Publication: Nursing Education Perspectives
Date published:
Language: English
PMID: 43404
ISSN: 15365026
Journal code: NHCP

With graduate nursing education delivered largely via online technologies, predominantly in the asynchronous format to accommodate the many needs of adult learners, one must ask whether online education adequately prepares graduates for the roles and skills needed to transform practice in an everevolving health care system (Kalisch & Begeny, 2010; Tucker, 2004). Communication tools within course management systems widely used for online course delivery enable students to develop skills in asynchronous, text-based communication but may not provide opportunities for graduate students to develop the effective oral communication skills (Cornelius & Glasgow, 2007; Smith, Passmore, & Faught, 2009) expected in professional practice, including the ability to articulate ideas clearly and succinctly and defend positions through extemporaneous question-andanswer exchanges with an audience.

For online nursing programs to evolve beyond the mere teaching of the content, attention must be given to fostering an educational approach that uses real-world contexts to facilitate proficiency in oral and written communication and equips students with the skills needed for practice. This article examines the effectiveness of synchronous role play as a teaching strategy to enhance oral presentation proficiency in online learning environments. The selection of appropriate technology to enable synchronous role-play activities and the development of strategies for supporting student learning in technology-rich, collaborative learning environments are discussed.

Background Most graduate students at this large public university are geographically dispersed, work full-time or part-time, represent different generations, practice with varying levels of professional experiences, and juggle multiple family and educational responsibilities. To accommodate their needs, all graduate online courses are offered asynchronously without required visits to campus.

An Applied Technology in Health Care course was developed to provide doctor of nursing practice (DNP) students with the knowledge and skills needed to inform decision- making about patient care and health care systems and provide leadership within health care systems and/or academic settings. The course aligns with competencies outlined by the American Association of Colleges of Nursing (2006), the National League for Nursing (2008), and the National Organization of Nurse Practitioner Faculties (2006) to provide a framework for graduate nurse education built on computer literacy, information literacy, informatics, and communication competencies.

Nurse practitioner master's degree and certificate students, as well as PhD students, enroll in this course, along with all DNP students, creating a diverse learning community of students of different ages, backgrounds, professional experiences, and levels of comfort and expertise with technology and online education. The challenge for the course designers was to provide flexible learning that would meet the needs of all types of learners and ensure that diversity resulted in a richer learning experience.

Instructional Design Approach The focal unit in today's health care system is the interdisciplinary team. Without practice in developing effective collaboration and communication skills, including the ability to speak extemporaneously and defend positions and answer questions on the spot, graduate-prepared nurses may not be adequately prepared to be successful team players and deliver professional presentations and proposals to management or to stakeholders. To enhance collaborative skills and oral presentation proficiency, the course instructor worked with an instructional designer to simulate a real-world context of presenting and defending a proposal in front of a management team. This learning activity supported the following course objectives:

* Apply computer and information literacy skills to the health care setting.

* Evaluate the ways in which health care data, information, and knowledge influence the design of information and decision support systems.

* Use appropriate ethical, regulatory, and legal standards when using, selecting, and evaluating information systems.

The final project for the course was designed using the authentic learning approach, which focuses on "real-world problems and their solutions, using roleplay exercises, problem-based activities, case studies and participation in communities of practice" (Lombardi, 2007, p. 7). Authentic learning projects use multiple sources and perspectives, requiring students work in teams and reflect on their collective and individual learning experiences. Such projects allow for multiple interpretations and outcomes and usually result in producing polished products (Lombardi). Online technologies form an excellent technological platform for authentic learning by creating spaces for collaboration and providing access to information sources, databases, archives, and professional networks, essentially allowing learners to practice professional behaviors in a safe environment.

The final project for the Applied Technology in Health Care course was a collaborative assignment to be completed in three stages. First, students were asked to develop a proposal for a clinical or administrative software application. The following situation was posed to the student teams: "You have been asked by your current (real or imagined) organization to identify, implement, and evaluate an information technology solution to solve an identified problem. Prepare a proposal to be submitted to your employer."

The second stage required students to produce a multimedia presentation of the proposal for review by the agency's management team. The final stage was a synchronous meeting with the management team (the entire class and instructor) for followup questions and answers. Successful completion of the entire project required mastery of the course material and demonstration of skills in the areas of teamwork, collaborative writing, multimedia creation, oral presentation, and entertaining questions on the spot.

To facilitate the learning process, the course instructional team created a structured and supportive learning environment, comprising asynchronous and synchronous elements, using the Blackboard (Bb)® course management system and Adobe® Connect(TM) virtual meetings. Adobe Connect provides a synchronous meeting environment in which participants can see and hear one another through the use of webcams and microphones. The Blackboard site was built to allow quick information retrieval and easy navigation through a menu of self-explanatory links. A guide to successful online learning, posted alongside the syllabus, explained the organization of the course and stated expectations for attendance, weekly study hours, and use of course-related technology. It also suggested strategies for getting started, organizing the study routine, communicating with the instructor and classmates, and collaborating with team members on course assignments. Students were provided with detailed descriptions and grading rubrics for each assignment.

