An appreciation of the need for health-care professionals to be thoroughly knowledgeable in the transmission and prevention of infectious diseases has been enhanced as a result of the epidemic of acquired immune deficiency syndrome (AIDS). Health-care providers must be educated in the basic principles of infection control to apply them to various hospital policies and procedures. However, nursing and medical education programs are frequently weak in the area of infection control (Association for Practitioners in Infection Control, 1977; Turner & Davis, 1980). Therefore, the development of curriculum in the basic principles of infection control could assist the student in integrating these principles into nursing practice.
The focus of this article is a study that was undertaken to determine whether self-managed instruction in the form of a programmed unit of instruction (PUI) in the basic principles of infection control is an acceptable alternative to classroom instruction for third-year baccalaureate nursing students. The null hypothesis being tested was: There will be no significant difference between nursing students who complete a PUI in the basic principles of infection control and those who attend a lecture on these same principles with respect to scores on the post-test.
The specific objectives for the study were:
* To evaluate the effectiveness of a PUI as an alternative to classroom instruction in teaching the basic principles of infection control to baccalaureate nursing students.
* To analyze the validity of a PUI in the basic principles of infection control among third-year baccalaureate nursinfection control among third-year baccalaureate nursing students.
* To determine if the content in an infection control PUI is appropriate for self-managed learning among thirdyear baccalaureate nursing students.
The theoretical framework for this study was reinforcement theory as presented by behavioral psychologist Skinner. According to Skinner, teaching consists of an arrangement of contingencies of reinforcement that expedite learning. He contends that although we use traditional methods, in most cases programmed instruction is more pleasing to students because they are "active" participants in their learning, rather than passive receivers of information (Bigge & Hunt, 1980).
Technological change and innovation have spurred numerous efforts to instruct learners in a more efficient manner than lectures and classroom discussion. The usefulness of technology in education, however, stems from the increased potential for achieving specific learning objectives in ways conducive to applying sound learning principles. A technology of instruction, therefore, "is a particular, systematic arrangement of teaehing/learning events designed to put our knowledge of learning into practice in a predictable, effective manner to attain specific learning objectives" (Heinich, Molenda & Russell, 1985, p.19). Over the years, the body of theory that most strongly influenced the development of today's technologies of instruction has been Skinner's reinforcement theory.
The importance of self-managed learning that links personal control with motivation and achievement is supported by several research studies reporting a positive correlation between perceptions of control and school achievement (Stipek & Weisz, 1981). Mager (1964) found that motivation and satisfaction increased as a function of the learner's control over learning. Motivation and learning theory suggest that self-managed learning enhances the individual's need to achieve by taking into account the basic human drive for success (Kinzie, Sullivan & Berdel, 1988); however, there is evidence to suggest that individuals who prefer high structure may not gain by totally self-managed learning. When studying the effects of self-directed learning and preference for structure among nursing students, Wiley (1981) concluded that students who prefer high structure may not benefit from selfdirected learning projects. Dolphin has pointed out the need for research in self-managed instruction: "We need to distinguish patterns in the effects instruction has on students in order to develop theories which are testable beyond a specific instructional system and then to evaluate the outcomes" (Dolphin, 1981, p.30).
The American Nurses' Association (ANA) Committee on Non-traditional Study for Self-Directed Learning has differentiated between self-designed and other-designed self-directed learning. It defines self-designed learning as those learning activities where the majority of the variables in the learning process are controlled by the learner. In contrast, other-designed learning activities are those in which someone other than the learner controls some of the learning variables such as the objectives, the learning activity, learning resources, and evaluation (ANA, 1978). Examples of other-designed self-directed learning activities include programmed instruction and computerassisted instruction (CAI).
Programmed instruction, by its very nature, is selfmanaged learning. It is learner-centered, focusing on the activities of the learner rather than the activities of the teacher. It can satisfy a variety of psychological principles and build on educational theories developed by Skinner (Heinich et al, 1985). According to Cheren (1983), selfmanaged learning occurs when the learner takes greater control over one or more aspects of the learning process. "Any progress along the control continuum in the direction of increased capacity to exercise control in any area of learning is progress toward the overall objective of greater self-direction in learning" (Cheren, 1983, p.24).
The use of self-managed learning also can improve the effectiveness and efficiency of the teaching/learning process while decreasing the amount of time and manpower utilized to provide education to college students. One researcher found that dental students Jearn as effectively by self-managed instruction as by attending a lecture, and in significantly less time. For the instructor, this means more time available for personal tutoring of learners with problems, counseling, advising, research, administrative duties, patient care, or improving the self-managed learning materials (Emling, 1974).
Self-instructional modules, such as programmed instruction, provide learners with frequent opportunities for self-testing and frequent feedback that satisfies their drive for success. The modules also allow for individual pacing and direction, as well as provide a consistent approach to the delivery of content (Espich & Williams, 1967). Espich and Williams (1967) describe four advantages to the use of programmed instruction. First, it allows for the integration of the principles of the behavioral school with the humanistic approach. Secondly, it gives the learner immediate feedback on performance and level of mastery. Third, it is self-paced, taking into account the basic human drive for success. Fourth, if the subject matter is stable, the use of programmed instruction is feasible. However, some students may find programmed instruction to be tedious and boring, and, like any other instructional materials, it must be varied and interesting. Although programmed instruction seems to be an effective learning device, the essential ingrethents that make it effective need further delineation (Heinich et al, 1985).
