Professional nurses who teach other nurses combine experiences and knowledge from clinical and conceptual components of nursing practice. Nurse educators have advanced educational preparation in teaching, learning, and assessment; and are able to blend educational activities in the teaching of professional nursing. It is essential that new nurse educators implement current methodologies and strategies to advance learning in the practice of nursing. Nurse educators direct their efforts and attention to thinking and how information is processed. Metacognition is the act of thinking about your thinking and involves active control over the cognitive processes engaged in learning. Educators are interested in learning which activities and resources will influence cognitive and metacognitive development. Metacognition requires attention to how learning occurs. How do educators influence the thinking process in choosing variables for teaching? Livingston (1997) relates that metacognition requires attention to how learning occurs and identifies that the most effective mechanism is providing the learner with “both knowledge of cognitive processes and strategies using both cognitive and metacognitive strategies and evaluating the outcomes of their efforts” (3). It is the learner who acquires cognitive and metacognitive skills but the educator influences this process. How receptive are nurse educators to include resources in electronic formats to develop cognitive and metacognitive learning processes?

This study was conducted to determine if faculty would be willing to adopt an e-Book in a nursing course. Several nurse educators collaborated on developing an e-Book for nurse educators and used this e-Book as an example of a textbook for a nurse educator course. Inspiring Future Nurse Educators is currently the only known e-Book native to the iAuthor software (Lauer-Pfrommer et al. 2014). As with any new technology, it is vital to assess the likelihood of adoption by faculty and learners. The premise of the e-Book was that visual designs with embedded interactive technologies adhere to Universal Design for Learning (UDL) and increase metacognition by creating a learning experience that is engaging for all learning styles and needs.

Much has been researched and published on metacognition and the use of technologies as a scaffold to increasing metacognition (Peters 2000; Lam, Lam, Lam & McNaught 2009; Chih-Ming & Chia-Chi 2010); however, very little is known about the use of digital interactive e-Books. The e-Books are content-based materials, which are developed in the electronic or digital format, are reviewed on a screen and have resources and the potential to change levels of understanding, comprehension, and learning. While resources have to be found and adapted for learning, the e-Book integrates a variety of digital resources for learning needs. Prensky (2011) identifies that the millennial population prefer technology for learning, and notes that the technology is part of their natural world. Books on hand held devices are very popular with all age groups, are portable, up-to date, incorporate links to multi-media resources and serve as guides and resources to capture knowledge and information. Incorporating hyperlinks and other multi-media attachments into the e-Books change the experience of reading, exposure to experiences and learning opportunities. Interactive e-Books embrace best practices in web technologies, audiovisual UDL and media based learning design. Although the potential effectiveness of learning with digital content may be subjective, it is the learner who demonstrates advances in metacognition. The purpose of this study is to explore nursing faculty’s perceived usage of interactive e-Book technologies to enhance metacognition in nursing students.

Design and Procedure

The study examined perceptions of usefulness, attitude, and preferences in an effort to predict faculty acceptance of the e-Book format. An e-Book for nurse educators, Inspiring Future Nurse Educators, was developed as a textbook for a nurse educator course (Lauer-Pfrommer et al. 2014) and was downloaded into iPads to be viewed by the recruited faculty members. The Technology Acceptance Model (TAM) was used in this study for its predictive ability in studies involving adoption of technologies (Venkatesh 2000; Kiraz & Ozdemir 2006; Venkatesh 2008).

Sample and Data Collection

Full-time nursing faculty members from a diploma school of nursing (n=10) were recruited to participate in this pilot study. Data collection occurred before exposure to the e-Book to measure their perceptions about e-Book usage; and the second collection occurred after using the e-Book. Data analysis was completed to examine if there were any changes to the faculty members’ perceptions of usefulness, attitude, and preferences post-exposure. SPSS software 21.0 was used for statistical analysis.


In addition to demographic data questionnaires, the TAM questionnaire by Venkatesh (2000) was adopted and modified for the e-Book survey with the author’s permission. A pretest was administered to determine perceptions of e-Book usefulness attitude, and preferences. The participants were then provided with iPads to review the format and interactive technology included in the e-Book. A post-test was administered to examine if their perceptions had changed.

Data Analysis and Results

When comparing overall pretest (mean of 44.80) and posttest scores (mean of 45.60), the increase was significant (p=0.000), signifying more favorable attitudes post-exposure to the e-Book. Post-scores on self-assessment about e-Book usage competence also increased from 1.30 to 1.50 with significance (p=0.000).

