Critical Review – McCutcheon et al (2015)

McCutcheon, K., Lohan, M., Traynor, M. and Martin, D. (2015) ‘A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education’ In: Journal of Advanced Nursing 71(2): 255 – 270


The UK Higher Education Sector has seen a rapid increase in the use of online and blended methods to deliver course content and to support learning (O’Neil et al 2014). McCutcheon et al (2015) conducted a systematic review of the literature to compare the effectiveness of online- or blended-learning approaches, in comparison with face-to-face teaching of clinical skills for pre-registration nurse education. The review highlights an ongoing lack of high-quality research into the effects of blended learning in this field, and the urgent need to address this in light of current policies and drivers affecting student nurses’ ability to learn clinical skills effectively in their practice placements.


McCutcheon et al (2015) identify a clear need for nurse educators in Higher Education Institutions (HEIs) to develop innovative and effective methods of delivering pre-registration education and training. A key component of nurse training is the requirement for 50% of the course to be spent developing practical skills involving direct patient care in a range of clinical settings (Nursing and Midwifery Council (NMC) 2010). However, several drivers, including current government austerity measures, staff shortages and high levels of staff turnover, have led to a reduction in the ability of qualified nurse mentors to deliver high quality learning experiences to student nurses on placement. (Traynor et al, 2010). The aim of this systematic review therefore, is to identify whether online and/or blended-learning approaches might have the potential to meet this shortfall and deliver effective training in practical clinical skills.

Key findings include a lack of consistency in the types of online and blended-learning approaches, and a lack of sufficient robust evidence with which to reach a conclusive position on the effectiveness of either approach.


The authors appear to have used a thorough search methodology, with reasoned justification for the parameters selected, which would make replication possible. The methodology included a review of ongoing research projects and unpublished literature, including student dissertations. This may help to mitigate some of the quality control issues associated with the current peer-review system (da Silva and Dobránszki, 2015). Inclusion and exclusion criteria were clearly stated, and justified. However, the authors excluded studies where the online teaching strategy used was for the primary development of theoretical knowledge. For areas such as drug calculations, for example, the theoretical knowledge is inextricably linked with the practical skills, which would be entirely unsafe without the underpinning numeracy skills. This parameter may, therefore, have excluded some relevant studies.

Two critical appraisal tools  were used to identify the study’s risk of bias. These were based on the JBI_MAStARI tool for the quantitative studies, and JBI-QARI for the qualitative studies. These appear to be appropriate and robust although access to the tools is restricted beyond the user guide cited in the review.

Data synthesis was designed to address key learning outcomes for clinical skills education, including knowledge, performance, self-efficacy and student satisfaction. It is difficult to ascertain the quality of the performance metrics for each study. Some studies clearly state that students were assessed via Objective Structured Clinical Examination (OSCE); a well-established and highly-regarded clinical assessment tool (Meskell et al, 2015) however, many seemed to use written assessments, which are arguably an invalid tool for the assessment of practical skills (Wright, 2007). The use of student satisfaction data as an indicator of high quality and high impact instruction and learning is also questionable (Jones et al, 2014).

The review concludes that online learning appeared to deliver a similar benefit to traditional teaching methods in 10 of the 13 studies. These findings are consistent with the ‘no significant difference’ phenomenon (Russell, 2001, cited in Hattie, 2009) and possibly lend further credibility to the ‘methods not media’ hypothesis (Clark, 2005, cited in Sung and Mayer, 2013), as it does not appear to be possible to separate the impact of the media used from that of the pedagogic techniques utilised.

The paper takes a realistic view of its own limitations, the most significant of these being the lack of a minimum quality threshold, which might have excluded some poor quality studies. Additionally, the authors acknowledge that only one of the studies reviewed reported medium-term post-intervention recall; the results and findings cannot, therefore be generalised to indicate a high quality of long-term retention of information or higher order transfer of skills into new situations.


This systematic review clearly identifies the need for nurse educators to identify areas in which online and blended learning approaches can be used to support student nurses in developing clinical skills.  It presents a well-structured review and critique of the current evidence base, along with clear recommendations for the use of this evidence to influence not only the pedagogic decisions of individual educators, but also future developments for policy and practice in nursing research and education. In conclusion, it makes a worthwhile and valid contribution to the emerging knowledge base in this field.


da Silva, J.A.T. and Dobránszki, J. (2015) ‘Problems with Traditional Science Publishing and Finding a Wider Niche for Post-Publication Peer Review’ In: Accountability in Research 22: 22 – 40

Hattie, J. A. C. (2009) Visible learning: A synthesis of over 800 meta-analyses related to achievement  New York: Routledge

Jones, J.,  Gaffney-Rhys, R. and Jones, E. (2014) ‘Handle with care! An exploration of the potential risks associated with the publication and summative usage of student evaluation of teaching (SET) results’ In: Journal of Further and Higher Education 38(1): 37 – 56

McCutcheon, K., Lohan, M., Traynor, M. and Martin, D. (2015) ‘A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education’ In: Journal of Advanced Nursing 71(2), 255 – 270

Meskell, P., Burke, E., Kropmans, T.J.B., Byrne, E., Setyonugroho, W. and Kennedy, K.M. (2015) ‘Back to the future: An online OSCE Managemenr Information System for nursing OSCEs’ In: Nurse Education Today 35: 1091 – 1096

Nursing and Midwifery Council (2010) Standards for pre-registration nursing education Online at: [Accessed on  30 January 2016]

O’Neil, C.A., Fisher, C.A. and Rietschel, M.J. (2014) Developing Online Learning Environments in Nurse Education (3rd edition) New York: Springer

Sung, E. and Mayer, R.E. (2013) ‘Online multimedia learning with mobile devices and desktop computers: an experimental test of Clark’s methods-not-media hypothesis’ In: Computers in Human Behavior 29: 639 – 647

Traynor, M., Gallagher, A., Martin, L. and Smyth, S. (2010) ‘From novice to expert: using simulators to enhance practical skill’ In: British Journal of Nursing 19(22), 1422 – 1426

Wright, K. (2007) ‘A written assessment is an invalid test of numeracy skills’ In: British Journal of Nursing 16(13):28-30


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