwell, 2017; Jacob et al.,

2014a; 2014b; Scarbrough, 2015). Jacob et al. (2014a) observe that undergraduate registered

nursing degree programs involve a significant amount of self-directed learning, intending to

develop lifelong learners.

Most prior studies regarding OE in nursing education focus on graduate-level students or

on practicing RNs from diploma or AD programs. These students are returning to school for a

baccalaureate degree (called RN-to-BSN programs) or for graduate-level education. Scarbrough

(2015) notes the overall success previously discovered in graduate training using asynchronous

OE. Anderson and Tredway (2009) report an increase in RN-to-BSN completion programs as a

result of the demand for formal education that enhances both critical thinking and problem-

34

solving skills. They observe that the need for teaching methods for enriching problem-solving

skills coincides with the need for increased access to online courses. Anderson and Tredway

assert that problem-based learning is salient for nurse education — particularly for practicing

nurses completing baccalaureate education — because the nature of nursing practice is a holistic

approach to problems and care. Carter and Rukholm (2008) also assess RN-to-BSN students

when they evaluate critical thinking and discipline-specific writing in an OE setting. Carter and

Rukholm observe that RN-to-BSN students develop their critical thinking skills as they write and

respond to writing within the discipline. While useful in supporting critical thinking skill

development, this process demands substantial time from the nursing faculty member (Carter &

Rukholm, 2008).

Benner et al. (2010) declare that nursing faculty and resource shortages require

alternative educational strategies if the profession is to maintain the necessary standards in

professional education. Allan and Aldebron (2008) also identify academic innovation as essential

in accommodating more students with fewer nursing faculty members. They reviewed 685

search results, including peer-reviewed, non-peer-reviewed, and non-scholarly publications, to

evaluate potential strategies for addressing the nursing faculty shortage. They found a lack of

published information addressing actual teaching strategies and a wealth of information

discussing the severity of the shortage and the potential consequences thereof.

Hoffman and Dudjak (2012) identify online course delivery, either synchronous or

asynchronous, as one mechanism for improving access to advanced education while meeting

increasing consumer demand for flexibility of study and innovation in nursing education. A wide

variety of OE and DE strategies can be implemented in nursing education to facilitate outcomes

comparable with on-campus nursing classes (Allan & Aldebron, 2008). Allan and Aldebron

35

(2008) state that interaction within the course, via electronic discussion, communication media,

chats, or email, is a substantial indicator of course quality in OE.

Domain-specific nursing knowledge, including instruction in both cognitive domain and

psychomotor domain content, can be taught using a variety of OE technologies (Borneuf &

Haigh, 2010; Hofmeyer et al., 2016; Lai, 2016; Lu et al., 2009; Pauly-O’Neill & Prion, 2013;

Rennie, 2009; Scarbrough, 2015; Sowan & Idhail, 2014). Sowan and Idhail (2014) state that an

interactive web-based course using streaming video technology was effective in meeting

students’ educational needs and the course objectives of a fundamental nursing skills clinical

course. Sowan and Idhail (2014) also observe high levels of student satisfaction with the OE

course. Lu et al. (2009) supplement FTF classroom teaching with web-based learning when

teaching intramuscular injection nursing skills. Pauly-O’Neill and Prion (2013) find that

combining e-simulation with traditional clinical experiences augments active learning and

improves student competence and confidence with pediatric medication administration while

allowing for the ethical consideration of placing a child under the care of a student.

Roh and Park (2010) compare the educational effectiveness of OE in nursing with

traditional classroom education in nursing. Their meta-analysis shows a small but significant

positive contribution of OE in nursing to student knowledge, attitudes, and practice performance.

McCutcheon et al. (2014) also critically evaluate the current evidence base for effective teaching

methodologies and modalities in nursing education. Their systematic review assesses the impact

of OE, hybrid, and FTF learning on clinical skill development and knowledge base in

undergraduate nursing students. McCutcheon et al. state that OE provides similar or improved

knowledge for undergraduate nursing students when learning clinical skills. Of the 13 papers

which assessed knowledge after teaching intervention, seven reported significantly higher levels

36

of knowledge after OE, two reported significantly higher levels of knowledge after FTF

teaching, and five reported no difference between OE and FTF learning. McCutcheon et al.

identify the need for additional research assessing the effectiveness of blended, online, and FTF

teaching methodologies.

Cant and Cooper (2014) report on an integrative review combining experimental and

non-experimental research to fully explore and describe the state of the evidence concerning

web-based simulation within nursing education. Simulation is an accepted standard in nursing

education, but e-simulation has a smaller evidence base (Cant & Cooper, 2014). Of the identified

studies, 18 primary program studies were included in the review. Most of the programs taught a

specific aspect of procedural patient care using multimedia, such as instruction on placing an

intravenous line. Others offered unfolding case scenarios to promote the development of critical

thinking and clinical decision-making skills. Cant and Cooper find high levels of learner

satisfaction in e-simulation, but note that available feedback is focused more on usability and

lacking in the evaluation of how well students achieved the learning outcomes. Cant and Cooper

also identify the benefit of e-simulation to accessibility regardless of geographic location,

provided sufficient internet access and speed is available to the learner.

Chapter Summary

Institutions of higher education recognize OE as essential to long-term institutional

success (Allen & Seaman, 2016). The number of students enrolling in online courses has grown

consistently since 2003 (Allen & Seaman, 2016). It spans a variety of disciplines in both the

sciences, health sciences, and humanities (Abrami et al., 2011; Abuatiq, 2019; Bernard et al.,

2009; 2014; Egorov et al., 2019; Hockridge, 2013; Unnisa, 2016). In nursing and the health

sciences, OE is used to teach primarily didactic content (Borneuf & Haigh, 2010; Rennie, 2009;

37

Salter et al., 2014). Skill-related foundational knowledge is taught via OE, but there is no

currently available methodology able to serve as a substitute for hands-on training in

psychomotor skills (Scarbrough, 2015).

This chapter has presented a review of the literature concerning educational practices in

nursing education. The chapter defined distance, online, and hybrid education, and it focused on

the scholarly contributions of OE, including information on how OE increases access to

advanced education and how effective course design is essential for maximizing student

learning. Learning outcome equality in OE and the importance of interaction in the OE setting

were presented. Both asynchronous and also synchronous OE delivery methods, which are

underrepresented in the scholarly literature, were then reviewed. AOE connects distance students

with course content and instruction while allowing scheduling flexibility for the student. SOE

connects student and instructors at the same time, decreasing scheduling flexibility, but allowing

for real-time access to the instructor and peers. The chapter concludes with information on pre-

licensure RN education.

38

CHAPTER 3: METHODS

This chapter presents the methodology used for this study and includes the theoretical

framework and research questions. This chapter examines the study design, sample, inclusion

criteria, setting, and variables. Ethical considerations are given. Data management is presented,

including collection, deidentification, and coding processes. The chapter concludes with a

discussion of instrumentation and reliability, statistical analyses, and limitations for this study.

