Examining the Efficacy of Online Self-Paced Interactive Video-Recordings in Nursing Skill Competency Learning: Seeking Preliminary Evidence Through an Action Research

Abstract

A key challenge in nursing education is how to teach the students clinical competencies effectively and to provide opportunities for practicing the fundamental nursing skills safely. The purpose of this study was to examine the competency scores of practicing a clinical skill and the satisfaction level of nursing students on three instructional methods using an action research: the online self-paced interactive video learning, demonstration-only method, and a video demonstration in class. Participants were both male and female nursing students enrolled in the Foundations of Nursing Course (N = 26, 6 males and 20 females; mean age = 19.42 ± 0.50) and were evaluated at precycle, postcycle 1, and postcycle 2. Each cycle of inquiry was planned to address the problems quickly and efficiently through four steps: planning, acting, observing, and reflecting. A triangulation technique was employed for data collection using a competency skill evaluation checklist, a satisfaction questionnaire, and a focus group feedback questionnaire. A video was developed in the researcher’s college pertaining to the practical skills. Each research cycle was successively built up on one another using the reflections and feedback from the students based on the previous cycle. The competency skills at various cycles did not demonstrate significant differences between three instructional methods, whereas satisfaction score was the highest with the online self-paced interactive video demonstration. Online video learning use as a supplement in nursing instruction is well supported and offers a promising alternative in teaching clinical skill compared with other teaching strategies. However, more rigorous studies are required to get further empirical evidence in replacing the demonstration method, for teaching nursing practical skill and in improving students’ learning ability and competence.

Introduction

Traditional teaching methods in nursing curricula are rapidly undergoing changes as the nurse educators have many modern innovative technologies to assist students with the mastery of the subject content [1]. Teaching foundation courses in nursing, which emphasizes mostly on the mastery of clinical skills, poses a challenge to the nursing faculty as students are not yet exposed to the clinical area, and there is a growing interest to accommodate and adopt new strategies in teaching [1, 2]. Classroom management skills by the nurse educators require providing the learners with legitimate and evidence-based experiences to engage them with active and independent learning methods, to promote self-learning, and to transfer it to the clinical arena [3]. In order to achieve a better learning performance, the nurse educator should adopt methods that produce high level of student involvement in the appropriate learning activity and utilize the available instructional time efficiently [4, 5]. Activities to enhance various knowledge delivery systems in the classrooms through interactive learning methods, utilizes student participation to make the educational experience alive, active, and enjoyable by increasing their motivation, while ensuring minimal distraction, which will in turn help to create a better environment for them [1, 4, 6].

For any acquisition of skill, visibility is a key component to be successful, which is enhanced by the use of multimedia technologies in the mastery of clinical skills [7, 8]. The strategic integration of visual media provides the adult learner powerful opportunities to prepare for professional practice [9]. E-learning, which is facilitated and supported through the use of information and communication technology [10, 11], comprises of all forms of learning and teaching to implement the learning process through a networked or non-networked media for delivering instruction [12]. Alonso et al. [13] describes e-learning as “the use of new multimedia technologies and the internet to improve the quality of learning by facilitating the access to resources and services, as well as remote exchange and collaboration”. E-leaning can take the form of courses as well as modules and smaller learning objects [14] and can be used for a variety of learning purposes which includes add-on function in conventional classrooms [11]. It is used extensively by on-campus student to regulate their activities in classes, laboratories, and other academic assignments or projects [11]. Some studies report that e-learning can either supplement or complement other traditional teaching strategies [15, 16], whereas few other studies report a higher preference with a positive perception towards e-learning among learners [2, 17–19].

