Journal of Nursing Education

Graduate Education in Nursing Leadership Through Distance Technologies: The Canada-Norway Nursing Connection

Carroll Iwasiw, RN, EdD; Mary-Anne Andrusyszyn, RN, EdD; Anne Moen, RN, MScN; Truls Østbye, MD, MPH; Lynn Davie, PhD; Turid Støvring, RN, MScN; Irene Buckland-Foster, RN, MScN



The Canada-Norway Nursing Connection was a collaborative project designed to provide an international educational experience for graduate students in nursing via distance technology. Computer-conferencing and videoteleconferencing were used to address nursing leadership content through case studies. The same technologies were employed to develop the project. The processes of planning and implementing the international linkage are described. Agreement about goals, content, context for online discussion, delivery methods, academic expectations, language support, and logistics was essential. The media proved to be effective for students to gain understandings about nursing leadership, health care, and the forces influencing the nursing profession globally. Insights from the project provided a basis for the development of a model for interactive, international graduate education that will be of value to educators dedicated to helping students gain a global understanding of nursing and health care issues.



The Canada-Norway Nursing Connection was a collaborative project designed to provide an international educational experience for graduate students in nursing via distance technology. Computer-conferencing and videoteleconferencing were used to address nursing leadership content through case studies. The same technologies were employed to develop the project. The processes of planning and implementing the international linkage are described. Agreement about goals, content, context for online discussion, delivery methods, academic expectations, language support, and logistics was essential. The media proved to be effective for students to gain understandings about nursing leadership, health care, and the forces influencing the nursing profession globally. Insights from the project provided a basis for the development of a model for interactive, international graduate education that will be of value to educators dedicated to helping students gain a global understanding of nursing and health care issues.

One way of moving the nursing profession forward is through experiences that expand nurses' understandings beyond traditional physical and conceptual boundaries. International sharing of perspectives about health care and nursing leadership may lead to enriched, global understandings of the forces influencing the profession. Traditionally, international education has been achieved by relocating learners to the country offering the desired learning experience (Colling & Wilson, 1998; Haloburdo & Thompson, 1998). Although studying abroad is enlightening and the value of immersion in a different culture cannot be underestimated, the costs associated with such experiences are often prohibitive. Distance technologies offer powerful alternatives for facilitating international learning opportunities, without the need for relocation.

The Canada-Norway Nursing Connection was a collaborative project; the goal of which was to provide MScN students with an opportunity to share in an international educational experience about nursing leadership through use of Internet-based computer-conferencing (CC) and video-teleconferencing (VC). The initiative started from personal connections among members who became the project team. The Canadian group comprised faculty from the School of Nursing and the Department of Epidemiology and Biostatistics at the University of Western Ontario (UWO) in London, and the Department of Curriculum, Teaching, and Learning at the Ontario Institute for Studies in Education, University of Toronto. The Norwegian members were from the Institute of Nursing Science at the University of Oslo (UO). All shared an interest in teaching and learning through CC. The nursing members of the team taught graduate courses in nursing adniinistration in Norway or Canada and these courses included some similar content. In 19961997 we conducted a small pilot project using CC, with graduate students in both countries, subsequent to which this project was formalized.

The purpose of this article is to describe the processes used to establish and implement the Canada-Norway Nursing Connection. A model for technology-based, interactive, international education is also presented.


The project team established a private CC space to share planning ideas about the educational endeavor. Computer-conferencing connected the team electronically and was an efficient, cost-effective, and timely way of ensuring that everyone's ideas were expressed, captured, and discussed. In addition to designing the educational portion of the project, it was essential to assess the available distance technologies. Because of the international nature of the project, language support was an important consideration. Discussion about expectations of students and logistical details arose concurrently with the larger planning issues. The team also had a VC to meet visually, finalize details, and test the equipment before student involvement began.

Conceptual Base for Educational Experience

Tenets of the social constructivist paradigm formed the conceptual frame from which we designed the educational project. "The important epistemological assumption of constructivism is that knowledge is a function of how the individual creates meaning from his or her experiences; it is not a function of what someone else says is true" (Jonassen et al., 1995, p. 11). We believed that through the collaborative efforts of all participants, collective information and experiences shared through critical dialogue and reflection would be transformed into knowledge that was personally meaningful and relevant (Jonassen et al., 1995; Schwandt, 1994). The student participants were adult learners with a wealth of personal and professional knowledge and experiences, who would have something of value to contribute and draw from the discussion. Learning would be embedded by sharing understandings through social construction of knowledge.


