Nurse Education Today 33 (2013) 1576–1580

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

YouTube as a source of clinical skills education

Ian Duncan, Lee Yarwood-Ross, Carol Haigh ⁎
Manchester Metropolitan University, United Kingdom

a r t i c l e i n f o s u m m a r y

Article history: Background: YouTube may be viewed as a great ‘time waster’ but a significant amount of educative material
Accepted 20 December 2012 can be found if the user is carefully selective. Interestingly, the growth of educational video on YouTube is
closely associated to video viewership which increased from 22% to 38% between 2007 and 2009.
Keywords: Objectives: This paper describes the findings of a study undertaken to assess the quality of clinical skills videos
Technology
available on the video sharing site YouTube.
YouTube
Design: This study evaluated 100 YouTube sites, approximately 1500 min or 25 h worth of content across 10
Clinical skills
Nurse education
common clinical skill related topics.
Methods: In consultation with novice practitioners, nurses in the first year of their university diploma
programme, we identified ten common clinical skills that typically students would explore in more detail
or would wish to revisit outside of the formal teaching environment. For each of these topics, we viewed
each of the first 10 videos on the YouTube website. The videos were evaluated using a modification of the
criteria outlined in Evaluation of Video Media Guideline.
Results: The topic with the biggest number of both postings and views was cardiopulmonary resuscitation
and more specialist, nursing or health related topics such as managing a syringe driver or undertaking a
pain assessment had less video content and lower numbers of viewers. Only one video out of the 100
analysed could be categorised as ‘good’ and that was the one in the Cannulation section. 60% of the CPR
and venepuncture content was categorised as ‘satisfactory’.
Conclusions: There is a clear need for the quality of YouTube videos to be subjected to a rigorous evaluation.
Lecturers should be more proactive in recommending suitable YouTube material as supplementary learning
materials after appropriately checking for quality.
© 2013 Elsevier Ltd. All rights reserved.

Introduction
This paper describes the findings of a study undertaken to assess
the quality of clinical skills videos available on the video sharing site
YouTube. One of the difficulties surrounding such easily accessible
information sites, for nurse educationalists, is the lack of clear under-
standing regarding the quality and accuracy of the content. This study
evaluated 100 YouTube sites, approximately 1500 min or 25 h worth
of content across 10 common clinical skill related topics.
Background
Launched in 2005, YouTube is an Internet application in which peo-
ple upload, share and watch videos through a simple and integrated
platform (Snyder and Burke, 2008; Cheng et al., 2007). Social media in
general is increasing in popularity and a 2006 survey found that
100 million video clips are viewed daily on YouTube and 65,000 new
videos are uploaded each day (USA Today, 2007). Recent statistics
⁎ Corresponding author.
E-mail address: c.haigh@mmu.ac.uk (C. Haigh).
report that 800 million people visit the site each month and 70% of
the internet traffic comes from outside the United States (YouTube,
2012). Due to the large amount of traffic YouTube receives, it inevitably
attracts a large amount of professionals to the site (Kruitbosch and
Nack, 2008).
The users of social media are commonly named in the literature by
such names as; the ‘millennials’ and the ‘net generation’ who have
grown up with the advancements of digital technology and use it in
their daily lives (Olsen, 2005; Tapscott, 1997). They do not only access
the Internet but use it as a form of communication and networking.
YouTube may be viewed as a great ‘time waster’ but a significant
amount of educative material can be found if the user is carefully
selective. Interestingly, the growth of educational video on YouTube
is closely associated to video viewership, which increased from 22%
to 38% between 2007 and 2009 (Purcell, 2010) and has attracted
attention in the education sector and scholarship (Snelson, 2011).
Academic institutions are able to utilise YouTube to form their own
‘channel’ where staff and students can make video clips to enhance
their course material and learning. Furthermore, Burke et al. (2009)
found that YouTube videos provided a fresh approach, enabled the
linking of theory to practice and had the ability to promote discussion
and critical thinking.

