Introduction
How can faculty help students transfer theory-based knowledge in science curricula to clinical practice contexts? What instructional strategies can promote application of classroom theory content to real-world contexts? Can technology help blend content and process during learning to support development of higher-order thinking and reasoning skills while promoting self-regulated learning? These questions provide pedagogical challenges for instructors and are often perceived as overwhelming learning tasks for students. Although teaching remains the task, technology can be an effective tool! Many faculty may find the thought of adapting their courses for an online-learning environment intimidating. After, all, we have become content experts in our chosen fields of study, not technology wizards! So how can we balance "high-tech" with "high teach" to achieve desired educational outcomes?
Proponents of the "universal design for learning model" (O'Neill, 2001) identify three tenets for making education accessible to all learners. Learners should be provided (a) multiple representations of content during instruction, (b) multiple options for expressing knowledge, and (c) multiple options for engaging in learning. Upholding these principles in an educational enterprise facilitated by technology might seem a daunting task, especially in the complex domain of science-based curricula. Web-based course management software, such as WebCTSM, provides a simple, yet elegant vehicle to create effective course infrastructure that supports instruction designed to promote knowledge transfer and improve access to learning resources.
This paper describes implementation of pedagogy designed to enhance learning in a complex clinical nursing course. Three instructional strategies are described: (a) multimode instruction (visual, aural, and text learning prompts); (b) interactive online discussion to support witnessed dialogue, coaching, collaboration, and communication; and (c) reflection and self-regulated learning. Implementation of the instructional design is enabled by the selective use of WebCTSM course management software. E-mail with file attachments, asynchronous threaded-message bulletin board, and links to informational resources on the course home page (Exhibit 1, Exhibit 2) and the Internet/World Wide Web are used to amplify learning in the course. Although the use of course management software offers a convenient method to facilitate incorporation of technology into the educational enterprise, some caution that template-driven systems may "present a threat to future innovations in teaching and learning". (see Kuriloff, "One Size Will Not Fit All)[link here to Tech Source Article July/August 2001] My opinion is that use of any technology or media in instruction requires thoughtful selection, application, and evaluation by individual instructors for each of their courses to ensure alignment of student, pedagogy, and assessment of desired learning outcomes. The template architecture of the course management software is a good place to begin, and allows faculty, especially those new to using educational technology, to adapt courses for online presentation with minimal technical savvy, and in my experience is flexible enough to provide an effective tool for innovative and creative teaching.
Strategy One: Multimode Learning With Online Progressive Case Studies
The domain of health care knowledge is immense, constantly changing, and overwhelming to the novice practitioner. The challenge to acquire, associate, and remember a great amount of factual detail in the practice of professional nursing requires an instructional process that moves beyond memorization of facts and theories to one that provides multiple opportunities for case-based learning, advanced problem solving, and promotes transfer of knowledge to new situations. Technology is embedded in the day-to-day work of many professions. To fully prepare students to assume professional roles and develop skills for life-long learning, it is essential that technology be integrated in the learning paradigm.
Transfer of theory knowledge to clinical nursing practice traditionally happens during clinical rotations through various hospital-based settings. Unfortunately, not all students have equal opportunities for clinical experiences synchronized with the theory "topic of the week." This is where a deliberate instructional design and selective use of Web-based technology can provide multiple opportunities to link new knowledge with clinical application in authentic contexts. I use the asynchronous threaded-message board (Exhibit 3) feature of the software to create an ongoing forum to engage students in discussion about progressive clinical case studies. I post new case studies about every two weeks and reveal the facts of each case gradually as students collaboratively work to identify missing data, form conclusions, and determine appropriate actions. I use reflective text prompts (process- and content-oriented questions) to stimulate discussion and help students focus on metacognition. Text learning prompts are supplemented with pictures, graphics, and aural cues to amplify learning by increasing reality, diversity, and complexity. I monitor the discussion, identify incorrect information as necessary, and facilitate discussion to reach case outcomes. To avoid directing the discussion, I use focusing techniques, such as posting additional reflective prompts and time- and sequence-sensitive questions (e.g. "What action would be a priority at this time?""). As students discover gaps in their knowledge, they use textbooks and search online resources to discover the best thinking and current evidence on a given topic. Students share their "Net finds" (Exhibit 4) with each other and in this way rehearse the skills of information retrieval, critical analysis, and consultation that are vital for professional development and life-long learning.
