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Vol.8, No.1 April 2002
Contents

Jimmy turns two!
On-line Problem-Based Learning Patient Situated Scenarios:
A comparison of 1999 and 2000 undergraduate student evaluations.

Refereed article

Author

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

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Abstract

An on-line, problem-based learning (PBL), patient situated scenario (PSS) was integrated to the undergraduate nursing program at Deakin University for the first time in 1999. The 1999 student evaluation of the on-line PSS illuminated issues of program interactivity, preferred learning mode and self-rated computer skill development. Comparatively, evaluations of the updated on-line PSS in 2000 revealed an increase in student satisfaction in these areas. However issues of accessibility and on-line text readability remained problematic.

Integral to student’s satisfaction with the on-line PSS was the re-establishment of facilitator support in 2000, which served to ‘situate’ students in the scenario. Minor technical and navigational improvements also made the computer mediated learning (CML) experience more user-friendly. The findings from this research support the notion of ‘face to face’ facilitation in conjunction with on-line PSS, whilst challenging many of the assumptions of incorporating CML to traditional teaching and learning in higher education.

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Introduction

The integration of CML to higher education has brought many challenges and changes to traditional concepts of teaching and learning. The ‘new’ teaching medium has resulted in widespread uncertainty for both students and teaching academics. The catalyst for the comparison of student evaluations of this on-line PBL PSS was twofold. Firstly, the notion of students as consumers. What was student’s experience and level of satisfaction with the on-line PBL PSS? Secondly, teaching academics as on-line PSS designers. What aspects of the on-line PSS needed development? The answers to such fundamental questions are integral to the future applications of CML in higher education, especially in light of the North American experience of students not going through the electronic door (Cervini 2001).

Background

The rationale for the implementation of CML has at times been unclear to both students and staff in higher education. However, despite the concerns three diverse but dominant discourses inform the use of CML, global markets, health care industry and pedagogical capabilities.

• Global markets

Reduced government funding in higher education has forced Australian universities to develop methods of deriving extraneous funds. As a result teaching and learning has had to change. There is Government expectation that universities will attract students from global markets and maximise revenue. The Internet has provided a platform for CML from which students regardless of geographic location can access subject and course materials. Reinhardt (1995) confirms that there is ample evidence that appropriate use of computers can boost retention rates and cut costs. Initial applications of on-line course materials were predominantly designed for postgraduate clientele. However, many higher education institutions, including Deakin University have integrated on-line CML to undergraduate nursing programs. Information technology has provided higher education with a global market place in which web based training is the currency to compete for education consumers.

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• Health care industry

Fullerton (1998) states the rapid pace of integration of computers into the health care practice environment presents both a challenge and an opportunity for nurse educators and their students. The advent of interactive computer technology promises yet another wave of diagnostic, treatment and documentation devices. Nurses must know how to use such electronic communication methods to practice in today’s world (Nova 1998). Nursing education has had to address the issue of student computer skills when preparing graduate nurses for their profession. Nursing graduates beginning clinical practice are expected to have computer skills. As a result CML is a content delivery medium as well as providing opportunities for students to develop computer skills.

• Pedagogical claims

Contemporary higher education organisations espouse flexibility, accessibility, and learner centred and service orientated programs as characteristics facilitated by CML delivery. Such characteristics are cognisant of the needs of life long learners, and are visible in university teaching and learning strategic plans. The concept of students having to ‘be there’ for the dissemination of information is dated. Interactivity and student engagement with content is achievable through CML. The philosophy of CML is congruent with PBL and contemporary adult learning theory in which students are expected to be self-directed. Undergraduate Problem-based Learning (PBL) Curriculum

Evidence based practice and new technology continue to change the demands of future nursing practice. The realisation of not being able to ‘teach’ everything student nurses ‘needed’ to know informed the use of PBL curriculum adapted by Deakin University, School of Nursing undergraduate program in 1995. PBL is a robust curriculum that values both content and process and empowers student nurses to develop generic clinical problem solving skills through engagement with ‘frozen’ and or ‘fluid’ clinical patient situated scenarios (PSS). 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 uses PSS 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 clinical 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 provides six PBL acute care PSS. The PSS were adapted from actual clinical presentations and are often ill-structured, open ended, or ambiguous (Fogarty 1997). The PSS are complex acute care situations with a number of interrelated concerns that seek to engage students in intriguing, real and relevant intellectual inquiry (Barrell 1995). Prior to 1999 the PSS materials were disseminated as hard copy resources and supported by facilitated sessions, planned resource sessions and facilitated nursing laboratories.

