Evaluation of undergraduate students' ability to perform health assessments is generally done through two methods: 1) teacher-developed examinations and 2) observation of students' performance of a partial or complete health assessment. Each of these methode has been useful, but not necessarily comprehensive in adequately evaluating students' performance and interpreting results obtained from health assessment. This article briefly reviews these traditional forms of evaluation and describes an innovative evaluation approach using computer videodisc technology.
Teacher-developed multiple choice (MC) exams often use written descriptions of situations and techniques that require the student to mentaUy visualize the situation, technique or findings. Constructing MC exam questions in such a way that students do not misinterpret the question stem is a major barrier. Physical exam findings are difficult to test in written examinations because they are usually presented as audio, visual, or tactile data. Thus, it is difficult to write descriptions of physical exam findings in a manner that does not reveal the correct answer.
Because students' ability to recognize actual finding« cannot be tested in a written exam, students may be required to perform a physical assessment under the observation of an instructor. Direct observation of students provides the opportunity for the instructor to see exactly what students are doing and how they organize themselves to perform a physical exam.
Observing students is very time intensive and may not allow for a comprehensive evaluation of students' interpretations of findings, particularly auditory. Each student performs a health assessment on only one client which allows for evaluation of how that student performs a health assessment of that client and how the student interprets data obtained from that client. It is not possible to compare assessment and interpretation of data from multiple clients.
Although these two methods of evaluation are widely used and important in the overall évaluation of students in health assessment, their limitations need to be recognized. Frustrations with traditional methods of evaluation for health assessment motivated the authors to investigate and develop newer and more innovative approaches to evaluation.
Description of Course
The health assessment course for which we hoped to improve évaluation methods is taught in the first quarter of the nursing curriculum. Students are juniors and have completed all their prerequisite nursing courses. The health assessment course is a 3-quarter credit course including 2 hours of lecture and 3 hours of laboratory practice per week. The focus is on assessment of healthy adults and it is the facultya philosophy that students need to be presented with what is normal before they can appreciate and recognize abnormalities. Information is presented to the students in lecture on a system-oriented approach. Following the lectures, students proceed to the lab portion where they are expected to practice on each other the examination techniques for the system that was presented in lecture. Write-upe of the history and physical exam of the system are expected from each student.
At the completion of the course each student is expected to perform an integrated screening history and physical on an individual of their choice. This history and physical is videotaped and given to their individual lab instructor for critique. The grade for this course is based upon a MC mid-term exam, a MC final exam, a lab grade, and the history and integrated physical. The final exam also includes the videodisc interactive program which will be discussed in more detail later.
Development of an Interactive Videodisc Computer Program
Dissatisfaction with the previously identified methods of evaluation led to exploration of computer videodisc technology and in-house production of a computer videodisc program. Funding was obtained from a local private foundation (Dumke Foundation) for the development and production of the videodisc. Funding from the Helene FuId Heath Truet Fund was obtained for the purchase of software to author the program(s) and hardware on which to play the program and videodisc. Our goals for the production of the videodisc were: 1) to include a wide variety of clients so that students would be exposed to diverse individuals with unique attributes; 2) provide more reality than written exams; 3) to meet a variety of needs within health care education; 4) to focus on health and basically normal or healthy responses.
Our first task was to develop a story board which identified the techniques we wanted to include and assure that we included a variety of individuals. The storyboard was based upon a test bank of questions that had been developed. This guided us in identifying specific situations and techniques that we wanted to include for evaluation. The storyboard also guided us in the taping process so that we knew what procedures were being taped that day.
Appropriate individuals between the ages of 20 and 50 were identified who would be willing to pose as clients. This age range was decided upon because the authors felt that gerontological assessment is a unique area of study and practice and therefore, should to be included as part of this videodisc program. Gender and cultural variations were hoped for, and there is a variety of males and females from various age groups, however, it was difficult to find representatives from a wide variety of cultures; one young Asian male is included. Clients were also reimbursed for the time they posed as clients.
Our goal of reality was achieved in a variety of ways. One way was to use a recording stethoscope, allowing us to record actual heart and lung sounds. Some of the recorded sounds were not as distinct and sharp as artificially reproduced sound; but more closely resembled what is heard in actual practice. The segments were taped from the examiner's point of view so that students would have the effect of performing the examination.
We wanted the videodisc to be appropriate for a wide variety of teaching and testing purposes so we did not include any teaching or explanation of the examination procedures. Each segment is complete in itself using only the audio of the examiner's instructions and/or the client's responses. Use of the videodisc is limited only by educators' needs and imagination.
The videodisc is a 1-hour encyclopedia of full motion and still segments portraying all adult systems: skin, lymphatic, thyroid, neurological, musculoskeletal, abdominal, respiratory, cardiovascular and reproductive. Each segment consists of examination of a specific component of a system, e.g., thyroid gland examination, listening to heart/breath sounds, and eliciting DTR's. Emphasis is placed on normal adult responses and results. However, there are instances where minor deviations from normal are included, e.g., breath and heart sounds. Instances of the examiner using incorrect technique are also included so that students have the opportunity to critique the examiner.