The amount of self-instructional programs in the health professions has grown dramatically in the past two decades. It has been found to be acceptable by students (Goldrick, 1987a; Griggs, 1977; Thompson, 1972) and to be as effective as carefully prepared lectures (Donabedian, 1976; Goldrick, 1987b; Johnson & Merkel, 1977; Lysaught, 1973; Owen, Hall, Anderson, et al, 1965; Santopietro, 1980; Thompson, 1972). Feldman (1969) also demonstrated that there were significant improvements in clinical behavior, such as handwashing after patient care, among nurses following a self-managed unit of instruction in asepsis.
Materials ana Methods
The content of the Infection Control PUI was designed to enable the learner to meet the following objectives in the cognitive domain:
1. Know the components of the infectious process;
2. Identify the types of pathogens that cause infections;
3. Name the routes of infectious disease transmission;
4. Identify risk factors associated with susceptibility to infection;
5. Describe the Centers for Disease Control (CDC) guidelines for isolation precautions;
6. Apply the principles of infection control to selected cases.
The content of the PUI module was divided into three sections. Section I consisted of material on the infectious process and was designed to assist the learner in attaining objectives 1 through 4. Section ? provided the learner with information regarding the CDC Guideline for Isolation Precautions to meet objective 5. Section III consisted of case studies of different infections/diseases, enabling the learner to apply all the principles of infection control outlined in the previous two sections (objective 6). Content validity of the PUI was established through the use of published infection control curricula and by a review of the content by four certified infection control practitioners who had at least 5 years of experience in infection control.
Precautions designed to reduce the risk of transmission of infectious agents have been established by the CDC based on the epidemiology of these agents. The content of the self-managed learning module used in this study was based on the CDC revised Guideline for Isolation Precautions (Garner & Simmons, 1983). This guideline represents the first major revisions in isolation precautions made by CDC since 1975. The relative stability of almost a decade in the information regarding isolation precautions satisfies the criterion of feasibility for programmed instruction outlined above by Espich and Williams (1967).
Programmed Unit of Instruction
The PUI was originally developed and pilot tested by one of the authors (Goldrick, 1987a). The PUI was designed with items arranged in a hierarchical order, allowing the learner to master the content in increments. The learner was asked to read the content presented in individual "frames" of information and to respond to questions based on the content before continuing to the next frame. This pattern provided both a tutorial mode and a simulation mode of instruction. The tutorial mode presented concepts and principles, whereas the simulation mode approximated real-life situations that allowed the learner to make choices without risks associated with an actual situation.
The pilot test was conducted with 40 nursing students from the senior class of a baccalaureate program at a public university (Goldrick, 1987a). The internal consistency of the PUI was .80, using the Kuder-Richardson Pbrmula 21 (KR-21) reliability coefficient. A Solomon Four-Group experimental design (Campbell & Stanley, 1966) was used in the pilot study to control for threats to internal and external validity. Results of a two-way analysis of variance on the post-test means of the four groups in the pilot study were significant for the treatment effect (p <.001). The interaction effect between the treatment and the pretest was found to be non-significant at the ? <.05 level, implying that the pretest did not sensitize the subjects to the treatment.
The PUI alao was field-tested with staff nurses at two Veterans Administration Medical Centers (Goldrick, 1987b). A non-equivalent control group design was utilized in the field test. A sample of 144 nurses was randomly selected from the two medical centers; the treatment (PUI) group consisted of 78 subjects from one medical center, and the control (lecture) group consisted of 66 subjects from the second medical center. Results of ANCOVA applied to post-test scores of the two groups revealed a significant difference in favor of the PUI (p = .0001). The field test demonstrated that a self-managed learning module in the basic principles of infection control could be an effective alternative to classroom instruction for continuing education for professional nurses (Goldrick, 1987b).
Pretest and Post-Test
The identical 10-item forced-choice pretest and posttest was developed based on the objectives and the content of the infection control curriculum. Content validity of the pretest/post-test was also established by the four certified infection control practitioners. The reliability of the pretest/post-test was established in the pilot study to be .60.
A five-point Likert scale opinionnaire was developed to rate the PUI on two variables: preference and complexity. The Likert scale for preference ranged from 1 to 5 with 1 indicating "never" and 5 indicating "always." The Likert rating for complexity ranged from "too easy" (1) to "very difficult" (5).
The sample consisted of 108 third-year baccalaureate nursing students from two universities, 32 from a private institution (University A) and 76 from a public institution (University B). The subjects were randomly assigned to either a lecture (control) group or a programmed instruction (treatment) group. Fifty-two subjects were in the treatment group and 56 subjects were in the control group.
