The multimedia capabilities of modern computers promise a rich contribution to nursing education, integrating video, animation, and graphics in a single courseware package. Use of computers in nursing education has evolved from elementary drill and practice tutorials to challenging presentations. Hypermedia technology has emerged as a powerful instructional method that allows users to experience new concepts, gain cognitive skills, and encounter realistic clinical situations in a safe environment. Effective learning of a skill requires sustained, deliberate practice within a cognitive framework, and simulation offers an opportunity for safe practice (Kneebone &ApSimon, 2001).
Information technology can enhance clinical teaching by increasing the amount of relevant clinical information available to learners, allowing for rapid integration of needed information into the teaching encounter, facilitating information processing within small groups, and compensating for the many discontinuities inherent in current clinical teaching environments. However, as many educators look toward future implementations of advanced, completely integrated medical information systems, they often overlook currently available information technology (e.g., CD-ROM textbooks), which can measurably enhance their teaching (Sandroni, 1997). Using the latest generation of design tools, computerassisted learning materials, such as CD-ROMs, can be successfully created in-house (Vogel & Bennett, 2001). The ergonomie guidelines used in the development of computer-assisted instruction (CAI) can have a positive influence on learning environments (Zandvliet & Straker, 2001).
Many studies claim the use of CAI is an effective alternative to traditional teaching methods (Edward, 1996; Halloran, 1995; Koch & Guice, 1989; Lo, Lo, Wells, Chard, & Hathaway, 1996; Mangione, Nieman, Greenspon, & Margulies, 1991). Use of this technology to teach psychomotor skills in the classroom also has been supported (DeAmicis, 1997; Froman, Hence, & Neafsey, 1993; Mangione et al., 1991).
Although few studies have found CAI to be superior to traditional teaching methods, many positive learning outcomes have been attributed to the use of multimedia computer technology. These include:
* Reduced learning time (Napholz & McCanse, 1994).
* Positive attitude change related to learning (Koch & Guice, 1989; Schare, Dünn, Clark, Soled, & Oilman, 1991; Wong, Wong, & Richard, 1992).
* Increased motivation to learn (Lo et al., 1996).
* Greater enjoyment and increased self-confidence (Gleydura, Michelman, & Wilson, 1995).
New developments in computer technology are changing the way educators perceive CAI. Nurse educators and practitioners can plan on using CAI capabilities that will be both possible and economical, as well as within the reach of most organizations (GleyduraetaL, 1995).
This study was conducted to determine whether educational training delivered by CD-ROM is more effective than printed materials in developing student nurses' cognitive, affective, and psychomotor skills.
Interest in using computer technology in nursing and medical education began in the mid-1980s ("CD ROM: What is it?," 1988; Wigton, 1987), and the first article on this topic was published in 1985 (Walker, 1985).
Computer-assisted instructional programs have been reported to enhance the learning process (Vicnitvejpaisal et al., 2001). They are inexpensive and allow easy access to self-instruction as a supplement to formal classroom training (Willy, Sterk, Schwarz, & Gerngross, 1998). In addition, there has been a high level of acceptance for this type of instruction, which is encouraging for educators involved in producing multimedia packages for teaching medical content (Willy et al., 1998).
If instructional design principles are followed when developing software, learners are challenged with lifelike, non-threatening scenarios to expand their critical thinking and decision-making skills (Sternberger & Meyer, 2001). An important feature of CD-ROM technology is that it is interactive, self-paced, and flexible enough for use in an open learning environment. CD-ROMs also can provide demonstrations of procedures, which may be repeated as many times as required for mastery (Bauer, Geront, & Huynh, 2001).
Surveys that measured children's knowledge, attitudes, and self-reported behaviors after using interactive computer technology demonstrated a significant difference in attitude learning among three groups - computer intervention, standard teacherled intervention, and control. Slight improvements were evident in the behavioral scores, especially within the computer intervention group, but the overall differences were not significant. These results indicate this educational tool is an effective way to introduce health education programs in typical classroom settings (Hornung et al., 2000).