Blended learning has become an increasingly popular form of e-learning, and is particularly suitable for the process of transitioning from traditional forms of learning and teaching towards e-learning [20]. Picciano [21] described blended learning as a method of instruction that combines online with face-to-face learning activities that are integrated in a planned, pedagogically valuable method in which some of the face-to-face time is replaced by online activities. An example of such an approach that combines e-learning technology with traditional instructor-led training is the use of lecture or demonstration supplemented by an online material [22]. Evidence shows that an access to online video in e-learning can increase students’ motivation and boost their creativity and cooperation [23]. Cogo et al. in Brazil [24] developed digital learning objects in nursing and evaluated its usage with forty-four undergraduate students along with ten faculty members. The study demonstrated satisfaction with the design of the visual presentation and the appropriateness of the content of digital learning objects, among the faculty and students.

Nursing practice requires that there is synchronicity of application of knowledge and clinical skills which has to be demonstrated by the nursing students while they are being prepared for their professional nursing role [25]. Since nursing profession is a discipline based on practice, it is highly crucial to provide the students with various opportunities to develop their clinical skills. This will enable the students to develop nursing competencies to practice safely and effectively without the need for direct supervision and to demonstrate a level of performance to apply effectively their knowledge, skills, and clinical judgment [26, 27]. A demonstration technique was initially used to teach the fundamental nursing skills and was effective in providing the students with concrete, realistic learning experience [4, 28]. However, currently, one of the biggest challenges in nursing is teaching different practical skills in the context of increasing number of students, within a limited amount of time, along with the minimum availability of clinical skill laboratories, which can restrain the performance of the students [29]. This also necessitates that learning should be viewed as an ongoing process and not confined to the classroom or skill labs alone. Therefore, design and implementation of a best practice exemplar in congruence with educational theory, to fit a large number of students for their repeated practice—for developing their competency skills—is gaining importance today [29, 30].

Constructivists affirm that context-based learning through technology will be very effective for the enhancement of learners’ knowledge construction, transfer, and application [31]. Interactive video instruction has emerged as an efficient, cost-effective [2], and time saving educational method, and has helped the student learners to practice skills without the presence of an instructor [32]. This differs from the traditional method, since students will have more self-learning responsibility and need to assume an active role in their learning environment [33, 34]. It also has the advantage of providing a multi-sensory experience [35] with ease of operation [32, 35], enabling the students to listen to the narrations repeatedly [36], in comparison with the traditional method, as most of the students fail to grasp the essential content with a single demonstration. Previous authors have used video in undergraduate [37] and post graduate level of nursing [38] and have found that the addition of a short video to clinical skills input had significantly improved the performance [39]. Online video-based learning has been tried in teaching nursing subjects like anatomy and physiology [2], oral medication [40], and neonatal resuscitation skills [18] and had also found to enhance psychomotor skills in nursing students such as life-support skills [41].

