Vol.8, No.1 April 2002
Contents
Online delivery of nurse education: the concerns of university educators
Refereed article
Author
David Gillham
BSc, RN, BN, MNSt.
School of Nursing and Midwifery
Division of Health Sciences
University of South Australia
email: david.gillham@unisa.edu.au
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Abstract
Australian universities increasingly need to generate income to ensure their survival and continual growth. Developments in Internet Communication Technology (ICT) and the strong demand for Australian university qualifications in Asian countries create the potential for income generation through the provision of offshore courses using online delivery. Australian universities have been quick to recognise and respond to these opportunities.
While this paper does not directly criticise the quality of online course delivery by Australian universities, the paper does highlight the relationship between resources and quality in relation to online delivery. Specifically, this paper emphasises the need for long term, national planning in relation to online delivery to ensure that marketable, global reputations for quality in online delivery are established by Australian universities. This paper calls for collaborative strategies for online course development designed to promote quality, thereby enhancing the credibility of Australian education and the long-term viability of the multi-billion dollar education export industry.
This paper focuses specifically on the online delivery of nurse education examining issues associated with the quality of online course delivery. The paper reports qualitative and descriptive data from a national survey of Australian nurse educators examining levels of Internet use, attitudes to online delivery, requirements for online delivery, and educators’ perceptions concerning the implementation of online delivery. Results of the survey indicate that nurse educators have positive attitudes in relation to the potential of online delivery but have many concerns related to the way in which online delivery is being implemented. This paper provides an extended discussion of the survey results by proposing collaborative national online nurse education development.
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Background
Australian universities are under considerable pressure to obtain greater levels of funding from non-government sources. As a consequence, at a local level, schools and faculties are increasingly moving towards income generation and the partial adoption of commercial management practices. The assumptions underlying these developments are that education is a marketable commodity and commercial income generation is beneficial for the short and long term. Taylor et al. (1998) surveyed three Australian universities, finding concerns in relation to teaching quality, research quality and academic freedom. While there has been widespread critical comment from all levels of academia in relation to the impact of funding constraints, such arguments are frequently dismissed by politicians.
The outcome is a situation where short-term commercial interests may be given precedence over long-term quality issues. This may lead to multiple, small scale, commercially dominated online education ventures in a global education marketplace. Australian universities have established a good reputation in Asia, as a result of many years of high quality traditional university education. This high quality education has helped to establish a multi-billion dollar education export industry. Ironically, rather than protect this industry by providing adequate financial resources to ensure the highest standards are maintained, current funding and competitive policies may encourage many schools and faculties to rapidly produce online courses with immediate profit generation the primary aim. Pockley (1997) suggests that funding cuts for higher education in Australia will lead to Australia falling behind South East Asia. If this occurs, the education export market may begin to disappear. This paper argues that inappropriate commercial ventures in the area of online delivery may severely damage the income generation potential of Australian universities and that, above all, well-funded national initiatives are needed for online education export. This paper focuses specifically on nurse education; however, the argument may apply equally across numerous disciplines.
In faculties and schools of nursing, funding restrictions have impacted heavily, with some nursing schools implementing staff cuts and reducing student intakes. Consequently, nursing schools also find themselves under pressure to generate income with fee-paying online courses providing potential for revenue generation. Simultaneous to these developments have been improvements in computer hardware and software and increased use of the Internet.