To prepare visual exhibits (Exhibit 5) for posting within the progressive case studies, I use various methods to capture and save data in JPEG file format. I obtain clinical photographs from purchased images, personally photographed digital images, downloads from clinical Web-sites, and by optically scanning images. Graphic illustrations are either optically scanned, inserted from source documents or downloads, or created using a simple graphics software program. Visual data are labeled with explanatory text notes and enhanced with color highlights for educational impact with Adobe PhotoshopSM software. Sound clips (such as heart and lung sounds) are available at clinical Web-sites or from purchased CD-ROMs. Image, graphics, and sound files (saved in WAVE format) are uploaded to the university host server and links to the files are embedded into the text frame of the threaded-message bulletin board. In this way, students are presented an integrated case study analysis with diverse, multiple representations of reality provided by the integration of visual, aural, and text learning prompts. Simple, elegant, and effective!
Strategy Two: Witnessed Dialogue, Coaching, Collaboration, and Communication
Witnessed dialogue occurs when one is present as an observer of an interaction between or among others. When students observe professional role models in learning contexts, they witness the impact of knowledge, experience, and communication styles. They observe problem-solving, decision-making skills, and the influential behaviors of others in the context of clinical practice. Witnessed dialogue engages students in thinking about collaboration and communication. When naturally-occurring opportunities for witnessed dialogue are not available, I prompt this type of learning activity by posting evocative prompts and interactive scenarios (Exhibit 6) on the bulletin board (e.g. ethical dilemmas, conflict, complex team work issues). I also encourage students to post their own experiences or those they have witnessed for group reaction and response.
Essential to the educational benefit of witnessed dialogue is facilitated debriefing. Post-event discussion provides a forum for students to sort out their own thinking and reactions to what they have witnessed or experienced. The participatory nature of the interactive and recursive threaded-message bulletin board (e-board) creates a collaborative learning community, wherein novice practitioners and the instructor as expert interact to refine skills of analysis and rehearse problem-solving strategies. Students share heuristic knowledge (the "tricks of the trade") as well as textbook knowledge, develop a sense of professional community, and learn to collaborate as they seek meaning and make connections among theory knowledge and applied clinical practice. Technology creates an electronic place to connect students in a web of learning that extends their cognitive apprenticeship from the clinical setting to an online environment.
Strategy Three: Reflection and Self-Regulated Learning
Self-regulated learners are active in seeking knowledge and skill. They engage in purposeful self-goal setting, structure their environments for learning, seek assistance when needed, and self-evaluate their performance (Zimmerman & Pons, 1986). Self-regulated learners are metacognitively, motivationally, and behaviorally active participants in their learning processes (Zimmerman, 1989). Through shared reflection with the instructor and peers, students receive feedback that provides insight about the depth and accuracy of their knowledge, and perspective on their thoughts and feelings. The outcome of reflection is learning (a new awareness and integration of information as knowledge) and active engagement to express knowledge and new expertise.
