Journal of Nursing Education

Insights Learned from Teaching Pathophysiology on the World Wide Web

Carolyn Yucha, PhD, RN; Tonya Princen, MA



This article describes a one-credit, graduate level pathophysiology module taught using the World Wide Web. Student outcomes are compared to those of students who took the same module in a traditional classroom setting. Although the majority of the graduate students were not Web literate, they became more comfortable with this instructional medium over time. A comparison of the Webbased instruction with the traditional format, both directed by the same instructor, showed no significant differences in student performance on a multiple choice examination.



This article describes a one-credit, graduate level pathophysiology module taught using the World Wide Web. Student outcomes are compared to those of students who took the same module in a traditional classroom setting. Although the majority of the graduate students were not Web literate, they became more comfortable with this instructional medium over time. A comparison of the Webbased instruction with the traditional format, both directed by the same instructor, showed no significant differences in student performance on a multiple choice examination.

Access to education is one of the major challenges facing nurses in states like Colorado, where a large proportion of the state is rural and transportation is impeded by the Rocky Mountains. This issue is especially critical for rural nurses who cannot attend distant universities because their small communities depend on their health care services. To meet the needs of such students, a variety of media have been used to provide distance learning. These include: correspondence classes, audio and video tapes, satellite television, cable television, computers, teleconferencing, interactive and compressed video, and faculty travel (Reinert & Fryback, 1997). Since Web-based instruction is the newest of these, little is known about the educational outcomes of this media in nursing education. To address these and other issues, we developed a Web-based pathophysiology module. We felt the interactive opportunities provided by the Internet would address key access issues faced by many nurses working in rural settings.

Students in the master's program at the University of Colorado School of Nursing are required to take three to six credits of pathophysiology depending on their program. Most students complete 9-15 credits of core classes before taking pathophysiology, but some students choose to take it earlier. Pathophysiology is composed of two, three-credit courses, with each course divided into three, one-credit modules. Module 1 is a prerequisite to each of the five subsequent modules and includes content related to all body systems. Module 1 is composed of five units: (1) cell physiology; (2) fluid/electrolyte balance; (3) acid/base disorders; (4) genetic basis of disease; and (5) cell growth and cancer. The remaining modules are organized by systems and consist of topics such as: psychoneuroimmunology; cardiorespiratory disorders; neurological and musculoskeletal disorders; endocrine and reproductive disorders; and renal and gastrointestinal disorders.

Because Module 1 is prerequisite to subsequent modules and has an enrollment limit of 40 students, it often becomes a bottleneck to student progress. To provide flexibility and greater options for students, Module 1 was offered during the summer of 1997 as a Web-based module. Since this was a pilot project in the School of Nursing, we decided to record the module development time of instructor and instructional designer; collect data on student attitude and time to complete each unit; and compare student grades in the summer Web-based module with those of other students who had taken the module in a traditional classroom lecture/discussion format. However, we recognize that there are several confounding factors in these data, and encourage further research on the effectiveness of online courses.


Developing the Module

In the traditional offering of Module I1 each of the five units is taught in a three-hour block using lecture and discussion. Since the instructor had previously taught the traditional module, development of the Web-based module began with the instructor's lecture notes. This development proved to be time consuming for both the instructor and instructional designer, who also coded the module for the Web using Hypertext Markup Language (HTML). Time summaries for instructor and designer are shown in Table 1. We kept our module content relatively simple, using no animation, audio or video, with the exception of linking to related materials already on the Web. If module content and design had included more types of media and more involved interactions, time for the instructor and designer would have drastically increased and additional technical development personnel would have been required.

Orienting Students to the Module

There were 14 students who registered and completed the summer Web-based module. They were master's students in the midwifery, clinical specialist, and nurse practitioner programs. Most students worked part-time or full-time while taking classes. None of the summer students had previously taken Web-based courses; only 3 were familiar with the Web; and only 4 had email accounts prior to the module. This lack of experience with the Internet is not unusual among nursing and older students (Miller, Piper, & Tucker, 1997; Mastrian & McGonigle, 1997). All of the summer students lived near the school and could have taken the same module in the traditional classroom setting had it been offered.

Students in the Web-based module attended a twohour orientation to the module and technology. They were provided with email accounts and shown how to access the module Web site. Using a printed syllabus, they were given an overview of the module and its requirements. At this session, students appeared enthusiastic about both the content and the technology. They liked the interactive nature of the critical thinking questions and being able to view the correct answers immediately.

