Distance Nursing Education in Alaska: A Longitudinal Study

RESEARCH. ABSTRACT. This study explored the benefits, problems, and effectiveness of educational delivery methods utilized in an associate degree nursing program at the University of Alaska Anchorage (UAA) over three years. The sample consisted of two groups of students in their final semester (traditional, on-campus students, n = 71; students from sites where course content was delivered through distance-delivery methods, n = 94). Student achievement data were compared to examine effectiveness. A researcher-developed survey was used to obtain demographic data and participant perceptions about various items rated on a Likert scale; the questionnaire also asked for narrative statements. The survey instrument was shown to demonstrate adequate reliability (Cronbach's alpha ≥ .68). No statistically significant differences were found between on-campus and distance-delivery participants' mean responses related to effectiveness. However, the distance participants evidenced statistically significant higher ratings for benefits and lower ratings for problems (p < .05), indicating that they perceived more benefits as well as more problems associated with delivery methods than did the on-campus group. Qualitative data corroborated and provided details to explain and clarify the quantitative findings. No significant differences were found between the distance and on-campus participants' scores for any of the eight student achievement assessments examined. Lived experiences led to significantly different perceptions of the benefits and problems associated with educational delivery methods. Key Words Nursing Education - Distance Education - Educational Effectiveness - Educational Delivery Methods - Benefits and Problems in Educational Delivery.

Publication: Nursing Education Perspectives
Author: Coose, Carol Sue
Date published: March 1, 2010

ASYNCHRONOUS LEARNING, made possible through the use of various technologies, enables entire classes or groups of students to engage in the educational process independent of the constraints of time and place. Hiltz and Turoff (2005) noted that at least two million higher education students in the United States were involved in distance education as of 2004. They called online learning "a new social process that is beginning to act as a complete substitute for both distance learning and the traditional face-to-face class" (p. 60). * Nursing education programs throughout the world are embracing distance education as a means to upgrade the educational credentials of large groups of nurses "in a timely manner without disrupting their employment" (Lewis & Farrell, zooy, p. 362). But, according to Shovein, Huston, Fox, and Damazo (2005), learning, and then managing the technology of distance delivery, redesigning courses into online or distance formats, and interacting with students via technology require faculty to have considerable time management and technological skills. With technology affecting the role and workload of nurse educators, faculty must determine how best to connect with students and support student learning. "The formidable task remains what it has always been for nurse educators: to design and adapt to learning paradigms that awaken the awareness of another to a nursing consciousness" (Shovein et al., 2005 y, p. 343).

Academic institutions, including nursing programs, are establishing new forms of electronic collaboration that can facilitate and improve student access to courses and student learning while also addressing the quality and cost of the educational program (Mills, Fisher, & Stair, 200 1 ). However, despite the increasing use of the Internet to deliver courses and enhance learning, there has been concern that little is really known about outcomes (Billings, 2000). Questions remain about which teaching and learning practices contribute to positive outcomes in technology-enhanced delivery of nursing education, and which support systems need to be in place for students and faculty?

In 2004, the National League for Nursing (NLN) published a position statement entitled A Call to Reform for Nursing Education, which challenged schools of nursing of all types to examine long-held traditions about the education of nurses.The NLN called on nurse educators to "design evidence-based curricula that are flexible, responsive to students' needs, collaborative, and integrate current technology" (2004, p. 47). Diekelmann and Ironside (2002) called for the development of a science of nursing education that documents the effectiveness and value of nursing education practices and also supports change or reform in nursing education.

As the number of distance-delivered courses in nursing multiplies, it becomes increasingly important to integrate best practices into course design and program implementation (Billings, 2003). This systematic study, analysis, and documentation of data regarding the educational effectiveness of a nursing program delivered through the use of distance technology will contribute to the body of evidence to support the science and delivery of nursing education.

Purpose and Methodology This study explored the benefits, problems associated with, and the effectiveness of educational delivery methods used in an associate degree nursing program in Alaska. This nursing program was offered on campus at the University of Alaska Anchorage (UAA) in a traditional classroom format, including lab and clinical, as well as via distance delivery through the use of online and other communication technology to deliver didactic content and testing.The established nursing program was delivered from the main campus to several smaller, rural communities with existing branch campus sites within the university system. A blended model of distance delivery was used that included: a) partnerships with local branch campuses for space (e.g., skills lab, office, computer lab, videoconference room), as well as student and technology support services; b) lab/ clinical nursing faculty who lived locally; and c) intensive clinical experiences requiring travel away from the home community to a larger clinical setting for specialty area experiences (e.g., obstetric, pediatric, psychiatric, and critical care), especially during the last two semesters of the program.