In another study, an interactive CD-ROM for nutrition screening and counseling was useful for dietary screening, feedback, skill building, and motivation in settings in which face-to-face counseling by nutrition professionals was not feasible (Block et al., 2000). Research on the efficacy of the nutritional education software, Nutri-Expert, in management of obese adult patients showed that the group using Nutri-Expert scored significantly better than the control group on tests of dietetic knowledge (Turnin et al., 2001).
For dental education, where much of the education involves visual transfer of both concepts and procedures from instructors to students, use of computers is helpful by making instruction more direct, better visualized, and more comprehensible (Wurdack, 1999). A computer program also was effective in changing the clinical behavior of orthodontists (Marsh, Hannum, Trotinan, & Proffit, 2001). Other research results suggest that using CD-ROMs as a distance education strategy can be effective for nurse practitioner students. Online quizzes were highly rated by students (Mangan & van Soeren, 2000).
However, other study results claim a contrasting conclusion. According to research in which the effects of CAI for dentists were measured, results showed that a CAI package had no effect on dentists1 behavior in treatment decision making ( Kay, Silkstone, & Worthington, 2001).
Because nurses are increasingly designing CD-ROMs, they must be aware of the instructional design needed to develop comprehensive and effective CD-ROMs that do not compromise the quality of education (Jeffries, 2000). Researchers found that the effects of cognitive style on performance were mediated by interface design (Effken & Doyle, 2001). However, for Internet delivery of ^ information to highly motivated professionals, it appears transitions and animations are not necessary and are more likely to decrease, rather than increase, the teaching material's effectiveness (Marsh et al., 2001).
No correlation was found between students' learning preferences or computer attitudes and test performance. Data indicate CAI provides a means of delivering educational content that results in an increase in knowledge that is not correlated with 4 computer attitudes or learning preferences (Lynch, Steele, Johnson Palensky, Lacy, & Duffy, 2001). The authors were interested in identifying the effectiveness of CAI compared to traditional learning methods because of these controversial issues.
The authors developed the CDROM and printed material of SanYin-Jiao pressure to reduce labor pain and shorten labor time. Both * versions encompassed theoretical and practical content. The creation process was segmented into five phases according to previous research recommendations (Eakin, Brady, & Lusk, 2001):
* Determination of program content.
* Creation of overall program design, including live action and still video, and addition of sound and ' graphics.
* Development and integration of tailoring pathways into the final intervention.
* Development of a database and participant handouts.
* Pilot testing of the CD-ROM.
A prospective, randomized intervention trial was used to assess the motivational appeal of the CD-ROM and evaluate its ability to elicit changes in knowledge, attitudes, and psychomotor skills related to SanYin-Jiao pressure. Researcherdesigned questionnaires, using 5point Likert scales, assessed the students' characteristics and solicited their ratings of aspects of the CDROM, including ease of use, clarity of instruction, interest, and convenience of use. Students' adherence to the procedure was determined by observation using a performance checklist.
Two groups of third-year nursing students were randomly selected to participate in the study, and all of them voluntarily agreed. Students in each group were informed the authors wanted to determine their recall of San-Yin-Jiao pressure following different forms of self-learning to evaluate the effects of CAI. Students were assured this activity was not a test and would not affect their educational standing in any way.
At the end of the 1-week self-learning period, students in both groups were observed individually as they performed the procedure. Their performance was documented using a checklist developed by the authors and based on the steps of the procedure. Five other researchers, who were nursing professors or instructors, performed the observations and evaluations. These researchers were trained in the use of the checklist until an interobserver consistency of 95% was achieved. A double-blind procedure was used, in which the evaluating researchers did not know to which group students had been assigned.
Volunteer fourth-year nursing students who were not involved in the study acted as patients and received San-Yin-Jiao pressure. The volunteer students were positioned supine on beds. The study students were directed to demonstrate the San-Yin-Jiao pressure and were coached by the evaluating researchers, if necessary, so they could continue on to the next step of the procedure. Each step completed satisfactorily was recorded with a positive sign (+), and each step that required coaching, was omitted, or performed incorrectly was recorded with a minus sign (-).
