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"Using the Internet in a Nursing Clinical Practicum Course: Benefits and Challenges"

AEJNE Volume 5 - No.2 March, 2000.

Helene Cunningham, MS (Nursing), MS (Biology), RN
Clinical Assistant Professor
School of Nursing
University of Massachusetts
Amherst, MA 01002
helene@nursing.umass.edu

Karen Plotkin, MS (Nursing), RN, CS
Clinical Assistant Professor
School of Nursing
University of Massachusetts
Amherst, MA 01002
kplotkin@crocker.com

Abstract

This article describes the process, benefits, challenges and recommendations for using the Internet in a team-taught nursing clinical practicum course. A main web page, clinical group web pages, and e-mail were used. In a survey done at the end of the course, many students commented that the Internet helped them access course assignments and information, provided useful resource links, and that e-mail facilitated communication. While some students found using this technology inconvenient and frustrating, most students would recommend the use of the Internet for future clinical courses.

Nursing students are required to use the latest information technology including the Internet to provide nursing care (AACN 1999). Thus, faculty must not only provide adequate and appropriate clinical experiences, they also need to teach students to use the Internet to "find, filter and critique in cyberspace." Students, in turn, need to adapt to navigating this information superhighway to research health care information to prepare them for optimal decision making (AACN 1999). The Internet can also provide job opportunities and assist in communicating with health care professionals (Simpson 1995), for nurse managers as chat room moderators for patient health care questions.

Saranto et al. (1997) argued that computers and information technology should be incorporated into all nursing curricula. However, nursing programs have varied opinions as to how this material would be incorporated, if at all, into the curriculum (Carty & Rosenfeld 1998). The new dean of the School of Nursing at the University of Massachusetts challenged the faculty to be creative and aggressively integrate technology into their courses.

Faculty may question how the Internet can assist in meeting objectives in a clinical practicum course. There have been clinical course web sites developed on the Internet (e.g., http://www.unc.edu/~bangel/n56/n56index.htm). This article describes the process, benefits, challenges and recommendations for using this information superhighway. The process of incorporating web-based technology in our clinical practicum course included many phases, which are similar to implementing the Internet in didactic courses. The first was to think critically about the goals and outcomes for the students and faculty when using the Internet. Once those were determined, the next steps were to design, implement, manage and evaluate this technology.

Description of the Course

The course is a 4 credit clinical practicum, team-taught by 7 faculty members to 56 junior level students. In this practicum students develop beginning proficiency in nursing skills (i.e., communication, assessment, teaching, and psychomotor) and apply principles of health promotion. Each faculty member facilitate their own clinical experiences for their 8 students at a variety of clinical sites (i.e., inpatient and community based).

Using the Internet

The Internet interface included a main web page for all 56 students, 2 "pilot" clinical group web pages, and e-mail. On the first day of orientation, students were offered assistance using the Internet and given a list of computer laboratories and help desks at the university. Only one student asked for assistance.

The goals of using the Internet in our clinical practicum were to:

• Facilitate communication between 7 separate clinical groups and 7 faculty members
• Provide resources (Table 1) on the Internet to supplement student learning
• Help students become more skilled at using the Internet
• Develop student awareness of the vast resources and opportunities for health care on the Internet
• Provide information and assignments about the course (Table 1) to students, clinical faculty, and other faculty teaching concurrent didactic courses.

Once the goals were established for the main web page, a clinical faculty member with web page experience volunteered to be the web page manager. Her role was to design, implement, and manage the main web page and be open to ideas and suggestions from the other 6 clinical faculty throughout the semester.

Since each faculty member independently facilitated their own clinical sites for their clinical group, there was not one main link describing clinical experiences for each clinical group. The web pager manager and a second clinical faculty member volunteered to "pilot" separate clinical group web pages for each of their clinical groups of 8 students.

The "pilot" clinical group web pages were designed to accomplish the goals listed previously. In addition, the clinical group web page would include information specific to the faculty's clinical group (Table 1).