Theoretical Framework: Social Constructivism

Constructivism holds that learners develop knowledge by evaluating their experiences to

create meaning (Ashcraft et al., 2008; Hsieh et al., 2016). Knowledge is constructed by the

student rather than transferred from the instructor (Altinay & Paraskevas, 2007; Giesbers et al.,

2014b). This process is not unguided discovery and knowledge construction; instead, it is the

facilitation of knowledge construction through carefully designed learning activities and

discussions (Ashcraft et al., 2008; Hsieh et al., 2016; Kala et al., 2010). Instructors provide

learners with the resources and support needed to help guide and manage their learning (Ashcraft

et al., 2008). Constructivists assert that learning is an active rather than a passive process (Hsieh

et al., 2016; Kala et al., 2010). Within the constructivist model, both personal and social

constructivism exist. Personal constructivism involves knowledge development through

cognitive activities that help individual learners create meaning from their experiences. Social

constructivism involves knowledge development through cognitive activities in a collaborative,

communicative environment (Ashcraft et al., 2008; Dixson, 2015; Kala et al., 2010). This study

utilized the social constructivist paradigm.

Social constructivist theories suggest that students learn through interaction in intellectual

communities (Bandura et al., 1961, 1963; see also Azhari et al., 2020; Lourenço, 2012; Dixson,

39

2015). This discourse or collaboration is the central mechanism for learning (Altinay &

Paraskevas, 2007; Azhari et al., 2020). Vygotsky, who is an essential figure in the development

and promotion of the theory of social constructivism, identified interaction as fundamental to a

learner’s ability to transform and reorganize prior learning into newer, more advanced concepts

(as cited by Shayer, 2003). Vygotsky held that a learner only develops as they participate in

social interaction using tools and signs (Lourenço, 2012). Vygotsky further argued that higher

cognitive functions are a result of relational events between persons and that learning develops

through complex dialectical processes (Lourenço, 2012). Social constructivism purports that

individuals create knowledge when they are actively engaged in communication or other human

interactions (Azhari et al., 2020; Hill et al., 2009). In the online environment, interactive

instruction and collaborative learning offer students the opportunity to collectively construct

knowledge and apply it to real-life situations (Hsieh et al., 2016; Kala et al., 2010).

Constructivist pedagogy complements the student-centered approach of OE (Bramer, 2020).

Student engagement involves active student participation and interaction in the

intellectual community (Dixson, 2015). This community may be a particular class session, a

course, a program of study, or a community of lifelong learners. In OE, social constructivism

requires students to interact meaningfully with others in the class, to learn content and skills, to

demonstrate that learning, and to value the acquired knowledge (Azhari et al., 2020; Dixson,

2015; Kala et al., 2010).

Engagement and interaction online may occur synchronously, asynchronously, or both.

Students work collaboratively to complete assignments and analyses, providing opportunities for

interaction, discussion, reflection, and knowledge creation (Ashcraft et al., 2008). Online

interaction is an active process (Hrastinski, 2009). Woo and Reeves (2007) note the essential

40

nature of interaction for all types of learning formats, including FTF classroom-based,

synchronous and asynchronous online models, and hybrid or blended courses. Increasing quality

interaction in online learning environments provides students with improved opportunities to

learn collaboratively and to be integrated into a learning community (Woo & Reeves, 2007).

Hrastinski (2008) notes that synchronous learning facilitates teacher-student

communication, helps students be more active participants in courses, and decreases feelings of

isolation that may occur in online environments. Anderson (2004) states that the lack of

synchronicity in online learning environments interferes with student interaction and removes

some opportunities for active learning. Increasing meaningful interaction in the online

environment increases students’ sense of community. Social constructivism holds that this

meaningful interaction or engagement is necessary for optimal learning (Ashcraft et al., 2008).

Social constructivism also holds that students must have time to reflect on instruction to

internalize the information and organize it into meaningful knowledge (Kala et al., 2010; Legg et

al., 2009). Asynchronous online instruction allows students time to reflect upon the content

before additional interaction with students and instructors. Asynchronous discussion forums

allow student time for thorough reflections and reorganization of prior learning (Allen &

Seaman, 2015). Synchronous and asynchronous online delivery both enable instructors to utilize

the social constructivist paradigm in creating online learning communities in which discussion

and social interaction can occur.

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Research Questions

This study posed three research questions to achieve its primary aims:

1. Is there a difference in pre-licensure baccalaureate nursing students’ HESI specialty

exam scores when content is delivered synchronously versus asynchronously in the

online educational environment?

2. Is there a difference in pre-licensure baccalaureate nursing students’ OSE scores

when content is delivered synchronously versus asynchronously in the online

educational environment?

3. Is there an association between pre-licensure baccalaureate nursing students’ HESI

specialty exam scores and OSE scores when content is delivered synchronously

versus asynchronously in the online educational environment?

Design

This study used a retrospective quasi-experimental two-group comparison design. The

treatment group met synchronously online with the instructor each week and participated

actively with classmates in the synchronous online forum. The comparison group completed the

same course activities but did so in an asynchronous online format via discussion boards. HESI

specialty exam scores and OSE scores concerning student engagement were compared between

the two groups.

Random assignment was not possible for the proposed study due to registration

constraints at the university. The study utilized a convenience sample of students who enrolled in

an online undergraduate pediatric nursing course. Students self-selected the synchronous or

asynchronous format during registration. The class schedule included the day and time of the

42

synchronous online class. Student data from both the treatment (synchronous) and comparison

(asynchronous) groups were collected and statistically analyzed.

Sample

The study used a convenience sample of students admitted in cohorts of 70 and 65

students to a baccalaureate nursing program. Data were collected for students who met inclusion

criteria during the spring semesters of 2016 and 2017 when these students were enrolled in an

online pediatric nursing course. Each cohort was divided into synchronous and asynchronous

sections.

Three initially admitted students withdrew or were dismissed from the program before

this course began: this fell within the expected attrition rate of fewer than five students. Thus,

none of those cases had test or scale scores, and so had no data to contribute. The demographic

data for the Cases of Attrition are available in Table A1. One student joined the first cohort as a

result of readmission following withdrawal. She repeated the course in an independent study

format, which did not require the pretest or HESI specialty exam. The demographic data for this

Excluded Case are also available in Table A1.

Inclusion and Exclusion Criteria

Inclusion criteria required the following:

• The student was enrolled in an online undergraduate pediatric nursing course

during the spring semester of 2016 or 2017.

• The student was enrolled in the course for the first time.

• The student completed the course. (A grade for the overall course served as

evidence of course completion.)

• The student completed the pretest and the course-associated HESI specialty exam.

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OSE scores from all students meeting inclusion criteria were analyzed. Three missing

OSE scores were treated as missing data and were excluded analysis by analysis. All enrolled

students (133) completed the course, receiving letter grades between A and D. There were no

letter grades of F, W, or X among participants. (An X grade is evidence that a student stopped

attending a course without official withdrawal. A W grade is evidence of official withdrawal

from the course.) Of the 133 students enrolled in the online pediatric nursing course, 132 met the

criteria for inclusion in the study. One student’s data was excluded since the student was

repeating the course.

Setting

The setting for this study was a Carnegie-classified doctoral research and teaching

institution located in the Intermountain West. This public university has a student enrollment of

approximately 15,000 students. The university’s School of Nursing offers Baccalaureate,

Master’s, and Doctoral degree programs. The Commission on Collegiate Nursing Education

(CCNE) accredits the School’s undergraduate nursing program (School of Nursing, 2020). The

School of Nursing admits 100-130 undergraduate students each academic year and offers

traditional and accelerated undergraduate programs. This study was conducted with participants

from the traditional undergraduate program. The target population for this study is baccalaureate

nursing students in rural areas of the United States.

