Diabetic foot care course: a quasi-experimental study on E-learning versus interactive workshop

Abstract

Background

Nurses, as multidisciplinary Diabetic Foot Care (DFC) team members, need to be trained in DF prevention and management. Regarding the increasing use of e-learning educational courses as the new learning strategy with potential benefits among health care providers, this study attempted to evaluate the educational effects of an e-learning course on DFC compared to that of an interactive workshop in the related knowledge attainment.

Methods

This was a quasi-experimental study compared two non-randomized groups consisting of nurses who attended an e-learning course (intervention group) and a face-to-face interactive workshop (control group) on DFC using a pre- and post-test design. The eligible nurses enrolled by convenience sampling. All five e-modules on DF prevention and care were the same for both groups. A P value of <0.05 was considered as significant.

Results

The study findings indicated that both e-learning course and interactive workshop increased DFC knowledge among nurses. There is a significant difference between the learning level (after training) in the intervention and control groups (P < 0.01).

Conclusions

The findings suggest that the e-learning course of DF could be as effective as conventional educational methods. However, considering the time, cost savings and providing an opportunity to learn anytime and anywhere, of the e-learning course, it is recommend for the future and required that more health care providers be trained to use of distance learning.

Background

It has recently been estimated that 463 million adults have Diabetes Mellitus (DM) which can increase to 700 million by 2045 [1]. Clearly, the prevalence of diabetes complications will also increase. Diabetic Foot Ulcer (DFU), as one of the common complications of DM, imposes an excessive burden on the patient, the patient’s family, and society [2]. In fact, DFUs are considered a prevalent problem [3], which require a strategy consisting of patient and healthcare providers’ education, multidisciplinary DF care, and regular monitoring [4]. Thus, it is recommended that healthcare professionals take part in a periodic educational program to improve the DF care of diabetic patients [5]. However, evidence has shown that traditional educational programs have led to improvement in the desired knowledge and clinical practice of healthcare providers in DF care [6–8]. In addition, traditional learning has limitations including time-space constraints and costs [9]. It should be noted that various online training programs are currently being held for health science graduates and postgraduates more than ever before [10]. In fact, as an alternative to traditional education, digital education in health care professional development could be more flexible and accessible. E-content of the courses can be edited, updated, and adapted to the individual needs of healthcare professionals [11]. Moreover, evidence assessing the impact of e-learning has suggested having positive impact on learning outcomes [12]. A meta-analysis study performed with the aim of comparing an online and face-to-face course shows similar outcomes between traditional and online educational methods [13]. Thus, due to the fact that DF care education is multidimensional and, to the best of our knowledge the impact of online courses on DF education has not yet been measured, in this quasi experimental study, we evaluated the educational effects of a DF care e-learning course on nurses’ learning compared to an interactive workshop of the same content.

Methods

Objectives

The aim of this study was to evaluate the educational effects of a DF care e-learning course compared with an interactive workshop in the related knowledge attainment.

Design

The study was a quasi-experimental design to compare two non-randomized groups, using a pre- and post-test design. We chose this approach because of the lack of random allocation sequence. The two groups consisted of nurses who participated in an e-learning course (intervention group) and face-to-face interactive workshop (control group) on DF care.

Participants and sampling

This study was a joint project between School of Medicine of Iran University of Medical Sciences and Iranian Diabetes Academy of Endocrinology and Metabolism Research Institute affiliated to Tehran University of Medical Sciences, both located in Tehran, the capital of Iran.

The study population consisted of nurses working at the hospitals affiliated to the both universities and not participating in any DF courses before and during this study. A convenience sampling method was recruited. In this regard the call was for nurses who have experiences in diabetes and diabetic foot care in clinics and hospital; accordingly the first 80 eligible candidates who had been enrolled over the same period of time were selected as the study sample.

The first 40 registered nurses were assigned to the face-to-face interactive workshop and the second half were assigned to the e-learning course on DF care. Both groups were similar in terms of free enrollment in the DF course.

