Elsevier

Nurse Education Today

Volume 109, February 2022, 105245
Nurse Education Today

Research article
The impact of online synchronous versus asynchronous classes on nursing students' knowledge and ability to make legal and ethical decisions

https://doi.org/10.1016/j.nedt.2021.105245Get rights and content

Abstract

Background

Educating nursing students on laws and ethics is essential since the nursing profession requires providing services that have many legal and ethical implications.

Objectives

The goal of this study was to measure the effectiveness of two teaching strategies (providing online synchronous classes versus asynchronous classes) on nursing students' knowledge of legal and ethical issues and their ability to make legal and ethical decisions.

Design

This study used a randomized control trial (RCT) design.

Sample and setting

A total of 127 students from two governmental universities in Jordan participated in and completed the current study. The students were randomly assigned either to the experimental group which received the synchronous classes (n = 60, 47.2%) or the control group which received asynchronous classes (n = 67, 52.8%).

Method

The two study groups were given a pre-test to measure their knowledge and ability to make legal and ethical decisions. After the pre-test, an online synchronous educational class about legal and ethical issues in nursing was carried out by the same educator twice a week and lasted for approximately 1.5 h each. At the same time, the students in the control group were provided with the same material but as asynchronous classes and were encouraged to watch the classes during the lecture. After completing the educational classes, both groups were asked to complete the post-test questionnaire.

Results

The results indicated significant outcomes in terms of increasing the knowledge and the ability to make an ethical decision of students who attended the educational classes. However, the synchronous and asynchronous classes did not result in significant differences in students' learning outcomes.

Conclusion

Educating nursing students about legal and ethical issues in the nursing profession is important to prepare them to make legal and ethical decisions. In addition, using different teaching strategies is quite important in educating nursing students.

Introduction

Nursing is a caring career that has a significant effect on people's lives, health, and well-being (Rainer et al., 2018). Many of the circumstances that a nurse encounters in practice present a problem that, if not treated properly, may have negative effects on the patient and anyone involved (Aliyu et al., 2015). Thus, nursing practice is regulated to ensure that the nursing standards are upheld to achieve healthy practices. Ethics and laws are two important components that have regulated several nursing care practices (Aliyu et al., 2015). Ethics are a well-founded set of rules pertaining to what is right or wrong (Olson and Stokes, 2016). Ethical principles prescribe what humans should do in terms of societal rights, responsibilities, and rewards (Saxén, 2018). According to the American Nursing Association (ANA), nurses, during their clinical practices, must adhere to the nursing code of ethics that includes autonomy, justice, beneficence, non-maleficence, veracity, and fidelity (Olson and Stokes, 2016). Following these ethical principles makes the nurse profession one of the noblest and humanistic professions in the world (Fowler, 2017). Therefore, nursing students must be introduced to these principles during their education to enhance their ethical sense and make it part of their practice.

In addition, medical laws are the rules and regulations that legislate nurses' practices like other health care professionals (Lu and Wedig, 2017). Medical legislations and laws vary from one country to another in terms of regulating the practices of health care professionals. For example, some countries have legalized the act of euthanasia (assisted patient suicide), whereas other countries consider it as illegal and incriminate the medical staff that assists this action (Miller et al., 2019). Thus, it is very important for nursing students to be introduced to the medical laws in their countries and taught how to act in a legal situation, which will help to protect them from any accusation of negligence or malpractice.

Ethics and laws are considered to be intertwined concepts because most of the cases that have legal implications have ethical implications as well (Olson and Stokes, 2016). For example, nurses are ethically obligated to not harm patients, but at the same time, any action that has an adverse impact on a patient's health will be considered as a form of negligence or malpractice. Nursing students should, therefore, be aware of the ethical and legal implications of their practice and be taught to work hard to achieve optimal standards of nursing practices.

Furthermore, nurses face a variety of ethical dilemmas in their daily work (Rainer et al., 2018). For example, a conflict may arise between choosing whether to adhere to a patient's right of making their own choices or imposing the nurse's choice which reflects their intention to prevent the patient from harming themselves. Thus, educating nursing students to solve ethical dilemmas is important to prevent the feeling of guilt (Savage, 2017). This also highlights the need for teaching students how to deal with an ethical situation and how to systematically handle the ethical dilemma as a part of their preparation to work in the actual field (Sari et al., 2018).

During the spread of COVID-19 and the period of quarantines and lockdowns, many nursing schools across the world were requested to change their teaching strategies from traditional classroom teaching to online or blended teaching (mixing traditional and online teaching) (Neil, 2020). Online teaching was a relatively new experience that required nursing schools to follow different teaching strategies in order to foster and enforce the education process (Morin, 2020). However, a debate was raised on how these different teaching strategies may be similar or different in their effectiveness measured in students' outcomes, especially in the nursing discipline, as most medical disciplines require practice and fieldwork more than other theoretical disciplines.

Synchronous learning refers to any kind of learning in which the learner(s) and instructor(s) are at the same location at the same time to facilitate learning. This includes in-person classes as well as live online meetings with an entire class or smaller groups. In synchronous learning, students commonly go through the learning route together and are accompanied by an instructor who can provide support while students work on assignments and perform activities. On the other hand, the primary assumption in case of asynchronous learning is that learning can take place at different times and places for each learner. As opposed to synchronous learning, instructors in asynchronous learning frequently set up a learning path for students to follow at their own pace.