Some of the clinical faculty used e-mail to receive weekly journals from students, allowing review and timely feedback before the next clinical experience. In addition, depending on the clinical objectives for the week, the clinical faculty member would choose some patients ahead of time and e-mail a patient assignment to the students (information was confidential and no names were used). The students would review patient-related information, begin to plan patient care and develop nursing interventions before coming to the clinical site. E-mail was also used to communicate any special reminders or changes to the students between clinical experiences each week. For example, a time change for a health fair was easy to communicate to students through e-mail before the event.

Evaluating the use of the Internet

The web page manager developed a survey to evaluate the usefulness of the technology. Students completed the survey at the end of the course for the main web page (N = 46), clinical group web pages (N =16) and e-mail (N =16). The survey asked about demographics, access, recommendation of web pages in the future, experience using the web and Likert type items about helpfulness [1 (not helpful)-4 (extremely helpful)] of different links and e-mail. There were also some open-ended questions about the web pages. Since some students did not complete all items, valid percentages were used.

Main and Clinical Group Web Pages: Benefits

The main web page facilitated communication for 56 students divided into 7 smaller clinical groups. In clinical practicum courses it can be difficult to relay information to faculty and students diffused over many geographical areas. The main web page ensured that everyone received the same information about the course.

Benefits of the main and clinical group web pages were similar. Students enhanced their computer skills through this experience as reflected by remarks such as: "ŠI know more than when I started." Since most students (74%) had not used the web in previous courses, doing so facilitated their thinking of the Internet as another resource for learning and communicating. This was the first clinical practicum in the junior year nursing curriculum so it exposed students to useful Internet health care resources on which they could expand in their future nursing careers. Students could begin to see more global aspects of learning outside their textbooks. The survey revealed that most students (85%) rated the resource links very or extremely helpful. Student comments included: "links were great and full of interesting and good information," and "it [the web page] had good resources."

The assignments and lab schedule links helped students stay focused and organized. More than 87% of the students rated the helpfulness of these links very or extremely helpful. They did not have to worry about keeping track of paper copies of guidelines for assignments. When the assignment was due, they could access the Internet at their convenience to print the guidelines. Many comments reflected these issues: "assignments were easy to get," "could print out extra copies of assignments if needed," "helped me to organize and keep track of what was going on," "having assignments right there," "quick way to find information on class," and "could see in advance what I had to do for the semester." Posting information on the Internet also helped free faculty from mundane tasks of Xeroxing and repeating directions and assignments. We could move off the stage and allow students to be more self- directed.

Specific to the clinical group web page, all students (100%) rated the clinical calendar, organizing a clinical day, medication and clinical expectations links very or extremely helpful. These links helped the students stay organized and focused for clinical experiences. This was illustrated by student remarks: "calendar schedule was extremely helpful," "it kept everything clear and organized," and "having the organizational sheets was great. I could always make copies if I needed." The calendar provided easy access to information about clinical sites, directions to sites, guidelines for the clinical site, and resource links to help students prepare for the clinical experience (Figure 1). Faculty did not spend time repeating directions each week, which can be a problem when students are assigned to a variety of clinical sites. Students (100%) rated the overall clinical group web page as extremely helpful.

Most students (80%) would recommend a web page for future courses. Interestingly, students with access to clinical group web pages were more likely to recommend a web page for future courses than students without such access (t test, p=.013). The possible reason for this statistically significant difference may be that they were using the web more, thus this expanded their experience and were more aware of the benefits.

Finally, faculty teaching other related didactic courses during the semester had easy access to the clinical course on-line. These, faculty could freely find information about what was being covered in clinical each week and relate their didactic content to the clinical.

