The proliferation of information technology has provided new teaching and evaluation methods. As a result, educators are now challenged with redesigning teaching strategies.
Innovative educators are developing creative learning experiences with technology. One such technology is the use of quick response (QR) codes with smartphones in the classroom.
Students prefer viewing information using smartphone applications (apps) rather than on Web pages.1,2 Removed from the traditionally “teacher-centered” learning model, students are comfortable in image-rich environments and wish to construct their own learning.2 They expect to be actively engaged, thrive on immediate gratification, and want instant answers.2 As a result, rapid evaluation of learning outcomes is now performed electronically.
Inclusion of technology within nursing education has been recommended by several organizations. The Quality and Safety Education for Nurses Institute (QSEN) recommended six global competencies, including information technology.3 Specifically, QSEN defines the knowledge, skills, and abilities nurses need to be proficient with technology and to provide safe patient care: to communicate, manage knowledge, mitigate error, and support decision making.3 In addition, the American Association of Colleges of Nursing included in their educational Essentials the need for nursing informatics competencies to be included in curricula, which will increase students’ knowledge and skills to enhance safe and effective patient care.4
One technological innovation finding its way into the classroom is the use of QR codes, which can be read by smartphones or smart devices. Quick response codes are two-dimensional square patterns that enable the coding or storage of more than 7000 characters.1 Quick response codes are commonly used to convey a Web or email address or link to Web sites.1 By using QR codes, students can save time by directly accessing necessary information quickly and easily without searching through volumes of unnecessary materials. Quick response codes enable student involvement and provide rich and rapid feedback, which is indicated as a primary predictor of learning and development.5,6 Rich and rapid feedback has been shown to be an effective strategy that validates knowledge and motivates learning.7
Although recommendations to use technology have increased in the evidence-based literature,8–10 limited studies exist that investigate mobile technology and perceived usefulness of mobile apps and learning outcomes in nursing education. Therefore, the purpose of this pilot study was to explore QR code use in a lecture and measure students’ satisfaction (met expectations, increased interest, helped understand, and provided practice and prompt feedback) and engagement (liked most, liked least, wanted changed, and kept involved) with QR use compared with a traditional lecture.
Quick Response Codes
Quick response codes were first introduced in 1994 by Denso-Wave, a Japanese company (Kariya, Aichi, Japan), as two-dimensional barcodes for tracking storage.11 Adapted from the more traditional barcode that can store 20 digits, QR codes allow storage of up to 7000 numeric and 4296 alphanumeric characters with mobile tagging of information, social media, and many other evolving technologies.12
Originally used in the classroom in preschool to grade 12, QR codes in the classroom can positively affect student motivation and satisfaction.13–15 Documented within both international and national undergraduate institutions, QR codes have been acknowledged as being used for a variety of reasons within educational settings.16–19
DeSilets18 described QR codes as emerging technology that will revolutionize the educational process with uses for creating digital portfolios for students, linking parents with important classroom information, and engaging students in a variety of activities. Bellot et al19 described the use of QR technology in a doctoral-level nursing course. Using a short descriptive survey, students reported high levels of satisfaction after the use of QR codes during a practicum course.20 Overall, students regarded QR codes as a positive and creative way to integrate information into a practicum experience.20 The authors concluded that QR code technology was a tool to optimize student learning.
Immediate access to materials was the focus of several studies related to classroom learning and the use of QR codes.14,21 Neal22 used QR code technology in a handout for those who preferred not to carry around the materials or books. Eighty percent of learners in that study self-reported enhancement of knowledge, quick access to materials as needed, and fewer printed materials to handle with the new technology.21 In their study using smartphone and QR codes, Lee et al12 reported successful use of QR codes in the classroom and recommended integrating technology into the classroom.
Smartphones have been noted as valuable technology tools that can enhance an individual’s learning and assist with meeting educational objectives and goals.23,24 Smartphone technology has been well outlined in the literature as a meaningful tool to enhance teaching and learning within nursing education by providing students with quick access to evidence-based information in several environments, including classroom, clinic, and home.25–29 Nearly 85% of American college students between the ages of 18 and 30 years own a smartphone.30 It has been estimated that smartphone users spend 89% of their time downloading and using “apps.”11 The average number of apps used is 28 for an average of 37 hours a month in those aged 18 to 24 years, and 29 to 35 hours a month for those aged 25 to 35 years.11
Several studies concluded that the type of device and the students’ familiarity with it may influence learning and recommended that future studies use devices more commonly used by students, such as iPhones.25,28,29 The integration of mobile technology may be a feasible means of optimizing nursing education and facilitating knowledge translation.