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It is therefore not surprising that nursing schools throughout Australia are rapidly moving into the area of online delivery. However, there is a profound lack of educational research in the area of Internet use for nurse education (Ribbons 1998). Online delivery is fundamentally different from traditional teaching in terms of information supply, learner control, the role of the educator, access to information and interaction with staff and students. Many authors have highlighted the potential of online delivery. For example, Kenny (2000) suggests use of the Internet can offer exciting possibilities for nurse education. Advantages of online delivery include access to worldwide information resources such as systematic reviews of research evidence, the ability to communicate over vast distances using email, the facility for multimedia capabilities such as audio, video and animation and advantages afforded by online discussion, discussion lists and online synchronous chat. However, online delivery may be viewed by some with skepticism and specific concerns in relation to the use of online delivery as a means of cutting costs and staffing levels. Ward (1997) highlights the issues of quantity and quality of Internet based information for nursing suggesting this will lead to fundamental changes in professional and geographic boundaries. For example, professional boundaries may change as nurses are able to expand their role through improved access to online education or Internet based decision support software. Similarly, the impact due to changes in geographic boundaries may be profound as information such as clinical guidelines are made available worldwide. However, Kenny (2000) cautions that the technology is growing so rapidly that blind acceptance is possible. Likewise Ryan (1998) cautions that universities are following the direction of the banking industry into the area of digital distancing by separating clients (in this case students) from service providers (educators) through the use of technology. Online delivery can potentially link students in Asia to educators in Australia with great efficiency and convenience via email and online discussion. Such online delivery combined with local face-to-face learning support, culturally appropriate content applicable to the local health care environment and adequate levels of interactive activity for students could be the basis for successful online delivery. However, resource constraints, infrastructure difficulties, language barriers and staff with competing interests can all combine to make digital distancing a reality for online offshore students. This paper, by reporting a survey of Australian nurse educators, highlights some of the possible pitfalls with online delivery. While many of these concerns relate to online delivery within Australia, they can easily be extrapolated to international online delivery.
While there is a substantial body of research addressing educational ICT interventions generally, there has been relatively little investigation of ICT for nurse education. Furthermore, most studies addressing online nurse education investigate the value of specific interventions rather than explore the political, professional, resource, technological, teaching and learning issues associated with online delivery.
Most nurse educators have a strong awareness of such issues and are therefore best positioned to identify the potential problems associated with online nurse education. This paper reports a survey of nurse educators throughout Australia thereby providing recognition of the expertise of this group and most importantly capturing the views of nurse educators at a time when their collective voice needs to be heard on the important issue of online delivery.
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Participants
Two hundred and ten nurse educators identifiable via the Internet and occupying nursing related teaching positions in universities in Australia participated in the study during 2000/2001.
The criterion for inclusion in the study was an accessible Internet email listing as an academic staff member of a school or faculty teaching nursing, excluding the Head of School. Consequently, the sample is best described as a convenience sample. An overall response rate of 76% was obtained comprising 38.6 % of staff employed at level C and above, 48.3 % employed at level B, 13 % employed at level A or occupying associate positions. There were 81.1% female and 18.9% male participants. Participants were all employed in university schools or faculties teaching nursing, thereby representing a very wide range of nursing specialty areas and including staff from supporting science areas. Notable exclusions from the study were university staff without readily accessible contact details and educators employed in hospitals and health care agencies.
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Materials
Participants were provided with a 5-part survey questionnaire. A covering letter explained the purpose of the study, with the completion and return of the survey indicative of consent to participate. The questionnaire consisted of the following measures:
Section A: This section examined the extent to which participants used computer resources in the context of their day-to-day working environment such as word processing, email, web-databases and authoring software thereby providing a measurement of computer use by study participants.
Section B: The Attitudes to On-line Delivery Scale (AO-LS) consisted of 26 questions that examined the extent to which participants saw on-line delivery as beneficial for the purposes of nurse education. Responses were measured on a Likert-type scale ranging from 1 to 5.
Section C: The Support for On-line Delivery Scale (SO-LS) consisted of 19 questions that examined the necessary requirements for the online delivery of nurse education. Responses were measured on a scale ranging from 1 for not useful through to 4 for essential.
Section D: This section included information relating to the participants’ level of employment, hours of employment, sex and specialty
Section E: Consisted of an open ended question 'What is your opinion of online delivery developments in your own institution?' and provided further opportunity for comment 'Please provide any further comments you have in relation to the online delivery of nurse education.'
Procedure
Initially the survey was conducted via email with an electronic response rate of n=46 (16%.) A hard copy follow-up mailout to non-respondents was very successful leading to the final total response rate of n=210 (76%).
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Results
Detailed inferential analysis of the survey data was carried out using SPSS consisting of factor analysis, reliability measurement, multiple regression, ANOVA and t-testing. While this data produced very limited findings in terms of statistical significance the factor analysis may be of value for readers planning to design questionnaires investigating online delivery. The survey constituted one component of the doctoral thesis written by the author of this paper. The details of the inferential data analysis are contained within the thesis. Descriptive and qualitative data collected by the survey were of far greater interest and are consequently reported here in detail.