A survey method was used for exploring nursing students' perceptions. Educational effectiveness was examined through the use of survey data as well as student achievement data. Achievement data analysis included the comparison of mean scores on eight different datasets obtained from existing UAA School of Nursing records: cumulative grade point averages (GPA) at graduation plus mean scores on six standardized exams: Nurse Entrance Test, Nursing Fundamentals I, Nursing of Adults I, Maternity and Child Nursing, Therapeutic Communication, and the RN-Computer Adaptive Test (RN-CAT). The final achievement indicator used in the analysis was pass or non-pass for the participants' first attempt on the National Council Licensure Exam (NCLEX-RN) to become a registered nurse.

A four-page survey instrument was developed by the researcher to obtain demographic data and student perceptions. Participants used a Likert-type scale to rate their level of agreement with 17 statements. Scores ranged from I (strongly disagree) to 4 (strongly agree); as all items were positively phrased, items with higher scores indicated positive responses, and lower scores indicated negative responses.

The content and details of the statements came initially from the researcher's personal experiences and observations, as well as a review of literature regarding distance delivery of education. A panel of nurse educators currently participating in distance delivery educational methods reviewed the statements, which were then further refined. Content validity was established.

The Likert scale items were grouped into the three areas explored in the study. The first seven items were statements related to benefits of the educational delivery methods; the next five were related to the problems encountered; and the last five items focused on effectiveness. The final items on the survey were two narrative prompts; the first asked for a statement describing at least two benefits of the educational delivery method, and the second, for a description of any problems encountered.

Results of the Study DEMOGRAPHICS The instrument was piloted with final semester nursing students in 2004; these students included the second group of students to be involved in distance delivery of the nursing program. The pilot data were incorporated into this study. Results of the pilot, as well as repeated analysis using longitudinal data (2004, 2005, and 2006), established adequate reliability of the survey instrument (Cronbach's alpha ≥ .68) for each of the total variables created from sets of survey items.

A total of 165 nursing students in the final semester of their associate degree education completed the survey instrument; 94 were distance and 71 were on-campus students.The total possible sample was 184 students; the response rate was 90 percent. Survey data came from three different graduating classes over a three-year period; achievement data were obtained from more than four years of existing records of student scores from the three separate classes.

Most participants were female (91.5 percent) and Caucasian (85.5 percent, n = 141). Other ethnic groups represented were Alaska Native (n = 10), Hispanic (n = 6), and African American (n = 3); two students were Asian/Pacific Islander, and two were Native American/Indian; one was described as "other."

Participant ages were varied, with 44 percent between the ages of 26 and 35. The majority indicated they were married (66 percent, ? = 108). Sixty-nine percent (n = 113) reported being parents, and 65 percent (n = 107) reported having children at home during their nursing education. Fifty-eight percent of the participants (n = 95) reported being gainfully employed during their nursing education; 19 percent (n = 31) reported working 30 or more hours per week, with I I students working 40 or more hours per week while in nursing school.

Forty-three percent of the participants (n = 71) lived in the Anchorage area. The others lived near the seven different distance nursing program sites; the number of students at the distance sites ranged from five to 32 per site.

QUANTITATIVE AND QUALITATIVE RESULTS Quantitative analysis of response ratings indicated that participant perceptions of the benefits associated with their educational delivery methods were significantly different between the two groups (distance and on-campus); this finding was not noted in the analysis of the pilot data. The overall mean scores for both participant groups on the benefits scale were positive (Item M ≥ 2.87 on a scale of I -4); however, the mean for the distance group (M = 20.70) was significantly higher than that of the on-campus group (M = 1 9.34). See comparisons for all three variable scales in the Table.

Results indicated that the distance group viewed the benefits of their educational delivery methods significantly more positively than did the on-campus group.This finding was corroborated through an analysis of the narrative responses; the distance group reported 153 statements regarding benefits (1.63 per student) as compared to only 89 benefit responses from on-campus participants (1.3 per student).

Differences were also noted between the two groups in the major themes identified from the narratives (defined as ≥ 32 percent reported as benefit in the narratives). Distance participants perceived the major benefit as location (63 percent), described most frequently as "the ability to stay in one's home community while getting an education." The next most prevalent benefits related to technology and/or increased competence with the use of technology (32 percent). While the themes reported by on-campus participants were similar, the rankings for the two major benefits were reversed. Technology-related benefits were listed by 41 percent of the on-campus participants, while 35 percent listed locationrelated benefits (e.g., face-to-face class, lectures, and direct contact with faculty).

Minor themes evidenced more pronounced differences. For example, "independence" or "becoming an independent learner" was mentioned by 19 percent of the distance group, in contrast to 4 percent of the on-campus group. Similarly, "time flexibility" benefits (such as flexible schedules and being able to work) were listed by 15 percent of the distance group in contrast to 6 percent of the on-campus group. Responses to other common benefit themes were close. Benefits related to clinical were listed by 19.5 percent of the on-campus group and 14 percent of the distance group, while benefits related to faculty/courses were almost identical (on-campus, 19.5 percent; distance, 19 percent).