In accordance with the conceptual framework, the Canadian and Norwegian educators collaboratively developed the goals for the project. These were negotiated over several weeks in the CC space established specifically for planning and through electronic mail (email).

The overall goals of the project were to: (a) provide graduate students and faculty with an opportunity to engage in an international learning experience, (b) expand participants' perspectives on nursing leadership and administration across borders and cultures, (c) critically examine assumptions related to health care issues in Canada and Norway, (d) develop participants' familiarity and comfort with VC and CC as media that support collaborative teaching and learning and as means to enhance professional relationships, and (e) examine the elements that contribute to the development of meaningful international linkages in graduate nursing education.

Course Analysis

It was agreed that the international experience would form an integral part of the courses we were teaching at UWO and UO. Therefore, the first step in deciding which concepts would be addressed in this project was to ascertain areas of conceptual similarity in the courses. We determined that there were three topics common to courses in Canada and Norway and we agreed these would form the basis for the development of shared learning activities for students. The topics were leadership, organizational change, and team building.

Contextual Application of Concepts

Once the conceptual areas were defined, we discussed the teaching strategies most suitable for simulating vigorous discussion and debate as ways to develop knowledge and embed learning. We agreed to use the case study method to achieve this goal. One central concept would provide the basis for each case. In preparation for case development, we shared relevant course materials and identified appropriate literature sources. The research assistant interviewed Canadian nurse managers to discuss situations they encountered in their practice and upon which the foundation of each case could be built. The case studies on nursing leadership, change, and teambuilding were developed, refined, and finalized online. It was important that the context of each case was directly relevant to the health care systems of both Canada and Norway.

Determination of Delivery Methods

Having assessed the technologies available in Canada and Norway, and determined the contextual approach to learning, we identified CC and VC as the two most feasible delivery methods. Most Canadian students had access to personal computers and were connected to the Internet from home, school, and/or work. Most Norwegian students did not have personal computers; however, they could rely on the available university computer laboratory facilities for access. Even though, in this case, CC was time- and place-dependent for most Norwegian students, the asynchronous nature of the environment eliminated the restrictions of time zones. Multiple messages from participants could be stored on the main-frame computer and accessed at any time by all participants throughout the project. In this way, messages could be reread and reflected upon, and ideas developed as the dialogue evolved.

Computer-conferencing had a good fit with the goals of the project. Academic interaction, which contributes to knowledge development and integration, could be promoted in this medium. Social dialogue, a component of CC, had the potential to enhance cross-cultural understandings. Moreover, the CC environment is flexible and dynamic, and lends itself well to discussion and debate, important elements to the critical analysis of case studies. Business, industry, and education have been using CC as a means of connecting learners electronically for over three decades; and, although much has been written about its application to education (Burge, 1993; Davie, 1989; Davie & Wells, 1991; Harasim, Hiltz, Teles, & Turoff, 1995; Wells, 1993), nursing graduate programs are only beginning to use this technology. The application of CC in the Canada-Norway Nursing Connection provided an avenue for learning more about how nursing students and faculty perceive the effectiveness of the medium at the graduate level.

Learning how to learn and how to facilitate peer learning in this medium were viewed by faculty as potentially enhancing participants' skill sets in information technology. It was anticipated that a clearer understanding of this technology could yield future personal and/or professional benefits.

The second delivery medium selected was VC. Because CC is primarily text-based and asynchronous, complementing it with a medium that supported visual and auditory contact, in real time, was seen as a means to facilitate personal connections among students. We determined that two VCs, one at the beginning of the project to lay the foundation for the online experience, and one at the end to bring closure, were the number required to meet project goals and stay within budget.

Provision was made for ongoing technological support since the students were new to CC and VC. Most faculty were comfortable with CC, but a technician was needed for the VCs.

Establishment of Academic Expectations

The team agreed that the online and VC experience would form the basis of a written assignment. The precise nature of the assignment would be different for the two groups of students because of variations in overall course expectations. Canadian students were asked to submit a reflective, scholarly paper derived from a concept or topic introduced during the online period. They were to integrate the understandings they gained during the computer conference in their papers. Norwegian students were to submit a critical analysis of the online experience, paying particular attention to the strengths and limitations of international graduate distance education and making recommendations for the future.

The amount of online participation expected of students and faculty was discussed. Each student was encouraged to write a minimum of three substantive messages weekly. We also negotiated which faculty member would have primary responsibility for facilitating/moderating the discussion of each case. All other faculty were free to participate as they wished.

