The health care professional student is expected to assimilate massive amounts of knowledge and skill in a concentrated period of time. The need to apply the knowledge and skill in patient care situations demands mastery of learning objectives. According to Bloom (1974, p. 4), ". . . most students can attain a high level of learning capability if instruction is approached sensitively and systematically, if students are helped when and where they have learning difficulties, if they are given sufficient time to achieve mastery, and if there is a clear criterion of what constitutes mastery."
The need to acquire and integrate the vast amount of complex knowledge required within the health care disciplines has led to the development of new instructional methods. One result has been the increased use of computers in education. One type of technological activity is known as computer-managed instruction (CMI). Computer-managed instruction is an instructional strategy whereby the student masters learning objectives through a process of prescribed learning resources and self-testing. As computer-managed instruction purports to provide for individualized learning, self-pacing, and flexibility in delivery of theory as well as less demands on faculty time, the question was raised as to the effectiveness of this method of instruction.
Objectives of the Study
The overall objective of the investigation was to determine the effects on student learning of computer-managed instruction as compared to the traditional lecture method. The comparison of the two methods focused on measures of cognitive performance, knowledge retention, time spent on learning, and learner attitudes and characteristics. Specific research questions were:
1. Is there a difference in cognitive performance of learners using CMI over the traditional lecture method?
2. Is there a difference in the learners attitude toward CMI and the traditional lecture method?
3. Is there a difference in the effectiveness of the instructional strategy which is related to the characteristics of the learner?
4. Is there a difference in the learner's retention of knowledge using CMI and the traditional lecture method?
5. Is there a difference in the time spent by the learner in meeting the learning objectives using CMI as compared to the traditional lecture method?
With increasing numbers of students, advances in application of computer technology, and economic restraints, computer managed instruction was seen as an effective instructional method for teaching selected nursing content.
Review of the Literature
Cooper (1982) defines a lecture as "a carefully prepared oral and formal presentation by a qualified speaker" (p. 39). Although the traditional lecture method has been used in the instruction of large groups for many years, it continues to be a valuable teaching technique. For certain content, such as disseminating factual material, and for certain learners, it may be the method of choice. The success of the lecture method is in large part due to the lecturer functioning as a role model in establishing positive attitudes towards the learning content. In the lecture it is possible to gain the student's attention, clearly present the instructional objectives, and to summarize the content in such a way that students are assisted in retention and transference of the material. One of the major disadvantages of the lecture method is its lack of control over ensuring that all students are attending to and learning the material being presented. In order that the content does not go "from the notebook of the teacher to the notebook of the student, without going through the minds of either," it is necessary to provide opportunities for questions and discussion within the lecture presentation (Cooper, 1982).
Computer-managed instruction is an instructional strategy whereby students are directed to a variety of learning resources in order to achieve the prescribed behavioral objectives. Student progress can be monitored, learning needs diagnosed, and additional learning materials can be recommended. CMI stores test items and randomly generates unique but equivalent test forms for each student. This requires the establishment of mastery levels for student achievement. In most CMI systems, mastery is defined as "a test score/number of correct responses exceeding some predefined value" (Leiblum, 1982, p. 128).
Ryba and Chapman (1983) describe the advantages of computers in terms of self-pacing, immediate feedback, and small steps. Other technological advantages discussed in the literature are cost benefits (decreased instructor-student time, decreased student time spent learning the material), and development of independence and creativity. Comparison of the lecture format versus the CMI in terms of applicability to the learning process is limited in the literature. Gallacher (1970), in a study of instructional treatment and learner characteristics in a CMI course, found that the most successful students enjoyed the active learning that CMI allows, were not particularly anxious, and had positive feelings toward the CMI method.
Lawler (1971), in a comparison of CMI and the traditional lecture method, reported that students in the CMI group achieved higher grades on a final examination than students in the lecture group. Dixon and Judd (1977), in a similar comparative study, found no significant difference between groups in the posttest or retention test measures and attitude. However, the authors indicate that their results "support the contention that for some student populations and some topics CMI can be as effective as an experienced instructor . . ." (p. 25). The results for both lecture and CMI depend on the quality of the instruction.
