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 Nurse Education Today 111 (2022) 105305

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Feasibility of using QR code for registration & evaluation of training and its
ability to increase response rate – The learners' perception
Elwin Ajeet Masih *
Professional Education and Training Nurse Trainer, Sherwood Forest Hospitals NHS Foundation Trust, United Kingdom

A R T I C L E I N F O A B S T R A C T

Keywords: Taking learners' attendance and obtaining an evaluation of teaching is a routine activity performed by teachers.
QR code The traditional method of taking attendance using pen and paper posed a huge challenge during the COVID-19
Registration pandemic. This has been time-consuming as compared to pre-COVID as well as frustrating for learners waiting in
Evaluations
a queue for their turn to sign the register. Quick Response (QR) Codes were used to complete registration to buy
Perception
back the time consumed using traditional methods of registration. Learners' evaluations are used as an instru­
ment to evaluate teaching quality. At the researcher's workplace, a traditional paper-based evaluation method
has been used for decades. However, over time a significant decrease in the response rate of evaluations was
noticed. The pandemic provided an opportunity of using QR Codes to obtain learners' evaluation of teaching
quality. This study assessed the learners' perception of using QR Codes for registration and evaluation, and the
likelihood of learners completing the evaluation surveys, thus increasing the response rate. Participants of the
study were asked to complete an electronic survey to help assess their perception of using QR Codes and a
comparison was made between the responses gathered using paper-based evaluations over 5 months and QR
Code evaluations over the same 5 months in the following year. The results of this study demonstrate that using
QR Codes for registration and evaluation is easy and straightforward, thus increasing the likelihood of learners
completing the evaluation. The comparison between paper-based and QR Code evaluations confirms that a
substantial increase in response rate can be achieved by using QR Code evaluations.

1. Introduction social distance rules during the COVID-19 pandemic.

The COVID-19 pandemic has proven itself as the biggest threat in the
QR codes can be easily created that link to websites, show a living human memory affecting health and wellbeing and the economy
geographical location, access a document or specific application. QR (Kickbusch et al., 2020). The pandemic has affected the clinical practice
codes were developed by Denso Wave in 1994, initially to track car within the healthcare (Koumpouras and Helfgott, 2020) and this has not
components during manufacturing. Since the evolution of smartphones been different in healthcare education and training. Where COVID-19
with cameras, QR codes got more attraction and were applied to a wide affected life in its entirety, it has also affected the course attendance
range of commercial applications such as marketing, social media, and registration process. The researcher noticed a considerable increase in
more recently QR codes have generated interest for their use in educa­ time consumed for signing the attendance register as compared to pre-
tion, presenting an opportunity to excite and engage learners in a way COVID, as well as frustration among learners. The process of obtaining
the teachers were unable to thus far (Karia et al., 2019). Healthcare physical signatures of attendees to record attendance was robbing the
education is evolving rapidly to integrate new technology, ranging from training time. It had become conspicuous to the researcher that there
virtual delivery of courses to using QR codes (Brodie et al., 2020) to was an absolute need to find an alternative to the traditional attendance
access learning material, register attendance, and gather evaluations. registration process. Masalha and Hirzallah (2014) recommended the
Taking learners' attendance during each class has been time-consuming use of QR codes to obtain attendance registers that convinced the
using the traditional method of signing the register (Masalha and Hir­ researcher to pilot and evaluate this method of obtaining attendance
zallah, 2014). It has been more frustrating for learners; queuing and registers. Modular Object-Oriented Dynamic Learning Environment
waiting for their turn to sign the register, especially when following (MOODLE) is used by the researcher's employing Trust for its electronic

* Corresponding author.
E-mail address: [email protected].