Variables and Instrumentation

Independent variables

The first independent variable in this study was group membership in the treatment or

comparison groups for the online education delivery format. All students participated in the

course via a Learning Management System (LMS); course requirements, including course

44

assignments and content, were the same for both the treatment and comparison groups. The same

instructor taught students in both groups during the same semester.

The treatment group met synchronously with the instructor for 90 min once weekly for

the first 15 weeks of the 16-week semester. Students joined a synchronous, interactive class

period via Blackboard Collaborate. Students received instruction and participated in active group

learning activities, such as creating teaching plans, care plans, discussing and evaluating current

research, completing or writing case studies, and other collaborative learning activities.

The comparison group completed all course requirements asynchronously on the same

weekly schedule as the treatment group. Asynchronous students received instruction via

asynchronous webcast, completed the same weekly assignments as the treatment group, and

participated in the completion of the collaborative group learning activities via discussion

boards. Virtual and in-person office hours were available for students in both groups who

wished to contact the instructor with questions or concerns.

The demographic variables included age (by year), gender (two categories), ethnicity (six

categories), prior college degree (two categories), and permanent rural address by zip code (two

categories). These represented independent control variables had a difference in group

equivalency been identified upon analysis. The student researcher selected age, gender, ethnicity,

and prior college degree as grouping variables to assess for any influences on student learning.

The permanent address identified which data were specific to the target population.

Demographic data were also collected and evaluated for any significant pre-existing

difference between the two groups. Complete data, including pretest, test, and scales scores and

demographic data, were obtained after course completion.

Dependent Variables

45

The first dependent variable was domain-specific nursing knowledge, as measured by

student performance on the HESI specialty exam for pediatric nursing. The HESI specialty exam

is a proctored exam administered by a computer via a proprietary website. The HESI score

assessed student performance. The total number of points possible is approximately 1,500 but

slightly varies each semester because one-third of the exam questions are replaced (B. Stuber,

personal communication, January 26, 2016).

The HESI specialty exams are 55-item exams, which each focus on a specific area of

nursing education, e.g. Critical Care, Fundamentals, Pediatrics, and others (Zweighaft, 2013).

Five of the questions in each exam are pilot questions which do not affect the students’ scores.

Content validity for each specialty exam is supported by using current textbook content, and by

using masters and doctorally prepared expert nurses to write test items (Elsevier, 2016; 2018).

Validity is reassessed on an ongoing basis (Zweighaft, 2013).

Reliability for the HESI specialty exams is determined by conducting item analyses on

each exam and statistically calculating reliability (Elsevier, 2016; 2018). Zweighaft (2013)

reports that reliability for the HESI specialty exams is determined using the Kuder-Richardson

Formula 20 (KR20) for every exam returned to Elsevier for scoring (p. S11). KR20 assesses for

“internal consistency reliability of a test made up of dichotomous variables” (American

Psychological Association [APA], n.d., para 1); that is, the test items are correct or incorrect. The

KR20 is used when test items vary in difficulty, whereas KR21 is used when test items are

equally difficult (APA, n.d.). An estimated KR20 is calculated prior to the exam release. During

Zweighaft’s (2013) study period, the estimated KR20 ranged from 0.84 to 0.92. A value of 0.8 is

considered the minimum acceptable value, which indicates that a test is reliable (El-Uri & Malas,

2013).

46

The HESI exit exam is highly predictive of student success on the National Council

Licensure Examination for Registered Nurses (NCLEX-RN), the licensing exam for RNs

(Elsevier, 2018; Zweighaft, 2013). Zweighaft (2013) states that the HESI specialty exams are

associated with significantly higher exit exam scores t(3655) = 12.42, p ≤ .0001 (p. S13),

suggesting that specialty exams successfully evaluate student acquisition of domain-specific

nursing knowledge.

The second dependent variable was student engagement, as measured by the 19-item

OSE, which has been shown to correlate with student learning behaviors in online courses (See

Appendix B). The OSE uses a 5-point Likert scale on which students rate how well different

behaviors, thoughts, or feelings are characteristic of the student or the student’s behavior. The

instrument is scored by totaling and averaging the Likert scores to obtain a total engagement

score (M. Dixson, personal communication, February 18, 2016).

The OSE was created by

1. reviewing existing measures of student engagement;

2. conducting a focus group to discuss how those measures would need to be changed

for the online environment;

3. creating a pilot of that initial instrument; and

4. performing a test of the instrument. (Dixson, 2015, pp. 4-5)

During development and testing, the OSE demonstrated face, expert jury, and concurrent

validity, along with reliability in the online environment (Cronbach’s alpha = .95; Dixson, 2015).

Engagement measures were compared against observable student behaviors to determine

external validity. The OSE correlated with application learning behaviors by students in the

online course (Dixson, 2015).

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The OSE has three primary functions: (1) to aid research into online course design, (2) to

provide feedback to instructors about the level of engagement of their students given the

course design choices made, and (3) to provide evidence of teaching effectiveness for

merit arguments, teaching awards, and promotion and/or tenure cases. (Dixson, 2015, p.

10)

Baseline knowledge assessment

Students may enter nursing courses with differences in baseline knowledge; for this

reason, a pretest was planned. The pretest allowed for the evaluation of any pre-existing variance

in content knowledge between the two student groups. The pretest consisted of 48 questions that

were taken from the fall semester 2015 final exam, in which they demonstrated reliability

(Cronbach’s alpha = .7). Students received participation credit for completing the pretest,

regardless of their score, as students do not enter a course with full knowledge of the course

content. The pretest proctor reported student participation.

Ethical Considerations

The study involved research about educational practices within an educational setting.

Therefore, it met the criteria for exempt status by the Institutional Review Board (IRB) of the

University of Nevada, Las Vegas (UNLV) as a minimal risk to human subjects was perceived,

and all human rights were maintained (See Appendix C). Confidentiality procedures were

implemented, including de-identification of data, reporting of aggregate data, and secure storage

of data. IRB approval was obtained before the collection of any data.

48

Study Procedures

Data Collection and Management

Student data from both the treatment (synchronous) and comparison (asynchronous)

groups were collected and analyzed statistically. All course data (pretest scores, HESI exam

scores, and OSE scores) were collected after final course grades posted to students’ transcripts.

Students completed the pretest on the first day of the semester, with scores recorded in the LMS.

The School of Nursing application system retained demographic data for each student. Course

participants took the HESI specialty exam in week 12 of a 16-week semester. Score reports for

each student were available in the proprietary system after the exam closed. Students completed

the OSE during week 15 of the 16-week semester. The OSE scores were recorded in the course

LMS. Demographic data were collected voluntarily from the students with their applications to

the School of Nursing. The School may use these demographic data for evaluation of educational

effectiveness, such as this study, and further program improvement.

The student researcher exported the electronic data from the LMS, the application system

reports, and the HESI exam faculty access system. LMS and application system data were

downloaded directly to Microsoft Excel for coding. The student researcher matched demographic

data to the course data for each student. Then the data were deidentified and coded before being

analyzed statistically. The categorical variable coding used If-Then formulas, and the student

researcher double-checked coding accuracy. HESI scores were entered manually into Excel from

the score report. These were verified for accuracy by the student researcher on three separate

occasions.

