The American Nurses Association (2002) has stated that nurses and their employers are jointly responsible for creating an environment in which competent nurses can provide quality outcomes. Despite these mandates, healthcare institutions are faced with the challenges of providing stimulating, relevant, and cost-effective continuing nursing education programs. The explosion of available nursing knowledge and the increasing need for nursing competencies through regulating bodies have also contributed to the challenges in continuing education (Belcher & Vonderhaar, 2005; Benson, 2004; Nelson, 2003; Smith, 2005). Today's nurses are faced with ongoing pressure to demonstrate proficiency in a variety of nursing skills. Consumer demands and the concerns of consumer advocacy groups have also influenced continuing education and competency development of nurses. One of the primary reasons for this increased interest is the Institute of Medicine's (1999) report, which declared that 98,000 patients die annually from medical errors while hospitalized.

Despite these obvious challenges, effective institutional-based continuing education programs are essential to assist staff nurses in maintaining professional competence. The traditional lecture has been the primary educational format used in continuing nursing education to date (Dougal & Gonterman, 1999; McAlpine, 1996). Although the lecture format can be an effective way to deliver information to a large number of nurses, many educational disadvantages to the live lecture format exist (Billings & Halstead, 2005; Harrington & Walker, 2003). Didactic lectures do not appeal to a variety of learning styles, lack learner participation strategies, require lengthy educator preparation, and are costly (Dunn & Griggs, 1998).

One alternative to the traditional lecture format is the use of online technology in continuing nursing education, also known as eLearning. Technology has revolutionized educators' ability to facilitate professional nursing competence through the use of online education. The use of eLearning in the staff development environment has only recently been explored (Benson, 2004; Bernhardt, Runyan, Bou-Saada, & Felter, 2003). Use of eLearning to provide continuing nursing education has many benefits, including user convenience, program design flexibility, adherence to adult learning principles, and accommodation of multiple learning styles. The remainder of this article will discuss the implementation of an online nursing education competency. Specifically, the online competency focused on the nursing care of the kidney transplant recipient. The purpose of this article is to examine the satisfaction and perception of learning on practicing nurses in the online environment.

LITERATURE REVIEW

A comprehensive literature review was conducted using both the CINAHL and ERIC databases. Major content areas identified included the impact of the online environment on nurses, the impact of online learning on nursing students, and theoretical principles of online education.

The Impact of the Online Environment on Nurses

Because of its potential benefits in staff development, nursing researchers have explored eLearning and computer-based instructional strategies as an educational medium (Attack, 2003; Attack & Rankin, 2002; Korhonen & Lammintakanen, 2005). Most existing research relates to nursing students and the online environment; however, little research exists regarding the impact of the online environment on practicing nurses. As a result, this literature review includes education research that considers both graduate nursing students and practicing nurses.

Convenience and flexibility have been cited by nursing researchers as contributing to nurses' satisfaction with the online learning environment (Attack, 2003; Attack & Rankin, 2002; Billings, Connors, & Skiba, 2001). Although multiple studies claim flexibility as an advantage to online courses, Korhonen and Lammintakanen (2005) found contradictory results when studying the impact of online learning and nurse managers. According to their qualitative study, the degree of satisfaction with the flexibility and convenience of online learning was directly related to certain time- and place-dependent conditions. For example, online courses were considered flexible and convenient only if the nurse manager had adequate home computer access and time at work and home to devote to studying online. Similar findings were reported by Attack (2003), who found that the convenience and flexibility offered in an online course were dependent on the nurse's ability to become more disciplined in overall study habits. Current literature demonstrates that nurses cite convenience and flexibility as advantages to online learning. However, adequate computer access, development of disciplined study habits, and adequate time spent studying all affect the nurses' satisfaction with online courses.

Self-paced learning has also been studied as it relates to the success and satisfaction of nurses in the online environment. Grant (1993) studied the response of nurses to self-paced learning modules during a nursing orientation program compared with a traditional lecture format. The self-paced learning modules were the method of choice for most nurses, although the authors noted that many nurses selected a blend of both self-paced learning and lecture as their preferred teaching strategies. Andrusyszyn, Cragg, and Humbert (2001) and Kozlowski (2002) found that self-direction, self-paced learning, and flexibility were cited by nurses as important advantages to the online learning environment.

Although there are advantages for nurses using the online environment, the literature review did uncover some barriers to implementation and use of online learning. Lack of computer access and insufficient computer skills are the most frequently cited barriers (Attack & Rankin, 2002; Billett, 1992; Criddle, 1995; Khoiny, 1995; Nowicki, 1996; Schmitt, Titler, Herr, & Ardery, 2004). Attack (2003) and Smith (2005) also reported that lack of computer skills negatively affects nurses' satisfaction in the online learning environment.