Even though video-based teaching materials have been found to offer a promising alternative in the nursing instruction within the university classrooms, there is no clear evidence that such a move can improve students’ learning ability and competence [42]. However, the use of video-based education has demonstrated a positive impact on improving the students’ satisfaction and acceptance [2]. There is a need to explore whether a self-paced video is systematically and objectively better, than the traditional demonstration method, in learning clinical skills, and whether it helps the students to achieve the educational outcomes [43]. The purpose of this study was to assess the undergraduate nursing students’ practice skill performance (competencies) using an action research, based on three instructional methods and to determine whether the online self-paced interactive video learning of the skill is better compared with the demonstration-only method and video demonstration in class in learning clinical nursing skills in the classroom. This study also aimed to determine which of the three instructional methods could be more satisfying for the students and intended to evaluate the various methods of teaching further through a focus group feedback. Action research can be defined in the field of education as the process of studying a school, classroom, or teaching-learning situation with the purpose of understanding and improving the quality of actions or instructions [44]. “Action research methodology is a systematic research process that can be articulated by the researcher, involving data collection and analysis as well as reflection and discussion with co-researchers or others for the purpose of making a change in the situation over time” [45]. According to Argyris and Schön [46], an action research takes its cues from its questions, puzzles, and problems from the perceptions of practitioners within specific and local practice contexts. Description and theories are built within the context of practice itself and are tested through intervention experiments anticipating a desirable change in the situation. The process of action research consists of a cyclical nature of inquiry, which follows a predefined process consisting of four steps: plan, act, observe, and reflect [47]. The action researchers continue to observe, reflect, and plan in an ongoing process, and the steps are repeated continuously (one follows another, or in a cycle) and applied to any learning situation or problem for continuous improvement in classroom instruction [48, pp.18–19]. Or, in other words, “action research work involve changing aspects of your teaching systematically, using whatever on-the-ground evidence that you can obtain that enables you to judge if the changes are in the right direction” [49]. Action research does not end (as problem solving does) with a single planning and acting cycle but continues on a spiral action and reflection, with the second and subsequent cycles based on the reflection of the previous cycle(s) [48]. The key characteristics of action research are that it is practical, reflective, and recursive [48]. An action research was chosen for conducting the study because there was an identified problem in the practice environment of the nursing students in learning the competency skill, related to the current practice of teaching instruction, which used the traditional demonstration method. It was also chosen to explore students’ experience and satisfaction for making a potential change in practice through a self-reflective inquiry as it is identified in action research goal, ‘to involve and to improve’. The validity of action research depends upon its ability to offer a solution to a practical problem, in the researcher’s own working environment, as it was suggested by many researchers [50]. This is the first study conducted in Bahrain using an action research to examine the teaching strategies and competency skills of nursing students.

Materials and Methods

The study used an action research methodology with quantitative and qualitative data (triangulation technique) to explore various perspectives of nursing students. The study was conducted as part of a postgraduate certificate for academic practice program (PCAP) at the researcher’s institution. The study was approved by the ethical committee of the candidate’s institution in agreement that the authorization and the rights of the produced study materials (e.g., videos) for the research will be preserved as an institutional property. A written consent was also taken from those students who agreed to participate in the study.

The participants were late adolescent students in the age group of 19–22 years, enrolled in the fourth semester of the baccalaureate nursing program. All male and female students, enrolled in the foundation of nursing course in current semester and willing to participate in the study, were included. The participants were excluded, if they were not eligible to take the foundation courses and if they were not willing to participate in the study.

A probability, cluster random sampling method was used for the selection of the participants. In addition, a small number of participants (4–5 students) were selected randomly from the same group for the focus group feedback interviews for collecting the qualitative data information.

The study was conducted in three phases with a cyclical nature of inquiry (precycle, postcycle 1, postcycle 2). The data was collected from 20 February 2017 to 23 April 2017. The outcomes were measured at each cycle and at its end using a variety of techniques employed for the triangulation method in the following action research process: observation using the checklists, questionnaires, and focus group feedback interviews. The feedback from the interviews was used to plan and make modifications for the next cycle. As per the literature, a triangulation method of inquiry is mostly employed in action research and helps to increase the validity of the findings [48, 51]. It involves the process of collecting multiple types of data from different participants and sources, from different stages of the project, to increase the validity and confidence of the findings and the scope of the study findings [48]. Data triangulation involves seeking different information from various sources and from different participants at various stages of research [51, 52].

Power analysis was not performed in this study. The reason for not doing it is because power analysis is closely linked to hypothesis testing, and in action research, you are not trying to support or to disprove a hypothesis [44, 48, 53]. Action research, unlike traditional research, focuses on participants in researcher’s own setting, and a small sample size may be eligible or probably needed for the focus of investigation [53].

Development of the Intervention Tool

The intervention used, in addition to the demonstration method, during postcycle 1 and postcycle 2 was video recordings of a particular nursing skill. It was developed prior to the data collection procedure of the postcycle 1, according to the stipulated and standardized guidelines of a specific nursing procedure particularly with the performance evaluation checklist used for the nursing students. The demonstration of the video recording of the procedure was carried out in a simulated and real-life environment, in the clinical nursing skill lab. The researcher herself, with the help of other expert faculty, had demonstrated the procedure. The recordings were taken along with the narrations of the procedures’ steps and rationales. The recorded video was given for checking content validation to the subject experts in the field before it was used for the students.

