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Computer Based Education: more than just a package.
AEJNE Volume 4 - No.1 October, 1998.
The information handling capabilities of the computer have been recognised for many years as having the potential to make a significant contribution to the educational process. Computer based learning can also be demonstrated to be educationally sound and is underpinned by learning theory. However, Ramsden (1992) feels that most of the predictions about the usefulness of computers in education have yet to be realised. In 1986 Romiszowski described "fields" of computer applications in education and divided them as follows - "informatics as content" and "informatics as instrument". To examine both fields is beyond the scope of this paper so, it is use of the computer as a vehicle for learning which will be discussed here.
Computer Based Learning (CBL) is the term used to encompass both the expositive and experiential uses of computers as a teaching tool. It offers students an interactive form of learning, enables self-assessment and supports many different teaching strategies. Students are able to engage in self-paced, self-learning and having some control over the direction of their educational experiences (Hardy, Conrick, Foster, McGuiness and Bostock 1996).
A serendipitous effect of CBL is that students also develop computer awareness and skills which will be useful in their future careers (Conrick, 1993). Wong, Wong, and Richards (1992) recount that many authors have cited the ability of CBL to increase computer literacy, reduce faculty workloads, maximise available resources, facilitate the development of decision-making skills and expand teaching methods in the clinical area.
Expositive use of the medium
Romiszowski (1988) refers to the use of computers for testing, drill and practice and programmed tutorials as a programmed or expositive use of the medium. These formats are frequently used because they are cost effective, can be made user friendly and the content can be easily changed by adding another database. However, they also foster a surface approach to the learning task in which students are rich with information but do not increase their knowledge or understanding (Conrick 1993).
Drill and Practice
The Suppes-Atkinson computer education model in which computer programs presented students with randomly generated problems, elicited a response, provided immediate feedback and then proceeded to the next question was pioneered in 1963. The Suppe-Atkinson model allows students to stay with the same type of problem until a level of proficiency is attained, before progressing to problems of a more difficult nature. This became known as drill and practice (Simonson and Thompson 1990).
Drill and practice provides immediate feedback to student. There is no waiting period for correction and therefore students do not practice their mistakes. The packages can be individualised allowing the student to work at their own pace and the computer can determine mastery before more complex questions are posed (Conrick, 1995). These programs can also keep efficient records of the student's progress, which can be accessed by the teacher. The advent of intelligent computer aided instruction (ICAC) or programs that incorporate artificial intelligence has meant that the computer cannot only keep efficient records but can analyse mistakes and explain the problem to the student. At this time, the ICAC technology is difficult, time consuming and very expensive (Simonson and Thompson 1990).
These types of drill and practice packages demonstrate theoretical underpinning and perhaps fit well with Skinner's operant conditioning theory (1953). Skinner advocated the use of operant conditioning in the design of instruction and proposed a new field of study that he termed the Technology of Instruction. Seels (1989) reported that the techniques of programmed instruction are still being used today in many CAL programs. However, research data on some aspects of drill and practice are mixed.
Koch and Rankin (1987) cite some researchers who suggest that after the novelty effect of drill and practice wears off the motivational power is lost. Others go as far as to suggest that drill and practice programs are very limiting in that exploration with the computer is not encouraged and the learner is never challenged to their fullest extent. The Digital Equipment Corporation (1983), Medows (1977) and others say that drill and practice is conducive to lower-level learning outcomes and rote learning. However, it is also said that quality drill and practice packages can hold student attention much longer than the traditional teaching methods. It is also suggested that drill and practice is useful as it gives immediate feedback, the instruction can be individualised, it keeps efficient records and is motivational (Simonson and Thompson 1990). In the final analysis however, it seems to depend on the objectives set for the package and learning approach taken.
Self-teaching programs have proliferated. These programs provide a short passage of information then question the user. Some of these programs give a degree of individualised teaching by adjusting to the level of knowledge exhibited by the student (Koch and Rankin 1987). Other programs are electronic page-turners, which are repetitive by nature, reward surface learning and have the potential to 'bore' the user (Simonson and Thompson, 1990). As with the drill and practice programs the quality is also variable.