The Impact of Online Learning on Nursing Students

Bloom and Hough (2003) studied nursing and allied health students and found that they were highly satisfied with the use of technology in learning. Additional nursing student studies have demonstrated satisfaction with the use of the online environment (Parker, Riza, Tierney, & Barrett, 2005; Ryan, Carlton, & Ali, 1999; Soon, Sook, Jung, & Im, 2000; Thurmond, Wamback, Connors, & Frey, 2002). Similar to results reported regarding practicing nurses, nursing students often cite convenience and access as the primary reasons to choose online courses (Billings, 1999; Soon et al., 2000).

Theoretical Principles of Online Staff Education

Learning theories and educational frameworks are the philosophical foundations that guide the selection of instructional strategies and learning activities. Andragogy (Knowles, 1980) and adult learning theory are commonly used as theoretical foundations for online course design both for nursing students and practicing nurses. Adult education literature reports that adult learners, including nurses, value online course designs based on andragogical principles (Ausburn, 2004; Bernhardt et al., 2003; Dyck, 1986).

The Constructivist Learning Theory is also commonly used as a theoretical basis for online course design (Moallem, 2001). The Constructivist Learning Theory evolved from both psychology and philosophy and holds that assimilation, accommodation, and construction are the basic components of learning (Billings & Halstead, 2005; Ryan, Carlton, & Ali, 2005). According to Constructivism, learners construct their knowledge by actively participating in the learning process and constructing their own meanings and understanding. Concepts that are central to the Constructivist Learning Theory include collaboration, learner autonomy, reflection, and experiential learning (Huang, 2002; Moallem, 2001). Huang (2002) and Ali, Carlton, and Ryan (2004) discussed Constructivist-based instructional principles for successful online adult learning. These instructional principles include providing an interactive learning environment through online discussion, critical thinking, reflection, timely positive feedback, establishment of collaborative learning projects, facilitation of meaningful learning experiences, and application of real-world knowledge. The Constructivist Learning Theory, along with the Adult Learning Theory, is the theoretical framework used for the development and implementation of the online staff nursing education programs discussed in this article.

DESCRIPTION OF PROJECT

Online Program Description

Nurses who care for kidney transplant recipients are required by Saint Francis Health System policy to complete an initial kidney transplant certification course and an annual recertification class to maintain their competence in the care of this complex patient population (Saint Francis Health System, 2005a). The annual kidney transplant competency course, originally several hours in length, was taught in a traditional classroom lecture-based format. In the spring of 2006, the traditional annual competency course was converted to an entirely online format. Prior to content development, a needs assessment of the transplant nurses was conducted.

Instructional Design Principles, Program Design, and Implementation

MC Strategies Webinservice(R) was the application used to complete the design and execution of this online competency. Saint Francis Health System chose this application because of its simplicity and ease of use. This application also allows nursing educators to easily modify content in order to meet the learners' needs.

Course access, hierarchical organization, flexibility, and self-pacing are some of the learning strategies included in the course design that were based on the theoretical underpinnings of Constructivism and Adult Learning Theory. The developed module is accessed from the Internet, allowing the nurse to complete the lesson from either the home or work environment. Internet access was provided to allow staff to obtain the course material from their home because studies have reported that the noisy stressful nursing work milieu can hamper online learning (Knapp, 2004; Rick, Kearns, & Thompson, 2003). Nurses at Saint Francis Health System have ready access to computer terminals for electronic documentation and Internet access to professional resources. The online course format of this competency is self-paced and will allow staff to learn in their preferred environment. Studies demonstrate that students retain a higher percentage of the information when they are allowed to learn at their own pace (Nelson, 2003).

The course content was organized hierarchically, with the least complicated material covered first followed by the higher level cognitive domains. The hierarchical organization and depth of the course content are based on Constructivist learning models and focus on the Constructivist instructional concepts of problem-based learning, solving of real-world problems, layering of information, and conceptual interrelatedness (Moallem, 2001).

Critical thinking skills are essential for a nurse practicing in a complex healthcare system. Case studies and problem-solving opportunities were included in the course content to appeal to adult learners' desire for immediate real-world application of knowledge (Knowles, 1980). Case studies also followed Constructivist learning principles of real-world problem application and knowledge linkage to everyday practice (Ali et al., 2004; Twibell, Ryan, & Hermiz, 2005). Specifically, the case studies were included to assist the learner in obtaining critical thinking and problem-solving skills for common complications after kidney transplantation.