To encourage reflection, self-regulated learning, and provide a vehicle for "cognitive coaching" (Grealish, 2000), I require students to submit a weekly electronic journal (e-journal). Students are provided a template e-journal document (available on the course Web-page) with text prompts that cue them to respond reflectively about their most recent learning experience. They use word processing to compose the e-journal, which ensures legible copy with correct grammar and spelling. I receive the e-journal via e-mail attachment and review the student's entry. This private dialogue between student and instructor affords an ideal opportunity for cognitive coaching (Exhibit 7) to assist students with making accurate connections among theory, content, and experiential knowledge. The activity of reflection encourages expression of personal reactions, values, and beliefs related to role engagement. I use reflective text prompts in e-mail correspondence with students and in written feedback to their e-journals to model the five-step process for cognitive coaching suggested by Grealish (2000). The coaching process includes: (a) assessment of understanding; (b) incident description; (c) modeling of thinking processes, terminology, and critical analysis; (d) recognition of patterns and knowledge links; and (e) critical questioning about the meanings of clinical events and self-identified areas of strength and needed development. I insert coaching comments in blue font, and return the e-journal to the student. Not only is this process convenient, it provides timely feedback and improves the quality of students' writing skills.
Outcomes
To evaluate students' perceptions of the overall effectiveness of using course management software as the course infrastructure, I used a 32-item online course survey administered at the end of the course. Students (N=16) rated various aspects of the course on a five-point Likert-type rating scale (1 = very poor to 5 = very good). Specific questions solicit perceptions on the effectiveness of using multimode instruction (visual, aural, text prompts) to enhance the learning process. Two open-ended questions invite students' overall narrative responses to indicate what they like about the course and their suggestions for course improvement.
Overall, students were very satisfied with methods used for instruction in the course and with WebCTSM as the course infrastructure (0 = 4.4, SD .6). They rated the use of visual cues for learning assessment skills and therapeutic interventions as good to very good (0 = 4.5, SD .8). Students reported the instructional methods enhanced communication among peers and the instructor, and facilitated learning complex content. Although 66% of respondents had no previous experience using online technology to support a nursing course and 33% reported having little prior computer experience, overall ratings for the technology used were very high (0= 4.8, SD .4). The convenience of access (any time, day, place) and the timeliness of feedback from peers and the instructor were most commonly cited as the benefits of using technology to support the course. Students offered feedback about the course(Exhibit 8) that expressed their individual learning needs and how the format of the course provided them support. Among the few comments for improvements were the need for improved quality of the downloaded pictures (minimum 150 pixels/inch), and a standardized format for attachments (rich text format) and compatible Internet browsers.
As the instructor, I observed that the course design and instructional methods facilitated by using course management software : (a) encouraged participation and interaction; (b) fostered peer collaboration and consultation; (c) enhanced the quality and depth of written communication; and (d) improved students' skills in deduction, recognition of data patterns, identifying missing data and priorities, and integration of theoretical concepts into clinical practice. Regular use of the threaded-message board encouraged thoughtful reflection, improved students' written communication skills, and fostered the sharing of successful and unsuccessful tips and strategies (heuristics). Students improved computer skills and comments indicate they got over "fears of technology" and a developed a positive attitude towards using computers for both individual and collaborative communication, and for ongoing retrieval of resource data.
Conclusion
Enhancing student acquisition of content and process knowledge in complex, science-based curricula requires a course design that promotes application of content to real-world contexts. Technology, used selectively and authentically, can facilitate learning and scaffold development of higher-order thinking by delivering content using instructional methods that support multiple representations of content, multiple options for expressing knowledge, and creative options for engaging learners. Web-based course management software provides course infrastructure to create a learning community that connects learners with vast resources and supports coaching, collaboration, and communication during the learning process. Students describe use of technology to deliver multimode instruction as enjoyable, convenient, and a satisfying way to learn and "bring the course content alive."
This paper is modified from a presentation at the 2001 WebCT Annual Users' Conference in Vancouver, British Columbia.
References
Grealish L. (2000). The skills of coach are an essential element in clinical learning. Journal of Nursing Education, 39(5):231-233.
O'Neill, L.M. (2001). Universal design for learning: Making education accessible to all learners. Syllabus, 14(9), 31-32.
Zimmerman, B.J. (1989). A social cognitive view of self-regulated academic learning. Journal of Educational Psychology, 81(3), 329-339.
Zimmerman, B.J., & Pons, M.M. (1986). Development of a structured interview for assessing student us of self-regulated learning strategies. American Educational Research Journal, 23(4), 614-628.
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