Interventions: Teaching interventions in intervention and control groups

• DF care e-learning course

The DF care e-learning course consisted of five e-modules, each containing self-directed e-learning components (Table 1). All the e-modules were prepared in Iranian Diabetes Academy (IDA) of Endocrinology and Metabolism Research Institute (EMRI) of Tehran University of Medical Sciences (TUMS) [14]. All lecturers of DF workshops contributed to the provision of scientific content and presentation for electronic e-modules. In all the mentioned e-modules, the user was initially introduced to the subject, instructor, objectives, introduction, and keywords of the e-module. The program started with one or more questions to grasp the learners’ attention followed by a voice-over PowerPoint lecture. Questions were also raised during the training program that would be answered after a short pause in the section following the program. The approximate time for each e-module was about 30 min. Resources used in e-module preparation and resources for further studies were listed at the end of each e-module. Summative evaluation was performed by a multiple-choice final exam given at the end of each e-module.

• DF care interactive workshop

Table 1.

Five e-modules presented for the interactive workshop and the course

e-modules (Learning materials of the e-modules are available at: http://ida.tums.ac.ir/)

1: Diabetic Foot Definition and Types of DF Ulcers

2: Diabetic Foot Assessment

3: Diabetic Foot Ulcer Assessment

4: Novel Dressing in Diabetic Foot

5: Principles of Diabetic Foot Management

The content of an interactive DF care workshop that was designed and hold for nurses [15] was used for the purposes of this study. The main topics discussed at the workshop were: DF definition and types of DF Ulcer, DF assessment, DF Ulcer assessment, DF novel dressing, and principles of DF management.

Each session of the workshop was presented by Diabetic Foot Group of EMRI (consisting of an endocrinologist, a nurse educator, a medical educator and a DF specialist) followed by a teamwork activity in which participants were divided into a small group with five members and actively discussed the issue to come up with an answer to the questions raised in case presentation, educational film demonstration, and a visual demonstration session. To sum up, all the topics discussed in the workshop were reviewed in the real time.

Outcome measurement

The learners’ knowledge of the DF course was assessed by a summative Multiple Choice Questions (MCQ) test (marked out of 20) which developed by the research team. It contains DF definition and types of DF Ulcers, DF assessment, principles of DF management, DF novel dressings, and DF Ulcer assessment.

The content validity was determined by calculating the content validity ratio (CVR) and content validity index (CVI) were calculated. The internal consistency and its test-retest reliability were measured by Cronbach alpha.

The validity and reliability of the questionnaire

In the first step of planning the DF workshop to improve technical and educational skills of nurses, an expert committee consisting of multidisciplinary team members (15 experts) participated in 5 group discussions to develop the main points of DF care. Accordingly, the main points necessary for discussion in the workshop [15] were as follows: DF definition and types of DF Ulcers, DF assessment, DF Ulcer assessment, DF Ulcer novel dressings, principles of DF Ulcer management, and finally, DF Ulcer novel treatment. Afterwards, to re-review the main points, four focus groups managed by a facilitator were conducted. Moreover, a literature review on relevant issues about DF care was conducted in order to merge into the main points. Finally, the initial questionnaire including 22 MCQ in the six areas was developed.

In the second step, validity and reliability of the questionnaire were assessed. Sixty nurses, who had not participated in the DF workshop before, filled the initial questionnaire. In order to calculate the CVR, the questionnaire was given to 10 members of the multidisciplinary team experts in DF care, and the responses were categorized on the basis of a three-point Likert scale,” necessary”, “helpful but not necessary”, and “not necessary”. The item score with above 0.62, would be appropriate and necessary (based on Lawsche Table) [16]. Regarding the scores of the items obtained comments and the experts’ point of views; two questions unable to measure the less relevant items to the DF care were excluded.

To distinguish between the means CVI and Waltz and Bausell’s CVI, the views of multidisciplinary team experts were received. The indices of “relevance”, “clarity”, and “simplicity” of the questions were examined according to the four-point Likert scale for each of the items; for example, for relevance (irrelevant (1), somewhat relevant (2), relevant (3) and entirely relevant (4)) [17]. Thus, for each item a separate CVI was measured and those items with a score of 0.75 and above were retained in the questionnaire [17].

Face validity of the questionnaire was determined by asking the viewpoints of the multidisciplinary team experts on DF care (10 experts in different related fields) to comment on reasonability, suitability, attractiveness, and the logical sequence of items. Moreover, 20 nurses were randomly selected from the target group who presented their views on fluency and understandability of the questionnaire items. The questionnaire was revised accordingly. Afterwards, in order to remove inappropriate items, the quantitative method of impact score was used. Thirty nurses were asked to give score to each question according to the five-point Likert scale consisted of:” very important” (5 points), “important” (4 points), “moderately important” (3 points), “slightly important” (2 points) and “not important” (1 point).

