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Vol.7, No.1 April 2001
Editorial | Contents

On-line Problem-Based Learning Patient Situated Scenarios:
Undergraduate Evaluation and Assessment Outcomes

Refereed Paper

Author

John Oliffe RGN, Grad Cert Paediatric Nursing
GradDip Adult Ed, M.Ed.
Lecturer Deakin University, Victoria, Australia
221 Burwood Highway
Burwood Victoria 3125
oliffe@deakin.edu.au
Fax 613 92446159, Ph 613 9244-6625

Abstract

The School of Nursing, Deakin University, incorporated an on-line, problem based learning, patient situated scenario to its undergraduate program for the first time in 1999. The on-line content was not formally supported with a nursing laboratory, planned resource or facilitated session, however, the content was examinable.

Student evaluation of the scenario illuminated issues of access, reading, preferred learning modes and perceived double loop learning. An analysis of the student examination outcomes, pertaining to the on-line content, was also insightful. The findings reveal strengths and problems in the integration of on-line technology to mainstream teaching, that serve as a reminder to the experienced and as an introduction to the novice information technology facilitator.

Background

Deakin University is a higher education organisation with a rich history in flexible teaching and learning, specifically distance education that traditionally has taken the form of hard copy text materials. The success of distance education has resulted from the identification and design of materials for predominately postgraduate clients that seek the flexibility of studying at home or work in a self-directed manner.

The Deakin University 1997 Strategic Plan acknowledged the success of distance education but identified that in order for the University to flourish over the next decade, teaching and learning had to change. Specifically Deakin University needed to offer instruction that was:

• flexible

• accessible

• technologically advanced

• learner centered and customer focussed

• service oriented

• cognisant of the needs of life-long learners.

Congruent with these strategic plan objectives, Deakin University proposed the use of low end, low cost, high volume and easily achievable technologies. The design and delivery of on-line content to undergraduate program was the specific focus.

Undergraduate Curriculum

Deakin University School of Nursing adapted a modified Problem Based Learning (PBL) approach to its undergraduate program in 1995. PBL evolved from innovative health sciences curricula introduced in North America in the 1950s and Canada in the late 1960s (Boud & Feletti 1997). Medical education through basic science lectures and clinical teaching had become an ineffective way to prepare students. Medical information and new technology rapidly changed the demands of future practice and, as a consequence, new strategies e.g. PBL were employed. The principal idea behind PBL is that the starting point for learning should be a problem or a query that the learner wishes to solve. PBL is a way of constructing and teaching courses using problems as the stimulus and focus for student activity, rather than the exposition of disciplinary knowledge. Students move toward the acquisition of knowledge and skills through a staged sequence of problems presented in context, together with associated learning materials and support from facilitators (Engel 1997).

"Nursing people experiencing complex acute illnesses" is a third level undergraduate core subject offered by Deakin University School of Nursing that incorporates PBL tutorials, planned resource sessions and nursing laboratories. The subject includes six problem situated scenarios. Planned resource sessions provide information, pertinent to the scenarios, from both a nursing and bioscience perspective. This is complemented by PBL tutorials and nursing laboratories in which problematic scenarios are explored, and student learning needs identified. The scenarios are designed based on real patient presentations that are ill-structured, open ended, or ambiguous (Fogarty 1997). It is often a complex situation with a number of interrelated concerns that seek to engage students in intriguing, real and relevant intellectual inquiry, facilitating learning from life situations (Barrell 1995).

An on-line problem situated scenario was incorporated into the subject for the first time in 1999, traditionally scenarios were presented in hard copy format. The program was composed on Frontpage and included scanned clinical case notes with linked respiratory cough and stridor audio files from a paediatric croup presentation. The site also included a facility for students to provide e-mail feedback regarding the site design and / or content to the first time author. The program was not supported by a fixed resource session, tutorial or nursing laboratory however the content was examinable.

Student evaluation

Following completion of the scenarios, a subject evaluation form was completed by participants. Included in the evaluation were three statements pertaining to the on-line scenario that participants were asked to rate as strongly agree (SA), agree (A), disagree (D), strongly disagree (SD) or not applicable (NA) and two questions asking for a yes (Y) no (N) response. The information was sought to illuminate issues of student acceptance, access, reading on-line, preferred learning modes and perceived double loop learning. The total number of students enrolled in the subject was 288.