To ensure that the control and treatment groups received the same information, a syllabus that included the identical content as the PUT was developed and followed by the two instructors who taught the content in the lecture mode. Subjects in the lecture (control) group were pretested and presented content in the lecture format, then post-tested. Subjects in the experimental group were given the pretest, the PUI (treatment), the post-test, and a PUI evaluation opinionnaire.
PRETEST SCORES BY METHOD OF INSTRUCTION*
Preliminary f-tests for independent samples were used to determine whether significant differences existed between the groups. ANCOVA was applied to the post-test means of the groups, with pretest scores and educational setting (University A or B) as covariates. The alpha level was set at .05. The analysis of co-variance design was utilized to control for initial differences in the groups that might confound differences between the groups' post-test scores (Huck, Cormier & Bounds, 1974; Kerlinger, 1973). Regression analysis was conducted between opinionnaire scores criterion variable) and educational setting (predictor variable) to determine whether significant relationships existed between educational setting and preference for or perceived complexity of the PUI. The statistical package for the social sciences was used for analysis.
The mean pretest scores of the study groups at both universities were identical (5.75). There was no significant difference between the lecture groups* pretest scores and the PUI groups' pretest scores (i = 1.50, p > .05) at both universities (Table 1). Although there was no significant difference in the post-test scores between the control groups at either university (£ = -0.44, p > .05) (Table 2), there was a significant difference in the experimental groups' post-test scores between University A and University B (i[501 = 3.00, p < .01) (Table 2).
Third-year baccalaureate nursing students who completed the programmed learning module in the basic principles of infection control scored significantly higher on post-tests than those who attended a lecture on these same principles, regardless of pretest scores and educational setting (p < .OOlXTable 3). Thus, the general nuil hypothesis of the study was rejected. The mean time (30 minutes) needed to complete the programmed module was significantly less than the mean time (55 minutes) needed to cover the same content in the lecture mode (p < .001 ).
The mean rating of the PUI for complexity on the five-point Likert scale opinionnaire was 2.9, whereas the mean rating of the PUI for preference was 2.6; with the majority of subjects (52%) stating that they would use this format "sometimes." There were no significant relationships between educational setting and preference for or perceived complexity of programmed instruction (p < .05).
POST-TEST SCORES BY METHOD AND EDUCATIONAL SETTING*
To test the main hypothesis of the study described in this article, a pretest-post-test control group design was utilized. The strength of this design lies in its control of factors affecting internal validity (Campbell & Stanley, 1966). furthermore, the randomization of the subjects into control and experimental groups from the total populations in which the selections were made allowed for a true experimental design, further controlling for threats to internal validity. The main problem with the pretest-posttest control group design is the ability to be generalized to non-pretested groups (Campbell & Stanley, 1966). However, as noted above, the instruments used in this study have been pilot-tested using the Solomon four-Group Design. No interaction effect between the treatment and the pretest was found in the pilot study; therefore, the results can be generalized to non-pretested groups (Goldrick, 1987a).
The results of this study are similar to those found in the pilot study (Goldrick, 1987a) except the type of subject was different; validating the use of the PUI among baccalaureate nursing students. However, generalizations to non-baccalaureate students must be made with caution. The study should be replicated with nursing students in other educational settings to further test the validity of the PUI.
The reasons for the difference between University A and B experimental groups' post-test scores are unclear. However, as other researchers have found, it is extremely difficult to carry out pure experimental research in education. It also must be kept in mind that superiority in teaching method was not a goal of the study. Equality of results, while providing an effective alternative to classroom instruction, was the objective.
ANALYSIS OF COVARIANCE: PERFORMANCE ON POST-TESTS* BY METHOD OF INSTRUCTION
The findings in this study are consistent with results from other studies that have shown that self-managed learning is an effective alternative or supplement to classroom instruction. Infection control content, cast in the self-learning mode, can be effectively and efficiently learned by third-year baccalaureate nursing students in both private and public universities. The fact that subjects in the treatment group indicated that the PUI content was manageable and that they would prefer this type of learning over lecture "sometimes" signifies the feasibility of incorporating the PUI as an adjunct or alternative to lectures. Thus, classroom instruction can build on PUI content learned outside the classroom. The programmed unit was also efficient since it took nearly half the time to complete the PUI module than it did to cover the same content in the classroom.
The primary goal of educational programs for health professionals is the transfer of the knowledge gained on achievement tests to clinical performance (Feldman, 1969). A limitation of this study is that only cognitive learning, not skill attainment, was measured. As previously noted, Feldman (1969) demonstrated that there were significant improvements in clinical behavior among nursing students following a PUI in asepsis. Hence, a study to determine whether actual infection control practices improved after completion of this PUI would seem warranted.
The design of the PUI content adapts itself well to CAI. Therefore, further research providing infection control content with interactive CAI technology is also indicated.
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PRETEST SCORES BY METHOD OF INSTRUCTION*
POST-TEST SCORES BY METHOD AND EDUCATIONAL SETTING*
ANALYSIS OF COVARIANCE: PERFORMANCE ON POST-TESTS* BY METHOD OF INSTRUCTION