https://doi.org/10.1016/j.nedt.2022.105305
Received 14 August 2021; Received in revised form 31 January 2022; Accepted 15 February 2022
Available online 18 February 2022
0260-6917/© 2022 Elsevier Ltd. All rights reserved.
E.A. Masih Nurse Education Today 111 (2022) 105305

learning courses. All staff members of the Trust have access to MOODLE infusions calculations workshop and manual measurement of blood
and are familiar with using the platform. Therefore, MOODLE was used pressure and catheterisation. The study participants were from different
to create QR Code registers. MOODLE was given preference over other professional backgrounds including registered nurses, midwives, oper­
electronic registration platforms, such as Jot form and Google forms, to ation department practitioners, allied health professionals, and health­
minimise the confidentiality breach of learners' personal data. MOODLE care support workers. Participants were made aware of the study and
is purchased and used by the Trust, thus is trusted for maintaining that their responses to the questions would be anonymised and used to
confidentiality. investigate the hypotheses.
Teaching quality is paramount to delivering high-standard education The COVID-19 pandemic has brought most of the conventional re­
that can be measured in different ways and sources (Feistauer and searches to a standstill, due to the need to socially distance and wide­
Richter, 2017) including electronic or paper-based evaluation forms. At spread lockdown, hence this promoted survey-based researches (Gaur
the workplace of the researcher, the traditional method of paper-based et al., 2020). Surveys are considered a well-established tool to collect
evaluations has been used for decades and was the only trusted quantitative and qualitative data. Since 1986, there has been a shift from
method for teachers to evaluate their performance and the course con­ traditional survey methods of using in-person or telephone interviews
tents. The COVID-19 pandemic provided an opportunity for a different and paper-based surveys to web-based surveys. Web-based surveys are
approach that reduces the risk of cross-infection, is cost-effective, and becoming increasingly common in research, because they allow rapid
improves the learners' response rate compared to the traditional paper- development and administration, fast data collection and analysis, low
based evaluations. A comparative study by Snyder et al. (2018) cost, and fewer errors in data entry as compared to paper-based surveys
concluded that QR Code based evaluations were significantly associated (Maymone et al., 2018). Surveys are valued methods to collect data
with usability, cost-effectiveness, and time efficiency. The system also pertaining to individual self-report about their opinions and satisfaction
minimises the risk of cross-infection by eliminating the use of paper and (Gaur et al., 2020). Considering the benefits, a web-based survey was
pens that go into different hands and touch different places, increasing used to collect data. The survey was developed and administered using
the risk of infection. Using the QR Code has dramatically increased the MOODLE with the opportunity for the learners to scan the QR Code and
number of evaluations (Ramalingam et al., 2020). According to a study complete the survey using a smartphone or tablet. To make it equitable
done by Bellot et al. (2015), creating and scanning a QR Code is easy; for staff to use QR codes, iPads were provided if they did not own a
83% of participants of the study agreed to the benefits of QR Code in smartphone. Questionnaires, being the most common survey modality
healthcare education and were likely to use QR Code technology in the for data collection, were used to collect quantitative and qualitative
future. Considering the challenges to using traditional paper-based data.
evaluations and the highly recommended usability of QR Code linked For hypotheses 1 (H1) and hypothesis 2 (H2), rated multiple-choice
evaluations for being easy and quick, allowing faster completion of questions were asked to obtain quantitative data, and participants were
forms than paper, the researcher decided to use QR Codes to collect asked to write further comments to support their selection to collect