Teaching the Module

The Web-based module can best be described as an interactive workbook. It includes the following components: (1) small "digestible segments" modified from the instructor's lecture notes; (2) interspersed critical thinking questions and answers; (3) case study discussions; and (4) links to Web sites related to the material. In addition, there are three components that are not on the Web: (1) textbook readings; (2) a two-page paper; and (3) an inclass final examination.

In each unit there were six to eight critical thinking questions and two or three case studies. The critical thinking questions were generally questions the instructor would have asked in a traditional classroom to evaluate the student's understanding of a concept. Once the student typed in an answer and submitted it to a database, he or she was presented with the correct answer in paragraph form. This system served two purposes. First, the instructor was not overwhelmed with email each time students answered a question. Second, the students received immediate feedback of the instructor's answer to the questions, which has proven to be a very powerful instructional strategy (Plowman, 1997). The instructor could then review the database of student answers to identify difficult or unclear concepts. The instructor emailed individual students or the entire class to provide further clarification when she saw signs of confusion. Students did not have access to other students' answers to the critical thinking questions.


TABLE 1Preparation Activities and Time Commitment for Web-Based Module Development


Preparation Activities and Time Commitment for Web-Based Module Development

The case studies were formatted as threaded discussions. Using this technology, students could read each other's responses that were "threaded" with each response to a message indented below the base message. The case studies generally dealt with patient care scenarios, compare and contrast types of questions, and statements of opinion.

The summer module proceeded over a seven-week period, with students working at their own pace. During this period, the instructor accessed a Web site that stored student responses two or three times per week to check on student progress. The instructor also reviewed student discussions in the case study section of the module and added some additional information intermittently to the group discussions. In general, the instructor spent two hours per week overseeing this module for 14 students. A multiple-choice final exam was conducted in person, at which time module evaluation forms were completed.

Evaluating the Module

It is important to note that many variables were not controlled in this study. These include student computer and pathophysiological knowledge prior to taking the module, student motivation, and availability of computers at home and work. In addition, these results are not generalizable to courses prepared and taught by other instructors.


TABLE 2A Comparison of the Overall Scores From Different Cohorts


A Comparison of the Overall Scores From Different Cohorts


How Did Students Perform in the Module?

All students completed the online module. The test grades of students in the Web class were not significantly different (F = 1.524, ns) from those of students taking the traditional classroom lecture/discussion module during fall 1993, 1994, and 1997, and spring 1998, as shown in Table 2 and the stem and leaf plot in Figure 1. A stem and leaf plot is a type of frequency distribution in which the actual data values are displayed. In this diagram, the stem depicts the ten's place of the examination score. The last digit of the score, known as the leaf, depicts the one's place and is used to indicate each observation. For example, the first stem is 4; to this is added the leaf of 7, resulting in a value of 47%. The last stem is 10; to this is added the leaf of 0. A grade of 100% was earned by 11 students. The bolded leaves indicate scores earned by those taking the Web-based version of the module.

One student (7.1%) failed the module and told the instructor that she had a number of personal problems during the summer and did not study adequately. In addition, she was planning on moving out of the state and did not think this module would transfer. Over the past five years, ten students out of 163 (5.5%) in the traditional classroom offering have failed this exam. Therefore, this percentage of failures is not unusual, regardless of the instructional mode.

Of course, there are some confounding factors in these comparisons. Students taking the classroom course in fall 1997 and spring 1998 also had access to the content on the Web to use as a supplement to class or in lieu of class were they unable to attend. Students in the Web-based module were able to contact the instructor for further clarification of confusing concepts by phone or in person. Nevertheless, the comparison of grades in the Web-based module with those in the traditional classroom in 1993 and 1994 showed no differences.

Figure. Test score stem-and-leaf plot. Stem width: 10.0; each leaf: 1 case; bolded are scores earned by students in the Web-based version of the course.

Figure. Test score stem-and-leaf plot. Stem width: 10.0; each leaf: 1 case; bolded are scores earned by students in the Web-based version of the course.

How Long Did It Take To Complete?

Traditional students are expected to spend 35-40 hours in study, plus 15 hours in lecture/discussion. Therefore, we expected online students to spend approximately 9-12 hours to complete each unit, or 45-60 hours to complete the entire one-credit module. At the end of each unit, students were asked how long it took to complete. For the five units, the average times were 9.4, 8.6, 7.0, 8.6, and 8.1 hours respectively. This totals 41.7 hours or an overall average of 8.3 ±0.9 hours spent per unit.

What Did Students Think about the Module?