Instruments for Data Collection

1. Competency skill evaluation checklist: This checklist was used to assess the competency of the nursing clinical practice skill observed during the action research cycle using numerous, elaborated items—pertaining to the skill. The item scores when summed up give the percentage of competency obtained for that particular skill. This checklist was developed, in consultation with subject experts’ of the faculty teaching the foundation of nursing course.

2. Satisfaction questionnaire: This questionnaire assessed the level of satisfaction of nursing students after the instruction was delivered to them. The questionnaire consisted of 14 items on a 5-point Likert scale (1 = strongly agree, 2 = disagree, 3 = agree, 4 = strongly agree, and 5 = not applicable) with an item on the type of instructional method used. The item score ranged from 14 to 70. In addition, it also included three items on the socio-demographic information of the candidates.

3. Focus-group interview-feedback questionnaire: This questionnaire was used to elicit a feedback on the method of teaching, to explore students’ views and experiences. This questionnaire included six descriptive items about the method of learning. The questions were “What did you like best about the method of learning?”, “What did you like least about this method of learning?”, “What are the strengths of this method of learning?”, “What are the weaknesses of this method of learning?”, “Compared to other ways of learning, was this method of learning useful? Why or why not?”. The students were also asked to share if they had any other comments with the method of teaching, which was utilized for the revision of the forthcoming cycle of action research.

Procedure—the Phases of Action Research Cycle and Data Collection

Prior to the data collection, the study procedure was explained in the classroom to the students by the first researcher, and an opportunity was given to them to ask any questions. All the questionnaires were coded prior to the distribution in the class or for the researcher’s use to keep the confidentiality of the study. Data was collected from the students enrolled in the researcher’s class at various time points with each cycle built up on the other, precycle, postcycle 1, and postcycle 2. The outcomes measured were the competency score of the skill performed, the level of satisfaction of the students with the specific method of instruction and the feedback on the methodology of instruction using focus group interviews.

During the precycle phase, the researcher demonstrated a particular nursing skill (Hand washing as a part of the isolation precaution) in the laboratory setting followed by the students practicing this skill under the faculty supervision. After the practice, all the students who have participated in the study were assessed using the competency skill checklist. The satisfaction questionnaire that was distributed to the students in the class was collected back by the researcher on the same day. A random number of 4–5 students were chosen by the researcher from the same group of participants to reflect on the teaching methodology and to give feedback, for planning and introducing the next cycle, once the competency and satisfaction assessment were completed. Their overall experience on the particular clinical teaching method and suggestions were taken into account to make revisions for the next cycle.

During the post cycle 1, the researcher demonstrated another nursing skill (surgical bed making) in the clinical laboratory setting, and then, a video of the same procedure was displayed in the skill lab. The students were allowed to practice the skill once in the nursing skill lab with the video. The assessment of competency, satisfaction, and method of instruction using students’ reflection and feedback were repeated, as it was done in precycle.

During the post cycle 2, the researcher introduced nasogastric tube feeding skill demonstration in the laboratory followed by a one-time practice of the students on the same procedure using the video. The students afterwards were given online access of the particular nursing skill for their self-learning and practice for the next three consecutive days to provide more flexibility and recapitulation of the content. Afterwards, the same assessments carried out in the other two phases of the cycle were repeated for the students.

The phases of the research with its details are given in Fig. 1.

Fig. 1.

Action research cycles with the various methods of teaching the clinical skill

For the ethical fairness of the research procedure and to ensure and promote the equality of the learning opportunity, the developed online video was made available for the remaining groups of students (who did not participate in the study) who were enrolled in other classes for the foundation of nursing course after all the study outcomes were measured.

