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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.38 no.2 Porto Alegre  2017  Epub July 13, 2017

http://dx.doi.org/10.1590/1983-1447.2017.02.66204 

Integrative Review

The contributions of digital technologies in the teaching of nursing skills: an integrative review

Maurício de Souza Silveiraa 

Ana Luísa Petersen Cogob 

a Escola de Saúde Pública do Rio Grande do Sul (ESP/RS), Programa de Residência Integrada em Saúde. Porto Alegre, Rio Grande do Sul, Brasil.

b Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil.

ABSTRACT

Objective

To analyze the contributions of digital educational technologies used in teaching nursing skills.

Method

Integrative literature review, search in five databases, from 2006 to 2015 combining the descriptors ‘education, nursing’, ‘educational technology’, ‘computer-assisted instruction’ or related terms in English.

Results

Sample of 30 articles grouped in the thematic categories ‘technology in the simulation with manikin’, ‘incentive to learning’ and ‘teaching of nursing skills’. It was identified different formats of digital educational technologies used in teaching Nursing skills such as videos, learning management system, applications, hypertext, games, virtual reality simulators.

Conclusions

These digital materials collaborated in the acquisition of theoretical references that subsidize the practices, enhancing the teaching and enable the use of active learning methods, breaking with the traditional teaching of demonstrating and repeating procedures.

Key words: Education, Nursing; Educational technology; Computer-assisted instruction

INTRODUCTION

Many educators and teaching institutions consider informatics resources as a possibility for teaching modernization, naming them “new technologies”1. However, it must be remembered that the mere use of technology is not a guarantee of a better learning experience. It is also necessary to develop pedagogical actions that allow for a critical connection to reality, built on autonomy and on the cooperation of students2.

Therefore, digital educational technologies (DET) are increasingly used in health courses, cooperating to the diversification and flexibility of activities, and allowing for a student to get access to content in real time and wherever they want, in addition to providing opportunities for the interaction among students outside of the physical space of the classroom3. These resources include videos, games and hypertexts, used in face-to-face activities or from a distance (e-learning), which can be broadcast on the internet, through DVDs, CD-ROMs, television or mobile phones (m-learning)4-6.

These multiple possibilities of technological resources targeted at undergraduate health students can be proposed and guided by many different educational paradigms, as evidenced in the systematic review published by the Pan American Health Organization7. The teaching strategies that use DET were positively evaluated by the students, and considered a resource that makes activities more dynamic, and replaces the repetition and the passivity of face-to-face classes. The results of this systematic review pointed out the necessity to conduct broader studies, evaluating the possibilities of incorporating new technological resources to teaching7.

Considering this, it can be noted that the DET are increasingly present in nursing teaching, be it inside the classrooms or in practice labs, introducing the concept of online simulations (e-simulation)1. A great number of technological innovations cooperate for the development of clinical nursing abilities, such as simulation, virtual learning environments and other digital didactic materials8. In the literature, there are reports that these technological resources dynamize teaching, and develop abilities and knowledges capable of mobilizing problem-solving actions2.

Nursing abilities can be conceptualized as activities that are peculiar to the exercise of the profession, related to the conduction of interventions whose objective is recovering and preserving human health. Among them are those related to daily activities such as corporal hygiene, sleep, rest, eating, hydrating and evacuating, as well as those related to therapeutic actions, such as the administration of medication, catheterizations, hand hygiene, vital signs checking, among others9.

The teaching of skills in the fields needs to be constantly improved, due to the complexity of the caring process, and should be based on evidences and integrate theoretical knowledge with practical actions. Curricular activities also cannot ignore the safety of the patients in the environment where they are offered care, nor that of the students during practice10. Therefore, the educational technologies are incorporated in Nursing teaching to collaborate in the development of the culture of safety for the patient8. If there is a chance for the student or the professional to simulate the execution of care in a virtual environment or in manikins, as many times as they need, it can help them to achieve and perfect their abilities.

Considering that the DET are increasingly present in the teaching of Nursing, and that there are many different materials that can be used with that purpose, the question became what are the benefits of using these technological resources to learn Nursing skills. The review of articles that analyzed these resources is relevant for the implementation of activities which can teach abilities that demonstrate to be effective in the teaching of Nursing, thus contributing to health education.

The objective of this study was to analyze the contributions of the use of digital educational technology in the teaching of Nursing skills.

METHODOLOGY

This is an integrative review of the literature that followed five steps: formulation of the problem, data collection, data evaluation, data analysis and interpretation, and results presentation11. In the formulation of the problem, the strategy PICO12 was adapted, and the following guiding question was presented: what are the contributions of the use of digital educational technologies in the teaching of Nursing skills.

Data collection was conducted in the following databases: Literatura Latino-Americana do Caribe em Ciências da Saúde (LILACS), MEDLINE/PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science (WOS).