In the classroom, a student is bound by the average progress of the group but a well-designed tutorial program can offer the student one-to-one, individualised instruction. As the program progresses, it is able to adjust the level and complexity of the tutorial to suit the knowledge level displayed by the student. The student, by having to drive the package, becomes an active participant in learning with some autonomy in the process. They maintain control over the rate of advancement and of their own learning. Further to this, the introduction of intelligent computer-aided instruction has the potential to expand the tutorial and to take learning from the surface approach to the deep. As mentioned previously the ICAC technology is difficult, time consuming and very expensive so use is limited at this time.
Adaptive Use of computer based education
Simulation, dialogue tutorials, and inquiry type database searches are referred to as adaptive or experiential uses of the computer in education (Romiszowski 1988). As computers become more available as tools for educators, it is desirable that there is an increased shift to a theoretical base in computer educational package design which will foster deeper approaches to learning ( Conrick 1993).
In clinical nursing terms, simulation refers to the verbal or pictorial description of a real-life patient care situation, but in reality it is generally an incomplete model that contains only the essential elements of what is being simulated. Nevertheless, simulation is recognised as one of the more effective methods of managing clinical teaching. It can be presented in many ways: role-plays; games; and computer programs. It encourages the student to become an active participant, to think more deeply and to become part of the educational environment (Conrick, 1993).
Although most reports in the literature are subjective and anecdotal, they catalogue a variety of advantages for using simulations in teaching clinical nursing. Clinical simulations have developed around patient management problems and according to tend to teach in two or more domains, such as psychomotor and cognitive or cognitive and affective simultaneously (Hanna 1991).
Dooling (1987:219) expands the advantages of simulation saying that it includes the following: 1) it focuses the learner's attention on the problem, eliminating the distractions that occur in real life; 2) it permits controlled manipulation of the patient care situation, with predictable results; 3) it allows the patient to escape the consequences of poor decisions made by a learner or an ill-informed care giver; 4) it ensures standardisation of a situation (particularly valuable for evaluative studies); and 5) it can be used to measure affective as well as cognitive learning.
Simulations offer the opportunity for expository learning which the literature regards as having many advantages. de Jong and Njoo (1992) also regard simulation as having very practical advantages such as being able to introduce catastrophes and reducing stress in treating patients. They see it as cost effective pointing to reduced expenditure for example in areas such as laboratory experiments. Dynamic modelling also allows processes to be speeded up or slowed down to make them more visible to the learner and they can also be used to simplify models from the real world in order to have them match the prior knowledge and level of cognitive development of the learner.
Simulation does have disadvantages in the considerable time and effort needed for design and the resultant cost incurred. In addition, there is little evidence supporting the relationship between clinical simulation performance and the clinical setting (Henry, LeBreck and Holzmer1993). Dooling (1987) also points to the lack of research-based outcomes as making it difficult to establish a reliable scoring system that allows quantification of specific decisions to specific outcomes.
Dialogue Computer Based Learning
Dialogue CBL is the 'intelligent' use of CBL in that the software is programmed to adapt to the individual learner. They actually 'learn about the learner' as the student either asks or respond to questions. Some dialogue packages are built on deep questioning techniques and multi-faceted analysis of the responses given by the student. These packages have the potential for integrated and transformative learning. However, these programs are difficult to program and are costly to develop, as a result there are not many Dialogue CBL programs available.
A further sophistication in CBL has been the use of multimedia that is essentially the use and integration of one or more media. Incorporation of still and motion picture, graphics, slides, film and film clips is possible. These programs are extremely flexible with the student having control over the courseware and learning. Many of these programs present a menu which lists the different learning areas related to the central theme or concept. This allows the student to select the learning direction driven by his/her learning need. It is also possible to integrate real life graphic displays of equipment, readings, sounds and waveform displays from various monitors. This lead to a more realistic experience and one that may further narrow the gap between theory and practice. The experiential use of CBL is becoming more common in nursing education and package designs are becoming more sophisticated.
One problem in Australia is, however, that the use of the computer in nursing education has been relatively slow and not many packages have been written specifically for Australian students. Unfortunately, in most cases imported materials are not applicable to Australian conditions because of differing terminology and units of measure. However, increasingly more work is being carried out in this area and advancement in package design and delivery methods have been seen.