Data Analysis

All the quantitative questionnaires were analyzed using the SPSS version 20. Mean, percentages, and standard deviation were used for descriptive analysis. A Friedman test along with multiple post hoc comparisons using Wilcoxon signed-rank test was used to compare competency test measures and satisfaction measures at different time points obtained using various instructional methods. Karl Pearson’s correlation coefficient was used to examine relationships between variables at various time points as well as to find the relationship between the number of times viewing the video and the competency test score at postcycle 2. The level of significance was set at p < 0.05.

The qualitative data for the focus group feedback was analyzed after the information was transferred by entering into a table for each cycle. The six items in the questionnaire were categorized into three themes in each cycle: the strengths or the advantages, the drawbacks or pitfalls, and the suggestions for the enhancement of each of the instructional method.

Results

The mean age of the participants was 19.42 ± 0.50. There were 6 males and 20 females (23.07% and 76.92% respectively) in the group.

Competency Score at Various Time Points

The total competency test measure obtained at various time points using different instructional methods is shown in Table 1. The mean competency score was lowest at postcycle 2 (M = 17.55 ± 2.54), compared with other cycles. The test measures compared using Friedman’s test at various time points did not demonstrate any significant differences between different cycles (χ² = 3.73, p > 0.05).

Table 1.

Competency test measures and satisfaction scores obtained using different instructional methods in the group at various time points

Phases of action research	Mean	SD	N	Friedman test	P*	Pair	Z	p$
Competency score
Precycle	18.23	1.31	26	3.73	0.155	Pre vs. post 1	0.857	0.391
Postcycle 1	18.25	2.63	26			Post 1 vs. post 2	1.13	0.260
Postcycle 2	17.55	2.54	26			Pre vs. post 2	− 0.686	0.492
Satisfaction score
Precycle	44.69	4.83	26	11.64	0.003	Pre vs. post 1	1.320	0.187
Postcycle 1	46.27	5.63	26			Post 1 vs. post 2	1.736	0.082
Postcycle 2	48.73	4.63	26			Pre vs. post 2	2.815**	0.005

$pair-wise multiple comparisons with Wilcoxon signed-rank test

*p < 0.05 level of significance

Satisfaction Measures at Various Time Points

The satisfaction measures obtained using different instructional methods in the group at various time points are shown in Table 1. The mean satisfaction score was highest at postcycle 2. There was a significant difference between satisfaction measures obtained at various time points conducted using Friedman test (χ² = 11.64, p = 0.003). The post hoc comparison carried out using Wilcoxon signed-rank test showed a significant difference between precycle and postcycle 2 (Z = 2.815, p = 0.005), whereas no significant differences were obtained between precycle and postcycle 1 and between postcycle 1 and postcycle 2.

Correlation between Satisfaction Scores and Competency Tests at Various Time Points

There was a strong positive linear correlation obtained between satisfaction score and competency test score at precycle (r = 0.652, p = 0.000), whereas no correlation was observed at other cycles (r = 0.222, p = 0.276 and r = 0.328, p = 0.102 at postcycle 1 and postcycle 2 respectively). There was also a strong positive linear correlation obtained between the number of times viewing the online video and the competency test score at postcycle 2 (r = 0.620, p = 0.001).

Focus Group Feedback Findings

The focus group feedback on the instructional methods was classified under the following themes: the strengths or the advantages, drawbacks or pitfalls, and suggestions for the enhancement of the instructional method. The students’ responses on each of these category themes at each cycle are described in Table 2.

Table 2.