The descriptors adopted for the research were extracted from the Bank of Descriptors of Health Sciences (DeCS) and the Medical Subject Headings (MeSH), and were: “Educação em Enfermagem/Education, Nursing”; “Tecnologia Educacional/Educational Technology” and “Instrução por Computador/Computer-Assisted Instruction”. The cross between the DeCS and the MeSH followed the protocol presented in Chart 1.

Chart 1 – Crossing the DeCS and the MeSH per Database. Porto Alegre, 2016 

Database Crossing
LILACS Educação em Enfermagem AND Instrução por Computador
Educação em Enfermagem AND Tecnologia Educacional
CINAHL Education, Nursing AND Computer-Assisted Instruction
Education, Nursing AND Educational Technology
MEDLINE/PubMed Education, Nursing AND Computer-Assisted Instruction
Education, Nursing AND Educational Technology
Scopus Education, Nursing AND Computer-Assisted Instruction
Education, Nursing AND Educational Technology
Web of Science Education, Nursing AND Computer-Assisted Instruction
Education, Nursing AND Educational Technology

Source: Authors.

Inclusion criteria included only articles obtained in researches with primary data which discussed the theme in the languages Portuguese, English and Spanish, fully available online, and published from 2006 to 2015. This period of bibliographic research was chosen considering the possibility of identifying digital resources that were still available for use. The exclusion criteria included abstracts from works published in the annals of events, dissertations, thesis or texts from government Institutions; studies with secondary data, such as reviews, reports or reflections were also excluded.

To evaluate the information, an instrument was chosen that contained the basic data of the articles selected, including title, year, year of publishing, objectives, methodology, results and conclusion. From the information provided by the data collection instrument, a synoptic table was elaborated to present the results, including the following aspects: contribution for the teaching of Nursing abilities, authors, type of DET and subject developed. It should also be highlighted that ethical aspects were observed in this revision article, quoting the authors and indicating the source in the paraphrases.

RESULTS

The cross between the DeCS and the MeSH identified a total of 6,917 articles in the databases, 164 in the LILACS, 926 in the CINAHL, 3,613 in the MEDLINE/PubMed, 20,098 in the Scopus and 116 in Web Science. 4,493 records were excluded for being duplicates, or for not refering to the theme of the study. The selected articles that fit the eligibility criteria were 76, and 46 articles that would not answer the guiding question were excluded. Therefore, 30 were selected for this integrative review (Figure 1).

Source: Authors.

Figure 1 – Diagram of the selection of articles for the integrative review. Porto Alegre, 2017 

From the 30 articles that composed the sample, 21 (70.0%) were in English and 9 (30.0%) in Portuguese. The periodical with the greatest number of publications is Nurse Education Today, with 9 (30.0%) articles. Regarding the year of publication, 2013 was the prevalent year, with a sample of 6 (20.0%) articles. Regarding the origin of the studies, it was noted that 11 (36.7%) were developed in Brazil.

After reading, analyzing and synthesizing the content of the articles, three thematic categories were identified, regarding the contributions of the use of DET in the teaching of Nursing abilities, which were: “Technology in the simulation with manikins”, “Stimulation to learning” and “The teaching of Nursing abilities”. Chart 1 presents the distribution of the articles analyzed according to the thematic category, the DET used and the subject discussed regarding teaching.

Chart 2 – Synoptic table of the articles included in the sample. Porto Alegre, 2017 (continue) 