The final part of the process required choosing which video segments were most appropriate to include on the videodisc and editing the segments on to a master tape. Dubbing of specific heart sounds and /or lung sounds was also included in this step. The master tape was then sent to a national production house for transfer to disc. After the videodisc was completed the next task was to develop software programs to correlate with the individual segments of the videodisc. The authoring system used in this process was "Quest" by Allen Communication, which is IBM/DOS compatible.
Use Within Health Assessment Course
Two computer videodisc programs are used within the undergraduate health assessment course. Each program utilizes a dual monitor approach- one monitor screen for the display of written text and a second monitor screen for the display of the videodisc still and motion segments.
One of the programs is part of the evaluation process and is a component of the final examination as mentioned earlier. In this procedure selected segments of the health assessment videodisc chosen from the various body systems are presented to the student on one screen. On the second monitor screen the student is presented with a multiple choice question that relates to interpretation and evaluation of the results obtained by the examiner as viewed on the videodisc monitor screen.
After students view the video segment they are requested to enter their responses to the multiple choice question. After the response is entered there is no indication of the correctness of the choice. However, students are informed of their final score at the end of the exam, At this point there is only one version of the exam, however there are enough video segments in each body system that multiple parallel versions of the exam may be developed.
Written teacher made multiple choice exams and the students' performance of a health assessment are still part of our evaluation process. It is the authors' assumption that written exams do test a different dimension of knowledge and for that reason are still included as part of the evaluation process. We believe the computer videodisc approach adds a significant dimension to the overall evaluation process but is not mutually exclusive of other types of evaluation. Further research is needed to determine differences in methods of evaluation and dimensions of knowledge and learning.
The videodisc is also used in this course as a short answer/fill-in-the-blank practice examination used as an adjunct to classroom lecture and laboratory practice. In this procedure, the student chooses which body system to review and then views various segments and questions related to that system- The number of segments presented varies between systems and ranges from three segments for the lymphatic system to 69 segments for the neurological system. This program uses the two screen approach as described Ln the previous section. During and/or after each video segment is displayed on one screen, the student is presented with a fill-in-the-blank question on the second screen. The response generally requires interpretation of the results obtained by the examiner in the video segment. Students may also be required to determine if the results are or are not considered normal. If the results are not normal, beginning students are not required to determine the extent of the abnormality or to diagnose the probable cause of the abnormality.
After an answer has been typed, the student is told whether the response is correct, and if not, what the correct response should be. Students may go through the various systems as many times as they wish. Students are encouraged to use the practice format in groups. When this has occurred it has generated discussion among the students and helped them to think through the responses to the questions. The multiple choice questions that are used as part of the previously described evaluation format acre based upon the practice short answer/fill-in-the-blank questions used in the practice format.
Other uses for this program relate to screening and remediation. Registered nurse students are required to complete the examination portion of the program as a method of determining their knowledge and skill level in health assessment techniques and interpretation. Decisions on placement in the undergraduate health assessment course is determined by their performance on this examination. Graduate students are also expected to use the program to update skills and knowledge in health assessment.
Student response to this type of evaluation has been overwhelmingly positive and helpful. Students have indicated that this program has helped them to direct their questions and increase their understanding of particular procedures, make application of the techniques that they were learning in class and laboratory practice, and preparing for their final physical exam performance. Many have indicated that it is of great help to them to be able to see the performance of the techniques and be able to observe the actual results obtained.
There have also been some complaints about the program which have focused mainly on the program flow. These aspects can be remedied by rewriting specific computer commands. Some complaints have centered on difficulty in hearing the heart and breath sounds due to background noise. In reality, part of the learning task is to distinguish actual heart and breath sounds from the inherent background noises asaociated with hospital environments. Overall, etudents' responses indicate that this program has benefited them in their study of health assessment and that they perceive this type of learning and evaluation to be helpful.
Advantages of Using Computer Videodisc Interactive Program
The greatest advantage to using this program is that it involves Uve action shots; allowing the student to observe what the examiner is doing and hear actual sounds that the examiner hears. Many videotape programs which have been developed for learning health assessment also have this advantage but they do not allow the student to make their own judgments regarding the correctness of the procedure(s) and the normality of the results. The computer videodisc interactive program thus helps to facilitate critical thinking skills in students.
The advantage of using this type of program as part of the evaluation process is that all students are exposed to the same situation and view the same results. This allows for comparisons among students and individual weaknesses may be readily identified.
Disadvantages of Using the Computer Videodisc Interactive Program
Disadvantages to using this program aare basically logistical and pertain to scheduling and limited hardware availability for student use of the practice program. Presently there are only two computer-videodisc players available. Some students have taken more than their fair share of time using the program. This may give those students an advantage when it comes to examination time.
Students have also spent considerable time memorizing the answers to the fill in the blank questions so that when the final examination time comes they will be able to achieve high scores on the examination component.
Use of computer videodisc interactive programs has provided faculty and students with a greater breadth of information for evaluation and learning purposes. For the students, it provides the opportunity to actually observe physical assessment techniques during testing rather than relying on descriptions in a written question. It provides faculty with a greater variety of opportunities and broader range of techniques to more accurately evaluate students. Ultimately, students are better prepared in the performance of physical assessment and collection of appropriate data in the provision of patient care.