As might be expected given the difference in educational delivery methods, perception of the problems associated with their respective delivery methods were vastly different between the oncampus and the distance participants. (See Table.) Distance participants reported nearly twice as frequently regarding problems as oncampus participants (distance, 131 problems, 1.4 per respondent; on-campus, 61 problems, 0.86 per respondent). Narrative responses corroborated the quantitative results.

Major problem themes (defined as > 28 percent reporting) listed by the distance participants were: faculty/course deficits (54 percent) and technology (5 1 percent). Interestingly, while the oncampus participants reported less frequently on problems, they concurred with distance participants on the two major problem themes: faculty/course (37 percent) and technology (28 percent). The major differences between groups in perception of problems were found in the themes identified as location (on-campus, I percent; distance, 20 percent) and time inflexibility (on-campus, 16 percent; distance, 5 percent). For the distance students, location problems concerned lack of face-to-face contact with faculty and the need to travel for intensive clinical experiences (e.g., expenses and housing). The on-campus students listed time problems, primarily as they related to inflexibility of schedules. Perceptions about the effectiveness of delivery methods were positive for both groups (on-campus, M = 2.89; distance, M = 2.90; scale 1-4). No statistically significant differences in the mean scores were found between the two groups.

As for achievement as a measure of effectiveness, no significant differences were found between the groups on any of the eight categories that were examined. This finding supports what has been reported regarding multiple studies of distance-delivered educational effectiveness (Russell, 2004-2007).

Conclusions and Discussion Because of the limited sample size (N = 165) and the skewed sample population, one should be cautious about drawing conclusions from this study. Generalizations should not be made beyond this population. It would also seem that, based on the patriarchal society found in most of America, there should be some differences in perceptions based on gender; the large majority of the respondents in this study were female.

It is highly recommended that studies be done with larger samples, with the goal of including more students over time to see if results vary as a program progresses. Improvements in the distance delivery technologies used over time, as well as increased experience, understanding, and improved performance by the nursing faculty, could affect results. Additional research with a broader population, from other levels of nursing education, could provide significantly different demographics and would be beneficial.

This study provided evidence that the nursing education needs of nontraditional nursing students who lived in specific small, rural communities in Alaska can be met effectively through blended, distance delivery methods. However, the results of this study, especially as they relate to the problems reported by students, clearly demonstrate that nurse educators, as well as students, need support and development as they use new and innovative instructional strategies, most specifically, distance-delivery teaching/learning technologies. With this in mind, based on this study, the researcher offers the following recommendations:

1. Promote faculty development and support in the use of distancedelivery modalities for nursing education. Faculty support needs to be at a minimal level of meeting the Institute for Higher Education Policy (IHEP) Benchmarks for Success in Distance Education (2000), category 6, regarding "Faculty Support" in teaching distance-delivered courses.

2. Collaborate with technology support staff and/or administration to promote improvement of the technologies used and enhanced support in the use of technology for both students and faculty. Technology support for distance education also needs to strive to meet the Benchmarks of Success (IHEP, 2000) listed in category I, "Institutional Support," and category 5, "Student Support." These benchmarks emphasize the need for Institutional support in the form of extended hours and times for technology support staff and help desks for faculty and student needs.They also indicate that it is essential to have competent and adequately trained staff to keep the infrastructure functioning effectively.

3. Increase emphasis and efforts by nurse educators to promote and enhance effective communication between distance students and faculty on the main campus. Effective communication between course faculty and distance students is essential according to the Benchmarks for Success (IHEP, 2000) under category 3, "Teaching/Learning."

The results of this study raise several questions that were not within the scope of the study. Analysis of the qualitative data presented challenging differences between the perceptions of the oncampus and the distance participants in several instances.These differences, along with other study results, lead to several questions that may be addressed through further study:

* Were there any demographic variables, such as age, gender, marital status, or hours worked while in school, that had a significant effect on participants' perceptions of educational delivery methods?

* Are the current on-campus delivery methods not promoting the development of nursing students into more independent learners, or do students fail to perceive that they are developing independence as learners?

* What are the barriers keeping ethnic minorities, and in particular Alaska natives, from entering or being successful in the nursing program? What would be helpful or effective in terms of needed support to increase the numbers of ethnic minorities in the nursing program?

* Do graduate perceptions of the effectiveness of their nursing education delivery methods change significantly once they are licensed as RNs and have functioned in the health care setting?

* Is there a significant difference in the job performance of nursing graduates based on their methods of educational delivery? In other words, do the distance graduates perform on the job as nurses to the same level as the on-campus graduates?


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Author affiliation:

About the Author Carol Sue Coose, EdD, RN, CNE, was professor and chair of the Associate Degree Nursing Program, School of Nursing, University of Alaska Anchorage from 2002 to 2009. Currently, she is professor at the School of Nursing, Northwest Nazarene University, Nampa, Idaho. For more information, write to her at cscoose@nnu.edu.

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