Main and Clinical Group Web Pages: Challenges

In the Internet survey completed at the end of the course, some students (24%) reported difficulty accessing a computer and still others experienced technical difficulties (26%) that faculty were not always aware of. This was also illustrated by the following comments: "I don't have access in my house so I had to go to campus and it wasn't always convenient. However when I used it, it was extremely helpful," "hard to access; didn't have own computer, " "living with 5 people off campus, hard to get on-line and to campus," "problem downloading," and "I'm not good with computers." A written survey at the beginning of the semester would have more accurately assessed students' ability to access and use computers than a verbal inquiry. Students may have been uncomfortable telling faculty of these problems. Since this course, the School of Nursing has responded to the access issue. More updated computers have been added to the nursing learning resource lab. This easy access is an important step in affecting the motivation of the students to use the Internet. Mikan (1992) reported that location and access to computers influenced the students' motivation to use them.

Faculty also assumed that students were regularly checking the web site, but found via the end survey that this was not always the case. Therefore a clearer and more systematic way to facilitate students consistently checking the web site for updates needs to be developed. It's important that the web page manager notes when the page was last updated and informs clinical faculty and students, for example an e-mail message to all about any major additions to the web page.

It was a challenge to change the mindset of both students and faculty who felt the intense need to receive a packet of information in hand (i.e., assignments) on the first day of class. Cravener (1999) found in a review of literature that adapting to technology could be difficult and often met with resistance. This remains a problem that hopefully will be desensitized over time. A student's comment from the survey summarizes these sentiments: " I really get frustrated using computers. I would rather have had a handout rather than using the web. It was a good learning experience, though. I know a lot more now than when I started."

Cravener's (1999) comments about increased faculty workload when using this technology rang true for the web page manager. The workload was very time consuming, especially designing and implementing. After this was accomplished, time was not a considerable issue. The effort it takes to Xerox and hand out assignments is more consuming than uploading them onto the web. The web page manager was also challenged to track and update information for both the main and her clinical group web pages through the semester. She highly recommends keeping computer folders and files organized and clearly named.

E-mail: Benefits

Overall, students found e-mail very helpful. E-mail facilitated communication about patient assignments before clinical, which students (81%) rated as very or extremely helpful. In clinical experiences, students spend time looking for charts and information before caring for patients. If students obtain information before coming to clinical, they are more prepared and can spend more time with the patient. As one student reported, "I like knowing my clinical assignment before I get to clinical so I can be prepared."

E-mail provided freedom from the constraints of time and schedule conflicts. For example, a student who might have liked to ask a question in post conference would be able to do so by e-mail. Most students (94%) rated using e-mail for questions or communicating with faculty as very or extremely helpful.

E-mail gave the students an opportunity to respond on their own time from diverse geographic locations. Eighty-eight percent of students rated e-mailing their journals as very or extremely helpful. They could e-mail their reflections (especially if home for the weekend) and receive the clinical faculty's response before the next clinical experience. Problems, concerns, goals, and clinical objectives could be clarified before clinical, thus freeing clinical time for patient care issues. These points were illustrated by comments such as: "it was easy to e-mail our journals instead of going to campus to pass them in," "e-mail is very helpful with the journal-saves some leg work & writing," "quick, easy, efficient-makes communication between instructor & I a lot easier, and I get a lot of useful information this way, ""e-mail addresses of all instructors and classmates was useful," and "easier communication with clinical instructor."

E-mail gave beginners more confidence in exercising their "voice" as they learned the language of the nursing profession. Typing an e-mail gave them an opportunity to reflect before they answered. One student reported: "I like e-mail because it helps me to go over and remember what I did the previous week."

Student evaluations can be problematic in clinical settings because they are very subjective. E-mailing journals gave faculty insight into the critical thinking skills of students. The quick turn around time of e-mail provides an ongoing dialogue regarding clinical issues with faculty and students. Paper copies of journals do not render expedient dialogue and issues may tend to get lost. Todd (1998) found this tool valuable when evaluating student progress in meeting course objectives. Mastrian and McGonigle (1999) used e-mail for students to respond to critical thinking assignments on the web. The e-mailed journals could be saved as files (with permission from the students) and faculty could reflect back on them for dialogue and clinical evaluations.

