It is a continuing challenge for nurse educators to provide the necessary learning experiences for studente to prepare them for nursing in an increasingly complex and technological society. One must provide stimulating and diverse learning experiences without overwhelming the student. Quality computer assisted instruction (CAI) can be a valuable teaching aid for it can cover basic course content as well as provide learning experiences (i.e., clinical simulations), which might not otherwise be available.
Students have frequently identified the study of pharmacology as difficult due to the quantity and complexity of information to be mastered. Clinical application of pharmacology, which reinforces didactic content, is often limited as students care for a limited number of clients on relatively few medications. Clinical exposure to psychotropic drugs may be particularly limited as students in mental health settings frequently have fewer clients due to the time required to develop therapeutic working relationships.
In response to the need to strengthen the psychopharmacology content and learning activities in our nursing curriculum and recognizing the potential of CAI, a Unit on Antipsychotic Medications was developed and implemented, using the Apple II microcomputer. At this time, only the major tranquilizer (antipsychotic) medication content has been computerized; however, any drug group could be similarly converted to CAI.
The following describes the CAI unit, its implementation, and student/faculty evaluation.
Initially, the student works through an introductory section which briefly describes the unit, provides instructions, and lists learning objectives. Next the computer user may select any of the three major CAI sections: (1) the Tutorial Review, (2) Clinical Simulations, or (3) lest. Students are encouraged to complete the Tutorial Review and Simulations before attempting the Test. At frequent intervals, throughout the CAI, students have the opportunity to stop, begin again, repeat a section, or progress to another area of study.
The three sections consist of separate programs (written in Basic) which can be used independently of each other, thus providing flexibility for individual learners. The entire unit requires a little over an hour to complete.
Tutorial Review: This section discusses significant facts relevant for the nurse caring for clients on major tranquilizers. It can be used as a substitute for assigned readings or as a supplement to reinforce written material. The Tutorial Review consists of a number of individual programs which enable the student to proceed at his own rate and repeat sections as needed. The following areas, including associated nursing interventions, are addressed: (1) antipsychotic drug classification, indications, and effects, (2) pharmacology and metabolism, (3) interactions and contraindications, (4) drug forms and dosages, (5) side effects (excluding extrapyramidal), (6) extrapyramidal side effects (including tardive dyskinesia), and (7) teaching needs and approaches for clients on antipsychotic drugs.
EXAMPLE OF INTERACTIVE QUESTION IN TUTORIAL REVIEW
Interactive questioning (multiple choice and true/false) are presented at intervals throughout the Tutorial Review. An example is shown in the Figure, The student types in his answer. If he is correct, bells sound and a congratulatory message is printed on the screen, thus providing positive auditory and visual reinforcement. Should the students answer be wrong, a message such as "Sorry, that's not correct. Press the Return Key to try again!" is printed out. Auditory messages denoting mistakes are not recommended for such sounds can be embarrassing for students in group computer lab environments.
Clinical Simulations: In this part of the CAI, the student confronts various clinical situations involving clients on antipsychotic drugs which necessitate making decisions. Issues such as legal aspects (i.e., the client's right to refuse medication), side effects, drug interactions, etc. are incorporated in the simulations. Based on how the student responds in the simulation, the program branches to a different outcome and sequence of events. However, all learners receive feedback as to whether or not they are proceeding favorably and should serious errors occur they are redirected toward more appropriate action.
Two different simulations were created pertaining to Miss Jones and Mr. Brown. In the first simulation, the student assumes the role of a nurse in a community mental health center and works with Miss Jones, a woman with long-term psychiatric problems on antipsychotic medication in the community. The nurse must make decisions related to orthostatic hypotension, anticholinergic toxicity, client self-medication with old prescription drugs, and tardive dyskinesia. Mr. Brown is an acutely ill psychotic client hospitalized in a mental health unit where the student assumes the role of a staff nurse. The nurse faces different problems in the acute care setting as compared to those in the community. The student must deal with rapid neuroleptization, dystonic reactions, Mr. Brown's "cheeking" of medication (hiding medication in his cheeks, rather than swallowing it), and his reluctance to continue on medication after his acute symptoms have abated.
list: The test consists of 25 multiplechoice questions. Simple directions are provided and then one question at a time is presented. After completing the test, students immediately receive raw and percentage scores. Then any questions they may have missed are printed out and the correct answers, as well as the original answers are listed. The test was programmed to serve as a means of student self-evaluation, but could be easily adapted to enable an instructor to review individual student test results.