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An on-line PBL PSS was composed on FrontPage and incorporated for the first time in 1999. The on-line PSS included scanned clinical case notes with linked respiratory cough and stridor audio files from a paediatric croup presentation. There was a facility for students to provide e-mail feedback regarding the PSS design and / or content to the author. In 1999 the program was not supported by a planned resource session, facilitated session or nursing laboratory, however in 2000 planned resource sessions and facilitated sessions were available in conjunction with the on-line PSS.PSS specificies

The on-line PSS introduces students to Jimmy, a 10 month old who has been admitted to the paediatric ward via emergency, accompanied by his mother Jane. He has had a 2-day history of a stridor, a barking cough and increasing restlessness.

The student is situated in the PSS as working a night shift on the paediatric ward and is asked to assess and admit Jimmy. Cues are provided to prompt the student to consider what they would include in Jimmy’s physical assessment and history taking. Later in the shift Jimmy appears to be experiencing increased respiratory distress. The cues prompt many students to consider what increased respiratory distress is, how it would be identified, measured and managed. The side bar links to Jimmy’s emergency treatment card, immunization record and schedule, medication and observation chart and progress notes that provide cues to assist the student in exploring the complexities and specificies of Jimmy’s presentation.

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Student evaluation

Following completion of the subject, student subject evaluations were completed and the overall results correlated. Included in the subject evaluation were three statements pertaining to the on-line PSS that students were asked to rate as strongly agree (SA), agree (A), disagree (D), strongly disagree (SD) or not applicable (NA) and two questions requesting a yes (Y) no (N) response. The information provided comparable student evaluation data over two years regarding interactivity, self-rated computer skill development, readability, preferred PSS delivery mode and accessibility. 288 students completed the subject in 1999 and 235 in 2000.

Not applicable (NA) responses to the first three questions were related to students not accessing the program on-line but sharing printed resources or not having accessed the materials at the time of subject evaluation. Whilst this was of concern the sharing of printed resources is congruent with the group work underpinning’s of PBL and is demonstrative of problem solving ability.

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The on-line PSS was interactive.
1999, n = 199 (69% return)
2000, n = 158 (67% return)

I developed computer skills through accessing the PSS on-line.
1999, n = 197 (68% return)
2000, n = 180 (76% return)

I prefer on-line PSS to hard copy text.
1999, n = 208 (72% return)
2000, n = 170 (72% return)

I printed out the scenario information.
1999, n = 198 (68% return)
2000, n = 168 (71% return)

I was able to access the PSS from my personal computer and / or the computer labs on campus.
1999, n = 199 (69% return)
2000, n = 169 (71% return)

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Discussion

• Interactivity

In 2000 67.4% of the student cohort Strongly Agreed (SA) or Agreed (A) the scenario was interactive as compared to 58.2% in 1999. In 1999 students reported difficulty in downloading the stridor and cough audio files, which was due to the publishing of the files rather than the end users ability or computer capabilities. The technical problem was rectified in 2000 and World Wide Web (WWW) resources and past exam multi-choice questions were linked to the PSS. These changes were made using FrontPage which is commonly available as a base utility WWW authoring tool at many universities.

Whilst these changes were minor they did add a new dimension to the PSS. In contrast to 1999, 2000 students experienced a PSS that was ‘working’ and they were able to experience more than a point and print experience. These subtle changes resulted in a 9.2% increase in student evaluation of interactivity of the PSS. The links to relevant WWW resources enabled students to experience ‘guided’ surfing, which was new for some students. Little feedback was received via the e-mail facility in 1999 or 2000 although some students posted e-mails to assure the author that they had visited the site as well as offer http addresses for future WWW resources. The student perception of interactivity may have also been influenced by the re-introduction of facilitated and planned resource sessions, which served to situate students and promote discussion regarding the PSS.