evaluations at the end of training. qualitative data. To investigate H1 ‘The course registration and evalu­
ation using QR Code is easy and straightforward,’ the responses for
2. Methodology participants to choose were; (1) Strongly Disagree, (2) Disagree, (3)
Agree, and (4) Strongly Agree. Along with these choices, the participants
After considering the use of QR Codes, the researcher submitted a were provided free text space to write their comments to support their
paper to the People Development Cabinet (PDC) which includes Deputy choice. For H2 ‘The use of QR Code affects the likelihood of learners
Director Training and Education – the chair of Cabinet and senior completing the evaluation’, the choices were; (1) less likely to complete,
managers within the Trust asking for their approval to pilot QR Codes (2) No change – wouldn't do it anyway, (3) No change – would do it
for course registration and evaluation, and conduct a study to assess the either way and (4) More likely to complete. A free-text box was provided
perception of using QR Codes among the learners. The paper was to write further comments to support their choice. These multiple-choice
approved by the PDC. survey questions and further comments to support the selection of re­
Studies show that the perception of learners is a stronger predictor of spondents' choice, elicit the same and/or similar response that supports
effectiveness and outcomes of tools and/or strategies used in the training the reliability of the survey. According to Gaur et al. (2020), reliable
and education (Shrestha et al., 2019). It was noticed that over time the surveys pose questions in a manner that evokes the same or similar re­
response rate of evaluations was hugely decreased and the survey forms sponses from responders, regardless of the construction of the questions.
were not completed properly. Therefore, there was a need to implement The web-hosted survey gives assurance of its reliability having the
a new system that can accelerate the response rate and encourage the advantage of storing data that bypasses the manual input, thus reducing
learners to complete the survey form properly in a timely fashion. The data entry errors (Maymone et al., 2018).
researcher took this opportunity to use the QR Code application to To investigate the hypothesis 3 (H3) ‘The use of QR Code increases
gather evaluations to find if there was an increase in response rate. the evaluation responses as compared to the traditional paper-based
A mixed-method design was employed for this study to investigate collection of evaluations’, all attendees of the courses over the 5
the following hypotheses; months were given QR Code evaluations and the number of responses
was compared to the total number of paper-based evaluations distrib­
1. The course registration and evaluation using QR Code is easy and uted and responses received over the same 5 month period of the pre­
straightforward. vious year. The distributed number of paper-based evaluations and
2. The use of QR Code affects the likelihood of learners completing the responses were counted retrospectively from the Trust's records for the
evaluation. previous year, because the study was not planned at that time. There­
3. The use of QR Code increases the evaluation responses as compared fore, the attendees of courses completing the paper-based evaluations
to the traditional paper-based collection of evaluations. were not aware of the study. Three courses from the aforementioned list;
blood transfusion, SSSA Training, and Intravenous drugs and infusions
The study was conducted over 5 months that recruited 570 at­ calculations workshop were excluded from the investigation of this
tendees, including men (n = 75) and women (n = 495), of different hypothesis as they were not run during the period of 5 months when
courses: non-medical clinical induction, blood transfusion, administra­ paper-based evaluations were distributed. A total of 520 participants
tion of intravenous drugs and infusions, central vascular access devices, were given QR Code evaluations and 508 participants were given paper-
venepuncture, and peripheral cannulation, Standards for Students' Su­ based evaluation forms.
pervision and Assessment (SSSA) training, intravenous drugs and