Additional module features included animation and graphics to emphasize important content. Graphics and animation were used in balance with static text to stimulate visual learners and maintain the learners' interest (Belcher & Vonderhaar, 2005; Cuellar, 2002; Peterson & Berns, 2005). Item validation (questions throughout the module that required answering before the learner could continue), positive reinforcement, functional links to Internet resources and hospital policies and procedures, and a printable summary of key points were also included in the course design. Resource links and printable handouts were included to improve learner-content interactions (Merriam & Caffarella, 1999; Thurmond, 2003).

Program development and content were approved by the Director of Education. After content development, a pilot test was conducted, and the results were used in continuing program development. The module was assigned to the appropriate nurses, who were given 90 days for completion. After Institutional Review and Ethics Board approval, a written survey was developed and distributed to the 20 nurses after the completion of the module. Since implementation, 20 kidney transplant nurses have completed the module along with a 20-question, multiple-choice online posttest.

EVALUATION OF OUTCOMES

The educational program was evaluated using the Web-based course outcome assessment framework proposed by Billings (2000). The framework has five major concepts which should be evaluated within the online education format. The evaluation categories include outcomes, educational practices, faculty support, learner support, and the use of technology (Billings, 2000). Sixteen of the 20 surveys were returned, for a response rate of 80%. The time to complete the lesson ranged from 2 to 45 minutes, with an average completion time of 23 minutes. The average online posttest score was 94.8%, with all learners passing the examination with a score of 80% or better. A score of 80% or better was required to demonstrate competency (Saint Francis Health System, 2005b).

A five-question Likert scale survey was administered after completion of the lesson. The overall evaluation of the lesson was cited as very good or above average by 100% of the nurses surveyed. All of the nurses also reported that the content level was appropriate for their job activities, and most nurses (87.5%) found the lesson very helpful for enhancing their job performance related to the care of the kidney transplant recipient. According to the course evaluations, 87.5% of the nurses agreed that the online format facilitated learning, and the remaining nurses somewhat agreed that the online format facilitated learning. Thirteen nurses (81%) perceived that learning took place in the online environment and were able to list specific learned concepts.

Written evaluation comments included the following: "it was a great refresher," "liked the use of the computer and eLearning because it can be done at a time that is convenient for me," "quick and useful resource," "I enjoyed the questions throughout to make sure the information is retained," and "good review."

CONCLUSIONS, LIMITATIONS, AND IMPLICATIONS FOR PRACTICE

This descriptive study examined the impact of an online kidney transplant nurse competency module on the perceived learning and satisfaction of nurses. The authors found that most surveyed nurses perceived that learning took place in the online educational environment. In addition, the nurses reported satisfaction with the online format and commented that online learning was convenient, flexible, and useful. These findings are consistent with the education literature, which reports that nurses are satisfied with a Web-based format particularly because the online environment provides convenience and flexibility (Fearing & Riley, 2005; Harrington & Walker, 2003; Irons, Jung, & Keel, 2002; Phillips, 2006).

As discussed in the literature review, drawbacks to using online learning include lack of computer access, lack of dedicated time for learning, and insufficient computer skills. Although the authors did not experience these issues in this project, other institutions may encounter these difficulties when implementing online learning. In addition, some institutions might have nurses who lack sufficient computer skills. Limitations of this study were similar to other educational research studies in that a small convenience sample was used; therefore, the results are not generalizable to all nursing environments.

According to Adult Learning and Constructivist principles, direct application and association of real-world principles and knowledge are essential to a successful learning experience (Forrest, 2004; Huang, 2002; Knowles, 1980; Moallem, 2001). This is particularly significant in the profession of nursing, where the critical test of learning is the application of knowledge to clinical practice (Sheridan & LeGros, 1995). Unfortunately, a paucity of research exists regarding the direct translation of online knowledge into nursing practice (Attack & Rankin, 2002; Beitz & Snarponis, 2006). Only one study that examined the ability of nurses to transfer knowledge learned in the online environment to practice was found. Therefore, future nursing education research should be directed at understanding both the impact of online learning on practicing nurses and the nurse's ability to translate knowledge into clinical practice.

In summary, nurse educators are faced with the challenge of providing relevant and effective education programs in an increasingly complex healthcare environment. This study demonstrated that the eLearning format provided a satisfactory and effective alternative for nurses in practice. In addition, this study provides further support for existing literature that states nurses can learn in an online environment if specific barriers are overcome. The challenge of ensuring competency for practicing nurses is complex. Educational programs that are designed using an online format provide a positive educational medium for learning.

REFERENCES