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2012.12.013
 I. Duncan et al. / Nurse Education Today 33 (2013) 1576–1580 1577

There has been a recognisable increase in the use of cyber-materials Methods

(Armstrong et al., 2001; Nicholas, et al. 2009). Haigh (2010) noted the
increased use of Wikipedia amongst health and social care students In consultation with novice practitioners, nurses in the first year of
and Agazio and Buckley (2009) highlighted the potential of video shar- their university diploma programme, we identified ten common clin-
ing sites such as YouTube as creative methods of teaching. It is argued ical skills that typically students would explore in more detail or
that students are now challenging the traditional model of higher edu- would wish to revisit outside of the formal teaching environment.
cation with the educator at the forefront of learning process and are Whilst acknowledging that search filters exist on the YouTube site,
demanding up to date models of learning (Clifton and Mann, 2011). we limited the search terms to simple descriptions of the clinical
As they are used to using technology they expect to see it being used skills in which we were interested. Head and Eisenberg (2010)
in class (Skiba and Barton, 2006). It is assumed that YouTube videos noted that students often struggled with developing sophisticated
can promote active participation as oppose to students being traditional search strategies and will, in the first instance use simple topic related
passive learners (Skiba, 2007) which complements the teaching of search terms.
modern health courses where there are elements of self directed learn- The topics, and therefore the search terms we used were
ing in their curriculums (Farnan et al., 2008).
• Venepuncture
There is an emphasis on modern education being innovative and
• Cannulation
creative (Snyder and Burke, 2008. National Center on Education and the
• Urinary catheterisation
Economy, 2006) and incorporating YouTube in education is seen to be
• Managing a syringe driver
an innovative tool and can be a useful way of maintaining student's
• Using pain assessment tools
attention and making learning memorable (Garrett-Wright and Abell,
• Wound assessment
2011 Clifton and Mann, 2011). These findings are positive but a concern
• Cardio-pulmonary resuscitation
that has been identified is that YouTube requires the user to be Internet
• Oral care
and information literate in order to use it effectively and not all educators
• Electro-cardiogram
may be as ‘tech savvy’ as students (Clifton and Mann, 2011). This may
• Aseptic technique.
lead to educators failing to provide 21st century education through
modern technologies and stresses that continual professional develop- For each of these topics, we viewed each of the first 10 videos on the
ment for educators and meeting their learning needs are also paramount. YouTube website during the month of December 2011. We selected
Very few papers have investigated student perceptions and usage YouTube rather than other video sharing sites such as TED (Technology
of YouTube but Snyder and Burke (2008) investigated YouTube as a Entertainment, Design) or Metacafe, as YouTube is the second most
learning aid and found that 89% of students stated that it had en- popular website in the world (after Facebook) with 790 million
hanced their learning and 73% reported that they would like educa-
tionalists to use it more in class. Another similar study by Jaffar
Table 1
(2012) investigated the use of YouTube videos in learning anatomy Evaluation criteria.
and found that that 98% of students used the videos and 92% agreed Adapted from Feller (1992).
that the channel helped their learning of anatomy. There have also
Content
been further reports of positive experiences of using YouTube in edu- • Early presentation of intent
cation (Kohle and Cuevas, 2010; Trier, 2007) but there is a lack of re- The purpose of the video should be apparent in the first quarter of the presentation
search to determine how and in what ways YouTube impacts on • Integrity of title
learning and achievement outcomes. However, Martin (2009) carried The title accurately reflect the purpose of the video
• No extraneous material
out a study on 1127 students to investigate whether there was a rela- The content of the video should match with the stated objectives
tionship between social media usage and grades but the results did • Use of correct technique
not indicate any correlation. Although the findings did suggest that The skills should be demonstrated to a standard comparable with that of face
YouTube was the second most visited video sharing platform and to face skills teaching
• Develops skills base
more importantly, 26% of Martin's sample reported using it for educa-
Video provides information that allows the student to develop/enhance their
tional purposes. skills base.
From the educationalists viewpoint, Moran et al. (2011) survey • Health and safety
1920 faculty members and reported that 98% had an awareness of The content is appropriate in terms of ensuring patient/practitioner safety
YouTube and 90% of them were using social media in the courses Production
• Picture quality
that they taught. YouTube was found to be the most frequently This included focus, clarity, colour accuracy and colour balance.
cited source of social media used in education and over 40% of educa- • Sound quality
tionalists required students to read or view social media as part of an This included clarity, volume pace and narrative
assignment. These findings indicate that there is a high usage of •Length
The length of the video should balanced with the content and other technical
YouTube from professionals in the education sector.
considerations
The positive aspects of using YouTube are identified but the liter- Users
ature frequently raises concerns over issues such as; the credibility of • Purpose, objective and audience
the video content and the time it takes to search for appropriate con- The general and specific learning objective should be clear
tent and to check validity (Jaffar, 2012; Burke et al., 2009; Snyder and • Synopsis
There should be a clear synopsis giving an accurate description of the video
Burke, 2008; Farnan et al., 2008). These are important issues and a
• Evaluation of effectiveness
specific intervention has been implemented by YouTube in 2009 There is a way of evaluating the effectiveness of the material offered
called ‘YouTubeEDU’ which seeks to collate and organize all the edu- • Discussion/activities/resources
cational materials being uploaded so it is easier to access which helps Specific suggestions provided to encourage the viewer to move from passive
to active involvement.
address any credibility and validity issues.
Each variable rated on 1–5 scale
Using video technology to facilitate learning has become easier to • 1 = unsatisfactory
incorporate in the classroom but the research for using YouTube • 2 = poor
as a pedagogical tool is limited (Kellner and Gooyon, 2010) and • 3 = satisfactory
there is clearly a need for additional research to supplement existing • 4 = good
• 5 = outstanding
knowledge.
1578 I. Duncan et al. / Nurse Education Today 33 (2013) 1576–1580