The on-line scenario was interactive.
(n=199; 69% return)

I developed computer skills through accessing the material on-line.
(n=197; 68%)

I prefer on-line content to hard copy text.
(n=208; 72%)

I printed out the scenario information.
(n=198; 68%)

I was able to access the on-line material from my personal computer and or the computer labs on campus.
(n=199; 69%)

Discussion

Interactivity
Not applicable (NA) responses of 9.5% were related to students not accessing the program on-line but sharing printed resources or not having accessed the materials at the time of evaluation. Whilst the majority of students agreed the scenario was interactive some 32.1 % disagreed (D) or strongly disagreed (SD) that the program was interactive. The program had stridor and cough audio files, links to clinical case notes and an e mail author feedback facility. Students experienced difficulty in accessing the audio files which was related to incompatible software. Little feedback was received via the e-mail facility. Many students currently in higher education grew up with multi media programs, much the same as baby boomers grew up with television. The result is a discerning sophisticated user who will not invest time in poor programs. The program's interactivity may be enhanced with the inclusion of a quiz, chat and audio software download facility, which would be achievable with more sophisticated authoring tools.

Development of computer skills
Not applicable (NA) responses of 11.6% were related to students not accessing the program on-line but sharing printed resources or not having accessed the materials at the time of evaluation. 53.7% of students disagreed (D) or strongly disagreed (SD) that they had developed computer skills through accessing the content on-line.

Much of the pedagogical claims for the inclusion of computer mediated learning are premised on the benefits of double loop learning, where the student develops computer skills as well as content analysis and synthesis. The student perception may have been due to the relative simplicity of the program or perhaps an underestimation of computer skills in the student group.

On-line verses Hard copy
Not applicable (NA) responses of 5.7% were related to students not accessing the program on-line but sharing printed resources or not having accessed the materials at the time of evaluation. Some 75.9% disagreed (D) or strongly disagreed (SD) with the statement ‘I prefer on-line content to hard copy. This was supported by 55.5% of respondents printing out the scenario information.

These results raise a number of issues, specifically gender, learning styles and the value of predominately text based documents on-line. The gender split of participants completing the on-line scenario was 96% female and 4% male. Research literature highlights gender differences in the use of information technology. Bernhard (1992) found that in spite of equivalent instruction, males completed a significantly greater number of learning activities on computers than females. Hattie and Fitzgerald (1987) found that 'more females than males dislike computers'. Newton (1991) found that females were seriously concerned about the computer's (lack of) intrinsic satisfaction. The research regarding gender and computer use, whilst not conclusive, certainly supports the need to research the preferred learning mode of a predominately female audience.

Whilst the electronic case notes were clear and legible, the computer display devices on which these documents are often viewed are significantly inferior to print. Wilkinson and Robinshaw (1987) reported significantly higher reading fatigue associated with computer screens relative to paper with results showing a degradation in performance over a fifty minute task. Valauskas (1994) also argued for the superiority of print for extended reading. Dillon (1988) identified browsing, light reading and formal studying as more frequent interactions with written material. Linear learning styles have historically been facilitated by chronological documents, rather than multi accessible links typical of on-line programs. The value of predominately text based documents on-line is contentious with the cynical view being that the advantage of long documents on line is to transfer the cost of printing to the user.

Access
Whilst 80.4% of respondents were able to access the material from home or the on campus computer labs 19.6% were not. It is unclear from the data whether this was related to computer access or participant skills. However the Uniform Resource Locator (URL) address for the program contained forty characters including an underscore that created difficulties for some students. Access would be enhanced by a direct link from the Deakin University home page and a user friendly URL. Concerns related to student access to on-line programs reflect issues of equity and quality of teaching and learning. On going evaluation of access issues is mandatory if on-line programs are to facilitate flexible learning in higher education.