Themes classified from focus group findings at various cycles of action research

Themes classified and summarized from different cycles	Precycle	Postcycle 1	Postcycle 2
Theme one: The strengths and advantages of the instructional method	Most of the students reported that they got an opportunity to practice what they learned. They also expressed that the demonstration method helped them in applying what they learned and more effectively than in class. Further, the face-to-face interaction between the student and the teacher in the demonstration method had enhanced the learning and helped to sustain the attention span.	During this cycle, students expressed that the learning occurred in a much relaxed environment, as there were more flexibility and adaptability in seeing the procedure. Flexibility was related to the advantage of manipulating the video and the adaptability was related to the suitability of this method to a large number of students. This increased their self-confidence in performing the skill.	The main advantage reported by the students was related to the flexibility to recapitulate the content learned as well as the availability of the method at their convenience. The students reported that this method helped them to increase their self-confidence as there was a chance of observing a particular step, while there is a doubt in the procedure. Moreover, there was an advantage of writing down the steps of the particular nursing skill, as well as the rationales of the procedure, which was written on the slides. The students also said that the option to download the video on their laptops or in their mobiles has optimized their learning.
Theme two: The drawbacks or pitfalls of the instructional method	The main drawback reported by the students was related to its time, as it was very difficult for them to recall all the steps completely after the procedure. Also, the large group of students hindered proper observation of the procedure, especially for those who were standing behind.	The main drawback reported by the students with this cycle was about the quality of the video and the lack of explanation in the procedural steps.	The students expressed that the quality of the video was not superior, and there is lack of interaction between the student and the teacher while playing the video. They also reported that there is no opportunity for them to clarify certain points when the video is played at home which can mislead them.
Theme three: Suggestions for the enhancement of the instructional method	Even though the students regarded the demonstration procedure to be useful, the retention of information was limited and thus, a suggestion for giving re-demonstration using a videotape was put forward by them.	The students expressed that the video should be freely available to them for repeated practices. There is a need to include teacher explanation with the steps shown in the procedure.	The main recommendation at this time was that there should be an opportunity to practice immediately following the procedure. The students also suggested to improve the quality of the video further with a lighter background and to have an interaction with the nurse and the patient in the video.

Discussion

E-learning is gaining a greater role in the clinical education of health care students and has advantage of the ability to access material at any time in almost any place. This study is aimed at assessing the baccalaureate nursing students’ competency skills of practice through online self-paced interactive video learning compared with other instructional methods and to determine their satisfaction measures through quantitative and qualitative outcomes using an action research.

The competency scores obtained using various methods of teaching at different cycles did not demonstrate significant differences between online self-paced video learning compared with the other nursing practice instructions—such as video demonstration in class and demonstration-only method. The findings of the present study were similar to a randomized controlled trial conducted by Bloomfield [54] in the hand washing skill performance of nursing students. In this study, both the intervention and the control group did not differ during the performance assessment of their skills at 2-week and 8-week follow-up, in spite of a slightly higher median score observed in the intervention group of students. In another study, measuring the effectiveness of procedural video compared with live demonstration among two groups of undergraduate dental students, during an orthodontic procedure, both groups showed a similar level of understanding and did not demonstrate statistically significant differences (p > 0.05) in their mean performance scores [55].

Even though the group in the present study did not demonstrate significant differences between the three phases of outcome measurement, the online self-paced interactive video learning method had a low mean score in competency (M = 17.55 ± 2.54) compared with the demonstration-only method and the combined video and demonstration in class method (M = 18.23 ± 1.35 and M = 18.25 ± 2.62 respectively). It was rather surprising that the students obtained a low mean score in the postcycle 2, in spite of using online video method of teaching, with demonstration and video in class method for teaching the nursing skill. It could be possible that live demonstration increases students’ confidence, enables the students to interact with the instructor, and clarifies their doubts compared with online self-paced video learning method. Another factor for the low mean scores could be the complexity of the task involved in online self-paced video learning method. The skill chosen for assessing the competency skill in postcycle 2 was nasogastric tube feeding techniques, which had more complex steps and principles, whereas the other two methods were hand washing and surgical bed making which involved few simple steps. It is also possible that the lack of difference between the cycles could be related to the availability of a number of freely available online videos of high quality which would have been already viewed by the students [56].