Mean year of nursing practice for the faculty (n=10) was 16.26 years. When comparing the years of nursing practice with the educators’ perceptions about e-Book improving their students’ understanding of materials, there was no difference between the means for pretest and posttest (both were 4.00), with no significance (p=0.734 and p=0.697). Examining the educators with more than 10 years of nursing experience, the scores increased from 43.13 to 45.00 after the post-exposure to the e-Book, but this was not significant (p=0.713). Post-scores for educators with more than 5 to 10 years of experience decreased from 51.50 to 48.00, but this was also not significant (p=0.109).

When examining age (mean age = 47.20) and their own self-description as novice, intermediate, or advanced use of technology, there was no changes pretest or posttest (p=0.439 and p=0.439). Most educators rated themselves as intermediate or advanced users. However, their posttest rating as advanced user decreased from 51 to 46.66 (p=0.041 and p=0.831) after the exposure to the e-Book. Using Spearman’s Rho, age and technology use level (novice, intermediate, or advanced) were examined but did not show any significance (p=0.525).

Using one way ANOVA, the post-scores for the educators who self-identified as using technology more than 4 times a week decreased from 47.75 to 43.25. For others who reported that they used technology less than once per week, their post-scores increased from 45.67 to 50.33, which was not significant (p=0.639). Post-scores of favorable attitude toward e-Book decreased for the nursing faculty, who used technology more than 4 times a week, from 3.75 to 3.50. For others who used technology less than once per week, their post-scores increased from 3.00 to 3.67, but it was not significant (p=0.465).


Technology in education has the opportunity to facilitate a learner-centered environment, which features new and interactive modes of engaging students (Littlefield et al. 2014). Digital Learning Objects (DLO) are described as “re-usable resources with pedagogical purpose” and can be embedded through hyperlinks as web addresses (Littlefield et al. 2014). DLO can be embedded in digital books to provide alternative and supplemental contents which can accommodate different learning styles. Using the learning objects in a digital product is ideal for sharing knowledge in a variety of contexts.

Research by Peters (2000) revealed that the digital format did not impede learning in a health education course and offered improvement in terms of motivation, retention, and reading persistence. When digital resources are consistently integrated into the learning environment, students develop a stronger appreciation and motivation to using resources which will build learning. Continued positive findings were concluded by Chih-Ming and Chia-Chi (2010) to show that learning performance and satisfaction “were superior” when digital resources were utilized.

Lam, Lam, Lam and McNaught (2009) identified that mobile learning extended the learning space beyond traditional classrooms offering students increased opportunities to enhance the learning experience. Developing the cognitive process to a higher level is the focus of learning and metacognition. Metacognition involves a process to know what you are thinking and experiencing. One must be actively aware of knowledge and how it was constructed. Metacognition is a construction of those cognitive structures requiring the learner to actively engage in the process of learning. Improvements in metacognition result when the learner is engaged in reading and learning at a higher level (McKeachie 2006). As educators, it is essential to use strategies and resources that will enhance cognitive structures to build metacognition.


This study explored perceptions of nursing faculty using an interactive eBook to enhance metacognition in nursing students. The strength of this study is that it is one of the few attempts at understanding perceptions of usefulness, attitude, and preferences in an effort to predict faculty acceptance of the interactive eBook format. Although the sample size was too small for generalizability, this pilot study could be replicated with a larger population.

Nurse educators incorporate a variety of teaching strategies to influence how individuals learn and how the process of learning can be enhanced. Continued efforts to seek innovative teaching/learning experiences, to change the development and growth of knowledge, and to help students be more aware of how they learn and how to regulate their learning are the main focus of metacognitive learning. With increased usage of interactive eBook in academic and clinical settings, educators need to advocate for greater use of the technology in educating nurses to enhance metacognition.

Dr. Mary Wombwell is a certified nurse educator who has taught in all levels of nursing education (LPN, Diploma, AD, BSN & MSN). Presently, she teaches in an Online program and in the RN-BSN & MSN programs at Holy Family University. She is involved in community service and serve as a Community Board Member for 2 agencies: Greater Philadelphia Health Action, Inc ( Health Clinic serving the needs of Philadelphia residents) and for a Continuing Care Retirement Community in Philadelphia. She is active in STTI – Delta Tau Chapter at-Large and her research interest is centered on Mindfulness, Wellness, Health Promotion and the RN-BSN student. Her professional practice areas consisted of experiences in Medical Surgical, Perioperative Services, Home Care and Community Health.

Dr. Boas Yu is a Gerontological Clinical Nurse Specialist and currently certified as a Nurse Educator and a Family Nurse Practitioner. She has over 13 years of experience in teaching geriatric nursing, medical-surgical nursing, and nursing administration/leadership. Her research interests include complementary/alternative therapies, caregiving practices, and metacognitive learning strategies. She is currently an associate director of graduate nursing programs at Henry P. Becton School of Nursing and Allied Health, Fairleigh Dickinson University.


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