After the students finished demonstrating the procedure, they were asked to complete a questionnaire regarding their knowledge, attitudes, and satisfaction with the learning materials. The questionnaires were self-administered by the students and required 10 to 15 minutes to complete.
To compare the researchers' evaluations of students' ability to perform the San- Yin Jiao pressure procedure, the chi square and £ test were used. Data were analyzed using the Statistical Package for the Social Sciences (SPSS), and results were recorded to two decimal places. The significance level was set at p = .01.
Characteristics Related to Maternity Nursing Education
Seventy-five students participated, with 36 students comprising the CD-ROM group and 39 students comprising the printed material group. It was assumed the students were identical in sociodemographic characteristics because they were registered in the same college and the same class. However, because variables such as delivery room experience, exposure to San-Yin-Jiao pressure issues, number of classes attended for labor and delivery, and experience in intrapartum nursing care may have some effect on the dependent variables, the authors analyzed the two groups for statistical differences and found there were no statistically significant differences. Time devoted to selflearning was 48.5 ± 27.8 hours for students in the CD-ROM group and 55.0 ± 30.0 hours for students in the printed material group. The time difference was not statistically significant.
Comparison of the Educational Effects of the CD-ROM and Printed Material
The instrument measuring knowledge of San-Yin-Jiao pressure asked about theoretical background and concrete methods of applying the pressure. The instrument measuring attitudes asked about value, affinity, and willingness to apply pressure. The instrument measuring behaviors determined the students' psychomotor skills and competency as they demonstrated the San-Yin-Jiao pressure procedure. The instrument measuring satisfaction asked about the students' contentment related to characteristics of the learning materials. Knowledge, attitudes, and behaviors related to the type of learning material were higher for the CD-ROM group, although no statistically significant differences were found. However, the satisfaction of CD-ROM group members was higher and was statistically significant (t = -4.326, p = .000) (Table 1).
Analysis of the Effects of Delivery Room Clinical Experience on Students' Self-Learning
According to the literature review, it could be assumed delivery room clinical experience could have some effect on students' ability to learn the San-Yin-Jiao pressure procedure. Because the number of students who had such experience was only 25, the effects were analyzed using the Mann-Whitney method. Analysis showed knowledge, attitudes, behaviors, and satisfaction were related to the type of learning material and were higher for the CD-ROM group. Knowledge (U = 27.50, p = .009) and satisfaction (U = 25.00, p = .004) for the CD-ROM group were statistically significant.
For the group with no delivery room clinical experience, attitudes, behaviors, and satisfaction were higher for the CD-ROM group, although only satisfaction was statistically significant (U = 140.50, p = .002). Knowledge for the printed material group was higher. However, it was not statistically significant (Table 2).
Evaluation of CD-ROM Content
Information regarding aspects of teaching-learning, learning supportiveness, and learning content was solicited from the CD-ROM group only. The mean score was 10.36 ± 2.25 (possible range = O to 16) for the teaching-learning aspect, which included questions such as:
Comparison of the Educational Effects of CD-ROM and Printed Material on Students' Self-Learning of the San-Yin-Jiao Pressure Procedure
Analysis of the Effects of Delivery Room Clinical Experience on Self-Learning of the San-Yin-Jiao Pressure Procedure
* "Is it motivational for learning?"
* "Is it permissive for trial and error?"
* "Does it provide appropriate feedback?"
* "Is it easy to start and finish?"
The mean score was 10.87 ± 2.30 (possible range = 0 to 16) for the learning supportiveness aspect, which included questions such as:
* "Is it user friendly?"
* "Are the graphics clear?"
* "Are the sound and audio audible?
* "Is it operational on computers with average functioning?"
The mean score was 16.28 ± 3.21 (possible range = O to 24) for the learning content aspect, which included questions such as:
* "Is the content correct?"
* "Are the learning goals specified?"
* "Is the content up to date?"
* "Is the content structured to goal attainment?"
* "Are the levels of examples appropriate for average students?"
* "Is the content beneficial or useful?"
