Effect of Video vs. Lecture/Demonstration in Improving Nursing Interns’ Knowledge and Skills Regarding External Ventricular Drain (EVD): A Quasi-Experimental Study

Introduction

Nursing is essential to a safe, effective, and compas- sionate healthcare system. As such, there are inherent requirements with regard to nurses’ technical profi- ciency, as well as skills in other areas, and a corre- sponding expectation of nurse educators and clinical nursing leaders to provide adequate professional de- velopment [1]. In an era of rapidly developing tech- nology and societal changes, conventional instruc- tional approaches have become inadequate [2]. A va- riety of teaching methods involving digital devices are being developed in response to these changes, and to increase learner participation [3]. According to meta- analyses, technology has improved learning [4], and much research backs up the efficacy of educational videos [5-7]. When used strategically, videos can be a useful and valuable component of a teaching toolkit [8]. Video is one of the many digital instructional tools available to teach nursing skills. This teaching method encourages more active learning strategies, as com- pared with the more conventional teaching methods of demonstrating and repeating procedures [9]. Videos that teach particular nursing skills have been the sub- ject of several research publications [10-13], and ap- pear to be a promising, pertinent, and widely-used in- structional technique that could improve the standard

of clinical skills teaching, even if there is a need for further research in the field [14]. Video is useful in the therapeutic setting for putting theoretical information into practice and developing various competencies [15]. Due to its effectiveness as a learning tool that students frequently favour, it is the medium of choice for teaching specific procedures [16]. Additionally, research demonstrates that video lectures are equally successful in imparting knowledge on particular subjects, such as crisis man- agement [17], and necessary skills to students of vari- ous learning preferences [18]. A study documented that medical students preferred video-based instruc- tion over traditional teaching for clinical skills such as surgical hand-washing [16]. Furthermore, participants reported great satisfaction with the effectiveness of video in imparting the knowledge and technical skills necessary for chest tube insertion [19]. Even though skill-based videos are growing in popularity among students [11], some studies show that they still prefer video as a complement to demonstration, rather than a replacement [20-21]. Video is becoming more important as a teaching tool, despite the cost and the requirement for teams of highly skilled people to generate even the briefest video content [22]. While video is an effective teach- ing and learning tool in the digital era, many video re- sources are less valuable without considering the best pedagogical practices, learning contexts in which video is most effective, and production methods for creating helpful video learning resources [23]. Since the literature contends that the effectiveness of teach- ing methods determines the calibre of nursing educa- tion, there is still some disagreement over the value of clinical educational videos [24-25]. Thus expert teams must create [26], and rigorously evaluate, high-quality educational movies [27]. When designing and implementing a video to be a use- ful component of the learning process, the instructor must consider three factors: cognitive load, the ele- ment of engagement, and encouragement of active

learning [8]. A conversational, upbeat approach can augment engagement by using audio and visual com- ponents to convey the various aspects of an explana- tion, and signalling to highlight key ideas or concepts [8]. Studies endorsing the ideas of Brame suggest us- ing short videos [7] and video-based environment technologies with embedded questions to encourage student learning [28, 29]. The setting is highly specialised, and is where clinical educators train new nurses, nurse trainees, and interns. The educational authorities, having investigated crea- tive training methods, developed video-based educa- tion with a view to serving a larger number of trainees and using time and resources efficiently. With their recommendations for instructional videos, the study authors created an instructional film using their exten- sive simulation, clinical, and educational experience. They also considered other suggestions for creating instructional videos [8]. The result was an educational video on External Ventricular Drain (EVD); a medical device used to drain extra cerebrospinal fluid (CSF) from the ventricles of the brain to control elevated in- tracranial pressure (ICP) developed specifically for the study, to compare the effectiveness of video train- ing versus lecture/demonstrations in enhancing the skills and knowledge of nurse interns on the subject of EVD. We aimed to identify effective teaching strate- gies, and to examine whether video recordings of lec- tures improved students’ ability to retain information immediately after hearing them. In this study, it was expected that nurse interns in Saudi Arabia would learn more from a recorded lecture than from a live one.