Descriptive data indicated nurse educators reported greatest use of word processing and email, with the next most frequent usage being use of the web for personal professional development and use of databases such as Cinahl and Medline. Usage levels for electronic journals, websites to prepare teaching materials, non-nursing health related web-resources and the Cochrane database were lower. The use of complementary therapy resources, web authoring software, clinical procedures and protocols accessed via the web, and professional discussion lists received the lowest usage rating.
Respondents agreed that online delivery can improve the accessibility of nurse education, improve learning opportunities and flexibility for students, provide good resources for sharing and discussion, and develop life-long learning skills in computing. Clearly nurse educators in general recognised the potential of online delivery. However, educators were particularly concerned about equity of access, workload issues for staff and the need for face-to-face contact with students. Educators were very sensitive in relation to the need for clinical placements for students and strongly oppose the use of online delivery to replace clinical placement.
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Qualitative Results
Section E of the questionnaire contained the question 'What is your opinion of online delivery in your own institution?' and provided the opportunity for further comments about line delivery.
Section E was analysed using Nvivo. Initial thematic analysis of responses indicated that most emerging themes were identifiable in both the main question and the opportunity for further comment. Consequently responses to the question and opportunity for comment were combined for the purpose of qualitative data analysis.
Themes identified were the potential of online delivery, face to face contact, clinical education, applications to undergraduate and postgraduate education, workload, infrastructure and technology and student learning issues. Each identified theme will now be addressed in turn. The quotes identified with respective themes are selected with the aim of reflecting the overall tone of responses.
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Potential
Participants identified the potential for the online delivery of nurse education highlighting flexibility and the enriching nature of the content available but cautioned that, depending on implementation methods, this potential may not be reached.
The potential is huge but if it is not prepared by people who truly understand the capacity and capability of the technology, it is a shallow teaching method.
While there was widespread recognition of the potential for online delivery nurse educators were generally not convinced that current work practices would lead to the fulfillment of this potential.
Online delivery has great potential for the delivery of course material to students, especially in postgraduate courses. However to achieve excellence in presentation requires money and resources that are not always available.
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Face to face
Many participants identified the issue of face-to-face teaching. While a small number of participants indicated success with solely online delivery, some participants indicated online delivery should be used in conjunction with face-to-face teaching.
Online delivery developments in my institution have added to the scope of nurse education in a way that complements not replaces face to face teaching.
Online has very useful applications but must be well developed with educational aims, well resourced and balanced with face to face teaching.
Students require interaction with peers and lecturers in order to have an enriching learning experience and until online technology can facilitate this better, online should remain in my opinion an add-on to either a face to face teaching component and / or hard copy materials and interaction via teleconferencing or some form of effective communication medium.
Educators identified face-to-face teaching as an essential component of undergraduate education.
Online is very important for postgraduate education but if used for undergraduate must be supplemented by face to face and clinical practice in hospital etc – is essential.
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Clinical Education
While only a small number of participants addressed clinical learning, there was strong support amongst this group for the need for face-to-face clinical teaching.
I do believe that the clinical aspects of nursing education needs to remain face to face and clinical placements for students to continue.
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Undergraduate and postgraduate education
While some participants reported online delivery as a component of undergraduate programs, others questioned the use of online delivery for undergraduate education.
We do use web based and computer strategies when teaching the undergraduate students who attend on campus lectures and are encouraged to undertake many learning activities using computer assisted learning tools.
Has limited applicability in undergraduate nursing courses.
Not used for undergraduates only postgraduates.
The limited support for online undergraduate education apparently related to the need for face-to-face teaching of clinical content for undergraduates. In contrast, those discussing the implementation of postgraduate courses generally viewed online delivery favourably.
Progressing very quickly and successfully. Three post-graduate courses now online.
Online delivery has enabled me to ‘teach’ more postgraduate students.Convenience and accessibility were apparently major advantages for online postgraduate education.
An excellent choice for those postgraduate students who cannot come to classes or for those who find it fits their lifestyles or who prefer online to print medium.
The advantages of online delivery for postgraduate students in rural and remote areas were highlighted in relation to access and convenience.