All of the students' scores were above the midpoint of the scale, so the authors concluded the students were satisfied with the CD-ROM-based learning.
Discussion and Conclusion
The instructional multimedia CDROM used in this study was developed as a self-paced, self-directed learning medium that would allow students to learn San-Yin-Jiao pressure in their own time, at their own pace. Researchers who developed a CAI program for surgical skills claimed the combination of information presented by the computer and the practice of psychomotor skills could be extended to other surgical and practical skills (Kay et al., 2001). Therefore, the CD-ROM developed and tested for this study was a combination of background knowledge of San-Yin-Jiao pressure and demonstration of the psychomotor skills involved. The results showed educational effectiveness in some areas.
The findings of this study were similar to those of a prospective, pretest-posttest, randomized intervention trial conducted to assess the motivational appeal of CAI and to evaluate its ability to elicit changes in knowledge, self-efficacy, and attitudes of children with asthma (Shegog et al., 2001). Repeated-measures analysis of covariance in that study showed knowledge scores increased significantly for both groups, but no between-group differences were found (Shegog et al., 2001).
In this study, student learning gains after using the CD-ROM were minimal. These findings challenge earlier suggestions by Bauer and Huynh (1998) that CD-ROM alone may be a suitable alternative to traditional teaching methods and that students who learn procedures using CD-ROM alone do not adhere more closely to recommended procedural steps than students who used traditional printed material. However, results of the current study were similar to results of a study by Bauer et al. (2001), which found that students who learned blood pressure measurement by both CD-ROM and traditional methods adhered more closely to the procedural steps than students who learned by only the traditional method.
The authors analyzed the limitations of this research design and the unexpected results as follows:
* Program factors. Students reported the CD-ROM had more motivational appeal than the printed material but was less convenient due to the lack of availability of computers with the required features (e.g., speakers to hear the explanations of the video demonstration). The printed materials were more convenient due to their portability.
* Learner factors. Students may not have taken the evaluation seriously because the results were not scored for credit and because they had several report submissions due the next day. In addition, students are still used to traditional printed materials and may feel more safe and confident with those types of media. Students' lack of adherence in demonstrating each procedural step can be attributed, to some extent, to the scenario created for the observational part of the study, although it was developed with clinical experts' verifications. Students were ushered into the room and asked to demonstrate on the standardized patients what they remembered of the procedure. It is possible this "artificiar context shifted students' focus from the procedure itself to other confusing environmental factors.
* Experimental design factors. Both groups were observed 1 week after distribution of the learning materials, and it is possible the learning time was not the same for both groups.
* Content factors. Apparently, face-to-face demonstration is mandatory for acquisition of certain clinical skills, so CD-ROM alone is not more effective for learning psychomotor skills. It also would be more appropriate and effective if the content were included in the context of the entire maternity nursing curriculum. Students who had previous delivery room experience obviously showed more competency in demonstrating San-Yin-Jiao pressure.
Results of this study suggest that although CD-ROMs are not substitutes for real-life, hands-on experience, they can enhance learning when used as an adjunct to traditional teaching methods Bauer & Huynh, 1998). It makes sense to use computer technology to enhance learning and complement printed materials. In time, software may become as good as traditional teaching methods and can be an alternative tool.
Although the CD-ROM developed for this study may have the potential advantage of conveying some procedural steps more effectively in a more accurate and unbiased way, results indicate it was not an effective teaching method when used in isolation and in lieu of traditional materials. However, as an adjunct to printed materials, the CD-ROM seems to have tangible benefits for students learning the San-Yin-Jiao pressure procedure in terms of conveying the theory and reinforcing the steps of the procedure.
Further research is needed to determine the long-term benefits of learning with CD-ROMs and using CD-ROM technology both inside and outside the classroom to optimize learning.
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Comparison of the Educational Effects of CD-ROM and Printed Material on Students' Self-Learning of the San-Yin-Jiao Pressure Procedure
Analysis of the Effects of Delivery Room Clinical Experience on Self-Learning of the San-Yin-Jiao Pressure Procedure