Materials and Methods

Research design The study utilised a quasi-experimental research method with a post-test-only design. The experi- mental group learned about EVD by watching the video, while the control group learned through a lec- ture/demonstration.

Setting and study participants The research was conducted in an acute healthcare setting in Riyadh, KSA, between June 2019 and May 2020. Nurse interns participating in the internship programme at the time of the study were eligible to participate; none had any prior knowledge about the procedure. The study participants were those nursing interns who fulfilled the sample selection criteria. The estimated sample size was 80; 40 in the experimental group and 40 in the control group. Group sample sizes of 12 and 12 achieve 99% power to detect a difference of 17.4 between the hypotheses that both group means are 55.1. The alternative hy- pothesis is that the mean of group 2 is 37.7, with an estimated group standard deviation of 7.8 and 10.5, and with a 0.05 level of significance, using a two- sided sample test.

Inclusion and exclusion criteria Nurse interns who were available during the study pe- riod and had not been exposed to the EVD procedure during their clinical practice in the current setting were included in the study. Interns who were not will- ing to participate were excluded.

Intervention: Instructional video The researchers created a video on the subject of EVD, lasting 28 minutes and 18 seconds. The video dealt with aspects of EVD such as its purpose, indica- tions, equipment, procedure, care, and aftercare is- sues, including zeroing, sampling, leveling, and read- ing of intracranial pressure (ICP). Using a whiteboard, the video first explained cerebrospinal fluid (CSF), in- tracranial pressure and external ventricular drainage, indication, care, and complications. The setting for the second part of the video was a well-equipped simula- tion lab. EVD system parts were clearly shown and explained using real parts and materials, followed by a demonstration of priming the system, calibrating the pressure transducer; fixing zeroing, draining, monitor- ing, sampling, and dressing.

The script and the steps in the video were based on the literature [30-31]. The video recording, voice record- ing, and final production were undertaken by a profes- sional team from the (audiovisual) advertising field. The video was recorded on mini-DVD disks (digital) and edited using Adobe Premiere Pro. Five experts re- viewed the video for content, clarity, audiovisual tech- nique, setting, voice, and procedure. Their suggestions for content and clarity were incorporated into the final product, but the information presented in the video and lecture remained unchanged. Data collection instrument Data were collected using a demographic form, a questionnaire to assess knowledge of EVD, and a competency checklist to assess skills. The question- naire consisted of 15 multiple-choice questions with a score of 1 for a correct response and 0 for each incor- rect answer, while each of the 15 items on the skills checklist could be answered with the options ‘met’ or ‘unmet’. These questionnaires, prepared from the same literature that was used for the video content, were presented to a panel of experts whose sugges- tions were incorporated. The Cronbach’s alpha value was 0.741, considered a good tool reliability bench- mark. Data collection procedure Data collection was initiated after receiving approval from the Institutional Review Board. The researchers explained the nature and purpose of the study to the participants and obtained their consent, after which the data were collected. The professional video, based on the latest evidence, was prepared and presented by certified nurse educators supported by video produc- tion staff. It was presented on a 50-inch television screen, to groups of 8-10 interns at a time. The data were collected first from the control group, and then from the experimental group. Before the intervention, the knowledge questionnaire was completed by the interns and the clinical educa- tors assessed their skills via the checklist. The participants in the experimental group were

shown the video, which involved a lecture followed by a demonstration, while the procedure was demon- strated to the control group by a clinical instructor fol- lowing a lecture. The participants were then given the same questionnaire, and the same educators assessed their skills on the same day. Statistical analysis Data were analysed using MS Excel-13 and IBM SPSS 25.0 software. The interns’ demographic char- acteristics, along with their knowledge and skill scores, formed part of the descriptive statistics. Cate- gorical variables were described as frequency, with the frequency percentage and mean ±SD for metric variables. Comparisons were determined by inde- pendent t-test to measure mean differences, and the chi-squared or Fisher exact test was used to measure association between categorical variables. Binary lo- gistic regression was performed to explore the

video group, but the difference was insignificant (p=0.583). Skill score Table 3 summarises the skill score of the participants in both groups. Table 2. Knowledge score of the respondents in both groups Items Description Lecture Video p-value

association, and all inferences were drawn at 95% confidence interval (CI). Ethical aspects The study was approved by the hospital’s Institutional Review Board (IRB LOG No. 19-313). Before enroll- ment, potential participants were informed of the pur- pose of the research. All participants were assured an- onymity and confidentiality, and informed that they could voluntarily terminate their participation at any time.

