There is an increasing need for nurses to possess critical thinking and problem-solving skills (Biley & Smith, 1998) because these are key components of nursing practice (Andrews & Jones, 1996; Perciful & Nester, 1996). Townsend (1990) indicated problem-solving skills can be promoted by problem-based learning (PBL), which aims to develop analytical and critical thinking abilities and to facilitate the synthesis of knowledge and skills. Therefore, PBL would be an excellent educational method for use with nursing students, but unfortunately, delivering PBL is expensive. However, technological advances, particularly in computing and telecommunications, may make the use of PBL more pervasive (Finucane, Johnson, & Pride aux, 1998).
Recent studies have revealed that the proper deployment and implementation of Internet or intranet technology in nursing education can reinforce learning by supporting structured discussions with students and teachers (Cariile, Barnet, Sefton, & Uther, 1998; Kim, Kim, Cho, & Kim, 1997; Park, Cho, & Kim, 1998; Yom, 2000). In addition, research has suggested audio teleconferencing and Web-based programs are effective means of delivering PBL in distance education (Giani & Martene, 1998) and computer-mediated conferencing is worth investigating as a possible adjunct to PBL strategies (Edwards, Hugo, Cragg, & Peterson, 1999). This article describes the application of a nursing educational program developed on the basis of PBL and Internet technology and reports student satisfaction and perceived learning effectiveness.
This study was conducted in two phases - the development of a Webbased educational program and application of this program using PBL strategies to teach undergraduate nursing students. The program was delivered to users through a Microsoft® Structured Query Language Server™ and Internet information server, using Windows NT 4.0 as the operating system. The basic format of this program was an HTML document, in which each page displayed a didactic toolbar on the left-hand side containing a set of icons linked to Orientation, Learning Module, Bulletin Boards, Learning Resources, an E-mail System, and a Survey (Figure 1).
The Learning Module consisted of three scenarios, each including data collection, problem identification, and problem resolution. Each scenario involved the same patient who had pain in the lower abdomen and bloody stools but who had a different status according to the disease course. The Patient's Data were developed on the basis of real data and were presented using both multimedia and extensive use of text. Students could explore the patient's data and save cues in their database. These cues could be retrieved later for identifying and solving problems. Students were required to make reasonable inferences of nursing problems and diagnoses in the Problem Identification process. The last part of the module was planning strategies for solving the patient's problems (Problem Resolution) (Figure 1).
Dining these processes, students discovered learning issues by themselves for later self-study. After studying these learning issues, students saved their results in Learning Resources, which were available for others to reference in Problem Identification and Problem Resolution. Discussions were possible through the Bulletin Boards. Identifying and self-studying learning issues and making use of discussions are essential characteristics of PBL. Each student browsed the Web pages and initiated these learning activities by clicking on the appropriate icon.
This educational program was delivered for 4 weeks to all sophomore students enrolled in a course on fundamental nursing at the two universities. The tutors, who were nursing faculty, provided information about Internet access, program operation, learning objectives, PBL process, the purpose of the online survey, and tutor contact details to students from the two universities separately. Two major learning objectives for students were acquisition of skills inherent in PBL and fact-based knowledge related to the patient's problems.
The tutor role is critical to students' learning outcomes and satisfaction with PBL (Andrews & Jones, 1996; Biley & Smith, 1998; White, Amos, & Kouzekanani, 1999). Therefore, tutors should have indepth knowledge of the course contents and be able to trace and explain the reasoning processes being undertaken. The tutors in this study prepared themselves by reviewing the concepts, theoretical basis, and processes of PBL, and the expected roles of tutors and students in the PBL process. In addition, the tutors practiced using this program thoroughly before the students became involved.
The tutors' effect on student satisfaction and their perceived effectiveness was tested by having the tutors assume two roles - facilitator and observer. The differences between these roles were explained to the tutors before the beginning of the program. Facilitators suggested discussion topics and provided immediate feedback to students both collectively and individually. However, observers did not suggest discussion topics nor provide feedback to students individually. Observers' involvement essentially was aimed at ignoring irrelevant learning objectives to keep the learning activities within the boundaries denned by the learning objectives. More frequent interaction with students occurred when tutors assumed the facilitator role than the observer role. The tutor at one university acted as a facilitator, and the tutor at the second university acted as an observer. At the end of the learning process, each tutor met students in a classroom and discussed the problems and their solutions.
Students responded to the online survey at the end of the program (Figure 2). The survey, which was « developed by the author, included the two dimensions of student satisfaction and learning effectiveness. Student satisfaction was measured in terms of Internet use and the discussion and feedback that are essential characteristics of PBL. The questions on learning effectiveness reflected the strengths of PBL and were based on research on evaluation of PBL curricula (Cawley, 1991). Learning effectiveness was measured using items such as clarity of learning objectives, *1 substantiality of the scenario and data, knowledge organization, motivation to learn, stimulation of interest, logical thinking, and fact-based knowledge accumulation. The resulting survey consisted of 10 items that were assessed using a 4-point scale, ranging from 1 = not at all to 4 = very much, and included open-ended questions to elicit students' attitudes toward the program.
Results were obtained from the 109 students who responded to the online survey, representing 88.6% of all participants. The remaining 11.4% of the participants did not complete this Web-based program. All respondents were ages 20 to 26, only 1 was a man, and all were inexperienced in PBL and clinical practice.