Student assessment
The student assessment for the subject included a 3 hour written examination that included 30 multiple choice questions and short answer questions worth 70 marks. The examination assessment was completed by 236 students. The on-line content was examined through the following 5 multi-choice questions. The written examination was the major assessment task of the subject constituting 70% of students’ final grade. The multi choice questions with bolded correct answers and results are as follows:

When compared with the airway of an adult, an infant has a:
a. Soft easily compressible trachea
b. Large tongue
c. Narrow nasal passages
d. All the above
n=130
Percentage correct 55%

Physiologically, when compared with adults, infants:
a. Have a higher respiratory rate
b. Are diaphramic breathers
c. Have a more compliant chest wall
d. All the above
n=130
Percentage correct 55%

Nebulised adrenaline's therapeutic actions in the treatment of croup are:
a Glottic vasoconstriction and reduction of oedema
b Tachycardia and tachypnoea
c Bronchconstriction and bradycardia
d Potentiates cell mediated immunity and reduces inflammation
n=106
Percentage correct 45%

Croup affects the following:
a Larynx
b Trachea
c Bronchus
d All of the above
n=144
Percentage correct 61%

Signs and symptoms of moderate to severe croup include all of the following EXCEPT:
a Barking cough
b Stridor
c Trachael tug
d Wheeze
n=99
Percentage correct 42%

Overall results from multi-choice examination

Discussion
The 5 multi-choice questions pertaining to the on-line content correctly answered were below the mean multi-choice score, both singularly and when grouped. Singularly, correct responses ranged from 42% to 61%, whilst cumulatively the mean for the 5 questions was 51%, some 17% below the overall mean for the multi-choice portion of the examination.This result may be related to the inequitable absence of planned resource sessions, tutorials and laboratories to support the on-line content. The six hard copy problem situated scenarios were supported by such conventional PBL methods. This result provides further evidence of the importance of facilitation in PBL. However due to the inequity regarding formal support, a comparison of hard copy and computer mediated scenarios is not credible.

Recommendations

• Continued analysis of student evaluation of on-line programs will facilitate identification and understanding of the intended audience and inform undergraduate nursing program design and mode of delivery. The identification of this audience will allow higher education institutions to define flexible learning and interactivity in terms of the student.

• Higher education facilities must formally support teaching academics in the development of on-line authoring and program design skills if they are expected to ultimately be responsible for on-line program development.

• Computer mediated student learning should be supported and evaluated under comparable conditions as traditional teaching and learning.

Conclusion

Computer mediated learning is a relatively new concept and as such brings unique issues to teaching and learning in higher education. This paper has illuminated the need for high quality visual presentations, user-friendly access, clear structure for text on screen and facilitation support in 'real' time. As Beckett (1998) argued, in order to put out spotfires, seize the moment, catch the nuance and make something unique out of human sensibilities as they are revealed, requires the facilitator to be there. Whether that is in person, on-line or both remains to be seen.

List of References

Barrell, J.(1995). Problem-Based Learning in Fogarty, R. Problem-based Learning and other Curriculum Model for the Multiple Intelligence’s Classroom. Melbourne: Hawker Brownlow Education.

Beckett, D. (1998). "Disembodied Learning: How Flexible Delivery Shoots Higher Education In The Foot: Well, sort of". Electronic Journal of Sociology Vol. 3. http:www.socoilogy.org/vol003.003/beckett.article.1998.htm (visited 26/8/98)

Berhard, J. (1992) "Gender-related attitudes and the development of computer skills: a preschool intervention". The Alberta Journal of Educational Research 38, (3) p.177-188

Boud, D. and Feletti,G. (1997). Changing problem-based learning. Introduction to second addition. The challenge of problem-based learning. London Kogan Page Ltd

Dillon, A. (1988). "Reading from paper versus reading from screen". Computer Journal, 31(5): p.457-64.

Engel, C.(1997). Not Just a Method But a Way of Learning in Boud, D.& Feletti, G. The Challenge of Problem-Based Learning. London: Kogan Page.

Fogarty, R. (1997). Problem-Based Learning and other Curriculum Models for the Multiple Intelligences Classroom. Melbourne: Hawker Brownlow Education.

Newton, P. (1991) "Computing: an ideal occupation for women?" In Jenny Firth- Cozeens & Michael A West (Eds.) Women at work. Psychological and Organisational Perspectives. Philadelphia, Open University Press.

Valauskas, E. J. (1994). "Paper-based or digital text: What's best?"

Computers in Libraries, 14(1):44-47.

Wilkinson, R. and Robinshaw, H. W. (1987). "Proof-reading: VDU and

paper text compared for speed, accuracy and fatigue". Behaviour and

Information Technology, 6(2): 125-33.

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