Prior to full implementation, this antipsychotic unit was pretested on a small group of students and faculty members. At this time, over 80 students have completed the unit. It is currently a required assignment for students in Nursing Practicum III, an undergraduate course which integrates community, family, mental health, and rehabilitation concepts. The unit is particularly beneficial in our integrated curriculum, for all students do not have a clinical experience specifically identified as mental health. The simulations provide some "clinical practice" with clients who have psychiatric disorders as their primary diagnoses.
This was the students' first experience using a microcomputer, although they had previously been exposed to a minicomputer earlier in the curriculum. Orientation to the Apple II computer and the CAI unit was provided through a 20-minute demonstration and written step-by-step instructions. Students then completed the unit independently in our university microcomputer lab. The unit is "user friendly," and requires the user to only press a letter designating his response and/or the Return Key in order to progress through the exercises.
Students were requested to anonymously complete a form evaluating this CAI unit. Their responses were overwhelmingly and enthusiastically positive. Over 95% stated they would prefer more similar learning experiences. No difficulties operating the Apple II were reported, and a number of students spontaneously commented that their fear related to computers was reduced through using the microcomputer. A minority of students (11%) did complain of having to wait for an available computer, and identified noise from other students in the computer lab as distracting.
Students commented on the value of the Tutorial Review and Simulations reinforcing each other and preparing them to take the Test. The use of positive reinforcement and immediate feedback throughout the unit were consistently identified as facilitating learning. When asked to compare the CAI approach with traditional lecture/ reading assignments, 85% of the students said they preferred the CAI. A frequent student comment was that they felt they learned more and retained information longer through this type of CAI.
The Tutorial Review was described as clear and concise, while the interactive questions at intervals necessitated immediate application of knowledge. Some students described the tutorial approach as "less boring than reading and lecture." However, a few students said they preferred a reading assignment as they couldn't take the computer home with them for review prior to a test in the course.
Although 41% of the students described the Tutorial Review, Simulations, and Test as equally beneficial in terms of learning, 53% said the simulations were most helpful. Student comments included statements such as "I was placed in a real-life situation in which I had to independently decision make," "I really had to think about drugs and their effects," and "The simulations increased my confidence in caring for patients on antipsychotic drugs."
The Test was also viewed positively by students. They described the Test as a low stress situation, and were appreciative of the immediate scoring and feedback regarding any incorrect answers . Several students explained that they repeated sections of the Tutorial Review which related to questions they missed. Six percent of the students identified the Test as the most valuable part of the CAI for them.
This CAI unit has also been received positively by faculty and has served as a stimulus to the development of further CAI, including pharmacology units, within our college. Teaching pharmacology effectively is difficult and this computerized approach appears to represent one promising alternative.
One identified problem associated with this CAI is that students have tended to take notes from the Tutorial Review, being fearful that important information will be forgotten. This was true even though there were several reading references on antipsychotic medications available. This is costly in terms of student time and utilization of computer hardware! Thus, the Tutorial Review might best be used as an optional or supplemental learning activity.
This CAI on antipsychotic medication appears to offer considerable promise as a methodology for teaching pharmacology. Although the effectiveness of the unit was not tested through a controlled, comparative study, student and faculty evaluation has been markedly positive. Our experience suggests that perhaps simulations provide more valuable learning for undergraduate students than do tutorial review or test formats . Perhaps this is because simulations present "real-life" clinical experiences, which are not available through any textbook. Overall, we have found developing and implementing this antipsychotic medication CAI on the microcomputer to be a challenging and rewarding experience both for faculty and students.
EXAMPLE OF INTERACTIVE QUESTION IN TUTORIAL REVIEW