One of these advances has been the use of the expert systems which are described as 'knowledge based systems using symbolic knowledge to solve problems that normally require human knowledge and attention' (Watt 1984 ;40). Packages such as the Clinical Decision-Making Nursing modules developed at The Queensland University of Technology (Conrick & Foster 1993) foster some of these principles. This is a CAL package for teaching nursing diagnosis based on the North American Nursing Diagnosis Association taxonomy. It can be used with other educational strategies to increase (nursing) diagnostic skills or as remedial tool for those requiring increased support. However, with many programmes what is not mentioned is the quality and the approach to learning encouraged by using this type of educational tool. If by using these types of program, transformative approaches to learning result then the use of computers in nursing education may well become more widespread.
The possibilities of virtual reality in nursing education are endless but have yet to be realised. Virtual patients may become the alternative to 'real patients' as clinical placements diminish. Some universities are already experimenting with virtual reality for example; the Iowa State University who have what is termed 'the cave' into which one can 'step inside' DNA components, and the HIV virus. The University of Missouri Advanced Technology Center is also working on several VR projects including an intubation simulator. However advances are slow and the technology expensive at this stage.
The Use of Computers in Nursing Education
Over the last few years, CBL as a teaching/ learning strategy has been shown to enhance critical thinking skills. Mahr and Kadner (1984) recognise that CBL can provide a problem-solving environment, which is assisted by automatic interaction and feedback and by making allowance for alternate paths. Laurillard (1987) agrees, seeing the inclusion of more than one path as giving greater access to the content and having the potential for greater understanding.
It is said that a program can encourage problem solving by providing a systematic approach to learning. The programs can also be devised so that restrictions can be placed on students, for example, students cannot look ahead to future steps in the process. Sometimes, it is the authoring package, which places these restrictions, but often it is the instructional design base of the package. Computers can also enhance the logical processing of information by the learner according to Pond, Bradshaw et al. (1991). All these features can be used in CBL and can help promote the student's clinical decision making skills.
However, when Laurillard (1987) investigated the educational effectiveness of CBL she noted that when students were allowed to work through information in their preferred way they exhibited a wide range of routes. So, by using a rigid framework in the approach to teaching Clinical Decision Making using CBL, we may restrict student's creativity, understanding and investigation forcing them into surface learning behaviours.
The provision of an interactive, self-paced method of learning away from the real situation is extremely important in areas of nursing where ethical issues such as safety may arise. CBL provides this and it can also be used effectively when appropriate experiences for the student are unavailable. Ethical reasoning, another important skill for the nursing practitioner to master, can also be practiced using computer technology. A student can make decisions in a safe, non-threatening environment and most importantly; can do no harm. Clinical reasoning skills can also be practiced in such an environment by using CBL situations. The courseware will offer as much positive or negative reinforcement as the package writer desires, at times deemed most appropriate.
Computer technology is developing at a frantic pace. Many situations we are faced with were not dreamed about even ten years ago. Although possibilities with CBL seem restricted only by imagination they are also restricted by price. Engaging with multimedia simulation and the interactive media requires very advanced systems on which to run the software. Hugh memory requirements, large storage space, very fast microprocessors are all required as are the personal to maintain them. This all adds up to a very large commitment in dollars terms. Perhaps the divisions of the future will become information rich school and the information poor school. What must be assessed are the effectiveness of this medium and ultimately its cost effectiveness.
Some of the research reviewing the effectiveness of CBL in nursing education has indicated that both primary and supplemental uses are as effective or more effective than other strategies for students in diploma, baccalaureate, and graduate programs (Belfry 1988; Brenton 1988). A study by Theirle (1986) showed that students instructed in drug dose calculation using CBL scored an average of 91% but those taught by lecture and self-instructional book in the previous two years had scores of 62% and 66%. Reynolds and Pontious (1986) also had positive results when using CBL but they also noted design problems.
Conversely, other researchers have reported that there were no differences in test scores in students receiving CBL over conventional learning. Day and Payne (1984) used multiple choice exams to evaluate the difference in students randomly assigned to either CBL or lecture groups. In this study, no differences were found between the teaching/ learning styles. Comparable studies by Gaston (1988) and Gilbert and Kolacz (1993) reached similar conclusions.
The use of computer based learning is not proposed as a panacea for all nursing educational ailments. It should be carefully planned into a curriculum and used as an adjunct to teaching. Koch and Rankin (1987) suggest that it is a powerful tool that may add new dimensions to the nurse teacher's role.
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