All students beginning the 2-year medical-surgical course were eligible to participate in the study. At the beginning of the course semester, all eligible students were invited to a meeting where the study was explained and questions were answered. A total of 45 students consented to participate in the study. The control group (n = 20) students were enrolled in a mandatory acute medical/surgical nursing course and had a grade point average (GPA) of 3.315. The intervention group (n = 24) students were enrolled in the identical course also in the same semester and had a GPA of 3.212. Admissions standards were equivalent for both groups.
In this pilot study, a quasi-experimental design was used. All approvals were gained from the university institutional review board. A convenience sample was chosen of nursing students within a medical-surgical nursing course with basic cardiac electrocardiography (ECG) content.
Two cohorts in a nursing education program at a state university received instruction in a one-semester medical/surgical nursing course. All students in both of the cohorts participated in the study. The instructor of record was identical for both cohorts. Both the control and study groups were expected to access relevant assigned information in advance of the class. The control group received course content in the traditional lecture format; the study group received instruction using QR codes.
We created our QR codes by first selecting a QR code generator from a Web search.31 A code generator is a necessary software program that stores and creates the QR code. Once the generator was located, we developed a QR code by typing in data and downloading it as a high-resolution encryption. Next, we created and selected the QR code design. Once the design was selected, a URL was created to insert the cardiac content of the code. The last step was to test the QR code and make sure the code “read” correctly. Internet access is not required to read the text created by a QR code; however, it is necessary to link to Web sites and videos that are connected to the code.
Students in both groups were assigned cardiac ECG lecture materials with the expectation of attending class prepared to engage in faculty-guided learning activities. Used as a method to measure the electric activity of the heart as an algorithm, the ECG can be used as a means to gain insight into an individual's heart health.32 Learning to interpret ECGs is an important skill for nursing students. However, because of the abstract nature and difficult subject matter, students often become overwhelmed while learning about the ECG; it is a confusing concept.32 Students in the study group were informed that they would be reading ECG rhythm strips by using QR codes. Student performance was evaluated using the same unit examination in each group.
During the unit lecture for the control group, there was no mention or use of QR codes. Quick response codes were introduced to the study group at the beginning of the cardiac unit. Two weeks before the ECG lecture, students in the study group were directed to download a QR reader onto their preferred device. Although it would have been ideal to be able to provide each student with a smartphone, this was beyond the scope of this project. Consequently, students were able to work together in groups of two on each available device. Apps that were free of charge were suggested; however, students were able to download any app they preferred. Students were further encouraged to become familiar with the various functions of QR codes.
In preparation for the cardiac lecture, the faculty downloaded a free QR code generator.31 Different ECG rhythm strips were designed, and the appropriate QR code was integrated into the correlating rhythm card. Each QR code was generated at no cost using the code generator. The QR codes contained images of an ECG readout and the pertinent educational content (Figure 1). The generated codes were printed along with each ECG strip to be assessed by the students. The codes and strips were printed on 8.5 in × 11 in cards and given an identification number.
For the lecture, the cards were displayed around the classroom as stations. Students were paired into groups of two and rotated through the set of stations, each with an emphasis on a different ECG rhythm and associated intervention. Once they worked to identify the rhythm and intervention visible on the card, they scanned the QR code as a self-check, which was linked to the correct answer (Figure 1). Students were able to self-evaluate their knowledge while receiving immediate feedback. During the first 30 minutes of class time, students worked in groups on the QR activity; the remaining time was spent in discussion of the students’ findings. The 8.5 in × 11 in cards were provided to the students to use outside class to further their exposure and knowledge of the cardiac rhythms.