Each participant was assigned a randomly generated number between 100 and 350; the

first student alphabetically did not receive the number 100. The student researcher then removed

49

names from the data file. A copy of names and corresponding participant numbers was held in an

encrypted file on a locked computer until study completion. Data destruction will occur upon

completion of the study.

Recorded permanent addresses, including street address and zip code, were evaluated for

rural classification using the “List of Rural Counties and Designated Eligible Census Tracts in

Metropolitan Counties” by the Office of Rural Health Policy (2018). After coding and verifying

each zip code as rural or not rural, the student researcher removed the full addresses and zip

codes from the data file.

After data coding for group sections, gender, ethnicity, and prior degree, the student

researcher removed identifying data from the data file. Then the data were sorted by participant

number, thereby rearranging the previous alphabetical order. Missing data ranged from 2% to

5%.

Data Analysis

IBM SPSS Statistics Subscription was used for statistical analysis, with an alpha level of

0.05. Pretest scores from the two groups were compared using independent t-tests to identify any

inherent differences in the student groups’ pre-existing knowledge of the nursing specialty area

at the beginning of the course. Student age was evaluated using an independent t-test. Other

student demographic data, including gender, ethnicity, the presence or absence of a prior college

degree, and permanent rural address, were evaluated using Chi-square tests.

The independent t-test evaluates differences between groups (Field, 2013). Pretest scores

were expected to be similar between the two groups and to follow a normal distribution since

students in the course completed similar pre-requisite requirements and the same preceding

nursing coursework. Student age was expected to follow the normal distribution for

50

undergraduate college students. Additional statistical control would have been warranted if either

of these data sets fell outside of a normal distribution (D. Feng, personal communication,

February 17, 2016).

Chi-square tests compare categorical variables, such as gender, ethnicity, the presence or

absence of a prior college degree, or permanent rural address (Field, 2013). These categorical

variables were independent of one another. The chi-square statistic compares the observed

counts in categorical variables with the expected counts (Field, 2013).

Statistical analysis of HESI scores and OSE scores for the two groups were evaluated

using independent t-tests. Pearson’s correlation was utilized to analyze any interaction effects

between HESI scores and OSE scores.

Study Limitations

One limitation of the current study was the potential bias resulting from the use of a

convenience sample. Data were collected at a single institution in the Intermountain West region

of the United States, resulting in a small sample size of 132 students, and insufficient power for

the study. A priori analysis indicated that nearly 800 students would be necessary to produce

sufficient power to identify a small effect size in the current study. Post hoc power analysis is

presented in the next chapter. Another source of potential bias was the self-reporting of

demographic data.

Chapter Summary

This chapter presented the methodological process undertaken for this study, included

both the theoretical framework and research questions. The study design, measures, sample and

setting, ethical considerations, variables, and data collection procedures were described. The

51

chapter concludes with a discussion of instrumentation, reliability, statistical analyses, and

limitations for this study.

52

CHAPTER 4: FINDINGS

Chapter Four presents the analysis of data and the findings of the current study, which

achieved all three study aims by answering this study’s research questions. A demographic

description of the sample, including the categorical variables gender, prior college degree,

permanent rural address, and ethnicity is presented. Missing data and assumption testing,

including normality and homogeneity of variance are addressed. Pre-intervention group

comparisons are described with the corresponding statistical analyses. Further data analyses

concerning each research question are presented along with instrument reliability.

The student researcher conducted statistical analyses using IBM SPSS Subscription for

Windows, using an alpha level of 0.05. Statistical analyses included descriptive statistics and use

of the following statistical tests: Chi-square, t-test with bootstrapping, Pearson’s correlation,

Cohen’s d, and Cronbach’s alpha. The post hoc power analysis used G*Power, version 3.1, for

calculation (Faul et al., 2007).

Demographic Characteristics of the Sample

The demographic characteristics of the sample are presented in Table 1. Age distribution

ranged from 20 to 49 years, with a mean age of 25.21 (±5.76) years, BCa CI [24.30, 26.20] (bias

corrected and accelerated confidence interval). The median age was 23 years, and the mode was

21 years. The majority ethnic group was Caucasian (83%), and most of the sample identified as

female (82%). (The application did not allow students to select a trans or non-binary gender or

allow for a multi-select option for race or ethnicity.) Twenty-eight participants of the 132

completed a previous college degree (any level) before applying to the School of Nursing.

53

Table 1

Demographic Characteristics of the Sample

Characteristic Entire Sample

Synchronous Group

Asynchronous Group

Statistics/ Significance between groups

Age (years) (N = 125) (n = 66) (n = 59) Mean (SD) 25.21 (5.76) 24.42 (5.19) 26.08 (6.26) t(123) = −1.621, p = .108 Median (IQR) 23.00 (7) 22.00 (7) 24.00 (5) Gender (N = 132) (n=67) (n=65) χ2 (1) = 0.136, p = .822 Female 108 (81.8%) 54 (80.5%) 54 (83.1%) Male 24 (18.2%) 13 (19.4%) 11 (16.9%) Race & Ethnicity (N = 132) (n = 65) (n = 64) χ2 (1) = 2.022, p = .224 African American 2 (1.5%) 2 (3.1%) 0 (0%) Asian/Pacific Islander 7 (5.3%) 4 (6.2%) 3 (4.7%)

Caucasian 109 (82.6%) 52 (80.0%) 57 (89.1%) Hispanic 9 (6.8%) 5 (7.7%) 4 (6.3%) Other 2 (1.5%) 2 (3.1%) 0 (0%) Not Reported 3 (2.3%) 2 (3.1%) 1 Prior College Degree (N = 132) (n=67) (n=65) χ2 (1) = 3.218, p = .090 Yes 28 (21.2%) 10 (14.9%) 18 (27.7%) No 104 (78.8%) 57 (85.1%) 47 (72.3%) Permanent Rural Address (N = 132) (n=67) (n=65) χ2 (1) = .237, p = .695

Yes 35 (26.5%) 19 (28.4%) 16 (24.6%) No 97 (73.5%) 48 (71.6%) 49 (75.4%)

Twenty-seven percent of participants identified a permanent rural address. An

acknowledged problem with this data set was that many students listed a student housing address

as their permanent address. Since students are not allowed to reside permanently in university

housing, the percentage of students having a permanent rural address (27%) is likely under-

reported.

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The two groups were not significantly different in terms of age, gender, ethnicity, prior

college degree, or permanent rural address. Participants in the Synchronous (treatment) group

were younger (M = 24.42, ±5.2) than participants in the Asynchronous group (M = 26.08, ±6.3).

This difference, −1.661, 95% BCa CI [−3.818, .519], was not significant t(123) = −1.621, p =

.108 and indicates that both groups were of similar ages, d = −.265.

Data Analysis

Statistical analyses used an alpha level of 0.05. Missing data ranged from 2% to 5% and

was excluded analysis by analysis. Before analysis, data were screened for outliers using the

extreme values for each data set, histograms, and boxplots. Data were also tested against relevant

assumptions. Assumption testing revealed that the pretest, HESI specialty exam scores, and OSE

scores met all requisite assumptions, including normality (all skewness and kurtosis values were

<|2|) and homogeneity of variance (all p-values were > .05 for Levene’s Test) for each set of

scores. Age statistics were skewed towards younger ages, as expected, given the young adult age

of traditional college students and the small sample size. For this reason, 5,000 bootstrapped

samples were used when analyzing the age data between groups. Post hoc power analyses using

G*Power version 3.1 are presented in Appendix B.