Course content was presented in weekly guides. These contained learning tasks for the week, textbook and online readings, links to resources, individual and collaborative learning activities with due dates and guidelines for submission, and instructor comments. The course site also contained detailed instructions for the use of required technologies as well as contact information for technical support. Special sections were created to house instructor and student information and to communicate on the class discussion board and in the virtual meeting room.

Facilitating Online Community and Collaboration For successful integration of information systems into health care, decisions about technology need to be made and carried out collaboratively to represent the interests of multiple stakeholders. To underscore this imperative, the majority of the course assignments were collaborative. Collaborative learning activities can significantly enrich students' learning experience in online environments and positively affect learning outcomes and satisfaction rates (Conrad & Donaldson, 2004; Palloff & Pratt, 2005).

The course designers followed the model of online collaboration described by Palloff and Pratt (2005), which underscores the critical importance of establishing a sense of community and developing social presence through communication and interaction, sharing of experiences and ideas, receiving and providing constructive feedback, and reflecting on the learning process. The course structure helped develop a sense of community by offering a networking environment and guidelines for communication and collaboration. At the beginning of the semester, students were placed in four information system (IS) consulting teams of five students each. During the first week of class, they viewed a short video recorded by the instructor on course objectives and requirements, the website layout, and tips for success. At this time, students were prompted to introduce themselves to their team and other classmates in a personal way and to respond to other students' introductions.

Essential components for successful teamwork include a shared team objective, appropriate equipment, knowledge of what to do, and the ability and desire to it (Brown, Huettner, & James-Tanny, 2007). To begin creating these conditions, students were directed to a series of team-building activities. Each IS team prepared a contract to articulate expectations about contributions and responsibilities. Contracts included the purpose and goal of the team, communication and collaboration norms, technology-related issues, conflict management strategies, and quality of deliverables. Contracts provided the basis for peer evaluations. While grades for projects were group grades, individual grades were adjusted according to the results of peer evaluations. To ensure more equitable distribution of leadership opportunities and workload among team members, each student signed up for a three-week leadership term.

By the end of the first week, each IS team determined an appropriate consulting name and built a team wiki, representing the team as a whole and providing a profile of individual members. (Wikis are collaborative websites that can be edited by any member of the group.) Team contracts were posted to the team wikis for review by the instructor and classmates. The wiki-building activity allowed teams to express their newly forged identity, highlight their members' backgrounds and talents, and negotiate roles and responsibilities. Throughout the semester, team wikis served as a collaboration platform and a tool for presenting completed projects to the instructor and classmates. The evolution of the wikis reflected the acquisition of new knowledge and skills and culminated with a complete consulting portfolio for each student team.

Each team had access to a secure work area equipped with a private discussion board, a file exchange, and an email function. Students were advised to conduct most project-related communication on the team discussion board as a means of documenting the planning process and each member's contributions to projects. Students were free to use personal communication tools depending on their preferences and needs. Initial team-building activities gave students opportunities to connect with each other and to test most of the technologies that they would later use for course projects.

Instructor Roles and Responsibilities Besides providing content and setting requirements for projects and activities, the online instructor performs many other functions, such as role model, mentor, conflict mediator, and cheerleader. Before the beginning of the course, the instructor posted her contact information and a short biography written in an engaging conversational style. A photograph of her in the office and a short video recording further enhanced her presence. The instructor actively participated in the introduction activities on the class and team discussion boards and provided feedback on team contracts and wikis.

From the beginning, the instructor modeled attitudes and behaviors expected of students as members of the learning community: active engagement in activities, timely participation in discussions, sharing ideas and experiences, enthusiasm about learning from other members of the community, and feedback on ideas and performance. The instructor logged in to the course at least once daily, and, at the conclusion of each week, she posted a short video with evaluative and encouraging comments. By closely monitoring activities and providing detailed comments on projects, the instructor was able to keep students motivated and prevent conflicts within teams from escalating. Carefully developed assignment rubrics, which specified each grading criterion and the level of achievement needed for a grade of A, B or C, streamlined the grading process and allowed the instructor to provide feedback to students within two or three days. Since course projects were built on each other, timely feedback from the instructor was necessary to guide students in improving the quality of the next product.

The Final Role Play Project The role play approach was carried out consistently through the semester as students explored the course content and discussed the transformative impact of technology on patient care and organizational structures. Students were encouraged to think of themselves as IS consultants; each project required them to perform functions expected of advanced practice nurses in health care agencies. The IS teams evaluated health care websites and software applications and constructed databases to inform clinical decision-making.