The majority of the research studies have described another mode of computer instruction, that of computerassisted instruction, and have been done in areas other than nursing. Ryba and Chapman (1983) identify another gap in the computer instruction research as being the investigation of how the cognitive and affective nature of computer-learner interaction may exert a significant influence on the ways students learn and the manner in which they perceive their own abilities.
The success of any teaching strategy would appear to depend on the particular learning objective to be achieved. For example, Newstrom (1980) found that programmed instruction was the most effective method for achieving knowledge retention; the case study method was the most effective for developing problem-solving skills. Another consideration in evaluating computer instruction versus lecture involves the examination of learning principles. Olivas and Newstrom (1981) maintain that the computer is most beneficial for facilitating learning through active participation and in providing the opportunity to practice what is being learned.
When considering the appropriateness of CMI, it is important to take into consideration the structure of the content to be learned, the level of learning desired, and the individual differences among learners (Hall, 1983). Knowledge can be structured in a manner which causes learners to respond throughout the range of Bloom's taxonomy from recall to evaluation (Bloom, 1976). When developing CMI programs, it is important to structure questions according to the level of learning desired. The effectiveness of CMI with a specific group of learners at a specific time cannot be generalized to other situations. The developmental stage of learners, for example, from novice to expert, influences the instructional strategies that will be used. Hall (1983) indicates that more important than instructional strategies is the ability of students to adapt to instructional environments.
The objective of the study was to determine whether CMI is an effective method by which first-year basic nursing students can learn Health Assessment content. The design of the investigation was quasi-experimental, incorporating two experimental treatments applied to two groups on two occasions. The experimental treatments were computermanaged instruction and traditional lecture presentation.
The theoretical component of the Health Assessment Course in the Faculty of Nursing, University of Alberta, was developed under PLATO computer-managed instruction. The course content is divided into 17 modules and each module is further subdivided into logically organized units of study known as instructional units. Each module contains objectives, learning resources and test items. CMI randomly generates equivalent test items for each learning objective. In order to progress to each successive module an 80 percent mastery level is required.
For purposes of the investigation, Modules D and E (Assessment of Ears and Eyes) and Modules J and K (Assessment of Lungs and Thorax, and Breast and Axilla) were used.
The theory for Modules D and E were presented in a three-hour classroom lecture, similarly for Modules J and K. Objectives and learning resources were identical to those outlined for CMI.
Subjects of the Study
The subjects in the study were the first -year baccalaureate nursing students at the University of Alberta, January to April 1984. The subjects (n = 99) were randomly assigned to two different groups at University registration. Group A consisted of 50 students; Group B consisted of 49 students. No attempts were made to control for age, sex, or grade point average of group members. It was assumed that the subjects had no previous exposure to Health Assessment content. From the self-reports obtained on previous computer experience, five students reported no experience with a computer. The majority of students (n = 85) had exposure to PLATO in an Anatomy course taken in the previous term. Nine students had taken a computer course, or had used the computer in other university courses.
On February 7, 1984, during the first Health Assessment class, both groups A and B were given a pretest on the content of Modules D and E (Eyes and Ears), and Modules J and K (Lungs and Thorax, and Breast and Axilla). This time was selected to avoid the problem of students reading and preparing for the test. The study was then described to the students to elicit their participation, and they were assured that participation or non-participation would in no way affect their course grade.
During the period of February 28, 1984, to March 9, 1984, Groups A and B received a one-hour orientation to CMI. Group A, from February 28, 1984, to March 5, 1984, completed Health Assessment Modules D and E (Ears and Eyes) using the CMI method. At the same period of time, Modules D and E were presented to Group B by the lecture method. Both groups then completed the posttest.
Then, from March 6, 1984, to March 11, 1984, Group B completed Health Assessment Module J (Lungs and Thorax) and Module K (Breast and Axilla) using the CMI method. Group A attended regularly scheduled classes to receive the content of Modules J and K by traditional lecture method. The posttest on Modules J and K was administered. Both Groups A and B completed a midterm examination immediately following completion of the modules, and a final examination on completion of the course in April. Thus subjects in Group A and B experienced both CMI and lecture presentation.