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E.A. Masih Nurse Education Today 111 (2022) 105305

3. Data collection and analysis Table 1

Tabulated responses for testing H1: The course registration and evaluation using
After completion of the prescribed timeframe for data collection, the QR Code is easy and straightforward.
data analysis functionality of MOODLE was used to pull the data from all The course Total Strongly Agree Disagree Strongly
responses and analyse the results. This functionality anonymised the registration/ responses agree disagree
data and gave the number of total respondents and number of total re­ evaluation using QR
Code is
sponses for each of the four selections of rated multiple-choice questions
straightforward?
and free-text responses. The data was then exported to Microsoft (MS)
Non-medical clinical 186 121 57 3 5
Excel to analyse and convert this to the percentage of responses for each
induction
selection of rated multiple-choice questions. MOODLE exported free-text Blood transfusion 6 4 1 1 0
data to a separate cell for each response. The next step was to analyse IVI study day 65 40 24 1 0
and synthesise the free text (qualitative) data. Thematic analysis was CVAD study day 14 12 2 0 0
used to synthesise the qualitative data to develop analytical themes Venepuncture & 89 61 21 1 6
cannulation
(Young and Waddell, 2016). This approach is often used by primary SSSA training 3 3 0 0 0
research as a method to identify themes and to analyse and interpret IVI workshop 13 10 1 0 2
these themes to contribute towards hypotheses investigation (Clarke and PSA workshop 16 8 7 0 1
Braun, 2017). Thematic analysis is sufficiently efficient and flexible to Catheterisation 35 22 13 0 0
Manual BP 9 7 2 0 0
allow interpretation required by a qualitative research (Walters, 2016).
Total 436 288 128 6 14
Thematic analysis despite its flexibility and wider use, presents a unique
challenge as identifying themes is the most difficult task due to the
intuition involvement; there is not enough practical explanation about
developing a theme (Vaismoradi et al., 2016). However, the thematic
analysis provides a systematic element to data analysis and is considered
the most appropriate methodology for qualitative research that supports
or rejects the hypotheses using an interpretation that allow the
researcher to determine the concepts and relate them to the hypothesis
to reach a conclusion (Alhojailan and Ibrahim, 2012). A theme is the
main product of data analysis which is a kind of agreement that is more
concise, accurate, simple, and short as compared to the whole text from
where the theme is extracted (Javadi and Zarea, 2016). Analysing the
information in the main text is a complex process which demands a huge
amount of work involving repeatedly going through the text to find the
themes. However, the thematic analysis provides an accessible and
systematic approach to generating codes from the qualitative data.
Codes are building blocks for themes that capture relevant features of
data potentially viable for investigating the hypotheses (Clarke and
Braun, 2017). A computerised software ‘NVivo’ was used to create codes
and then these codes were categorised into potential themes. NVivo
automatically counts the number of times a category is referred to
within the main text (Jugder, 2016).
To investigate H3 ‘The use of QR Code increases the evaluation re­ Fig. 1. Results for testing H1 as percentages.
sponses as compared to the traditional paper-based collection of eval­
uations’, data was collected retrospectively from the Trust records for
the time period when paper-based evaluation forms were given to the Table 2
Tabulated responses for testing H2: The use of QR Code affects the likelihood of
participants. The number of total participants was manually counted
learners completing the evaluation.
from the paper-based registers which were scanned and saved in a
shared drive folder with the dates of study days. In the same way, total Does the Total More No No Less
electronic responses likely to change change – likely to
responses were manually counted. The QR Code evaluations were
method affect complete – would wouldn't complete
simultaneously added and stored to the MOODLE platform without the likelihood of do it do it
manual input, thus reducing the data error. The total number of par­ you completing either anyway
ticipants was pulled from the QR Code registers and the total number of the evaluation? way
responses from QR Code evaluations hosted on the MOODLE. This data Non-medical 186 113 65 4 4
was exported to MS Excel sheet. MS Excel was used to convert the data clinical
into percentages to compare if there was a percentage increase in induction
Blood 6 3 2 0 1
evaluation responses using QR Code evaluations.
transfusion
IVI study day 65 37 24 2 2
4. Results CVAD study day 14 9 5 0 0
Venepuncture & 89 52 33 1 3
cannulation
To investigate H1 and H2, the survey was distributed to 570 at­
SSSA training 3 1 2 0 0
tendees of different courses; 436, including men (n = 59) and women (n IVI workshop 13 6 3 1 3
= 377), completed the survey. For each course, the number of partici­ PSA workshop 16 8 8 0 0
pants and their responses were exported to MS Excel, where these re­ Catheterisation 35 20 13 0 2
sponses were converted to percentages for easy interpretation and using Manual BP 9 5 4 0 0
Total 436 254 159 8 15
the data to investigate hypotheses. Table 1 and Fig. 1 show the data and
its conversion to percentage based on each response for H1. Table 2 and
Fig. 2 show data and its percentage for H2.