Pre-Intervention Group Comparison

In addition to demographic data, a proctored pretest evaluated for any pre-existing

variance in baseline knowledge of the nursing specialty area between the two student groups.

Pretest scores for the two groups were evaluated using independent t-tests with bootstrapping.

Bootstrapping strengthens statistical analyses by estimating the properties of the sampling

distribution from the sample data (Field, 2013). Bootstrapped data in this analysis used 1,000

bootstrap samples. Analyses used the bias corrected and accelerated (BCa) confidence interval to

55

improve accuracy. On average, participants in the Synchronous group scored lower (M = 53.68,

±8.3) on the pretest that participants in the Asynchronous group (M = 54.56, ±7.8). This

difference, −.882, 95% BCa CI [−3.536, 1.985], was not significant (p = .531) and suggests that

both groups had similar baseline knowledge of the content area at the start of the course, d =

−.113. However, similar is not the same as equivalent. These findings were expected since

students in the course completed similar pre-requisite requirements and the same preceding

nursing coursework. As presented in Figure 1, pretest scores followed a normal distribution.

The pretest questions demonstrated reliability in the fall semester 2015 final exam (Cronbach’s

alpha = .7). However, when used as the pretest, reliability was lower (Cronbach’s alpha = .6).

Figure 1

Population Pyramid Showing Distribution of Pretest Scores by Group

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The ethnicity category reported low numbers in the African-American, Asian/Pacific

Islander, Hispanic, and Other subcategories. The Chi-square test examined the expected

frequency. The minimum expected frequency was .99, suggesting that the Chi-square test was

not appropriate for this categorical variable (See Table 2). Thus, the data were collapsed into

Caucasian and Non-Caucasian categories (see Table 3). The resultant Chi-square test showed

that there was no significant association between type of course delivery and ethnicities reported

by the students χ2 (1) = 2.022, p = .224.

Table 2

Expected Counts for Ethnicity Variable, Uncollapsed and Collapsed Data

Variable Synchronous group

(n=67) Expected count

Asynchronous group (n=65)

Expected count Total

Ethnicity African American 1 1 2 (Uncollapsed) Asian/Pacific Islander 3.5 3.5 7 Caucasian 54.9 54.1 109 Hispanic 4.5 4.5 9 Other 1 1 2 Total 65 64 129 Ethnicity Non-Caucasian 10.1 9.9 20.0 (Collapsed) Caucasian 54.9 54.1 109.0 Total 65 64 129

Table 3

Contingency table for Ethnicity, Collapsed Data

Variable Synchronous group (n=67)

Asynchronous group (n=65) Total

Ethnicity Caucasian, Non- Hispanic 52 57 109

Other 13 7 20 Total 65 64 129

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Research Question One

The first research question sought to determine if there was a difference in the HESI

specialty exam scores of pre-licensure nursing students when content was delivered

synchronously versus asynchronously in the online environment. No significant difference in

HESI scores between groups was found. Students in the Synchronous group scored higher (M =

836.46, ±142.99) on the HESI specialty exam than students in the Asynchronous group (M =

827.58, ±151.99). This difference, 8.878, BCa 95% CI [−43.494, 60.828], was not significant

t(130) = .346, p = .730, and suggests that both groups performed similarly on the HESI specialty

exam for the course, d = .058. Similar scores do not necessarily indicate that scores are

equivalent. There is the possibility that a Type II error exists due to the small effect size and

insufficient power (see Appendix D, Table D1). Statistical analysis of HESI scores for the two

groups was evaluated using independent t-tests with bootstrapping (1,000 samples). HESI scores

followed a normal distribution, as shown in Figure 2. Reliability statistics for the HESI specialty

exams were lower than expected for these cohorts (KR20 = .60 for the Spring 2016 exam,

combined groups; KR20 = .58 for the Spring 2017 exam, combined groups; personal

communication, RN Specialty Exam Summary Report, Sessions 311175 & 355895, April 2,

2018).

58

Figure 2

Population Pyramid Showing Distribution of HESI Specialty Exam Scores of Both Groups

Research Question Two

The second research question sought to determine if there was a difference in the OSE

scores of pre-licensure nursing students when content was delivered synchronously versus

asynchronously in the online environment. No significant difference in OSE scores between

groups was found. Students in the Synchronous group scored their online engagement in the

course via the OSE scale lower (M = 3.927, ±.40) than did students in the Asynchronous group

(M = 3.984, ±.38). This difference, −.057, BCa 95% CI [−.176, .064], was not significant t(127)

= −.818, p = .415 and suggests that both groups identified their engagement in the course

similarly, d = .149. As with research question one, similar scores do not necessarily indicate that

scores are indeed equivalent. There is the possibility that a Type II error exists due to the small

effect size and insufficient power (see Appendix D, Table D1). Statistical analysis of OSE scores

59

for the two groups was evaluated using independent t-tests with bootstrapping (1,000 samples).

OSE scores followed a normal distribution, as shown in Figure 3. The 19-item OSE

demonstrated reliability in this study (Cronbach’s alpha = .82). Table 4 reports means and

standard deviations for both HESI specialty exam scores and OSE scores.

Figure 3

Population Pyramid Showing Distribution of OSE Scores of Both Groups

Table 4

Means and Standard Deviations of HESI and OSE scores with 1000 Bootstrap Samples

Scale Combined group Synchronous group Asynchronous group p HESI specialty exam (N=132) (n=67) (n=65) 832.09 (146.99) 836.46 (142.99) 827.58 (151.99) ns OSE scale (N=129) (n=66) (n=63) 3.96 (.39) 3.93 (.40) 3.98 (.38) ns

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Research Question Three

The third research question looked for an association between pre-licensure baccalaureate

nursing students’ HESI specialty exam scores and OSE scores when the content was delivered

synchronously versus asynchronously in the online educational environment. Pearson’s

correlation analyzed any interaction effects between HESI scores and OSE scores for each group.

A small correlation was found between HESI scores and OSE scores, which may account for a

small effect of one score upon the other, as represented in Table 5. Neither correlation was

significant as all ps > .05 (See Table 5). The difference in correlation between the two groups,

.096, is also not significant, z = .549, p = .58.

Table 5

Correlation between HESI Specialty Exam Scores and OSE Scores by Group

Group r p BCa 95% CI Lower Upper

Synchronous group .218 .078 -.001 .426 Asynchronous group .122 .342 -.126 .367

Note. Bias corrected and accelerated confidence interval

Chapter Summary

This chapter presented the data analysis and findings of the current study. Sample

demographics, including age, gender, prior college degree, permanent rural address, and

ethnicity were presented. Pre-intervention group comparisons are reported with the

corresponding statistical analyses. Statistical analyses by research question were presented. The

HESI specialty exam scores and the OSE scores of the two groups were statistically analyzed

61

and shown. Instrument reliability is given. Correlation between the HESI and OSE scores is also

reported. The study achieved all three aims in answering the research questions.