Rapid changes in information technology make interactivity hard to define. What is contemporary this year is dated the next. Many students currently in higher education grew up with multi media programs, much the same as baby boomers grew up with television (Oliffe and Rushton 2001). The result is a discerning user who will not invest time in poorly designed programs. Clearly, student perception of an on-line PSS as interactive requires more than an image and text on the screen. However as with all ‘good education’ realistic and appropriate PSS content can be enhanced but not substituted by CML interactivity. The foundation of effective interactivity is quality content. Whilst not advocating a minimalist approach much can be achieved with the basics as this PSS illustrates.

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Development of computer skills

In 2000 48.8% of students compared to 35.5% of students in 1999 agreed (A) or strongly agreed (SA) that they had developed computer skills through accessing the PSS on-line. This was an increase of 13.3% in 2000. The result was encouraging given the impending registration of the cohort and level of computer competency expected of the practicing nurse. Much integration of CML is premised on such practical benefits, where students develop computer skills as well as content analysis and generic problem solving skills. Whilst the PSS was a relatively simplistic design, almost half the student cohort in 2000 stated that that they had development computer skills as a consequence of engaging with the on-line PSS. The PSS required students to interact with the computer enough to log on, type a http address, surf the links and print, download or read the resources. Whilst students are often assumed to have such computer skills the data suggests that we may have overestimated many student’s level of computer literacy.

On-line verses Hard copy – Students preference and printing

In 2000 26.1% as compared to 18.1% in 1999 agreed (A) or strongly agreed (SA) with the statement ‘I prefer on-line PSS to hard copy’. Despite the 8% increase in students expressing a preference for on line PSS delivery, the majority of students continue to prefer hard copy materials. The finding was supported by the result that in 1999 55.5% and 2000 52.3% of the student cohorts reported printing the PSS resources. These results raise a number of issues, specifically gender, metacognition, reading on line and learning styles.

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• Gender

The gender split of participants completing the on-line scenario in both 1999 and 2000 was approximately 96% female and 4% male. Research suggests gender differences in the use of CML. Mitra et al. (2000) found that females were less positive about computers than men and their use levels were less frequent. Berhard (1992) noted in spite of equivalent instruction, males completed a significantly greater number of learning activities on computers than females. The research regarding gender and computer use, whilst not conclusive, certainly supports further longitudinal studies that investigate the use of CML by a predominantly female undergraduate nursing audience.

• Learning styles

Linear learning styles are nurtured with chronological hard copy resources, rather than the PSS multiple links available on the side bar menu. Some students may have found the lack of structure difficult. However the lack of chronology of the PSS resources provides the opportunity for students to sort through and piece together the information, which is reflective of the clinical practice setting. Whilst this potentially ‘new way of learning’ may have created student dissatisfaction initially, there are direct benefits for student’s in the development of such cognitive skills.

• Metacognition

The expectation that student’s will have the metacognition required to appreciate the relevance of CML to their clinical practice is problematic. Students may reject CML, ambush the facilitator and demand that they be taught from the behaviourist ‘teachers’ corner. This is a common occurrence in PBL curriculum but even more so when on-line PSS are integrated. The facilitator must have a ‘helicopter view’ to see the relevance of computer skills to clinical practice in order to ‘sell’ on-line PSS. Basic skills such as viewing blood results, paging by e mail, cardiac monitoring and accessing web based hospital governance systems are integral to today’s clinical practice. The teaching academic that resists CML and denies its relevance to students and self is dated and ignorant of the contemporary demands of clinical practice.

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• Reading on line

Whilst the electronic case notes were clear and legible, the computer display devices on which the PSS resources are often viewed are significantly inferior to print. Valauska’s (1994) research supports the notion of superiority of print for extended reading. However monitor resolution capabilities have improved greatly in recent years and such developments will enable future learners to read from monitors rather than hard copy. The publishing of pre-dominantly text-based documents on-line is contentious, the cynical view being that the motivation of such practice is to transfer the cost of printing to the user. However it should be acknowledged that students have the control to decide what resources they print from on-line PSS. Historically disseminated hard copy resources have not guaranteed that students will read them.