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E.A. Masih Nurse Education Today 111 (2022) 105305

Table 4
QR code evaluation responses over the same 5 month period in the following
year.
Course Number of Number of responses Responses
attendees received %

Non-medical clinical 264 248 94%

induction
IVI study day 61 53 87%
CVAD study day 14 14 100%
Venepuncture & 118 106 90%
cannulation
PSA workshop 19 13 68%
Catheterisation 34 24 71%
Manual BP 10 9 90%
TOTAL 520 467 90%

text from all responses is not in agreement with the system being easy
and straightforward and argues that scanning the code seems to be
confusing for some people if they are not hands-on with technology.
However, instructions in the form of a step-by-step guide were provided
Fig. 2. Results for testing H2 as percentages. to ensure that novice users could successfully register and complete
evaluations on the first attempt at using QR codes. The application is
To investigate H3, ‘The use of QR Code increases the evaluation re­ cost-effective, as compared with paper forms and supports the Global
sponses as compared to the traditional paper-based collection of eval­ green agenda.
uations’, 508 participants of different courses over 5 months were given
paper-based evaluations and 520 participants were given QR Code
5.2. Scanning the QR code at the end of a course encourages completing
evaluations for the same courses over the same 5 month period of the
the evaluation that can be done from anywhere and at any time, enabling
following year. For paper-based evaluation (Table 3), only 268 partici­
more learners to complete the evaluations
pants completed and returned the evaluation form. Whereas, using QR
Code evaluations (Table 4), 467 participants completed the evaluations
57.78% coverage of the entire text of all gathered responses has
which were simultaneously stored on MOODLE.
generated this theme. Scanning the QR Code enhances the accessibility
of the evaluation questionnaire which can be accessed from anywhere
5. Analytical themes and at any time. This can be even completed at home or on the way out
of the classroom after finishing the training, rather than staying behind
The following four overarching analytical themes were identified to complete the evaluation and handing it over to the teacher. The QR
while analysing the qualitative data obtained from the submitted Code is displayed at the end of a classroom session to prevent the
surveys. learners from forgetting to complete the evaluation. Thus, it is a prompt
and therefore completion of the evaluation is much more likely. How­
ever, 5.28% coverage of the entire text reflects that some people are
5.1. The use of QR codes for registration and evaluation is excellent,
more likely to complete paper-based evaluations.
efficient, easy, and straightforward

This theme reflects the perception of learners; what they think about 5.3. QR code registration and evaluation saves time and is essential for
using this method of registration and completion of evaluations at the continuous improvement
end of a course they have attended. A vast majority of respondents
evaluated the use of QR codes as an excellent and brilliant tool that is This theme was merged while coding the survey data. The use of QR
easy and straightforward to use. The respondents said that this does not Codes for registration and evaluation is not only easy and straightfor­
require someone to be a technology expert, but is absolutely easy to ward, but is also a fast and efficient system that saves time for enrolment
manage if they have the right equipment, such as a mobile phone or a and evaluation. This encourages more learners to complete the evalua­
tablet with the ability to scan the code, and it is a way forward. Scanning tion, which is essential for continuous improvement.
the QR Code instantly redirects to the page for submission of the
enrolment key, provided by the teacher, to complete the registration and 5.4. Using QR code is safe and efficient in preventing cross-contamination
for evaluation to the questionnaire page. However, 1.29% of the entire
This was another unintentional merging theme, which recommends
Table 3 the use of QR Codes to improve the safety of fellow learners and teachers
Paper-based evaluation responses over 5 months. by taking away paper registers and evaluations especially during the
Course Number of Number of responses Responses COVID-19 pandemic. This method of registration and evaluation re­
attendees received % duces the possibility of cross-contamination, as compared to signing a
Non-medical clinical 150 71 47% paper-based register and passing it on to the next learner to sign. There is
induction a similar risk of cross-contamination when completing the paper-based
IVI study day 107 37 35% evaluation and handing it over to the teacher.
CVAD study day 40 18 45%
Venepuncture & 97 60 62%
cannulation 6. Discussion
PSA workshop 73 61 84%
Catheterisation 38 18 47% The study examined the feasibility of using QR Codes to complete in-
Manual BP 3 3 100% class registration from learners' perspective and the increase, if any, in
TOTAL 508 268 53%
the likelihood of learners completing the evaluations, thus increasing