Thematic category Authors Type of DET Subject
Manikin simulation technology Chen; Grierson; Norman, 2015(13) High fidelity simulator in manikins and low fidelity simulators in software. Evaluation skills
Johannesson; Silén; Kvist; Hult, 2013(14) Multimedia software Simulator Male vesical catheterization
Jung; Park; Lee; Jo; Lim; Park, 2012(15) Virtual reality with the haptics device Venous puncture
Jöud; Sandholm; Alseby; Petersson; Nilsson, 2010(16) Multimedia software Simulator Male vesical catheterization
Learning stimulus Góes; Fonseca; Camargo; Oliveira; Felipe, 2015(17) Educational software Vital signs
Mettiäinen; Luojus; Salminen; Koivula, 2014(18) Online course with texts and multimedia tools Drug administration
Sowan; Idhail, 2014(19) Online course with videos Drug administration
Bloomfield; Jones, 2013(20) Explanatory narratives, videos, photographs, online periodicals and quiz Nursing skills in general
Frota; Barros; Araújo; Caldini; Nascimento; Caetano, 2013(21) Virtual learning environment Venous puncture
Galvão, Püschel, 2012(22) Mobile-platform multimedia application Measurement of central venous pressure
Holland; Smith; McCrossan; Adamson; Watt; Penny, 2013(23) Video Drug administration
Lin, 2013(24) Videos and material sharing through technology Vesical catheterization
Cogo; Silveira; Pedro; Tanaka; Catalan, 2010(25) Virtual learning environment Vital signs
McMullan, Jones, Lea, 2011(26) Interactive online activities Drug calculation
Tanaka; Catalan; Zemiack; Pedro; Cogo; Silveira, 2010(27) Virtual learning environment Vital signs
Cogo; Pedro; Silveira; Silva; Alves; Catalan, 2007(28) Hypertext, educational games and simulations Nursing skills in general
Silva; Cogo, 2007(29) Hypertext with illustrative images and educational game Venous puncture
Tsai; Chai; Hsieh; Lin; Taur; Sung; Doong, 2008(30) Virtual reality simulator Fully implanted catheter injections
Teaching of nursing skills Góes; Fonseca; Camargo; Hara; Gobbi; Stabile, 2015(31) Virtual learning environment Vital signs
Sowan, 2014(32) Videos Drug administration
Lopes; Ferreira; Fernandes; Morita; Poveda; Souza, 2011(33) Educational software Male and female vesical catheterization
Teaching of nursing skills Cardoso; Moreli; Braga; Vasques; Santos; Carvalho, 2012(34) Video Punction and heparinization of a fully implanted catheter
Bloomfield; Roberts; While, 2010(35) Self-learning module in a computer Hand washing
Salyers, 2007(36) Educational software Nasopharyngeal aspiration and catheter insertion
Sung; Kwon; Ryu, 2008(37) Blended learning Drug administration
Woolley; Jarvis, 2007(38) DVD media and closed television circuit Nursing skills in general
Bloomfield; Cornish; Parry; Pegram; Moore, 2013(39) Multimodal course Nursing skills in general
Simonsen; Daehlin; Johansson; Farup, 2014(40) Online course Drug calculation
Cogo, Pedro; Silva; Schatkoski, Catalan, Alves, 2009(41) Hypertext, educational game, simulation Oxygen therapy
Kaveevivitchai, Chuengkriankrai, Luecha; Thanooruk; Panijpan; Ruenwongsa, 2009(42) Virtual learning environment Vital signs

Source: Authors.

DISCUSSION

The articles in this review show the contribution of different technologies for the teaching of Nursing skills. In face of the great amount of technologies, it was found that the terminology DET can refer to a high-fidelity simulation manikin13, a virtual environment simulator15, videos23, educational games29, mobile apps22, hypertext28, as well as complete courses with more than one agregate digital resource18. There is an expressive technological production in the health field, and Nurses are a part of the multiprofessional team responsible to develop these resources.

These digital materials were produced to be used in different contexts, such as face-to-face teaching29, online courses39 or specifically destined to mobile phones22. The classroom, in this context, transcends the face-to-face physical environment. Since most of these resources were generated for students and undergraduates, which are mostly young, their accessibility in mobile devices respects the characteristics of these connected users, who can access the education objects in the time and place required.

In the analysis of the articles, three thematic categories were found, and are here presented. The subject “Technology in the simulation with manikins”13-16 was characterized by studies that presented an integration of the use of software in the simulation settings, offering greater precision and realism. The practices that associate these two tools aided the students in their comprehension of the anatomy involved in the procedure, and made it easier for them to learn the necessary manual skills14. Likewise, the possibility of repeating the skill many times in simulators gives confidence to the student, and according to them, collaborates for the safety of the patient, diminishing their chance to cause any damage16.

An evaluation of the performance of learners have shown that, through the use of a peripheral venous puncture using manikin simulation, virtual reality, and the association of both resources, the association of these two technologies ensured a better performance15. In another study, that also combined the use of virtual simulation software with simulation manikins, the development of cognitive and motor skills had better results regarding the traditional methods of teaching abilities13. The association of different technological resources develops many different abilities, promoting a meaningful learning experience.

The thematic category “Learning stimulus” united the articles that related the incorporation of DET in active learning methods, allowing for the protagonism of the student17-30. The educational software for the teaching of nursing skills stimulates the independence of the students, contributing to the association of theory and practice, as well as recovering subjects, such as anatomy and physiology, that had been studied in previous semesters17.

The subjects that develop abilities have face-to-face classes but, by using a virtual learning environment (VLE), they promote a better utilization of the theoretical content, making the experience more dynamic inside the classroom and boosting the interest of the students in their own learning experience27. In a Brazilian study, that used VLE with problem-based learning about vital signs, the experience was mentioned by the participants as new and interesting, as it stimulated discussions and the curiosity of the students in seeking new alternatives25.

On the same line, hybrid teaching practices can be mentioned, that is, face-to-face activities associated to long-distance activities, that involve the theme drug administration20. In this study, videos, narratives, quizzes, and images presented in a virtual environment were evaluated, and were considered important by the students for the development of their clinical skills, also considering the practical laboratory activities20.