Only option often for postgraduate study in country areas.
However, participants also identified concerns in relation to computer access and computer literacy for postgraduate students.
We are developing online study options for students, however many in our postgraduate student pool have limited computer knowledge and resources. Nurses are predominantly women and it is often difficult for them to access the funds required to purchase computer software and up to date hardware.
It is notable that access was identified as both an advantage and a concern. This suggests that those with Internet access were able to improve their access to educational resources.
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Workload
Workload and related quality issues were consistently identified. Many participants indicated that online delivery constituted an additional workload requirement with no time or insufficient time allocated to the development and delivery of online materials.
Preparation increased workload enormously and the writing is not factored into workload.
There’s no extra salary for it either – just a bigger workload.
The time devoted to online students is a workload issue for staff as it often exceeds time spent with on-campus students.
Educators were clearly concerned that inadequate workload allocation to online delivery was very detrimental to the quality of online delivery.
Online has potential to increase workload and decrease quality of teaching as many do not believe it requires the same degree of expert input as didactic teaching does.
I have personally found that online most subjects have limited depth and still require many adjuncts. Nursing is and will always be practical application and I do wonder at the direction we are taking.
Poorly designed and structured online subjects are a gross waste of time and energy both for the educator who had to do it and for the students who will try to use it.
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Infrastructure and technology
Infrastructure and the need for appropriate technology were identified as problematic by a number of participants. Some participants also indicated that not only did the technology need to be in place but staff needed the skills to use this technology.
Potential for progressive and flexible learning is great however the infrastructure was not a priority when the technology was launched upon us.
Little support or training given in ‘how to do it’
The proliferation of online learning applications has been experienced by many staff and students as bewildering
However we could be more innovative if the technological infrastructure allowed this.
Comments on infrastructure and technology were variable suggesting some universities had well established technical support while others did not.
The basic infrastructure at this campus is very poor so we are not using much online delivery but we are being pressured to do so from main campus.
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Student Learning
Student learning issues were identified by a large number of participants. Sub-themes identified in relation to student learning included communication and interactivity, individual learning needs, technological and access problems and student computer literacy.
Still developing but issues of teaching and learning quality and efficiency have not been sufficiently addressed.
The need to maintain close contact with students and respond with urgency was highlighted, as was the value of interactive learning exercises. While some participants reported successful student learning with online delivery others indicated this was not appropriate for all students.
I find it demands increased work for staff and a strong commitment to respond to students responses (urgency) not there previously.
Quality of teaching survey results are equivalent to on-campus taught subjects.
We must acknowledge that online does not suit all of our students and prospective students.
Participants were concerned about slow access in rural areas and the impact of poor infrastructure upon student learning. Participants also identified concerns in relation to fear of computers.
Educating students to be unafraid of computers in nursing is also important and we don’t really address that to the fullest degree yet.
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Limitations of the survey
While the response rate was 76%, it should be noted that selection bias is possible. In addition, it must be noted that the sample of those with accessible email addresses does not include nurse educators with incompatible email systems to those of the researcher or those educators working in hospitals and health care settings. While a satisfactory response rate and meaningful data were collected through persistence, there is considerable scope for further questionnaire improvement. It is likely more careful attention directed to the specialist feedback and pilot phase of the questionnaire design process may have lead to improved questionnaire design. Nonetheless, given this is an area virtually devoid of research, useful progress has been made in terms of providing a basis for further research. The approach of surveying educators as crucial players in the implementation of online delivery has been beneficial.
The questionnaire did not raise the possibility of a coordinated national approach to online nurse education, as proposed in this paper. Consequently, it is important to acknowledge that the discussion of coordinated online development to follow, proposed by the author as a solution to the resource and quality dilemma, is not necessarily representative of the views of educators surveyed.
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Discussion
Results of the survey reflect the rapid and widespread implementation of online delivery. Qualitative data was generally highly consistent with descriptive results. Clearly nurse educators recognise the potential of online delivery. Some survey respondents reported problems in relation to infrastructure, technical support and resource and workload issues. In contrast many respondents did not identify these issues at all. This suggests that there may be substantial differences between universities in relation to technical and human resource support for online delivery. Some online courses have been successfully implemented but such success is apparently dependent upon student learning needs, the type of course, student support, technical support and resource allocation. One respondent captured most major issues
Great ideas are emerging. Little emphasis given to the time required to develop, implement and update resources. Ongoing costs severely under-estimated. Success depends upon students’ level of computer literacy, access to up to date hardware and software, efficiency of the system.