The score of each question was separately calculated and questions with more than 1.5 points were retained [16]. According to the scores, no question was eliminated. Then, the internal consistency of the questionnaire was assessed by Cronbach alpha and test-retest reliability.

Cronbach’s alpha was measured to assess questionnaire reliability. An alpha value greater than 0.8 (alpha ≥0.8) shows high internal consistency however, alpha greater than 0.70 indicates desired internal consistency [18]. So 50 nurses were asked to the answer the questions of final version of the questionnaire, and Cronbach’s alpha of 0.92 was calculated.

To check the stability of the instrument, the test–retest reliability was measured. The questionnaire was given to 40 nurses who filled the questionnaire twice with a two weeks’ interval. A normal distribution of the acquired scores was showed following by one-sample Kolmogorov–Smirnov test; therefore, the Pearson correlation coefficient between the two completed questionnaires was 0.94, which showed questionnaire stability.

Statistical methods

A correct answer was scored one point and an incorrect answer received zero. The Kolmogorov-Smirnov test was used for measuring the normality of the statistical sample. Additionally, using the paired t-test, the difference between the mean scores in the pre-test and post-test of the students in the two groups was examined. The Levin test was also used for homogeneity analysis of the variances between groups (intervention and control). A P value of <0.05 was considered as significant. The SPSS software version 16 was used to analysis.

Ethical consideration

The Ethics Committees of Iran (Ref No: IR.IUMS.REC.1396.32723) and Tehran University of Medical Sciences (Ref No: IR.TUMS.EMRI.REC.1397.053) approved the study. A written informed consent form was secured from all the participants to use their data anonymously. The information was confidentially managed by the researchers in accordance with the approved Ethics Committee protocol of COPE.

Results

A total of 73 nurses, including 33 nurses (45%) in the e-learning course (intervention) and 40 nurses (55%) in the workshop (control), participated in this study (Fig. 1). The socio-demographic data of the participants is shown in the Table 2. The mean age of participants in e-learning course and workshop groups is 37.49 and 37.04, respectively. The normal distribution of the data was confirmed by Kolmogorov–Smirnov tests (P = 0.212).

Fig. 1.

Allocation of the study participants

Table 2.

The socio-demographic data of the participants (n = 77)

Demographic Variables	Gender	Intervention group N (%)	Control group N (%)	Total N (%)
Gender	Male	10 (30)	14 (35)	24 (33)
	Female	23 (70)	26 (65)	49 (67)
	Total	33 (100)	40 (100)	73 (100)
Age	≤ 25	2 (6.06)	1 (2.5)	3 (4.1)
	25–35	9 (27.27)	12 (30)	21 (28.76)
	35–45	21 (63.63)	25 (62.5)	46 (63.01)
	≥45	1 (3.03)	2 (5)	3 (4.1)
	Total	33 (100)	40 (100)	73 (100)

As shown in Table 3, there is a statistically significant difference between the mean scores in the pre- and post-test in both intervention and control groups (p = 0.001). However, there was no significant difference between the two groups in the pre-test and both groups had almost the same mean score (p = 0.415).

Table 3.

Mean pre-test and post-test scores of the participant groups

	Variable	Groups	Mean	SD	T	P Value
Pre-Test	Acquired Score	Intervention	2.18	0.26333	3.76	0.211
		Control	2.15	0.51802
Post-Test	Acquired Score	Intervention	3.21	0.18776	5.12	0.001
		Control	4.30	0.39714

The results of the covariance analysis in Table 4 show that there is a significant difference between the learning level (after training) in the intervention and control groups (P < 0.01). Accordingly, 66% of the learning value (after education) was related to interactive workshop training. This value was also 42% for the e-learning course group indicating that 40% of the changes (in the mean scores on post-test) in the intervention group are related to the e-learning course education.

Table 4.