4
E.A. Masih Nurse Education Today 111 (2022) 105305

the evaluation response rate as compared to the traditional paper-based use the application.
evaluations. The results are in favour of the hypotheses. QR Codes are
versatile and novel tools for improving the classroom experience in a
fast, easy and fun way to engage learners (Crompton et al., 2011). 7.1. Limitations
In response to the questionnaire posed to investigate H1, results
show that participants strongly agreed that using QR Codes for regis­ This study could be improved upon by investigating the impact of
tration is easy and straightforward. According to the results, 66% of additional variables which could factor into the perception of QR code
respondents strongly agreed and 29% agreed. Although, 29% of re­ technology and its usage. Certain demographic factors could affect the
spondents selected their response ‘Agree’, they are in line with H1 ‘ the perception; for instance, age. According to Czaja et al. (2006), older
course registration and evaluation using QR Code is easy and straight­ adults are less confident in their ability to successfully use technology as
forward,’ making it a total of 95% respondents in agreement with using compared to young adults. However, the number of older adults using
QR Code registration. Attendance of a course can be completed easily technology is increasing and is similar in numbers to their younger
using the QR Code application, as compared to any other attendance counterparts (Olson et al., 2011). Thus, further study into the effect of
system (Galib and Shehjad, 2019). However, there are some barriers to age, and possibly other demographic factors, such as gender and
using QR Codes, such as cultural background and technical knowledge, ethnicity, upon the perception of QR codes usage for registration and
that need to be addressed (Snyder et al., 2018). This study shows that evaluation of training is recommended.
having a good support mechanism in place, for instance, written in­
structions available in the classroom or sent to the learners prior to them CRediT authorship contribution statement
attending the course, builds the confidence of novice users in using the
QR Code application. A registration system that requires the input of a I have revised the manuscript as advised by the reviewer's feedback.
teacher every time a learner registers to the lesson, robs the class time of I have submitted the following files:
the learners, especially for late arrivals (Masalha and Hirzallah, 2014).
In response to the questionnaire posed for testing H2, the results 1. Response to Reviewer
show that there is an increased likelihood of learners completing the 2. Revised manuscript with changes marked in colour (green and red)
evaluations as compared to the traditional paper-based method. 58% of and have explained in the Response to Reviewer that green is for text
respondents said that they are more likely to complete the evaluations deleted from the original manuscript and red is the additional text.
using the QR Code application, as this is a stimulant to do so when it is 3. Revised manuscript – a clean copy
displayed at the end of the session. Using online feedback via QR Code is
simple and less expensive, hence yielding a higher response rate and is
Declaration of competing interest
instantly available to the teacher for a quicker analysis (Onimowo et al.,
2020). Although 37% of respondents said, there will be no change as
I ‘the author’ certify that there is no conflict of interest with any
they will be completing the evaluations either way, a comparison of
financial/research/academic organisation, with regards to the contents
paper-based and QR Code evaluations shows a 37% increase in the
and/or research work discussed in the revised manuscript.
response rate of evaluations when using QR Code application. This is a
significant increase to support H3.
Acknowledgments
While analysing the qualitative data, two themes; ‘QR Code regis­
tration and evaluation saves time and is essential for continuous
The author thanks Joy Simpson (author's line manager) for her
improvement’ and ‘Using QR Code is safe and efficient in preventing
support and proofreading and Shaleem Ajeet for proofreading the paper.
cross-contamination’, were unintentionally merged. Although they are
important themes, the study was not aimed at investigating them;
therefore specific questions were not asked. Thus, there was insufficient References
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