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CHAPTER 5: DISCUSSION

This final chapter contains a summary and discussion of the study findings. The chapter

includes an examination of the demographic characteristic and the study findings, organized by

the research questions. Chapter Five also addresses the implications of this study for pre-

licensure nursing education and includes recommendations for future research. Study limitations

are submitted, and the dissertation concludes.

Summary of Study Findings

The purpose of this study was to determine if the method of OE delivery — synchronous

or asynchronous — affected selected learning indicators for pre-licensure nursing students.

These indicators included HESI specialty exam scores and student engagement scores

Demographic Characteristics

The statistical analyses suggest that the two groups had similar characteristics and

baseline knowledge at the outset of the online course. Each group performed similarly on the

pretest, and demographics of age, gender, and ethnicity were comparable for both the treatment

(synchronous) and control (asynchronous) groups. Both groups also had similar rates of students

with a prior college degree and students with permanent rural addresses.

Research Question One

The first research question sought to determine if there was a difference in the HESI

specialty exam scores of pre-licensure nursing students when content was delivered

synchronously versus asynchronously in the online environment. No significant difference was

found in HESI scores between groups.

The analyses imply that both groups scored comparably on the HESI specialty exam for

the course. While this suggests that the specific course delivery format did not significantly

63

influence student learning, it confirms that pre-licensure nursing students can learn essential

didactic information in an online course. Both study groups learned the content in online

environments, and students in both groups scored well on the HESI specialty exam. Study

findings cannot conclusively state that course delivery format does not influence student learning

due to the possibility of a Type II error related to insufficient statistical power (due to small

effect size and sample size; see Appendix D, Table D1).

The current study supports the findings of Bryan-Green (2015), Scarbrough (2015), and

Thrane (2020) that the online environment is conducive to acquiring domain-specific nursing

knowledge. Bryan-Green observed that online programs increase student access to nursing

education without the need for additional physical space. Students educated online were well-

prepared for entering the clinical environment, but further study in online learning for the pre-

licensure nursing student was indicated (Bryan-Green, 2015). Scarbrough found that

synchronous OE using videoconferencing afforded distance students a comparable educational

environment to on-campus learners, and that synchronous OE may offer improved student-

faculty interaction and support (Scarbrough, 2015). Scarbrough also identified a need for

continued research using synchronous technologies for pre-licensure nursing education at a

distance. Thrane found that students successfully learned content relating to palliative nursing

care in an online course. Asynchronous online discussions allowed nursing students to have time

for thoughtful reflection and to practice difficult conversations about challenging nursing roles at

the end of life (Thrane, 2020). Clearly, pre-licensure nursing students learn online in both

synchronous and asynchronous environments.

Of note, students taught in the online setting (combined synchronous and asynchronous

groups) scored higher (M = 832.06, ±146.99) on the HESI specialty exam than students taught in

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the FTF setting by the same instructor (M = 831.55, ±147.05) in subsequent semesters. This

difference, .539, BCa 95% CI [-30.041, 33.156] was not significant t(322) = .032, p = .974, and

therefore supports earlier studies finding that students in the online setting perform equally well

with students studying FTF, d = .004. McCutcheon et al. (2014) found that online learning was

“no less effective” than FTF education. Shachar and Neumann (2010) found that distance

education had comparable or improved outcomes compared with FTF instruction. Keefe and

Wharrad (2012) also found support for e-learning to enhance nursing education. Ajabshir (2019)

found that OE, either in synchronous or asynchronous format, was superior to FTF instruction.

Research Question Two

The second research question sought to determine if there was a difference in the OSE

scores of pre-licensure nursing students when content was delivered synchronously versus

asynchronously in the online environment. No significant difference in OSE scores was found

between the two groups.

The OSE analysis indicates that students in both groups were comparably engaged in the

online course. Again, the possibility of a Type II error exists due to insufficient statistical power

(related to small effect size and sample size; see Appendix D, Table D1). Therefore, this study

cannot conclusively state that the course delivery format does not influence student engagement.

The study does support the theory that engaged students succeed in online learning. Of the 132

students, 126 were identified as “highly engaged,” as evidenced by OSE scores above 3.4. It is

interesting that of the six students not identified as “highly engaged,” two left the School of

Nursing immediately after the semester in this study, and two commuted more than one hour

each way for other courses at the university during the same semester.

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These findings suggest that factors other than OE delivery format contributed to student

engagement, highlighting the importance of sound instructional design regardless of the planned

delivery method. Other factors known to affect student engagement in OE include effective

instructional design (Lawton et al., 2012; Song et al., 2003), varied teaching methods (Kalelioğlu

& Gülbahar, 2014), collaborative learning activities (Ajabshir, 2019; Ashcraft et al., 2008;

Hampton et al., 2017), and interaction between students, instructors, and peers (Banna et al.,

2015; Bernard et al., 2009; Bolliger & Halupa, 2018; Bond et al., 2020; Egorov et al., 2019;

Hampton et al., 2017; See Appendix E).

Revere and Kovach (2011) note that technology can promote learner-centered education

when integrated with course content in engaging activities. Technology alone does not equate

with learning (Silveira & Cogo, 2017); it is the professional educator that must connect the two.

Instructors spend time building online communities (Boling et al., 2012; Revere & Kovach,

2011) that are student-focused and interaction intensive. Fostering interaction, and therefore

engagement, helps students create knowledge and achieve desired learning outcomes (Banna et

al., 2015).

Other student characteristics may also be responsible for levels of engagement in online

courses. Peck et al. (2018) identify students’ self-regulation, motivation, and attitudes as

essential mediators of success in OE. They emphasize that no environment ensures learning;

students must maintain active involvement in their learning processes for education to occur.

Peck et al. also identify factors such as work and family responsibilities as impacting students’

availability to participate in educational opportunities actively.

Research Question Three

66

The third research question looked for an association between pre-licensure nursing

students’ HESI specialty exam scores and OSE scores when the content was delivered

synchronously versus asynchronously in the online environment. Pearson’s correlation analyzed

interaction effects between HESI scores and OSE scores. A small positive, but not statistically

significant, correlation was found between HESI scores and OSE scores, suggesting that one

score may influence the other to some extent.

This finding is supportive of other literature that shows that engaged students have better

learning outcomes in OE (Bond et al., 2020; Dixson, 2015; Dixson et al., 2017; O’Flaherty &

Laws, 2014; Martin & Bolliger, 2018). Had the sample been larger, the current study may have

found more conclusive support. Martin and Bolliger (2018) found that participants valued

strategies that provided student-instructor interaction. If engaged students are learning, it follows

logically that this learning would manifest in test scores. O’Flaherty and Laws (2014) found that

exam pass rates increased for learners who demonstrated engagement in virtual classes.

Implications for Nursing Education and Research

Recent research in OE addresses protocols for synchronous hybrid learning environments

(Butz & Stupnisky, 2017; Zydney et al., 2020). This blended instruction connects on-campus and

distance students, combining FTF instruction for both groups. Given the sudden transition to

fully online instruction experienced by many institutions of higher education in March 2020, the

current study is relevant; it identifies that FTF instruction can be conducted effectively online.

All students can be online, creating a single learning community, rather than the “mutually

exclusive” groups of learners identified by Butz and Stupnisky (2017, p. 120). Although it is not

hands-on, synchronous online instruction is face-to-face.