Table 2 Table 4
Overview of video data. Statistically significant post-hoc comparisons.

Topic Total/percentage Date of Number of views Venepuncture Syringe drivers

viewed top post of top post (M = 26.0 SD = 6.8) (M = 10.80 SD = 6.1)

Venepuncture 590/1.7 2010 234,730 Wound care

Cannulation 554/1.8 2010 448,774 (M = 13.10 SD = 6.2)
Urinary catheterisation 940/1.0 2008 650,397
Cannulation Syringe drivers
Managing a syringe driver 112/9.0 2010 9148
(M = 24.20 SD 9.6) (M = 10.80 SD = 6.1)
Using pain assessment tools 326/3.0 2011 5891
Wound care
Wound assessment 254/4.0 2009 25,196
(M = 13.10 SD = 6.2)
Cardio-pulmonary resuscitation 27,700/0.01 2010 4,599,292
Syringe drivers Venepuncture
Oral care 13,100/0.07 2011 119,394
(M = 10.80 SD = 6.1) (M = 26.0 SD = 6.8)
Electro-cardiogram 11,900/0.08 2010 383,755
Cannulation
Aseptic technique 417/2.4 2011 138,730
(M = 24.20 SD 9.6)
CPR
(M = 24.4 SD = 7.7)
Wound care Cannulation
visitors per month and 100 billion page views and the only video (M = 13.10 SD = 6.2) (M = 24.20 SD 9.6)
sharing site in the top 10 websites (Scott, 2011), thus it is was CPR Syringe drivers
reasonable to assume that this would be the site that the majority (M = 24.4 SD = 7.7) (M = 10.80 SD = 6.1)
of students would use. Aseptic technique Syringe drivers
(23.1 SD = ^.£) (M = 10.80 SD = 6.1)
The videos were evaluated using a modification of the criteria
outlined in Evaluation of Video Media Guidelines (Feller, 1992) as All significant at the .05 level.
shown in Table 1.
Members of the team (a practising nurse, a health care academic specialist, nursing or health related topics such as managing a syringe
and a biologist) viewed each video separately and a consensus score driver or undertaking a pain assessment had less video content and
was developed for those videos where opinions differed. Each video lower numbers of viewers.
could achieve a maximum score of 65 and was categorised as follows; We carried out a comparison of means across all groups (Table 3).
Although the mean scores for each separate category varied from
01–12 Unsatisfactory 11.40 (mouth care) to 26.00 (venepuncture) the overall means across
13–25 Poor the sample was 20.0. A one-way between-groups analysis of variance
26–39 Satisfactory was conducted to explore the impact of content upon overall mean
40–53 Good quality score. The sample was divided into 10 groups (to reflect the
54–65 Outstanding. 10 content areas). There was a statistically significant difference at
the p b .001 level in mean scores across the topics: F (9, 90) = 4.1
Videos on YouTube are not presented in order of posting, with the p = .001. Despite reaching statistical significance, the actual differ-
newer ones first but by are sequenced by number of views so we also ence in mean scores between the groups was quite small. The effect
looked at how long the top video had been on the site in order to assess size, calculated using eta squared was .2. Statistically significant
how current the most popular/useful information being presented was. post-hoc comparisons using the Tukey HSD test are summarised in
We subjected the modified scale to analysis using Cronbach's alpha. The Table 4.
scale showed a Cronbach's alpha of .84 which suggests good internal Catheterisation (M= 18.4 SD = 9.4), pain assessment (M= 21.0
consistency. SD=6.5), mouth care (M=21.0 SD=9.7) and ECG (M=17.4 SD=8.3)
did not differ significantly from any of the other groups.
Table 5 shows the summary information provided by cross tabu-
Data/Results lating the individual video content with the classification criteria.
It can be seen that only one video out of the 100 analysed could be
Table 2 shows the topics selected, the total number of videos on the categorised as ‘good’ and that was the one in the Cannulation section.
site, the longevity of the post and the number of views of the top video. 60% of the CPR and venepuncture content was categorised as
It can be seen that the topic with the biggest number of both post- ‘satisfactory’. The worst video content was found in the syringe driver
ing and views was the cardio-pulmonary resuscitation one and more content with 70% of the videos analysed falling into the lowest