Summer students were asked to complete a Likertstyle questionnaire; 13 of 14 students complied. These data provide specific information on what these students believed they learned in the Web-based module, which features of the module were most effective for their learning, and their attitudes about the experience.

The majority of students thought their computer skills and familiarity with the Web increased during the module. However, of particular interest and concern was that students believed they learned less using the Web-based module than they would have in the traditional classroom. Test results, shown in Table 2 and depicted in Figure 1, do not support this perception.

Regarding instructional strategies, students found the critical thinking exercises with immediate feedback very helpful, and most of them believed that the links to outside sites contributed to their learning. The case studies were not considered as helpful. It was noted that students responded to each case as though they were responding alone, rather than building on previous student responses. While many students communicated with the instructor via email and voice mail, there was little communication among the students. Students made only partial use of the unit outlines and objectives while studying.

Student attitudes about the module were not very positive. In fact, 12 of the 13 students completing the evaluation forms reported that they would not gladly take a Web-based module again. Although this group of students may not be typical of the target audience for Web-based courses, they are typical of graduate nursing students. Most graduate students in nursing are older students who graduated from high school before computer literacy was required and received their BSN degrees before Webbased instruction was available. Our students were local students who could easily get their education in the traditional classroom setting. We believe the results of this small study may have been different if rural students who would not otherwise have access to the module participated instead.

Finally, many of the students had difficulty initially accessing the module from home. Therefore, Web-based instruction offered little benefit to them with the exception of allowing them to work when and where they wanted. Mastrian and McGonigle (1997) have also found negative responses to technology based assignments. Their nursing students reported early frustration with computer technology and initial feelings of being overwhelmed.

Since this was the first Web-based module for all of these students, they had to deal with new technology at the same time they were dealing with pathophysiology content. Their feelings about the module may have been different if they had previously taken other Web-based courses.

In addition to these Likert-style questions, students were asked some open-ended questions about the process they used in completing the Web-based module. Most students printed each page of the module, read the pages along with their textbook, answered the questions on paper, and then signed back into the module to answer the critical thinking questions and respond to the case studies. While most students enjoyed the flexibility of the module, they also stated that they would have preferred the interaction of the classroom. This group of students interacted little with the instructor and even less with each other.


We feel very comfortable that Web-based instruction is providing at least comparable learning opportunities for students. Preparation of Web-based instruction is time consuming for both the instructor and instructional designer/HTML programmer. Even when the course has already been taught in the traditional setting, large amounts of time must be invested to adapt the course for optimal use of Web capabilities and resources.

Since many students are not computer or Web literate, courses offered via the Web must be user-friendly and an orientation to the media must be provided. Over time, students become more comfortable with the media and are able to focus on course content. It is critical that nursing students become very comfortable with computers since they are used in every aspect of patient care. Some might even argue that the skills gained in Web-based instruction are more important than the pathophysiology content itself because of the potential impact the Web has on every aspect of our society (Fleming, Levie, & Howard, 1993).

This comparison of the traditional format with Webbased instruction showed no differences in student performance on a multiple-choice examination. It must be acknowledged that such examinations may not differentiate between deeper levels of understanding students may achieve, and that more research is necessary using other forms of evaluation (e.g., essay, oral) (Jones, 1995; White, 1992). Although it is acknowledged that skill development involves a different cognitive domain than does knowledge development, it is interesting that DeAmicis (1997) also showed comparable learning when comparing interactive videodisc instruction with the traditional lecture/discussion for teaching intravenous therapy skills.

Numerous research studies have concluded that having students work together is much more powerful than having students work alone (Johnson & Johnson, 1985; Johnson & Johnson, 1986). Therefore, in future Webbased course offerings, we would make greater use of the interactive capabilities provided by the World Wide Web. First, we would require that each student enter into each discussion at least once. This would enhance interaction of students who are geographically isolated from one another. The disadvantage of this is that for maximal learning, students must be completing the course assignments around the same time, rather than at their own pace. Second, to enhance interaction and ensure that each student is making a contribution, we would create small groups (3-4 students each) who work together to complete each case study. Third, we would provide for chat rooms for students to have online discussions with one another at designated times.

We would not add animation, audio or video to this module at this time, as many students do not have the resources necessary to access these. It is impossible for an instructor who is new to Web-based instruction to consider all the possibilities in Web-based educational systems during the first online offering of their course or module. Therefore, we recommend that courses be revised and new interactive strategies be tested for their effectiveness within each type of course.


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Preparation Activities and Time Commitment for Web-Based Module Development


A Comparison of the Overall Scores From Different Cohorts


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