Schoenfeld-Tacher and Dorman (2021) measured the perspectives and academic performance of veterinary medicine students, in an asynchronous online toxicology course given at the North Carolina State University. The authors found that the students' academic performance was unaffected by the delivery method. The lack of instructor interaction was an important perceived barrier in the asynchronous course. The results suggested that although some veterinary students perceived the switch in delivery format negatively, the method of delivery did not adversely affect their performance in this preclinical course. Furthermore, Belliston (2020), used a convenience sample of 132 nursing students enrolled in a bachelor's program in nursing at a public university in the intermountain region in the US. The researcher used. The experimental group met for synchronous online classes with the instructor each week and actively participated with classmates in the synchronous online forum. The control groups completed the same course and activities in an asynchronous online format via discussion boards. Both groups took the Health Education Systems, Inc. (HESI) specialty exam and the Online Student Engagement (OSE) exam. No significant difference was found in the results of both exams between the two groups. The findings suggest that pre-licensure nursing students can learn essential didactic content in an engaging online environment.

The majority of online learning takes place asynchronously, with synchronous learning occurring mainly when there is a special requirement for live discussion or contact, or as a method to foster community among students. The goal of this study is to measure the effectiveness of two teaching strategies (providing synchronous classes versus asynchronous classes) on nursing students' knowledge of legal and ethical issues. The study also aims to measure the effectiveness of these teaching strategies on improving the nursing students' ability to make decisions regarding legal and ethical issues and solving ethical dilemmas.

Section snippets

Design

The current study utilized a randomized controlled trial design (RCN) to meet the goals of the study. Two sections of the same course were randomly assigned to the experimental and control groups. The experimental group completed online synchronous educational classes and the control group viewed the asynchronous classes by watching the recorded lecture.

Sampling

According to the G* power software (Faul et al., 2007), the minimum sample size to achieve an adequate power level of 0.80 and a medium effect

Sample characteristics

Of the 160 students who agreed to participated in the current study, 33 students were excluded because they did not take the post-test or they didn't complete more than 50% of their pre- or post-test. As shown in Table 1, a total of 127 students participated in the current study and completed the pre- and post-test. The participants were randomly assigned to either the experimental group which received the online synchronous educational classes (n = 60, 47.2%) or the control group (n = 67,

Discussion

The objective of this study was to assess the effectiveness of an educational program on nursing students' knowledge of legal and ethical issues and their abilities of ethical decision-making. A second objective was to differentiate between students' outcomes when using online synchronous educational classes versus the use of asynchronous classes. In general, the results indicated significant outcomes in terms of increasing the knowledge and abilities of students who undertook the educational

Limitations and recommendations

One limitation of this study is using only two governmental universities which could affect the external validity of the study and limit its generalizability to other non-governmental universities. The researchers recommended replicating the study using a larger sample size and including more universities. Another limitation is that some students in the study may have had internet connection problems during the online synchronous class which may have affected their understanding of the

Conclusion and implications

The results of this study indicated excellent outcomes for education classes in terms of increasing nursing students' knowledge and abilities to make an ethical decision and solving an ethical dilemma. However, no significant differences were found between the online synchronous educational classes versus the asynchronous classes. Thus, educating nursing students about legal and ethical issues in the field of nursing is important to prepare them to make legal and ethical decisions and to solve

CRediT authorship contribution statement

Mohammad Suliman: Conceptualization, Methodology, Writing - Original Draft; Wafa'a Ta'an: Investigation, Asem Abdalrhim; Project administration; Investigation, Loai Tawalbeh: Software, Formal analysis; Maen Aljezawi: Data Curation, Writing - Review & Editing.

Funding

The authors received no financial support for the research.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (20)

  • L.L. Olson et al.

    The ANA code of ethics for nurses with interpretive statements: resource for nursing regulation

    Journal of Nursing Regulation

    (2016)
  • D. Aliyu et al.

    Knowledge, attitude and practice of nursing ethics and law among nurses at Federal Medical Centre, Bida

    American journal of health research

    (2015)
  • S.L. Belliston

    The Effect of Asynchronous Versus Synchronous Online Course Delivery on HESI Scores and Student Engagement for Rural Pre-Licensure Nursing Students

    (2020)
  • M. Bijani et al.

    Nurses’, nursing students’, and nursing instructors’ perceptions of professional values: a comparative study

    Nursing Ethics

    (2019)
  • B. Cerit et al.

    Ethical decision-making and professional behaviour among nurses: a correlational study

    Nursing Ethics

    (2013)
  • F. Faul et al.

    G* power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences

    Behav. Res. Methods

    (2007)
  • M.D. Fowler

    Why the history of nursing ethics matters

    Nursing Ethics

    (2017)
  • L. Kohlberg

    The Philosophy of Moral Development Moral Stages and the Idea of Justice

    (1981)
  • S.F. Lu et al.

    Malpractice laws and incentives to shield assets: evidence from nursing homes

    Journal of Empirical Legal Studies

    (2017)
  • D.G. Miller et al.

    Advance euthanasia directives: a controversial case and its ethical implications

    Journal of medical ethics

    (2019)
There are more references available in the full text version of this article.
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