E-mail: Challenges

Although this ongoing dialogue was valuable, it made faculty more accessible to students. Thus, teaching time was expanded for faculty. As Noble (1998, p. 35) states, "Faculty struggle at all hours of the day and night to stay on top of technology and respondŠ to e-mail, to both the students and administrators to whom they now become continuously accessible." It was also more time consuming for faculty to type comments by e-mail than just making notes on a paper version of a student journal.

For those students with University Internet accounts, the e-mail lag time sometimes could be about 15 hours. One student reported: "the only thing I can think of as not helpful is the lapse time in getting e-mail in the University system." Also the University phone lines for accessing the Internet could be very busy at certain times of the day, making it difficult for students to get on-line.

The survey identified a challenge with the use of the technology itself, as shown in comments such as: "I encountered some difficulty in sending my e-mails correctly which was annoying for me" and finally "I am still not sure how to send attachments." Those students lacking e-mail skills needed to be self-directed to get assistance or learn on their own.

"Bytes for Future Thought": Where Do We Go From Here?

The approach for managing the web- based technology in a team-taught clinical practicum is very important. It is recommended that those resources within the college or university be explored. Faculty also need to decide who should be responsible for managing the web page. We would recommend one faculty member be designated to manage the main web page and each clinical faculty member be responsible for their individual clinical group web pages. Support from technologically proficient colleagues is essential. To save faculty time, a template and a consultant should be accessible to all clinical faculty as questions about designing, implementing and managing a web page develop.

Assisting nursing students and faculty with the transition to using the Internet in a clinical pracitcum course can be difficult. Students and faculty need to let go of the traditional pedagogy and confront their anxieties about computer technology (Miller et al 1997). It seems not long ago that we were challenged to go from the typewriter to the computer. Would anyone go back to the typewriter? Learning to use a word processor was slow and each step needed to build on the next. As with the Internet and teaching a clinical practicum course, we would recommend initially instituting only a few teaching methodologies related to the Internet, evaluate the outcomes, and in the next clinical practicum build on the technology pedagogy and teaching experience.

There are many possible uses of the Internet to build on for this clinical practicum course. As other faculty develop web pages in the curriculum, more horizontal and vertical links could be made to the content of didactic courses. For example, a research course being taught concurrently with this course could include critically critiquing health care web sites, transcribing critical thinking research skills, filtering information, organizing what information was found, and discussing copyright and confidentiality issues related to the Internet.

Discussion forums within and outside of clinical groups could be implemented with the use of bulletin board programs. This type of program has the potential to foster and evaluate critical thinking. Faculty could post a clinical scenario each week and invite students to respond to the question and to each other's comments. In addition, exercises and quizzes could be submitted on-line by the students to review critical thinking in regard to skills students will be implementing in the clinical setting (i.e., communication, teaching, psychomotor skills, assessment, medication dosage calculations, etc.). Course and clinical instruction evaluations could also be submitted on-line by students (Barber et al, 1999). A group of students could implement a health promotion teaching project on-line with faculty supervision (Bliss et al 1999). More resource links could be added, including professional nursing organizations, on-line journals, government agencies, communication skills, etc. (Clark 1998). As technology develops, students could view nursing procedures (e.g., universal precautions) video tapes on the web site during their own time, instead of using valuable lab time. Telementoring could be initiated whereby junior students could communicate with more experienced students or nurses in other schools of nursing, locally and/or internationally.

Conclusion

It is very important not to lose sight of traditional teaching methods involving face to face interactions. The Internet is not meant to replace but to strengthen the traditional teaching tools of imparting information, guidance and feedback in a clinical setting. In summary, we found that some challenges and benefits of the Internet for didactic courses13 were also the same for this clinical praticum course. The Internet assisted students to be more self-directed, gave them a broader professional perspective (Clark 1998), and a new venue for communicating. Students gained confidence in expressing their clinical opinions and questions to faculty through e-mail. The survey revealed that many students came to nursing with limited exposure to the Internet in education. Teaching this clinical practicum course with web-based technology opened a door for these students, leading them one step closer to a future in which a world of health care resources is just a click away.