Table 3
Comparison of means across groups.

Descriptives

Total

N Mean Std. deviation Std. error 95% confidence interval for mean Minimum Maximum

Lower bound Upper bound

Venepuncture 10 26.00 6.880 2.176 21.08 30.92 14 35

Cannulation 10 24.80 9.612 3.040 17.92 31.68 12 41
Catheterisation 10 18.40 9.477 2.997 11.62 25.18 11 37
Syringe drivers 10 10.80 6.161 1.948 6.39 15.21 4 22
Pain assessment 10 21.00 6.583 2.082 16.29 25.71 12 34
Wound care 10 13.10 6.262 1.980 8.62 17.58 6 24
CPR 10 24.40 7.792 2.464 18.83 29.97 10 32
Mouth care 10 21.00 9.718 3.073 14.05 27.95 8 35
ECG 10 17.40 8.383 2.651 11.40 23.40 10 37
Aseptic technique 10 23.10 6.385 2.019 18.53 27.67 15 33
Total 100 20.00 8.911 .891 18.23 21.77 4 41
 I. Duncan et al. / Nurse Education Today 33 (2013) 1576–1580 1579

Table 5
Crosstabulation of data.

Crosstab Classification Total

Unsatisfactory Poor Satisfactory Good

Venepuncture Count 0 4 6 0 10
% within video content .0% 40.0% 60.0% .0% 100.0%
% within classification .0% 10.0% 20.0% .0% 10.0%
% of total .0% 4.0% 6.0% .0% 10.0%
Cannulation Count 1 4 4 1 10
% within video content 10.0% 40.0% 40.0% 10.0% 100.0%
% within classification 3.4% 10.0% 13.3% 100.0% 10.0%
% of total 1.0% 4.0% 4.0% 1.0% 10.0%
Catheterisation Count 5 2 3 0 10
% within video content 50.0% 20.0% 30.0% .0% 100.0%
% within classification 17.2% 5.0% 10.0% .0% 10.0%
% of total 5.0% 2.0% 3.0% .0% 10.0%
Syringe drivers Count 7 3 0 0 10
% within video content 70.0% 30.0% .0% .0% 100.0%
% within classification 24.1% 7.5% .0% .0% 10.0%
% of total 7.0% 3.0% .0% .0% 10.0%
Pain assessment Count 1 7 2 0 10
% within video content 10.0% 70.0% 20.0% .0% 100.0%
% within classification 3.4% 17.5% 6.7% .0% 10.0%
% of total 1.0% 7.0% 2.0% .0% 10.0%
Wound care Count 5 4 1 0 10
% within video content 50.0% 40.0% 10.0% .0% 100.0%
% within classification 17.2% 10.0% 3.3% .0% 10.0%
% of total 5.0% 4.0% 1.0% .0% 10.0%
CPR Count 2 2 6 0 10
% within video content 20.0% 20.0% 60.0% .0% 100.0%
% within classification 6.9% 5.0% 20.0% .0% 10.0%
% of total 2.0% 2.0% 6.0% .0% 10.0%
Mouth care Count 3 4 3 0 10
% within video content 30.0% 40.0% 30.0% .0% 100.0%
% within classification 10.3% 10.0% 10.0% .0% 10.0%
% of total 3.0% 4.0% 3.0% .0% 10.0%
ECG Count 5 3 2 0 10
% within video content 50.0% 30.0% 20.0% .0% 100.0%
% within classification 17.2% 7.5% 6.7% .0% 10.0%
% Of Total 5.0% 3.0% 2.0% .0% 10.0%
Aseptic technique Count 0 7 3 0 10
% within video content .0% 70.0% 30.0% .0% 100.0%
% within classification .0% 17.5% 10.0% .0% 10.0%
% of total .0% 7.0% 3.0% .0% 10.0%
Total Count 29 40 30 1 100
% within video content 29.0% 40.0% 30.0% 1.0% 100.0%
% within classification 100.0% 100.0% 100.0% 100.0% 100.0%
% of total 29.0% 40.0% 30.0% 1.0% 100.0%