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The current study identifies the need for additional research with larger sample sizes to

further evaluate online course delivery to pre-licensure nursing students. Findings suggest the

need for further evaluation of specific interaction treatments in the OE environment to assess the

treatments’ impacts on learning outcomes and student engagement.

Online instruction increases access to higher education for students in rural and remote

areas, where geography or distance limit travel to institutions of higher education. This expanded

access benefits rural areas by offering educational equity, increasing the supply of RNs, and

improving the quality of health care available to rural or remote communities.

Limitations

Limitations of the current study include the potential for bias resulting from the use of a

convenience sample. Data were collected at a single institution, resulting in a small sample size

of 132 students, and insufficient power for the study.

There was the possibility of knowledge diffusion from the treatment group to the

comparison group as students in both groups interacted with each other in their other nursing

courses. Some students also studied the pediatrics course content together in self-selected groups,

which may have included students from the synchronous group, the asynchronous group, or from

both groups.

Summary and Conclusion

Nurses are essential for the provision of health care in the United States (AACN, 2019a).

Improved access to quality nursing education may help alleviate the shortage of nurses who work

in rural communities (Marlow & Mather, 2018) and, subsequently, enrich the quality of care

available to those communities. Studies concerning the quality of OE for pre-licensure nursing

students are mostly absent from the nursing education literature.

68

The current study’s findings may serve to guide future course design in pre-licensure

nursing programs, to facilitate effective, accessible, pre-licensure nursing education in

geographic areas that must rely upon OE to meet the demand for nursing education (Yang et al.,

2019). The study suggests that didactic content can be successfully delivered online to pre-

licensure nursing students. The current study also implies that online learning environments can

be engaging, whether delivered synchronously or asynchronously. Prior research in online

student engagement supports the nurse educator who must design engaging online courses. The

current study may also serve as preliminary work for fully online nursing instruction to be used

in times of pandemic or for learners in high-risk groups who risk exposure or illness by attending

a physical classroom.

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APPENDIX A

Table A1

Demographics of the Missing or Excluded Cases (n = 4)

Characteristic Missing/Excluded data (n = 4)

Age 20-24 1 25-29 0 30-34 1 35-39 0 ≥40 1 Not Reported 1 Total 4 Gender Female 2 Male 2 Total 4 Ethnicity Caucasian 4 Total 4 Prior College Yes 1 Degree No 3 Total 4 Rural Permanent Yes 1 Address* No 3 Total 4

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APPENDIX B

Online Student Engagement Scale (Dixson, 2013; used with permission)

Within that course, how well do the following behaviors, thoughts, and feelings describe you?

Please answer using the following scale:

1. not at all characteristic of me

2. not really characteristic of me

3. moderately characteristic of me

4. characteristic of me

5. very characteristic of me

1. Making sure to study on a regular basis

2. Putting forth effort

3. Staying up on the readings

4. Looking over class notes between getting online to make sure I understand the material

5. Being organized

6. Taking good notes over readings, PowerPoints, or video lectures

7. Listening/reading carefully

8. Finding ways to make the course material relevant to my life

9. Applying course material to my life

10. Finding ways to make the course interesting to me

11. Really desiring to learn the material

12. Having fun in online chats, discussions or via email with the instructor or other students

13. Participating actively in small-group discussion forums

14. Helping fellow students

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15. Getting a good grade

16. Doing well on the tests/quizzes

17. Engaging in conversations online (chat, discussions, email)

18. Posting in the discussion forum regularly

19. Getting to know other students in the class

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APPENDIX C

UNLV Biomedical IRB - Exempt Review Exempt Notice

DATE: May 9, 2018

TO: Mary Bondmass, PhD FROM: Office of Research Integrity - Human Subjects

PROTOCOL TITLE: [923730-1] The Effect of Synchronous versus Asynchronous Online

Course Delivery on HESI Scores and Student Engagement for Rural Pre-Licensure Nursing Students

ACTION: DETERMINATION OF EXEMPT STATUS

EXEMPT DATE: May 9, 2018

REVIEW CATEGORY: Exemption category # 4

Thank you for your submission of New Project materials for this protocol. This memorandum is notification that the protocol referenced above has been reviewed as indicated in Federal regulatory statutes 45CFR46.101(b) and deemed exempt.

We will retain a copy of this correspondence with our records.

PLEASE NOTE:

Upon final determination of exempt status, the research team is responsible for conducting the research as stated in the exempt application reviewed by the ORI - HS and/or the IRB which shall include using the most recently submitted Informed Consent/Assent Forms (Information Sheet) and recruitment materials.

If your project involves paying research participants, it is recommended to contact Carisa

73

Shaffer, ORI Program Coordinator at (702) 895-2794 to ensure compliance with the Policy for Incentives for Human Research Subjects.

Any changes to the application may cause this protocol to require a different level of IRB review. Should any changes need to be made, please submit a Modification Form. When the above-referenced protocol has been completed, please submit a Continuing Review/Progress Completion report to notify ORI - HS of its closure.

If you have questions, please contact the Office of Research Integrity - Human Subjects at IRB@unlv.edu or call 702-895-2794. Please include your protocol title and IRBNet ID in all correspondence.

Office of Research Integrity - Human Subjects 4505 Maryland Parkway . Box 451047 . Las Vegas, Nevada

89154-1047 (702) 895-2794 . FAX: (702) 895-0805 . IRB@unlv.edu

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APPENDIX D

Table D1

Power Analyses for Independent t-test and Pearson Correlation

Hypothesis Students in the synchronous group will have different HESI specialty exam scores than students in the asynchronous group.

Students in the synchronous group will have different OSE scores than students in the asynchronous group.

The relationship of HESI specialty exam scores to OSE scores will be similar within each group.

Students in both the synchronous and asynchronous groups will have similar pretest scores.

Independent Variable

Group membership: Synchronous or Asynchronous

Dependent Variable(s)

HESI specialty exam score

OSE score HESI specialty exam score OSE score

Pretest score

Statistic Test Independent t-test Independent t-test Pearson Correlation Independent t-test Post hoc Power Analysis

67 & 65 participants Power: 6.6% α = .05; d = .06

66 & 63 participants Power: 13.9% α = .05; d = .15

66 & 63 participants Power: 8.5% α = .05; d = .09

67 & 65 participants Power: 9.6% α = .05; d = −.11

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APPENDIX E

Instructional Design, Teaching, and Assessment Strategies to Support Student Engagement

Online

Instructional Design Strategies:

• LMS course organized in weekly format

• Each block included the weekly objectives, the assignments with due dates, and the links

for the recorded lectures.

• First class held face-to-face to review the syllabus, course schedule, expectations,

methods for contacting the instructor, and to complete the proctored pre-test.

• Formative adaptive assessments for each textbook chapter

• Recorded lectures in 20-minute segments

• Recorded lectures opened only after submission of the formative adaptive assessment for

the related content

• Course announcements no more than once weekly

• Weekly announcements included a recommended schedule for the week.