Results

Demographic data

The data analysis showed no significant differences in the random allocation of the 40 nurse interns or the socio-demographic characteristics across the two study groups. Table 1 shows the participants’ demo- graphic data.

Discussion

A high-quality educational video was created for this study, covering the advanced procedure of EVD, with the aim of assessing the knowledge and skills gained through two different educational methods. The find- ings showed no statistically significant difference be- tween the groups’ overall knowledge and competence ratings. The lecture group had a slightly higher knowledge score than the video group, but the differ- ence was insignificant (p=0.583), and the video group outperformed the lecture group with regard to skill. The variation in knowledge might be due to the inter- active discussion during the lecture, which was not available for the video group. Numerous studies have found that classroom instruction and video are equally effective in enhancing procedural knowledge [32-36]; however, this study found that video-based lectures are more successful than the standard teaching meth- ods of lecture and demonstration. Concerning the skill score, the video group performed better than the lecture group in the present study. Other studies have demonstrated the effectiveness of

video presentation [37,38], and our results agree with one study that showed great promise for the use of vid- eos in education [39]. While the literature generally supports the use of video in clinical skills, one study contradicted that view [40], noting that video is not an adequate substitute for a live demonstration by teach- ers for mastering practical skills. That the lecture group had a slightly higher knowledge score than the video group, while the video group out- performed the lecture group in skill, supports the no- tion that no one method can replace another. Instead, research generally supports the integration of video into the lecture format, rather than as a substitute [41,42]. The literature also suggests the importance of combining multimedia with standard methods when teaching complex procedures [43, 44]. When interpreting the study results, several limita- tions should be taken into consideration. This study only involved nurse interns at a frontline hospital care provider site, and the limited sample size is a limita- tion. Moreover, surveys with self-administered ques- tionnaires conducted cross-sectionally have recall, framing, and rating bias limitations which can result in distorted findings. These limitations can be addressed by conducting fu- ture research with a larger sample size, choosing an advanced procedure in which participants have no prior knowledge, carefully selecting the research questions, and choosing an appropriate data collection method. In addition, as technology advances to im-

prove high-quality video, the questionnaire and check- list should be revisited for additional changes when conducting future research on this topic.

Conclusion

This study found no distinction in knowledge acquisi- tion between live lectures with demonstrations and videotaped lectures with demonstrations. Knowledge was gained via both the live demonstration method and the video method. Although the difference was not statistically significant, nursing interns’ skill per- formance was somewhat better in the video group than in the conventional one. The study concluded that video could complement other teaching strategies and training in advanced clinical skills. Based on our con- clusions, it is recommended that traditional classroom instruction be combined with video tutorials to en- hance clinical proficiency in complex procedures such as EVD. The nurse education and quality improve- ment administration can use these findings as evi- dence to support the development of methods to raise the standard of clinical education, with a focus on in- structional design. In the long run, video-assisted training may prove to be a financially prudent inter- vention.

NURSING /PRACTICE IMPLICATIONS This study shows educators the advantages of combin- ing teaching and learning techniques to better impart clinical skills. It is the duty of nursing educators to in- tegrate various teaching techniques in order to opti- mise learning, rather than limiting it to the classroom. Nurse educators should encourage the administration to use the study findings to inform data-driven deci- sions on technology investments, thereby ensuring high-quality and cost-effective video production in clinical education.

Funding

This work was financially supported by the research centre of the study setting (Grant no. 019-046).

CONFLICT OF INTEREST The authors declare no conflict of interest, financial or otherwise.

Acknowledgments

The authors wish to express their sincere gratitude to the nurse interns who volunteered to participate. They also wish to thank the research centre in the study set- ting for the services provided to facilitate the success of the study.