After the lecture, an investigator-adapted survey questionnaire was administered to measure students’ satisfaction (met expectations, increased interest, helped understand, and provided practice and prompt feedback) and engagement (liked most, liked least, wanted changed, and kept involved) with the QR use.33,34 The questionnaire also included questions to assess previous knowledge of QR codes. The instrument was developed based on literature review results for items addressing elements of student satisfaction and engagement in technology-based learning, and instrument content was reviewed by two content experts. The first section of the instrument consisted of three questions to assess previous knowledge of QR codes. The second section of the instrument consisted of four items related to satisfaction and was rated on a 5-point Likert scale: 1, “strongly disagree,” to 5, “strongly agree.” The third section consisted of four open-ended questions adapted from the Online Student Engagement Scale (OSE) describing what was “most” or “least” engaging with the use of QR codes.34 The OSE is a 5-point, reliable and valid Likert scale measuring total engagement and subcomponents of skills, emotional, participant, and performance characteristics. Skills engagement involves abilities required to achieve academic success (eg, current on course readings). Emotional engagement includes affective methods of application (eg, applying course materials to real experiences). Participation is related to activities that demonstrate involvement in the course (eg, discussion forum). Performance is related to success in the course (eg, examination scores).34
Data were analyzed using SAS version 9.3 (SAS Institute, Cary, NC). Descriptive and inferential statistics were used to compare examination scores between the groups. For the examination scores, results were determined overall and specifically in relation to knowledge and application according to Bloom taxonomy. A t test was conducted on the mean examination scores between the students who received the traditional lecture with QR codes and the students who received classroom lecture only.
Overall, 95% of the students in the study group responded to the QR code questionnaire (Table 1). Of the respondents, 10% reported using QR codes at least once, and one-third reported being familiar with QR code technology. All of the students (100%) reported being very knowledgeable in the use of apps and smartphone technology. Using a Likert scale (1, “strongly disagree,” to 5, “strongly agree”), all students reported that scanning QR codes was easy, 90% stated that they found the QR codes to be more helpful than traditional textbook pictures, and most (97%) felt that the QR codes helped improve their learning of cardiac rhythm strips.
Students in the study group indicated high levels of total engagement of 79.8 (≥66.5, highly engaged), with a mean score of 4.18 (>3.4, highly engaged). The highest mean (SD) scores for the engagement subcomponents were emotion (4.72 [0.76]), followed by performance (4.66 [0.53]), skills (4.63 [0.68]), and participation (3.79 [0.86]).
Overall, students in both groups performed similarly on all measures. No significant differences (P < .05) were noted in mean examination scores between students who received traditional lecture (mean [SD], 6.22 [1.65]) and students who received classroom lecture with QR technology (mean [SD], 6.16 [1.92]), t(1) = 0.11, P = NS (Table 2). A small yet positive association was identified between students’ satisfaction with QR codes and overall examination scores (Kendall rank correlation coefficient, 0.372; P = .001). In addition, 92% indicated that the answers provided were informative and helpful, 98% thought that the codes covered the necessary information, and 95% reported that QR codes would be beneficial in the clinical setting. All of the students reported that they would most likely use QR codes in the future.
In this study, although not statically significant, emotion was the highest engagement variable, with a mean (SD) score of 4.72 (0.76), which relates to student level of effort toward course work and instructor effort to make the course materials meaningful and relevant. In the course evaluation, students expressed gratitude to the faculty for the use of QR codes and for the creative use of technology for learning in the classroom. Multiple additional qualitative comments demonstrated student confidence in overcoming anxiety with reading cardiac rhythm strips and that the immediate feedback made learning fun, for example, “The practice is good and having access to the answers helped me understand the strip better,” and “I was nervous when the instructor said we were going to read rhythm strips. The codes made it fun and helpful at the same time.” When students were asked about their experience with the QR code learning activity, most indicated a desire to continue QR code use in future classes.
Some students reported familiarity with smartphones; therefore, this may have contributed to ease of use. Others reported gratification with instant feedback and the ability to get the correct answer. In addition, students reported positive attributes in learning with QR codes. One student reported, “very helpful and fun at the same time”; another indicated, “I thought it helped me a lot. It allowed me to practice and check my answers.”
When asked what they liked least about the QR code exercise, one student indicated that “the strips were not the same as the textbook.” Students in the study group were asked whether they would like to continue the QR code exercise in future classroom sessions. More than 90% (n = 15) indicated their desire to continue using QR technology in the classroom. When asked how they would rate satisfaction with QR codes as a learning activity, most (92%) indicated that they were strongly satisfied with the exercise. One additional comment that emerged from the answers to the questionnaire was students’ hesitation to indicate that they did not have a smartphone or that they did not have a phone that could download a QR code reader. The result of the linear regression did not suggest a relationship between the performance on the examination and the frequency of QR code technology (P = .154). Likewise, no relationship (P = .48) was noted when only considering the examination scores.