Access

In 2000 24.4% and in 1999 19.6% reported being unable to access the on-line PSS from their personal computer and / or the computer labs on campus. It is unclear from the data whether this was related to computer access, participant skills, and server or service provider efficiency. The Uniform Resource Locator (URL) address for the PSS 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. Internet provider capabilities may have contributed to some regional and rural students personal computer WWW access difficulties.

In 2000 24.4% of students reported being unable to access the on-line material, a 4.8% increase from 1999. Student accessibility to content raises issues of equity and quality of teaching and learning. Outages in the universities system have been problematic. Many higher education institutions have been forced to address sustainability and support measures as a result of the integration of CML. Whilst outages and network failures may reflect the implementation dip associated with a relatively new medium it is unacceptable as a regular occurrence. The four-lane information highway that many universities bought in good faith can’t accommodate the student traffic. The bottleneck has resulted in peak hour education traffic jams. One espoused advantage of CML is 24 / 7 availability. Outages have resulted in the need for duplication or plan ‘b’ hard copies much the same as many teaching academics back up their PowerPoint presentations with conventional overheads. On going evaluation of access issues is mandatory if CML is to provide flexible learning in terms of the student.

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Conclusion

CML is a relatively new concept and as such brings unique issues to teaching and learning in higher education. Young (2000) argues that brevity, 5 second sound bites, channel surfing, instant gratification, fast moving images, constant stimulation, and shorter attention spans all reflect today’s student society. Implicit to such views is the notion that higher education suddenly has to change everything in teaching and learning because the audience has changed. It is naive to assume that CML will re-write the characteristics of adult learning and the constituents of quality teaching and learning. There is a danger that all that nursing education has learnt and achieved prior to CML will be cast aside as redundant. Reinhardt (1995) confirms that numerous studies show that technology alone is not the solution. This research supports the notion of ‘face to face’ facilitation in conjunction with on-line PBL PSS. It also demonstrates that relevant content and simplistic design are sufficient to engage students in learning.

Perhaps it is time for higher education to work with what it has. Rather than duplicating, changing and upgrading software programs it is imperative infrastructure capable of supporting CML is developed. Issues of student access often obscure the discourses that informed the use of CML in higher education. We cannot always be sure what to expect when education content becomes ‘live’. However longitudinal research of student evaluations will illuminate the complexities of integrating CML to higher education.

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List of References

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

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

Cervini, E. (2001) "Virtual universities are a flop, warns Web pioneer". The Age Newspaper, EducationAge supplement Wednesday Feb 28 2001, pp.3.

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.

Fulerton, J. (1998) "Enhancement of basic computer skills, Evaluation of an intervention." Computers in Nursing Vol. 6 No.2 p.91-94

Mitra, A., Lenzmeier, S., Steffensmeier, T., Avon, R., Qu, N., and Hazen, M. (2000) "Gender and Computer use in an Academic Institution; Report of a Longitudinal Study" Journal of Educational Computing Research Vol. 23 No.1 p. 67-84.

Nova, A. (1998) "Using E-mail in an Undergraduate Nursing Course to Increase Critical Thinking Skills." Computers in Nursing Vol. 16 No. 2 p.115-118.

Oliffe, J. and Rushton, C. (2001) "Computer mediated simulation learning opportunities" Australian Electronic Journal of Nursing Education Vol. 7 No.1 http://www.scu.edu.au/schools/nhcp/aejne/archive/vol7-1/index.html#

Reinhardt, A. (1995) "New ways to learn" Byte March 1995 Vol. 20 No. 3 p.50

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

Computers in Libraries, Vol. 14 No. 1 p.44-47.

Young, K. (2000). Informatics for Healthcare Professionals. Philadelphia, F.A. Davis Company

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Last modified on: Monday, 16-May-2011 08:13:00 EST