The results of the nurse educator survey reflect willingness on the part of nurse educators to be involved with online delivery and a strong desire to promote the highest quality nurse education. Nurse educators clearly question whether current practices will lead to the delivery of high quality online education. It is strongly apparent from the survey results that nurse educators are concerned that if online courses are developed with insufficient resources, this will lead to a reduction in quality.
While the survey results indicated nurse educators are concerned with the quality of online nurse education they did not express concerns about the education export market. Consequently, it is important to emphasise that the discussion of education export markets reflects the concerns of the author and not research data. However, the hypothetical scenario of Australian universities providing offshore courses with low quality content, minimal interactive capabilities and poor support for students would have serious consequences. Given the complexities of cross-national and cross-cultural education this could lead to poorly educated students and graduates providing inappropriate and inadequate health care. This would not only damage the credibility of Australian nurse education but impact upon the perceived standards of Australian universities across all disciplines. While there are examples of high quality offshore online nurse education amongst courses currently in operation, it is important to completely eliminate the possibility of low quality online delivery due to the implications for Australian education export.
Clearly, providing adequate time and resources for the development of high-quality online courses within individual institutions would greatly assist this situation. However, such developments are unlikely given present funding pressures. It is apparent that the results of this survey do not describe a well-coordinated national effort to develop high quality online nurse education.
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Conclusion
Collaborative resource development provides a solution to many of the problems associated with online course development. This paper proposes that a national approach to online nurse education is developed urgently. Establishing centres of expertise in particular universities and the consolidation of links with health care agencies would assist this development. Furthermore the implementation of a national approach to online nurse education would mean that information resources could be shared by collaborative organisations. Importantly, a database of online resources able to be updated by centres of expertise but accessed across all universities could be established. The strength and intellectual property value of this concept would lie with the update and review processes, thereby establishing strong credibility for online Australian education content. In this way Australian content would have a strong competitive advantage in global education markets. Furthermore, Australian universities and their students could share the database. This would allow individual universities the opportunity to continue to deliver their own courses using the national database as a resource. The database could remain password protected and be used in conjunction with both online and traditional delivery.
The argument advocating a shared online education database is extremely simple and can be applied across multiple disciplines. Traditional approaches to education, gradually developed over hundreds of years, have been based upon direct knowledge transfer from experts to students on a localised basis. Internet technology fundamentally changes this situation in that expert knowledge can be immediately available globally to large numbers of students. Current competitive approaches to online delivery are using outdated educational processes in a manner unlikely to capture the full potential benefits of online delivery.
Developing multiple, similar online courses for the same online education market is inefficient. As the survey data indicates, educators strongly acknowledge the link between resources and quality with respect to online delivery. Quite simply, all that is needed is to fully exploit the capacity of the Internet for sharing information. It is ironic that current university policies superficially designed to maximise the value of education as a commodity may in fact discourage sharing of information and collaboration between universities. It is likely that in 5 –10 years time successful online universities will be those which have established sound global reputations for quality online delivery. Consequently, this paper argues that long-term commercial success will be dependent upon the quality of online delivery and that this can best be developed through cooperation and collaboration.
This proposed national collaborative approach to education would revolutionise competition between universities. Nurse education provides a logical starting point given the strong and persistent battle for survival encountered by university based nurse education. The successful establishment of a national nurse education database would provide great stimulus for such development across other disciplines.
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List of References
Kenny A 2000 Untangling the Web... barriers and benefits for nurse education: an Australian perspective. Nurse Education Today 20 (5): 381-8
Ribbons R 1998 Practical applications in nurse education. Nurse Education Today 18 (5): 413-8
Ryan R 1998 Time and tide: teaching and learning online. Australian Universities Review 41 (1): 14-19
Ward R 1997 Network. Implications of computer networking and the Internet for nurse education. Nurse Education Today 17 (3): 178-83
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Last modified on: Monday, 16-May-2011 08:13:00 EST