Teaching Strategies with Interaction:

(SC – Student-Content, SI – Student-Instructor, SS – Student-Student)

• Case studies:

o Individual completion (SC)

o Unfolding cases with group discussion (SS)

o Creation of cases for specific patient conditions (SI, SS)

• Links to outside resources

o Condition-specific organizations (SC)

76

o Federal and State Government resources (SC)

• Video clips with patient symptoms (SC)

o Pertussis cough

o Various seizure presentations

• Review of patient education handouts (SC)

• Student critique of publicly available informational videos for target audience, accuracy,

and key information (SC, SS)

• Discussion forums, Asynchronous Group:

o Students were required to post directly in the discussion forum rather than

attaching the content as a separate file

o 15-minute teaching plans (SC, SI)

o 5-minute care plans (SC, SI)

o Viewing a simulated nurse “shift report” followed by questions about each

student’s decision making (SC, SS, SI)

o Unfolding case studies (SC, SS)

o Evidence-Based Practice: Students read a current research article and posted two

items they learned. Emphasis was placed on student’s identifying items outside of

“textbook” answers and explaining why this learning was relevant to nursing (SC,

SI)

• Synchronous in-class discussions, Synchronous Group:

o 15-minute teaching plans (SC, SI)

o 5-minute care plans (SC, SI)

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o Receiving a simulated nurse “shift report” followed by discussion about each

student’s decision making (SC, SS, SI)

o Unfolding case studies (SC, SS)

• Discussion forums, Synchronous Group:

o Evidence-Based Practice: Students read a current research article and posted two

items they learned. Emphasis was placed on student’s identifying items outside of

“textbook” answers and explaining why this learning was relevant to nursing (SC,

SI)

Assessment Strategies:

• Formative

o Weekly adaptive assessments for each textbook chapter

o Instructor replies to discussion forum posts

o Synchronous discussion with peers and instructor for Synchronous online section

• Summative

o Course exams included varied question types: essays, multiple choice, short

answer, matching, and pediatric medication math

o HESI Specialty Exam for Pediatrics

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CURRICULUM VITAE

Susan Luke Belliston, MS, RN, CNE

Idaho State University School of Nursing 921 South 8th Ave., Stop 8101, Pocatello, ID 83209-8101 Phone: 208-282-3278 Email: bellsus2@isu.edu VISION: To achieve excellence in nursing through education, service, and leadership I. ACADEMIC AND PROFESSIONAL PREPARATION: A. EDUCATION University of Nevada, Las Vegas; Las Vegas, Nevada Doctor of Philosophy in Nursing: Nursing Education December 2020 Regis University, Denver, Colorado Graduate Academic Certificate in Health Care Education May 2010 Master of Science, Nursing: Leadership in Health Care Systems October 2009 Graduate Honors Bachelor of Science in Nursing May 2004 Summa cum Laude College of Southern Idaho, Twin Falls, Idaho Associate of Science in Nursing May 1999 B. LICENSURE AND CERTIFICATION

Registered Nurse, Idaho, License #28438, exp. 08/2021 Certified Nurse Educator (CNE), National League for Nursing, exp. 03/2021 Basic Life Support, Healthcare Provider, American Heart Association, exp. 07/2020 Neonatal Resuscitation Program (NRP), Provider, American Academy of Pediatrics, exp. 06/20 S.T.A.B.L.E. Program, Provider, exp. 02/2021

C. PROFESSIONAL EXPERIENCE Dates employed Position Employer and Location 2011 – present Staff Nurse Portneuf Medical Center; Pocatello, Idaho 2010 – present Clinical Assistant Professor Idaho State University; Pocatello, Idaho 2006 – 2010 Staff Nurse Dayton Children’s Medical Center (2 years as Process Dayton, Ohio Improvement Project Coordinator) 2008 Travelling Staff Nurse Cincinnati Children’s Hospital and Medical Center; Cincinnati, Ohio

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(Contracted through American Mobile Healthcare) 2000 – 2006 Staff Nurse Primary Children’s Medical Center (4 years as Charge Nurse) Salt Lake City, Utah (2 years as Unit Neurology/ Neurosurgery Resource Nurse) 1999 – 2000 Staff Nurse Cassia Regional Medical Center Burley, Idaho II. PROFESSIONAL AND COMMUNITY SERVICE A. AFFILIATIONS/MEMBERSHIPS 2008 – present Sigma Theta Tau, Member 2014 – 2016 National League for Nursing B. PROFESSIONAL ACTIVITIES 2014 – 2020 Sigma Theta Tau, Theta Upsilon Chapter; Program committee, Chapter Co-

President; Chapter President; Chapter Treasurer 2013 Reviewer: Lippincott Williams & Wilkins: Essentials of Pediatric Nursing, 3rd

edition; Laerdal Simulations: Pediatric; Essentials of Pediatric Nursing, 2nd edition

2010 – 2011 Rural Nursing Association, Membership Committee Chair 2008 – 2009 Ohio Children’s Hospital Association Collaborative for Surgical Site Infection

Prevention: Member 2008 – 2009 Surgical Antibiotic Prophylaxis Program manager 2008 – 2009 Quality Practice and Patient Safety Nursing Council: Mentor and Member 2008 – 2009 Joint Commission readiness monthly education C. COMMUNITY VOLUNTEER EXPERIENCE 2012 Teddy Bear Clinic, Pocatello, ID 2011 Brooklyn’s Playground Construction (Disability Accessible), Chubbuck, ID 2006 – 2010 Rehabilitation Center for Neurological Development, Piqua, OH June 2008 United Way, Columbus, Indiana, Flood Relief August 2007 United Way, Findlay and Ottawa, Ohio, Flood Relief 2002 – 2006 Primary Children’s Medical Center Foundation, Salt Lake City, UT D. UNIVERSITY 2018 – 2019 Undergraduate Curriculum Council: Chair 2018 – 2019 Ethical Guidance and Oversight Committee: Member 2017 – 2018 Undergraduate Curriculum Council: Vice Chair 2016 – 2019 Undergraduate Curriculum Council: Member E. SCHOOL OF NURSING 2013 – 2014 Curriculum Council: Member

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2012 – 2014 Faculty Development Council: Member 2012 – 2014 Baccalaureate Completion Program Coordinator 2010 – 2014 Admissions and Advancement Committee: Member 2010 – present Undergraduate Council: Member 2010 – present Faculty Council: Member F. CONTINUING EDUCATION TAUGHT 2006 Spina bifida 2005 Infant development III. HONORS AND AWARDS: 2016 Portneuf Medical Center, WIN Award 2009 Regis University, Graduate Honors 2008 – present Sigma Theta Tau International, Member 2004 Regis University, Summa cum Laude 2003 Regis University, Outstanding Nursing Student Award 2003 Primary Children’s Medical Center, Judy Blaufuss Scholarship Recipient IV. RESEARCH/SCHOLARSHIP ACTIVITY A. PEER-REVIEWED PRESENTATIONS Division of Health Sciences Research Day, Idaho State University March 2017 Pocatello, ID A Model for Nursing & Health Education in the 21st Century (Encore Presentation) Division of Health Sciences Research Day, Idaho State University April 2016 Pocatello, ID Co-author: Christy Sabel Specialty Certification in Nursing for Improved Patient Outcomes Division of Health Sciences Research Day, Idaho State University April 2016 Pocatello, ID Co-author: Christy Sabel Nurse Educator Specialty Certification Division of Health Sciences Research Day, Idaho State University March 2015 Pocatello, ID A Model for Nursing & Health Education in the 21st Century

Division of Health Sciences Research Day, Idaho State University March 2014

Pocatello, ID Student Proficiency: Documentation in the Era of Electronic Health Records