The mean scores (and standard deviations) of the items used to measure student satisfaction with this program were as follows:
* Satisfaction with Internet use: 2.03 (.96).
* Satisfaction with discussion: 2.58 (.84).
* Satisfaction with tutor feedback: 2.71 (.89).
These results indicate students were reasonably satisfied with the PBL program.
Regarding the learning effectiveness of the program, the results were as follows:
* Clarity of learning objectives: 3.38 (.80).
* Substantiality of scenario and data: 3.15 (.73).
* Motivation to learn: 3.01 (.85).
* Stimulation of interest: 2.80 (.83).
* Knowledge organization: 2.96 (.78).
* Logical thinking: 3.24 (.71).
* Fact-based knowledge accumulation: 3.21 (.68).
These results indicate students found the program helpful.
Students were asked what they liked most and least about the program and to provide a rationale for their responses. Responses to this open-ended question were assessed by content analysis. The major advantages of the program were:
* It was independent of time and space because it was Web based (18.2%).
* The learning contents may be memorized for a long time due to the self-directed learning (13.6%).
* Knowledge seemed to be easily applied in practice due to the use of patient simulations (12.8%).
* The program helped students think critically (9.1%).
These results correspond to recognized strengths of PBL - that it increases the ability to apply knowledge and think critically.
Figure 2. Students' satisfaction and learning effectiveness survey.
Students described the disadvantages of this program as follows:
* Time consuming (16.2%).
* Difficulties with computer accessibility (10.7%).
* Unfamuiarity with Web-based programs (10.2%).
* Network or program operation errors (7.1%).
These results indicate a major challenge of Web-based PBL is to reduce the technological barriers, which will decrease learning time and, thus, students' frustration. Other limitations included inadequacy of discussion (7.1%) and feedback (4.6%).
To assess the effect of the tutors on student satisfaction and learning effectiveness, the t test was used (Table). Students who were guided frequently by the tutor reported significantly higher scores for satisfaction with discussion, satisfaction with feedback, clarity of learning objectives, substantiality of scenario and data, knowledge organization, motivation to learn, and stimulation of interest than students who received less guidance from the tutor.
The program used in this study was based on PBL and a computer network system, so the discussion focuses on advantages and disadvantages of these aspects of the program. Nursing is a practice-based profession, and in real practice settings, nurses must gather and organize information to identify problems. Nursing education must include strategies to enhance students' problem identification abilities. Such strategies were emphasized in this program, as well as data gathering. Therefore, this program can provide nursing students with realworld situations before they begin their clinical experiences and a safe environment in which to develop their professional skills.
Independent fTest Comparing Tutor's Role With Student Satisfaction and Learning Effectiveness
Another benefit of this program is the possibility of updating and adding scenarios and data. The nursing profession is rich in unpredictable, complex, and ever-changing problems, so unique problem-solving decisions seldom exist. Therefore, it is beneficial for nursing students to face many varied situations to become familiar with different types of decisions and consequences (Schon, 1987). This program is well suited to efficiently meeting the needs of variety and flexibility in a learning system. In addition, because it is Web based, it is easy for many users to access the program simultaneously, thereby reducing the cost related to face-to-face PBL.
This educational program does have some disadvantages. Because group dynamics and interaction are important formal processes in PBL, learning issues usually are explored through group work in face-to-face interactions (Biley & Smith, 1999). However, in this program, students were encouraged to identify learning issues by themselves, rather than through collective brainstorming. Discussion with group members occurred only via the bulletin boards, which was difficult to use effectively because written and asynchronous communication could be ignored or easily misunderstood due to its contextual nature (Hillesheim, 1998). This explains why students in this study responded with low scores regarding their satisfaction with the discussions. Use of audio and video teleconferencing for synchronous communication would make group interactions more effective in Web-based PBL.
Another barrier to this online program was computer and Internet technology itself, which was described by students as a major disadvantage. This is especially true for students who are not experienced at using the appropriate technology and whose access to the necessary equipment often causes frustration and anger because of the amount of time consumed and the failures that occur (Boston, 1992). For students who are new to PBL and online programs, this Web-based PBL program may present a formidable challenge. A student orientation process is needed to overcome these technological barriers (Ndiwane, 2001).
The relationship between students and tutors has been identified as a key factor in the success of asynchronous, online educational programs (Hillesheim, 1998). This research showed that students who were provided with frequent feedback by the tutor had higher mean scores for 7 of 10 items related to satisfaction and learning effectiveness. Students receiving less feedback from the tutor had more anxiety due to the unfamiliar computer program and experienced feelings of uncertainty due to lack of confidence in achieving an acceptable knowledge level. Effective feedback could improve accessibility to the tutor and allow students to achieve a higher comfort level with this new learning method. This indicates tutor accessibility and the amount of interaction between tutor and students play an important role in the effectiveness of Web-based PBL.
A new educational program was tested on a small group of students, and results showed this Web-based program is an effective method of delivering PBL to nursing students, although the program was unfamiliar to students and presented technological barriers. These data show the interaction between tutor and students influences student satisfaction and learning effectiveness. However, a systematic evaluation of the program based on system performance, content, and effectiveness as a learning tool is required.
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Independent fTest Comparing Tutor's Role With Student Satisfaction and Learning Effectiveness