In a study conducted by Quyami et al. [57] comparing a computer-assisted learning with text-based only method and a combination of both these methods, significant improvement of learning was demonstrated in the computer-assisted learning group as well as the group which used a combination method compared with text-based only method. It was also demonstrated that the students whose educational performance was high had better learning outcomes which were independent of the method of teaching, but students with lower test scores had a better performance in the computer-assisted learning. The present study did not assess the basic cumulative grade point average (CGPA grades) of the participants. In a study done by Fayaz et al. [58], the experimental group of dental students who were taught with the video tape in the practical procedures had a significantly better performance than the traditional method in which the students were taught by two instructors in the classroom. Moreover, in that study, the students were doing the practice skills while they watched the video, which could have been a reason for the better results. As suggested by Ericsson [59], improvement in performance skills are associated with improved quality and quantity of practice, which requires the participant to take an active role in deliberate practice for the acquisition of skills. Moreover, it cannot be forgotten that there are many potentially confounding factors that can impact the educational experience as well as some specific characteristics of individual student learners which can influence the learning outcomes. This has to be appropriately identified and addressed and should be best employed for teaching large groups of students.

The satisfaction scores obtained was highest for the online video viewing compared with other two methods. This partially supported the study conducted by Intachai [4] among nursing students, where there was a higher satisfaction score for the method using demonstration and video compared to the lecture, for the blood pressure measurements; whereas Powell, Canterbury [60] did not find any significant difference between the faculty demonstration and faculty-generated videotape on medication administration skill practice.

The higher satisfaction scores found using the online self-paced interactive video were in contrast to the findings observed by Fathil et al. [61] in the polytechnic students, where a positive relationship between online video lecture and skills were noticed, but had a lower satisfaction in a flipped classroom environment. Also Salyers [62] in a web-based instruction using interactive videos in comparison with the classroom instruction yielded a lower student satisfaction score in spite of the better performance in final theoretical and practical skill tests. Similar to our study results, Donkor [63] found that video-based instruction produced greater satisfaction among learners in studying the practical skills. However, even though the nursing students in the current study had higher scores in satisfaction in the post-cycle with online self-paced interactive video learning compared with other methods, it did not reflect in their competency test results. One of the reasons could be that they had limited interaction between material, peers and the teacher, and did not get an opportunity to immediately practice the steps of the skill following the procedure. Student engagement and interaction have a large effect on the learning outcomes, and at the same time can cause variances in the performance [61]. E-learning can be a disadvantage for those with poor IT skills as there is no IT support for the students if they are faced with any technical issues, and may not help them to develop social interaction (peer interaction and teacher-learner interaction), engagement with patients, reflection, listening, or caring which is considered as an integrated component in nursing skill learning [22, 64]. The present study did not examine the IT skills of the particular nursing students to determine if it had influenced their learning. In contrast to our study results, Lee et al. [38], in a randomized controlled study on teaching pediatric skill procedure using a DVD-based teaching in the interventional group, demonstrated non-significant study results in the candidates’ perception and satisfaction compared with the control group who were exposed to the traditional, face-to-face approach. It could be that the self-directed learning could have given them more freedom to choose, and more flexibility, which derived more satisfaction compared with the classroom demonstration. Another reason could be that viewing video online resulted in better observation of the treatment steps than seeing the procedure in a crowded group. In spite of having a lower score in the competency test result, the higher satisfaction reported in the online video learning in the present study was rather promising. Learner’s satisfaction is a key in deciding the success of an educational program [22], and there is a relationship between the two, each contributing to the other [65]. However, it has to be decided in long run through more educational researches whether it really produces a positive outcome.