Similarly, the mobile apps and educational videos have been a supporting tool to practical skill classes. The DET can present the bases of the procedure, as well as the materials, and the step-by-step conduction of the Nursing technique22-23. The presence and use of multiple tools makes the learning process more attractive, allowing for the building of individual and collective learning experiences for the students21. The access to DETs outside of the classroom, as a complement to teaching, has been mentioned as a factor that contributes to the acquiring of skills, and has generated a greater satisfaction among the students23.

The flexibility of digital resources, which can be accessed whenever and however the students prefer, stimulates them to study independently, contributing to their autonomy in the learning process20. A digital object that allows for the students to study independently can be used to strengthen the theoretical and technical knowledge in graduation nursing courses18.

It is worth highlighting that, although the DET are versatile and impacting instruments, their mere presence does not guarantee an effective educational process27. That demands nursing teachers to identify the most adequate pedagogical referential for them to have a good DET support. Moreover, the challenge of the professors is in the proposal of DET activities that involve and motivate the students towards a learning process that integrates their experiences and previous knowledge20.

The third category was titled “The learning of Nursing abilities”31-42, and it presents the articles that demonstrate that the DET contributes to the acquisition of knowledge and the development of technical skills, without disregarding the importance of the moments of supervised clinical practice.

The teaching of Nursing skills traditionally resorts to expository classes and to the practical demonstration in a teaching lab. The role of the student in this setting is restricted to observing and then repeating the demonstration. Studies have proposed to incorporate the DET in teaching activities, diminishing the time taken in expository classes and repetitive subjects37. The creation of digital tools with the aim of supporting and strengthening the learning process was a useful resource, viable for the teaching of nursing skills, and quite different from the monotonous expository classes38. In this context, the students have access to the content, with a more detailed presentation, images with better resolutions, references to the theory that support the procedure, resources that integrate audio and video, exercises that problematize the theme, and that can challenge their curiosity, as they can digitally simulate the procedure before it is ever done face-to-face31-33, 36. The face-to-face classes are richer, with the teacher guiding the learning process, clarifying doubts and giving support to laboratory practices. The use of the DET as a tool to improve traditional methods is a valid option, capable of generating a change of attitude in students, focusing on learning.

The DET have been used to prepare for laboratory practices, diminishing anxiety and improving the performance in the moment of the execution of Nursing skills32. As a complement for the teaching of abilities, they aided in the theoretical review of the stages to be executed, collaborating with the self-learning of the Nursing student23.

The creation of a safe environment for practical activities offers students the option to repeatedly conduct the same procedure, allowing mistakes to be a tool for an improvement of their technique, increasing the safety of the students, and, in the future, not risking the health of patients31. Preparing a nursing student with proper knowledge and abilities is an essential part of a nurses training. To do so, it is necessary to develop safe practices, so that the needs of the patients are effectively answered39. Therefore, the DET can be considered a group of resources that promote meaningful learning and diminish the exposition of patients to health-care-related damage.

FINAL CONSIDERATIONS

In this integrative review, different types of DET were identified in the teaching of Nursing skills. These digital materials make teaching more dynamic and allow for the use of active learning methods, breaking the molds of a traditional teaching, which is focused on demonstrating and repeating procedures.

In the analysis of the articles, it was highlighted that educational technologies contribute to the teaching of nursing skills, improving the acquiring of the theoretical references that subsidize practice. It is important to prepare the students in simulated and virtual realities and to use manikins, so they only conduct the procedure on humans after having demonstrated ability and confidence. This method allows for the self-recognition of eventual mistakes before the procedures of care are applied to a real patient. Hybrid teaching modalities that integrate the DET and manikins in simulated environments are flexible methods that develop critical thought and prioritize the role of the students.

One of the limitations in the adoption of these resources is the high cost for the acquiring or development of the DET, which makes it so that many institutions have no access to them. The permanent education of professors and a strong institutional support can try to diminish that distance, guiding them when it comes to the development of more accessible digital materials, such as videos, for instance.

The recommendations for the teaching process are subsidized on the need of graduation Nursing courses to analyze the most adequate and effective resources to be used in their reality, associating the best possible technology to the most adequate teaching method. Similarly, researches in the area of educational informatics can get closer to nursing practices, developing proposals of high quality digital materials, and presenting a resource that is closer and more reliable for its environment.

As limitations of this study, it should be highlighted that no quasi-experimental studies were found that could allow for a more precise description of the evidences in the investigated theme. The lack of vocabulary standardization, both in the descriptors and in the abilities, also restricted the broadness of the searches.

Acknowledgment

The researchers thank for the CNPq financial support.

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Received: July 14, 2016; Accepted: April 11, 2017

Corresponding author: Ana Luísa Petersen Cogo. E-mail: analuisa@enf.ufrgs.br

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