Language Support

It was agreed that English was to be the conference language. Although English is the second language in Norway, many professional texts and journals are written in English. The Norwegian students' English language skills were advanced and we anticipated that they would see the collaborative project as an opportunity to practice speaking, reading, and writing in English. Nevertheless, we recognized that learning in a second language would be a challenge. To allay any anxiety, the team arranged for translators to be available in Canada and in Norway throughout the project.


The starting and finishing dates for the project were important considerations that needed to be determined quickly. Establishing time parameters for the project was more complex than initially apparent, since the dates of the academic terms and the sequencing of course content were markedly different in the two countries. Scheduling of dates and times for VC was problematic because classes were held on different days of the week and there is a six-hour time difference between Canada and Norway. To accommodate both programs' schedules, Canadian participants were asked to be at the university on a day other than their usual class day and at a time when classes were not normally scheduled (7:30 am EST). This was a decision that was negotiated to accommodate Norwegian participants, most of whom traveled less frequently and greater distances to attend classes. Class attendance was not mandatory for Norwegian students so attendance at the VCs and participation in the CCs was beyond what would normally be expected of them.

Arrangements were made for students to register in the CC and have practice with the conferencing system (CAUCUS, Screen Porch Inc.) before the case discussion began. Students in both countries were provided with guidelines on how to use CAUCUS. To facilitate technical understanding, the main points were translated into Norwegian.

An important decision was the timing of the distribution of cases to students. They were eager to begin the experience; yet, we wanted the majority of discussion to take place online and not solely among classmates. It was necessary to balance the opportunity for spontaneous discussion among students in both countries with the need for adequate preparation for the case analysis.

Submission dates for written assignments also had to be negotiated. These varied between the two groups because of different lengths of Norwegian and Canadian academic terms. In addition, a decision about the dates for students to complete instruments related to project evaluation had to be determined.


The learning activities occurred over seven weeks in Autumn 1997, with two more weeks devoted to evaluation of the project. Some unanticipated problems arose that led to changes in the planned design.

Initial Video Teleconference

The first VC among all participants, designed for everyone to meet each other visually and begin dialogue about the health care systems of Norway and Canada, was not successful. Only the audio (but not the video) link could not be established. Students and faculty were very disappointed. Following numerous attempts, the VC was abandoned and the teaching team in each country described the project and the expectations to their individual groups. Information about each country's health care system was then uploaded to the online conference so students could read this material when they accessed CAUCUS. This introductory data provided a common frame of reference about the health care systems and served as a contextual base for the case analyses.

Practice with Computer Conferencing

Following the unsuccessful VC, participants had ten days to practice sending and retrieving messages from a social space established in the CC. They had the opportunity to introduce themselves and engage in relaxed social conversation in an effort to help make the technology more transparent. This time period was not as generous for Norwegians as Canadians. Norwegian students had access to the Internet only at the University on their class day. Practice on CAUCUS took place for a portion of their regularly scheduled class time. Unless they made extra trips to the University computer facilities, they had only two opportunities to practice using the technology before the case discussions began. This was not the case for Canadians, all of whom had regular computer access at home, work, and/or the university.

Case Analyses

Following the practice period, three weeks were dedicated to discussing the cases, one each week. The online conferencing replaced regular class meetings for Canadian students and they participated individually throughout the week, mainly from home, and mainly in the evening. The Norwegian students participated from the university computer lab once a week. To cope with the volume of messages generated weekly by Canadian students, the Norwegians decided to work in small groups (four students/group), reading the messages, discussing the messages and cases, and then posting a group response.

Final Video Teleconference

The three weeks of CC were followed by a final VC. This time, audio and video links were established immediately, much to everyone's relief. Students and faculty met and debriefed about the overall experience for more than 90 minutes. Participants were excited to finally see each other and subsequently cited the VC as an essential component of the project.

Continued Online Debriefing

During the final two weeks, the CC space was left open so any continuing discussions could be concluded. No further messages were entered by students.


Students completed a bilingual questionnaire that had been developed to determine student learning and their perceptions of the international experience. Content analysis of the online dialogue and an assessment of student assignments were also conducted to evaluate the processes and outcomes of the project.