The dictionary defines a log as "any of various . . . journals or records in which are noted sequential data on the speed or progress or performance of something." Learning logs may be helpful in analyzing and reinforcing training (Cooper, 1982b). Both Groups A and B completed and submitted a Learning Log during the test weeks, describing the types of learning activities employed, time spent, and reaction to the content of the modules. Additionally, the students completed a Course Evaluation to critique the CMI versus the lecture method of instruction. An Attitude Questionnaire consisting of a semantic differential scale rating CMI was administered to both Groups A and B prior to beginning the modules, and again at the completion of the modules. The semantic differential developed by Osgood, Suci, and Tannenbaum (1957) is a technique for measuring the psychological meaning of concepts to an individual. The students were asked to rate each item on a 7-point bipolar scale, thereby selecting which adjective best described their attitude toward CMI.
Discussion of Findings
In determining the effects of experimental treatments and the differences between groups, descriptive statistics, correlations, and analysis of variance were employed. Cognitive performance was assessed by the students' achievement on pretests and posttests, a midterm examination, and a final examination. Both Groups A and B demonstrated a significant improvement (p<0.05) in mean scores from the pretest to the posttest on Modules D and E ( t - -12.09 with df - 84, p -0.000) and J and K (t = -17.55 with df -89,p = 0.000) (Table 1). The mean score obtained on the pretest for Modules D and E was 9.56 while the posttest mean score was 13.52. For Modules J and K, the pretest mean score was 15.10, and the posttest mean score was 23.77.
On the mid-term examination, Group A obtained a mean score of 4.60 on questions based on Modules D and E following CMI; Group B obtained a mean score of 4.729 following lecture presentation. Group B obtained a mean score of 10.896 on questions related to Modules J and K on the mid-term examination following CMI; Group A obtained a mean score of 11.140 following the lecture presentation. The pretest and posttest examination for Modules D and E had a KR-20 reliability of 0.1445 and 0.4543 respectively. The pretest and posttest examination for Modules J and K had a KR-20 reliability of 0.3055 and 0.6612 respectively.
On the final examination, Group A obtained a mean score of 6.400 on questions based on Modules D and E following CMI; Group B obtained a mean score of 6.306 following lecture presentation (Table 2). Group B obtained a mean score of 4.755 on questions related to Modules J and K on the final examination following CMI; Group A obtained a mean score of 5.280 following lecture presentation.
T-TEST RESULTS OF PRETEST - POSTTEST SCORES
COGNITIVE PERFORMANCE SCORES
At the end of the term, each student was required to demonstrate the physical examination techniques learned during the health assessment course. On this practical examination, which required application of the content from Modules D and E and J and K, the mean scores obtained by Group A was 80.816, while the mean score obtained by Group B was 81.020 (Table 2).
To establish if significant differences existed between Group A and Group B in scores obtained on Modules D and E (Ears and Eyes) on the pretests and posttests, the midterm examination, and the final examination, a oneway analysis of variance was performed. No significant mean differences (p<0.05) were found between Groups A and B on Modules D and E on the pretest (f = 1.12 with df = 96, ? = 0.29) and posttest (f = 2.15, with df = 84, ? = 0.15), midterm examination (f = 0.19, with df = 96, ? = 0.68) and final examination (f - 0.21, with df = 97, ? - 0.65). Concurrently, no mean differences were found between Group A and Group B on Modules J and K (Thorax and Breast) on the pretest (f = 0.02, with df - 96, ? = 0.89) and posttest (f = 0.76, with df = 89, ? = 0.39), midterm examination (f = 0.31, with df = 96, ? = 0.58) and final examination (f = 2.84, with df = 89, ? - 0.1).
ATTITUDES TOWARD CMI
Therefore the study would indicate that CMI is at least as effective in bringing about learning in students as measured by written and practical examination scores as the traditional lecture method. These findings tend to be consistent with those found in the literature.
Is there a difference in the students' attitude toward CMI and the traditional lecture presentation? For these firstyear baccalaureate nursing students, CMI did not prove to be a positive instructional method as assessed by the Attitude Questionnaire. Table 3 illustrates that students in both Groups A and B found CMI to become less useful, less appropriate, less stimulating, more disturbing, less enjoyable, less accurate, less satisfying, and ineffective. As these students became involved in CMI, they found it to be less convenient, more frustrating, and slower than they expected. The attitudes that tended to remain constant toward CMI were the degree of difficulty, familiarity, and the fairness. On the whole, these students did not rate CMI as an enjoyable or valuable experience. Their attitudes tended to be more negative than those reported in other studies (Dixon & Judd, 1977; Gallacher, 1970).