‘unsatisfactory’ category and 100% of the syringe driver videos being
identified as either ‘unsatisfactory’ or ‘poor’. Taking the entire sample
as a whole, Table 5 shows that 69% of all of the videos analysed were
of substandard quality. From a clinical skills (rather than a production
values) perspective 31% of the videos evaluated demonstrated poor or
unsatisfactory infection control techniques, with a further 37% not
acknowledging infection control issues at all, 35% used poor or unsatis-
factory technique and a further 50% did not discuss the importance of
correct technique at all. 30% of the entire sample did not include
information within the video that would encourage or aid a student to
further their knowledge.
The relationship between total quality score (as measured by the
adapted Feller scale) and number of ‘likes’ was investigated using
Spearman's rho. There was a strong positive correlation between
number of ‘likes’ and overall quality score rs = .845 n = 100 p = .01
with a high quality score being associated with a great number of
‘likes’ on the site.
Limitations to the Study
The main limitation of the study is that only 10 videos of the hun-
dreds available for each of the topic were viewed, an average of 2.3%
of available material, however Digital Point, an online webmaster
forum, suggests that most individuals rarely venture beyond the first
page of their search results (1999). Thus, although not necessarily rep-
resentative of the entire content the sample in this study does reflect
the immediate information that would be available.
Discussion and Conclusion
The data presented here suggests that overall the 100 most easily
accessible or watched clinical skills focussed YouTube videos are not
necessarily clinically robust or invested with high quality production
values. Overall the quality and/or content of the site was poor al-
though the analysis suggests that different topics were often weak
in different areas. Little work has been done on what criteria lecturers
use for the selection or recommendation of YouTube videos to their
students. Burke et al. (2009) note that lecturers tend to choose
YouTube content from credible sources such as the World Health
Organisation when incorporating such content into classroom based
sessions. This study would suggest that some guidelines aimed at
the self directed and independent learners that universities expect
their students to become would allow students to evaluate from
themselves the accuracy and applicability of ‘stumble across’ content
by which we mean the sites that come up from a broad search of
YouTube subject matter. There is evidence within the data that
1580 I. Duncan et al. / Nurse Education Today 33 (2013) 1576–1580
quality is recognised by viewers and approval is expressed in terms of
the ‘like’ button on the YouTube site. However there is concern to be
expressed around the low levels of safety awareness inherent within
the content that would suggest that there are wider issues that con-
cern educationalists.
In conclusion, nursing students are increasingly turning to cyber-
space to supplement their studies. However, the use of such videos is
primarily restricted to the classroom setting where lecturers impose a
degree of selection and quality control upon the material used. Given
the expectation of most faculties that students will take responsibility
for enhancing the foundation material provided in the formal classroom
setting there is a clear need for the quality of YouTube videos to be
subjected to a rigorous evaluation. This paper has shown that the con-
tent of clinical skills focused on YouTube content suggests a need for
lecturers to be more proactive in recommending suitable YouTube
material as supplementary learning materials.
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