This study explored the use of QR codes as a learning aid within a cardiac clinical course. The response rate was 95%, and the sample self-described as knowledgeable in the use of apps and smartphones, although not very familiar with QR codes specifically. Students reported that scanning QR codes was easy and more helpful than traditional textbook pictures. They felt that the QR codes helped improve their learning of cardiac rhythm strips. No significant differences (P < .05) were noted in mean examination scores between groups.
Although there was no statistically significant difference in examination scores, satisfaction scores were high in the study group, and there was a small yet positive association between how students perceived their learning with QR codes and overall examination scores. Students indicated feeling most engaged when course work activities could be applied to real-life situations. The engagement subcomponent of performance was rated second, indicating students’ desire to perform well in class and obtain good grades. The answers provided by means of the QR codes were described as informative, helpful, and covering the necessary information. In addition, most students reported that QR codes would be beneficial in the clinical setting, and all students reported that they would most likely use QR codes in the future.
Students in this study identified QR codes as a useful application on the smartphone and for improving their clinical knowledge. The students had positive perceptions of QR code usefulness, knowledge, and skill acquisition for cardiac rhythms for the clinical setting. These results are consistent with findings from similar studies in nursing education in relation to using mobile technology to enhance clinical knowledge.7,8
Mobile technology use, including QR codes, is increasing in general collegiate classrooms.14 Clay35 indicated that nursing educators need to quickly shift toward mobile technology to provide students a flexible and interactive way to learn clinical skills before entering the clinical setting. Quick response codes are free to generate and may be cost-effective compared with other technologies that cost to use.
Limited Wi-Fi connectivity and cellular access can make it costly to download the free app. Students need to have the necessary technology to read the codes. While many students have smartphones, some do not. To promote a positive experience, the exercise was completed in pairs so all students could participate. Severely wrinkled codes and small code size may limit the ability of the reader to connect the code to the information.
Time and preparation are the biggest challenge in integrating innovation in the classroom. It is important to test the QR code before releasing to students for downloading. Troubleshooting the URL to ensure a correct link to the desired information is another important part of the preparation.
The policy of not allowing phones in the classroom can also be another important factor to consider. While educators may view student use of the smartphone in the classroom as distracting and a nuisance, students enjoy being able to use their phones in class. Instructors have a rich educational opportunity when they embrace smartphone technology in the classroom.
Limitations of this study include the lack of generalizability due to the small sample size. In addition, students were academically homogeneous, meeting the same admission requirements for the nursing program. Outcomes assessed included using traditional methods of test scores. Results may have also been influenced by the faculty inexperience in teaching with technology in a classroom approach, preparing QR codes, and interactive activities. Finally, a longitudinal assessment that measures clinical reasoning to better understand learning outcomes using QR codes is needed.
This study explored the use of QR codes as a learning aid within a cardiac clinical course. Although this study did not demonstrate significant differences in students’ satisfaction or engagement when using QR codes in the classroom, the results did demonstrate overall high engagement levels for students who used the QR code technology, as well as positive feedback on evaluations. The QR codes were well received, and most students preferred their use than the traditional methods of lecture. Most notable was that the QR codes allowed student flexibility with self-assessment of knowledge level by providing immediate feedback and expanded ability to correct and recall information. Although the use of QR codes was not noted as a contributing factor in examination scores, students provided positive comments that supported use of the codes.
Future studies could explore the implementation of QR code technology across the curriculum, starting at the beginning of the program. For example, smartphone technology could be incorporated in the student’s program orientation by scanning a QR code for the address and map of their clinical site or scanning a QR code for the instructor’s contact information. Implementing smartphone technology into the traditional classroom can allow nursing faculty to spend more time on application and analysis of the students, in addition to meeting the standards of QSEN.
Overall, the use of QR codes was a creative and positive way to integrate technology into the classroom to provide students with instant positive feedback. Students want and expect the use of technology in the classroom.8 Nursing educators should consider incorporating newly emerging technologies that support student development of clinical reasoning skills to facilitate higher levels of learning. The QR codes served as a cost-effective learning aid to supplement student learning.
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