The final project required writing a proposal for a software application, presenting it to the management team (other students in the class and the instructor), and entertaining follow-up questions. Meeting with the management team was conducted with webcams in a virtual meeting room. To facilitate work on the final project, the course instructor, using the technology required for the project presentation, met with representatives from each IS team. This session imitated a consultation with an expert and offered opportunities to clarify requirements and expectations for the presentation, brainstorm new ideas, and discuss the team processes and possible team realignment if needed. Each IS team was asked to prepare an agenda for this meeting and compile a list of questions for the instructor. Use of webcams and microphones enabled the virtual meeting participants to see and hear each other and achieve resolution on all agenda items efficiently and effectively.

The four teams then prepared written proposals and recorded multimedia presentations with narrated PowerPoint slides using Adobe Connect. Their goal was to convince the management team to implement their proposal. Proposals and presentations reflected the interests of each team, for example, drug reference software programs, electronic medical records systems, and open-source and proprietary educational applications.

The management team carefully reviewed the proposals and presentations and then met virtually for follow-up questions and answers with the instructor acting as meeting chair. A detailed protocol for this meeting was developed and posted in advance on the course site. Each team fielded questions posted by the management team. This role-play activity simulated the real-world context of behaviors expected of both management and APNs when making decisions on deploying new technologies in health care. Students were graded on the quality of the proposal: scope of informatics problem, significance of the problem, environmental risk analysis, system analysis, application of an appropriate mode for identifying system requirements, feasibility of the solution, hardware/software selection, implementation plan, education plan, evaluation plan, potential issues, organization, use of appendices, tables, futures, and grammar. Evaluation of oral communication skills included presentation content and delivery, use of communication aids, and response to the synchronous questioning.

Formative and Summative Evaluation Online courses provide multiple venues for instructors to solicit feedback on the course from students. Discussion boards, online surveys, and email can be used to collect evaluative comments. At the midpoint in the semester, 19 of the 21 students completed a short online survey to evaluate the course and suggest improvements. When asked about the amount of learning in this online course as compared to the traditional classroom environment, students responded: less than in the classroom (10 percent); about the same (37 percent); and more than in the classroom (53 percent). Ninety-five percent indicated that feedback from faculty was prompt and detailed; 89 percent felt that the teaching methods facilitated student learning; all agreed that the course was academically challenging; and 95 percent indicated that projects enabled them to apply course concepts to professional practice. Comments included: "The readings are appropriate and I enjoy them" and "Except for the amount of work, I am really enjoying this course." Based on the student feedback, modifications were made to eliminate several minor activities in the remaining part of the semester.

Another online survey evaluated the effectiveness of the final project; 18 students replied. When asked the extent to which the final project/exam provided an opportunity to apply concepts learned throughout the course, all indicated that it enhanced the opportunity to apply course concepts; 94 percent also responded that the final project/exam provided an opportunity to develop oral presentation skills. Students offered the following comments: "The process simulated the intensity of being grilled and having to defend your conclusions in a proposal"; "It was the longest 20 minutes I have experienced recently, but I think the experience is a useful one"; and "It resembled a lot of professional experiences required professionally of nurses, such as facing a research or mock review committee to defend research articles or proposals and candidate/PhD defense."

Students shared advice for future students in the class: "Take the time to complete the readings and reflect on the application to your practice or position in academia"; "This is also a great opportunity to work as a member of a team"; and "Be considerate of the timelines for each activity and enjoy the new knowledge."

The total score on the summative course evaluation was considerably above the college mean, and most students gave very favorable reviews. However, a few class members did not see the value of group work and developing knowledge and skill in computer applications and technology in health care: "I do not see how this course plays a role in my professional career as an APRN. I am not an IT specialist and do not understand why we need to go so in depth into computer systems" and "Group work was extremely difficult to undertake and assimilate."

Resistance to new knowledge and skills, both in learning and in professional practice, is a reality that should be expected and recognized. It should not slow our momentum to continually explore and utilize innovative practices and technologies in health care and education.

Nursing students must learn these skills to be competitive in today's world. The implementation of this pedagogical strategy led to some difficulties; for example, the need to master new communication technologies and negotiate the schedules of all students in the class to arrange for synchronous activities. In addition, some students preferred to remain anonymous online communicators and were reluctant to engage in synchronous role play.

Lessons learned from teaching this course for the first time include: a) be very specific about the project requirements; b) provide reliable technical support and multiple opportunities to practice with technology; c) closely monitor collaborative work processes; d) provide and solicit feedback; e) model expected behaviors; and f) faculty engagement throughout the course is critical. Research is needed to evaluate the effectiveness of the pedagogical strategies and communication technologies described in this article. Implementation of similar online teaching strategies in other academic programs and disciplines will require collaboration between online educators, instructional designers, and technical support professionals.


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Author affiliation:

About the Authors

Joan M. Culley, PhD, MPH, RN, CWOCN, is an assistant professor at the University of South Carolina College of Nursing, Columbia. Vera Polyakova-Norwood, MEd, is director of online learning at the University of South Carolina College of Nursing. Contact Dr. Culley at for more information.

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