Acknowledgment

Appreciation is expressed to Dorothy Gilbert, PhD, RN, Associate Professor, School of Nursing. University of Massachusetts, for her valuable support in the development of the manuscript.

References:

American Association of College of Nursing (AACN) 1999 Essential Clinical Resources for Nursings Academic Mission. Washington DC: AACN, 8

Barber K, Wyatt K, Gerbasi F 1999 On-line interactive evaluation in course and clinical instruction. Nurse Educator 24(2): 37-40

Bliss J, Allibone C, Bontempo B, Flynn T, Valvano NE 1998 Creating a web site for on-line social support: Melanocyte. Computers in Nursing16(4):203-207

Carty B, Rosenfeld P 1998 From computer technology to information technology: Findings from a national study of nursing education. Computers in Nursing 16(5): 259-265

Clark D 1998 Course redesign: Incorporating an Internet web site into an existing nursing class. Computers in Nursing16(4): 219-222

Cravener PA 1999 Faculty experience with providing online course: Thorns among the roses. Computers in Nursing 17 (1): 42-47

Mastrian K, McGonigle D 1999 Using technology-based assignments to promote critical thinking. Nurse Educator 24(1): 45-47

Mikan KJ 1992 Implementation process for computer-supported education. In Arnold JM, Pearson GA. Computer Applications in Nursing Education and Practice. New York NY: National League of Nursing, 191-199

Miller JJ, Piper L, Tucker DA 1997 Strategies for getting students on the superhighway. Nurse Educator 22(5): 40-43

Noble D 1998 Selling academe to the technology industry. Thought and Action: The NEA Higher Education Journal 14(1): 29-40

Simpson R 1995 Surfing the Internet. Nursing Management 26(7): 18-19

Saranto K, Leino-Kilpi H, Isoaho H 1997 Learning environment in information technology: The views of students. Computers in Nursing 15(6): 324-332

Todd N 1998 Using E-mail in an undergraduate nursing course to increase critical thinking skill. Computers in Nursing 16(2): 115-118

Table 1. Main Web Page and Clinical Group Web Page Links

Main Web Page Links (http://www-unix.oit.umass.edu/~n398e/w398e98/index.html):

• Syllabus
• Professors' names and e-mail addresses
• Clinical evaluation tool
• Professors and clinical groups
• Lab schedules
• General assignments
• Special announcements
• "Pilot" clinical group web page links for 2 clinical groups
• Resource links (i.e., medication dosage calculations, physical exam techniques, nursing assessment, lung sounds, and Agency for Health Care Policy and Research [AHCPR] )

Clinical Group Web Page Links (http://www-unix.oit.umass.edu/~n398e/w398e98/clinwe.htm):

• E-mail addresses of students within the clinical group
• Guidelines for organizing a clinical day
• Clinical expectations
• Medication administration preparation guidelines appropriate for the clinical site
• Calendar

Oct. 19 Monday	Oct. 20 Tuesday	Oct. 21 Wednesday	Oct. 22 Thursday	Oct. 23 Friday
1. Journal Due (e-mail) (Click here for guidelines) 2. Check Community Web site (click here). Bring one page of interest on Oct. 22. 3. Check Diabetes Web Site (click here) for information for Blood Sugar Table. E-mail YC about information for Blood Sugar poster.		Nursing Rounds at Rehab Center from 10-11:30 am. Meet in Conference Room: Please wear name tag and nice clothes (no uniform necessary). Students to attend: 1. A. M. 2. M. M.	Community Survey (click here for form to bring): 8 am Pre conference meet at Senior Center. Bring one page from Community Web site. 8 am-2pm Assess community 2-3 pm Post Conference Morrill 404	Health Fair at Middle School. 7am -2 pm. (click here for directions and parking) Read handouts on guidelines for giving flu, pneumonia and tetanus immunizations. Bring stethoscope; wear white uniform and nametag. Be prepared to do teaching and check blood sugars via Precision Glucometer at Blood Sugar table.

Figure 1. Clinical Group Calendar Link Sample

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