Results of analysis of covariance in intervention and control groups

	Mean Square	F	P Value	Effect size	Statistical power
Post-test (Intervention)	46.02	8.66	0.000	0.40	0.05
Post-test (Control)	79.46	20.83	0.001	0.66	–
Group	8.316	34.24	0.000	–	0.01

Discussion

The main finding of the current study was that both the e-learning course (intervention) and workshop (control) led to enhanced knowledge in DF care among nurses. However, face-to-face education in the interactive workshop resulted in slightly higher scores compared to those of the e-learning course. Similar to the present study, findings of Uding (2002), Wright (2008) and Moattari (2014) in their studies showed that diabetes knowledge increased after educational interventions [19–21]. However, the mentioned researches did not compare educational strategies. In addition, this research are consistent with the results of the meta-analysis performed by Cook (2008) on internet-based learning in health professions education confirmed that there was similar effectiveness between internet-based and traditional methods [13]. It should be mention that different educational topics including the diagnostic and therapeutic practice and other areas of patient care have included in Cook study while the current study considered DFC knowledge of participant.

Moreover, similar finding in a similar research suggested by Wright (2008) who compared nurses’ knowledge about diabetes and diabetes management after finishing lecture-based and computer-based diabetes interventions in which the education was conducted with PowerPoint slides. The findings of the study suggested that basic knowledge of diabetes increased in both lecture-based and computer-based groups. It is important to point out that one of the domains considered in this study was special needs of diabetics and diabetic foot care. Similar to the other diabetes-related areas [20], the knowledge of the topic, increased in both conventional and online educational groups. Participants in this study unlike the present study have evaluated by two post-tests (an immediate and a 3-week post-tests). Although minimal differences were found in the knowledge scores of the two groups (lower score in the online group), an e-learning educational program provides more flexibility, saves travel costs and time for patient care [22].

However the findings of Huang (2019) in a review which assess the digital health professions education on diabetes management in his review suggested that digital education could be more effective than traditional education in improving knowledge and skills of diabetes management [23]. It should be stated that all 12 included studies in Hoang review evaluated the diabetes knowledge and skill [23] while the current study focused on the DFC with more practical dimensions. Although, digital education is rapidly altering health professions education and is expected to be came more popular in the coming years.

In this regard, the notable advantages of using online training such as cost effectiveness and the chance of preparing different instructional strategies should be considered [24]. It is also worth mentioning that delivering e-learning courses compared to lecture based-courses are less costly for health professional training. Likewise, it is an appropriate method for self and flexible learning which is simply updated [25]. Meanwhile, it is undeniable that interactive educational programs such as a workshop for nurses as adult learners seem to be more effective, since active participation could enhance the retention of information [26].

Additionally, the result of the current study suggests that participation in the e-learning program was less than face-to-face education. Given the importance of DF education to all healthcare providers, especially nurses, the use of e-learning courses for Continuous Medical Education (CME) would be helpful to more people encourage to participate in e-learning courses likewise traditional ones and clearly more people could be trained [26].

Conclusions

Implementation of an e-learning course as well as conducting workshops is effective in DF education. Thus, educational courses such as CME in which e-modules are incorporated, would be a time and cost-effective method for education of health professionals. According to the study findings it is recommended that future studies create e-learning content on diabetes for diverse audience and to compare and contrast their effects with those of conventional methods.

Limitations of the study

The study limitations include convenience sample selection with no randomization, inability to assessing the mere knowledge of participants in DF care courses, and pre- and post-test effects on intervention and control groups.

Abbreviations

DM

Diabetes Mellitus

DF

Diabetic Foot

DFU

Diabetic Foot Ulcer

DFUM

Diabetic Foot Ulcer Management

EMRI

Endocrinology and Metabolism Research Institute

IUMS

Iran University of Medical Sciences

TUMS

Tehran University of Medical Sciences

Authors’ contributions

ZS, BL designed the study. MA, MS, MRA, NM, MRMR and HA hold the workshop and prepared e-modules as interventions of the current study. GR analyzed and interpreted the data related to the knowledge of nurses who participants in this study. MA and SB was a major contributor in writing the manuscript. All authors read and approved the final manuscript.

Funding

Iran University of Medical Sciences vice-chancellor for Research (grant number 1396-10-25-1251) and the Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences vice-chancellor for Research (grant number 1396-03-97-222) have financial support in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Data availability

All data generated or analysed during this study are included in this published article.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethics approval and consent to participants

The authors seriously considered ethical issues such as avoiding plagiarism, securing informed consent, avoiding misconduct and data fabrication and/or falsification, avoiding double publication and/or submission, and redundancy, etc.

Consent for publication

Not applicable.