Based on the course evaluation, 46% of the students wanted to see less or no CMI offered in Health Assessment. Fifty-one percent found CMI not helpful or useless in helping them learn Health Assessment content. Thirtynine percent preferred lecture method over CMI, with 58.7% suggesting a combination of instructional methods. These findings are consistent with those of Ostmore, Von Hoozen, Scheffel, and Crowell (1984), who found that baccalaureate nursing students preferred learning strategies that are traditional in nature and are teacher directed.
Are learner characteristics and instructional method related? The mean age of students in Group A was 20.620 and 20.735 years for Group B. The overall age range of students was from 18 years to 32 years. Group A had a mean Health Assessment course grade of 6.776 and Group B had a mean grade of 6.592 on a nine-point scale. The Grade Point Average (G. P. A. ) for the academic year of Group A was 6.476 and Group B, 6.349. Since no measurable differences in learner characteristics were observed between the groups, variables such as age, experience, and aptitude did not appear to influence their performance or attitude towards the learning strategy.
Does CMI require more or less time to meet the learning objectives of the Health Assessment Modules? From the students' self-reported Learning Logs, they estimated spending 138 minutes meeting objectives of the lecture method, and approximately 223 minutes meeting the objectives by CMI. There was no significant difference between groups in the time spent meeting the objectives by either teaching strategy. It can be noted that both groups spent considerably more time meeting the learning objectives by CMI than the lecture method.
Implications of the Study
The findings of the study suggest that CMI is as effective as the traditional lecture method in learning; Health Assessment content. These findings are consistent with results obtained by Hagopian, Wenett, Ames, Gelein, Osborne, and Humphrey (1982). A study by Talley, Witzke, and Dieken (1982) also found that CMI was effective in learning course content, but that some student dissatisfaction with the system was noted. In a study by Schleutermann, Hölzerner, and Farrand (1983), 12 graduate nurse practitioners reported no preference between paper and pencil latent image format, and computer-assisted instruction, nor were there any differences in student performance when comparing the formats. Although the examination scores were similar for both groups, the comments from the Course Evaluations and Learning Logs suggest that CMI did not help the students to attain higher levels of learning, such as understanding and application. They viewed CMI as a "testing" rather than a "learning" experience.
The major factor revealed was in relation to the students' decidedly negative attitude toward the CMI program. This is of concern since Davis, Alexander, and Yelon (1974) suggest that "a student is more likely to continue learning if instructional conditions are more pleasant" (p. 208). Based on the self-reports, several students stated that they did not return to the computer after the initial signon. The students described several major concerns about CMI. One negative aspect of CMI identified was the lack of feedback as to why answers were incorrect. This may be due in part to the learning styles of these students which, as Ryba and Chapman (1983) indicate, may be motivated more by external factors than internal ones. "Whether a student is, in reality, able to exert control over instruction may not be so important as the internal sense or feeling she or he has of being in control. It is this inward state of control which appears to be vital for improving academic achievement" (Ryba & Chapman, 1983, p. 49). Another negative aspect of CMI was the lack of opportunity for interaction. As McLeish (1976) pointed out, the lecture presentation provides the opportunity to relate content to practical situations thereby aiding in the transfer of knowledge. In addition, students found it difficult to access the PLATO terminals at convenient times. A further frustrating aspect of CMI was due to problems within the program format such as non-acceptance of alternate but correct responses, and being re-directed back to the beginning of the program when incorrect responses were made.
CMI purports to provide individualized learning, selfpacing, and flexibility in the delivery of theory. The results of the study would support this claim that CMI is an acceptable alternative instructional strategy. The Health Assessment content lends itself to the format of learning resources and mastery of learning objectives. However, this study would indicate the importance of taking into consideration the characteristics of the learners and the quality of the CMI program.
