Setting and Sample
A comparative prospective and retrospective quasi-experimental design was carried out for this study. The sample was composed of students in the Sino-foreign cooperative program between the School of Nursing of Yangzhou University and the University of Yangzhou. In the prospective group, referred to as the ‘distance learning format’ group, participants were first-year students enrolled in 2019 (n=48) who were taking the Fundamentals of Nursing Ⅰ course. A retrospective control group, referred to as the ‘control group,’ were first-year students enrolled in 2018 (n=36) who were taking the Fundamentals of Nursing Ⅰ course. Students in the Sino-foreign cooperative program are taught in English in all courses. Admission scores for the nursing program in our university are similar from year to year, so students in these two groups began with a similar knowledge base. The 36 students enrolled in 2018 learned the course material through campus-based formats (face-to-face formats) and the 48 students enrolled in 2019 learned the course material through a distance-learning format. Regardless of the setting, students were taught the same content and fundamentals by nursing faculty members with identical assessment objectives.
This study was approved by the Yangzhou University Nursing School Ethics Committee. Students who were included in the study offered written informed consent.
Description of the Fundamentals of Nursing 1 course
The content of the Fundamentals of Nursing Ⅰ course includes infection control, sleep and pain management, client hygiene, vital signs assessment, circulatory and ventilatory support, nutrition, mobility, and safety. This course at our university is composed of 54 class periods, which meets 4 times a week (45 min/class period) over 14 weeks in the spring semester. The course was team-taught by seven faculty members. Since this course is the only specialized basic course in the spring semester, the academic engagement and self-efficacy of students are usually evaluated in this semester to promote the improvement of subsequent teaching methods.
Fundamentals of Nursing 1 course offered in face-to-face modality
The face-to-face format was held in the classroom and was mainly didactic with patient cases incorporated throughout the lecture to engage students in discussion and enhance the learning of the material. Didactic materials and learning objects were given to students before the lectures. In class, teachers usually presented the objectives and content of the lessons first and then delivered this content as a lecture. Students then discussed particular topics with each other under the guidance of the teacher during class; after class, the teacher assigned corresponding homework for students to complete independently.
Fundamentals of Nursing 1 course offered in a distance education modality
The distance education modality was asynchronous and took place on the Yangzhou University Network Teaching Platform, where didactic materials and homework were posted and where class activities could be completed. The platform also offered a section where students could ask questions about knowledge points from class or topic discussion.
The weekly course content for distance learning was the same as that of the face-to-face format, but the delivery of the format was different. Before each class, teachers needed to prepare all kinds of teaching materials. First, a lecture guide list was posted to the platform as an MS Word document, which informed students of the knowledge points to be learned in the class, the corresponding learning materials, the approximate amount of time it takes to learn each knowledge point, and the learning objectives; each knowledge point was arranged according to the learning order. Secondly, some videos of the key points and difficulties of the lesson were provided by the teacher, with each video tending to be 15 to 20 minutes in length. These were also uploaded to the platform. Other teaching materials related to the course content were also posted to the platform, including news videos, industry technical standards, scientific articles, reference books, and presentations of lectures by the teachers. Finally, teachers posted homework assignments similar to homework given to students in the face-to-face format. All the above materials were uploaded to the platform 48 hours before the lesson began. If students had some doubts about the lesson, they could post their questions in the section for questions and answers. After students accomplished the learning tasks on the platform independently, teachers answered the questions or discussed the topics related to the lesson with students in the question-and-answer section of the online platform within the time set by the teacher.
Data collection and study outcomes
Academic performance was assessed by grades of the final written examination. For the examination, the difficulty of the written examination and teachers who marked test papers in face-to-face format and distance education format was similar. The grades ranged from 0 to 100, with ≥40 being a passing mark.
Academic self-efficacy was assessed by a self-efficacy questionnaire before the start of the course and after the final lesson. The self-efficacy questionnaire was developed by Pintrich et al9 and translated and revised into Chinese10. The questionnaire was divided into 22 items in 2 self-efficacy dimensions, which included learning ability and learning behavior. Each dimension comprised 11 items that were measured by a 5-point Likert scale, from 5 to 1, indicating that the respondents strongly agreed, agreed, generally agreed, disagreed, or strongly disagreed with the question. The total score ranged from 22 to 110. The higher the total score, the higher the sense of academic self-efficacy. The total Cronbach's α coefficient of the scale was 0.815, the retest reliability was 0.87, and the internal consistency of each dimension was 0.85 and 0.71. Self-efficacy for schoolwork was measured before and after the course for both face-to-face and distance education formats.
The academic engagement of students was evaluated by a Chinese academic engagement scale before the start of the course and after the final lesson. The Chinese academic engagement scale 11 was revised according to Utrecht Work Engagement Scale-Student developed by Schaufeli 12,13. There were 17 items in the Chinese scale, and it was divided into three dimensions: vitality, focus, and dedication. From "completely disagrees" to "completely agrees," a 7-point scale of 0 to 6 is adopted. The higher the score, the higher the level of academic engagement. The total Cronbach's α coefficient of the scale was 0.951, and the Cronbach's α coefficient of each subscale was 0.858, 0.913, and 0.905.
SPSS software (version 22.0 for Windows, Chicago, IL) was used for statistical analysis. Continuous variables conforming to a normal distribution were described as mean ± standard deviation, and those that do not conform to the normal distribution were described by quartile. Two independent sample t-tests were used for inter-group comparison. Categorical variables were described by frequency and composition ratios and were compared with the Chi-square test. P < 0.05 was considered statistically significant.