Students preferred face-to-face interaction and felt that was the best way of enhancing their learning and developing their skills, which were evident from the focus group findings, even though a large majority felt that the demonstration had taken a long time. Similarly, Cannon et al. [66] in their project have reported that one of the major student concerns was not to replace video for live demonstrations. Fathil et al. [61] have reported that student interaction can contribute to the learning outcome variance and has a large effect on their performance. Also, even though video can contribute to student engagement, it might not significantly contribute to their learning outcomes. The high rate of satisfaction expressed by the students regarding the online self-paced video learning was mainly in regard with its availability on demand and convenience for repeated observations, which was similar to the study findings by Cannon [66]. According to Race [67], one of the most essential factors that underpin successful learning is learning by repetition. The self-confidence expressed by few students with online video was similar to the study conducted by Holland et al. [40]. The online videotapes of the professional nurse in dealing with a critical clinical situation can help to develop self-efficacy and facilitate introverted students to engage completely [18]. However, online video learning should be used judiciously and is best suited to be used as a supplement rather than a replacement for enhancing overall teaching and learning experience [68]. It also requires that videos are updated on a regular basis based on scientific research and ongoing clinical developments [68].

The feedback obtained through focus groups’ reflections at the end of each cycle provided significant and valuable information to make modifications for the next cycle. Their descriptions about the teaching instructions and suggestions contributed to the successful planning and implementation of the forthcoming cycle and were instrumental in maximizing the applicability of the particular teaching method in that cycle. The students’ reflections about their learning helped to evaluate and examine the methodology of teaching in the current context of the researcher’s practice environment, and provided cues for meeting diversified student needs and introducing approaches to increase student satisfaction and engagement. Consultation with the students is one of the ways of improving the quality of learning and teaching [69].

Limitations and Recommendations

Several limitations were encountered in the present study, including a small sample size and lack of a control group, if employed would have given better empirical evidence for a real practice. Also, the risk of possible contamination of data also could not be ruled out, as the students might share the feedback about their performance with other colleagues and would have possibly influenced the feedback results. Since this is an action research conducted in one setting with 26 participants, its applicability to other settings has to be based on the contextual similarity to transfer the findings by collecting factual evidence. In the future, research can be conducted with larger samples, evaluating skills of similar complexity and using a control group. The study also did not examine if the GPA level of the students and the complexity of the task involved in the procedure had some influence over the competency levels, for which future research is needed. The effects of improving the practical skill by means of hands-on practice can be evaluated as well in future studies. Further empirical studies to compare the competencies between demonstration method and online-self-paced video recording with hands-on-practice can also be conducted.

Conclusion

This study has demonstrated that unlimited access to an online self-paced video contributes to increased satisfaction among nursing students compared with other methods of teaching clinical skills but not to contribute significantly to increase their competency levels. While the clinical competency of qualified nurses is a challenging issue that continues to evoke a debate about the effectiveness of the currently used methods for teaching clinical skills, this study holds a promise for increasing the students’ competency if online video learning is used as an adjunct in teaching clinical skills. A consensus in selecting appropriate strategies in teaching clinical competencies along with a judicial consideration of integrating other innovative newer technologies could effectively improve the performance-based skills of nursing students. The study also highlights the need for more rigorous studies to guide our teaching practice. Action research is the golden tool that can be used to search for the on-the-ground evidence that supports the change in the teaching strategies [70, 71]. Indeed, action research intends to foster learning about one’s self and one’s environment [50]. Assessing the effects from different perspectives was so comprehensive, and the finding of each cycle and the student’s reflections throughout was the driving force for introducing more changes to influence the students to progress successfully. Applying transformative reflective practice is the key that ensures ongoing professional growth and enhancement.

Compliance with Ethical Standards

All the ethical guidelines have been followed while conducting the research and preparing the manuscript.

Conflicts of Interest

This research has been carried out as a part of the postgraduate certificate for the academic program of author Naseem Saeed Ali at the author’s institution. Author Naseem would like to state that she did not receive any funding for carrying out the research.

Author Bindu John declares that she has no conflict of interest.

Ethical Approval

All procedures performed in this study were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.