Computer conferencing with complementary VC proved to be an effective means of providing interactive, international graduate education in nursing leadership. The online discussion was of a quality equal or superior to classroom discussion. Students learned about leadership and health care systems in Canada and Norway, enjoyed the experience, and felt a bond with their international counterparts. Video teleconferencing was perceived to be such a desirable part of the experience, that at least a brief visual linkage is recommended whenever possible. The case studies provided a relevant context in which to discuss current and historical issues pertinent to the health care systems of both countries and to the nursing profession internationally. There was a strong fit between the delivery medium and the case format. Discussion of case studies provided the context for the construction of knowledge through dialogue that integrated analysis, synthesis, and evaluation. The detailed evaluation results are described elsewhere (Andrusyszyn et al., in press).


Many insights were acquired from this international distance experience. First, adequate time for collaborative planning is essential. The critical nature of this cannot be over emphasized. The needs and priorities of all partners must be recognized, respected, and addressed through open negotiation. At times, compromises may be necessary to facilitate the project. For example, in this project the Canadians participated in the VCs at an inconvenient time and the Norwegians extended their class day to participate in the CC.

Developing shared expectations for all aspects of the project is fundamental. Expectations about the total project, curriculum, and participation need to be consistent between partners. It is critical that the quality of existing programs not be compromised and that the project be fully integrated into, and developed with, the intent of enhancing those programs. The content of the shared experience must be congruent with the goals of the original courses, unless a separate course is developed. The latter would require substantially more planning and development time.

Another key element in the development of international educational experiences through distance technologies is, of course, access to technology and technological support. Participants need to have similar, compatible, and access to the chosen technologies. Difficulties with access may result in frustration and an imbalance in the quality and quantity of contributions. In this project, Canadian students, having more consistent access to computers, could read and respond to fewer messages each time they entered the conference. They contributed individually and had more time to compose new questions.

Computer lab facilities were available to Norwegian students outside of class time. However, commuting distances and employment precluded additional use of the computer lab. Most did not have their own computers or access to the Internet and thus were dependent on University faculties.

Since returning to the University to participate in the project was not practical, they worked in small groups to reflect on issues arising from the cases and created responses that represented their collective thoughts.

Although this approach created an imbalance of the number of contributions between students in the two countries, it was an effective means for the Norwegians to cushion some of the stresses associated with using new technology and reduced the pressure of responding individually in a second language. Using a parallel organizational structure by partners may have alleviated the imbalance.

Lastly, it is essential that there be a common language for planning, implementing, and evaluating the experience, or that translation be readily available. The opportunity to contribute in one's native language, provided an interpreter is available, would improve communication and show evidence of cultural sensitivity. This should be considered when planning the experience so that adequate time for translation is incorporated into the design.

We were fortunate that the written and spoken English proficiency of Norwegian students, including disciplinespecific language, was advanced. Despite their language facility, they expressed feelings of "cultural pain" when describing ongoing communication. It was difficult to capture nuances of written messages and to express subtleties in a second language.


Successful interactive, international distance education is comprised of the interrelationships of several critical elements: common language, shared project expectations, mutually agreed upon curriculum, similar access to technology, and adequate time. Without a common language, there will be no communication, no planning, and no educational project. Without shared expectations, there will be no clear direction for the experience. The curriculum goals, conceptual framework, content, processes, and methods of assessing learning must be negotiated so the expectations and priorities of all partners are addressed. Of critical importance are decisions about technology. Regular, easy access and ongoing support for all participants is mandatory. The time dedicated to the international learning experience needs to respect the differing cultural contexts of participants and programs and be sufficient to allow for goal achievement.

Figure. Model for international graduate education through technology

Figure. Model for international graduate education through technology

The relationships among the elements of interactive, international distance education are presented in the Figure. A common language is a prerequisite for developing and sharing educational experiences. Collaborative planning and agreement about expectations, curriculum, technology, and time availability will facilitate meaningful international learning experiences.


The process of developing and implementing an interactive, international learning experience in nursing leadership for graduate students has been described. It is important to emphasize that the planning did not occur in a linear, sequential manner. Rather, planning was iterative, with recent discussions and decisions influencing previous choices. Considerable time was required for planning. Computer conferencing and VC proved to be valuable technologies for international education, and through these media, MScN students in Canada and Norway developed insights into nursing leadership and health care in their own and the partner country.

International, graduate-level nursing education can be a reality for educators dedicated to the value of gaining a global understanding of nursing and health care issues. Interactive technology provides a means to internationalize education. Through sharing of local and national understandings, graduate students in nursing will develop global perspectives.


Funding for this study was provided by the NODE Learning Technologies Network http: 1 1


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