For this group of "novice" learners, the lecture strategy appeared to provide the rules and structure required for this level of knowledge acquisition. It is possible that with CMI alone, the retention and application of knowledge to the practical situation may not have been as successful. Interaction and feedback seem important in assisting these learners. Consequently, one would question the advisability of using CMI as the sole teaching strategy with these first-year nursing students. Difficulties experienced with the CMI program suggest the need to reconsider the design and technological quality of the program. Another approach would be the development of a computer assisted instructional program which might meet the students' need to have actual instruction as part of the program format. For this group of learners, a more appropriate strategy may be a combination of lecture presentation supplemented with CMI.
With the massive amount of knowledge and skill required in the nursing profession, development of effective strategies for assisting the mastery of learning objectives is critical. In designing instructional strategies, the characteristics of the learners, the level of learning objectives, the content to be mastered, and the technological quality of programs need to be carefully considered. No one instructional strategy is appropriate for all learners. Although CMI has several advantages as an alternative teaching strategy, its effectiveness cannot be generalized to all learning situations.
- Bloom, B. (1976). Human characteristics and school learning. New York: McGraw-Hill.
- Cooper, S. Q982ai. Methods of teaching revisited: The lecture. Journal of Continuing Education in Nursing 73(4), 39-41.
- Cooper, S. (1982b). Methods of teaching revisited: Experiential diaries and !earing logs. Journal of Continuing Education in Nursing, ¿3(6), 32-34.
- Davis, R.H., Alexander, L.T., & Yelon, S.L. (1974). Learning system design: An approach to the improvement of instruction. New York: McGraw-Hill.
- Dixon, P.N., & Judd, W.A. (1977). A comparison of computermanaged instruction and lecture mode for teaching basic statistics. Journal of Computer- Based Instruction, 4(\\ 22-25.
- Gallacher, P.D. (1970). An investigation of instructional treatments and learner characteristics in a computer managed instruction course. Dissertation Abstracts International, 31, A4543-A.
- Hagopian, G., Wemett, M., Ames, S., Gelein, J., Osborne, F., & Humphrey, E. (1982). Methods to teach physical assessment skills to community health nurses. Journal of Continuing Education in Nursing, 13(5), p. #.
- Hall, K. (1983). Content structuring and question asking for computer-based education. Journal of Computer-Based Instruction, 10(1 & 2), 1-7.
- Hon, D.C. (1981). Space invaders, videodiscs and the "bench connection." Training and Development Journal, 12, 11-17.
- Huckabay, L., Anderson, N., Holm, D., & Lee, J. (1979). Cognitive, affective and transfer of learning consequences of computerassisted instruction. Nursing Research, 28, 228-233.
- Lawler, R.M. (1971). An investigation of selected instructional strategies in an undergraduate computer-managed instruction course. Dissertation Abstracts International, 32A 1190.
- Leiblum, M. (1982). Computer-managed instruction: An exploration and overview. Association for Educational Data Systems Journal, 15(3), 126-142.
- McLeish, J. (1976). The lecture method. In N.L. Gage (ed.), The psychology of teaching methods. Seventy-fifth yearbook of the National Society for the Study of Education. Chicago: University of Chicago Press.
- Newstrom, J.W. (1980). Evaluating the effectiveness of training methods. The Personal Administrator, 1, 55-80.
- Olivas, L., & Newstrom, J. (1981). Learning through the use of simulation games. Training and Development Journal, 9, 63-66.
- Osgood, C., Suci, G., & Tannenbaum, P. (1957). The measurement of meaning. Illinois: University of Illinois Press.
- Ostmore, P., Van Hoozen, H., Scheffel, ?., & Crowell, C. (1984). Learning style preferences and selection of learning strategies: Considerations and implications for nurse educators. Journal of Nursing Education, 23(1), 27-30.
- Ryba, K.A., & Chapman, J.W. (1983). Toward improving learning strategies and personal adjustment with computers. The Computing Teacher, August, 48-52.
- Schleutermann, J., Hölzerner, W., & Farrand, L. (1983). An evaluation of paper-and-pencil and computer-assisted simulations. Journal of Nursing Education, 22(8), 315-323.
- Talley, R., Witzke, D., & Dieken, M. (1983). Computerized program for internal medicine junior clerkship cognitive knowledge. Journal of Computer-Based Instruction, 9(3), 115-119.
T-TEST RESULTS OF PRETEST - POSTTEST SCORES
COGNITIVE PERFORMANCE SCORES
ATTITUDES TOWARD CMI