Development of an Interactive, Multimedia CD ROM to Teach Medication Administration to Undergraduate Health Professionals
|
Pamela Jeffries, Ph.D., R.N. Rhett McDaniel, Multimedia Consultant Michael Vaughn IntroductionTraditionally, nursing skills have been taught in small groups with a demonstration and return- demonstration format. However, faculty complain about the boredom of having to teach the same skill over and over to different groups. There is also the worry of presenting information to one group and not another, thus providing inconsistent information to the learners. There is a need for change in how skills are taught, but change that assures learning outcomes that do not compromise quality education. Other considerations include the need for health care professionals to become self-directed and, at least initially, to have a learning environment where they can observe the results of their actions without consequences (Urick and Bond, 1994). To provide one such change in teaching basic nursing skills, we designed a computer program using various types of media and a "hyperlearning" or nonlinear approach to teach medication administration. This paper describes the development of our program. Literature ReviewRecent trends in higher education include a shift from a teaching to a learning paradigm (Dolence and Norris, 1995), specifically, a shift in emphasis from teaching to learning, from teacher-directed to self-directed learning, and from passive to interactive learning (Billings, 1996; Dolence and Norris, 1995). Barr and Tagg (1995) discuss a shift from the traditional, dominant learning paradigm in which the activity of teaching is conceived primarily as delivering a 50 minute lecture. In this paradigm, learning environments and activities are learner centered and learner controlled. With the paradigm shift, instructors recast their role from knowledge disseminators to facilitators and from teachers to organizers of learning (Skiba, 1997). Teachers become instructional designers, creating learning experiences and environments for students to use - often through teamwork, and without the teacher being present for every structured learning activity. The learning-centered paradigm requires changes in teaching-learning practices. The Principles of Good Practice that were created in 1987 from a study supported by the Lilly Endowment, the American Association of Higher Education, the Education Commission of the United States, and the Johnson Foundation (Chickering and Gamson, 1987) have been shown to contribute to good student performance and satisfaction when colleges and universities systematically engage in these behaviors (AAHE Bulletin, 1996). These principles include: 1) adequate student/faculty contact, 2) cooperation among students; 3) active learning; 4) prompt feedback; 5) time on task; 6) high expectations and 7) respect for diverse talents and ways of learning. Chickering and Ehrmann (1994) suggest that faculty members who already work with students in ways consistent with the principles also need to incorporate these practices into technology-assisted interactions they create or purchase. Faculty need to avoid materials that are simply didactic and instead search for or create materials that are interactive, problem-oriented, relevant to real-world issues, and motivating for students. The Hyperlearning Model (Jeffries, 1997, 1998) is one way to incorporate the important teaching-learning principles described by Chickering and Gamson (1987; Chickering and Ehrmann, 1994). The Hyperlearning Model is a non-linear model of learning that was the framework for the interactive, multimedia software that we developed. A traditional model is a sequence of topics covered in a series of lectures held in classrooms at regular intervals. Everyone proceeds at the same pace regardless of their interest, prior experience, knowledge of the subject, or demands on their time. At the end, grades are assigned to indicate level of achievement of the student (Denning, 1996). The Hyperlearning Model allows for independent, interdisciplinary learning tailored to the individual’s needs. The learner can go through the interactive CD program at his/her own pace. Trial competency skill checks can be taken and the learner can backtrack to review information as often as needed. A teacher can offer guidance if the learner is heading in the wrong direction. In contrast to the linear model, everyone who exits the program gets the same grade and obtains competency on the particular skill; the variables are the length of time and path followed to obtain the skill. For teaching basic skills such as medication administration that require a specific competency and decision-making skills, we have found multimedia software to be a viable instructional strategy. The Hyperlearning ModelThe Hyperlearning Model framework used was designed on "dimensions," with the learner able to go through all the dimensions or opt to "jump" and do only the dimensions where knowledge was lacking. The dimensions in the context of basic nursing skills are general principles, process/mechanics, client teaching, critical thinking, and professional applications related to the skill. These dimensions in the hyperlearning model pictured in figure 1 were operationalized as follows:
This model allows great flexibility in learning. Dimensions can be targeted to various disciplines such as, in the health professions context, nursing, allied health, emergency medical technicians, paramedics, medical assistants, and others. The media can be designed to add discipline-specific content. The learner may or may not need to go through all dimensions, depending on the content being covered and its relation to the expectation of other care workers. Also, experience and skills may influence what students will need to cover. Pre-and post-tests will be designed to evaluate each student’s knowledge of a particular basic skill. If a student achieves the required competency level on the pre-test, the option of performing the skill will be offered without the student being required to proceed through the computer program. Additionally, it’s possible to have testing and evaluation built into other parts of the program, especially the critical thinking section. It’s also possible to have testing scattered throughout a program so that students are tested as they learn various concepts or processes. Selecting the MediumThe literature suggests a great range in the amount of time it takes to develop quality computer software. Estimates of preparation time vary from 50 to 200 hours for a 1-hour computer lesson (Reynolds, 1984; Armstrong, 1983). Using lectures and other written course materials to develop a computer lesson script reduces time. The development of a completed script from lectures and written course material required approximately 35-40 hours for this project. Actual programming of the script, addition of multimedia features, debugging, and testing required another 80 or more hours but will vary depending on the complexity of courseware lessons. Another way of looking at the development time is by differentiating the technical phases. The design phase for non-interactive computer programs which includes both instructional design and design of the interaction, usually takes 1/4 to 1/3 of the total development time. The remaining time is spent on the development phase which includes media development, interface development, and programming. The total time for the project depends on the complexity of the information being presented and the complexity of the design, both of which can be limited by the budget for the project. For the medication administration program, three types of programming were developed: tutorials, simulations using graphics, and computerized tests. Tutorials were developed for small areas of content within the course unit. Small units enable students to focus on manageable, specific content areas within the total course content. The tutorial section focused on content review and clinical situations. Graphics, sounds, and videos of actual medication administration were incorporated into lessons to illustrate particular medication administration skills. Students demonstrated better understanding of difficult concepts when they were illustrated graphically. In summary, there are numerous benefits of using interactive multimedia as an instructional strategy to learn basic skills such as medication administration (See Table 1). Production ProcessA. The Design Phase During the instructional design phase of this project, the nursing faculty member, also referred to here as the subject matter expert, decided on the content, generated ideas about how the content could best be delivered, formulated objectives for the program, and planned interactions for the student. Designing the interaction was next. It involved deciding how best to present the instructional information, determining how interaction should occur, and designing the function of buttons and other screen elements. The instructional design and interaction design tasks are highly interdependent and, unlike the phases of the development process, cannot be done separately. Key players in this and other phases were the computer program designer and a media specialist who developed the video, audio, photographic, and graphic elements. In the initial design phase, the subject matter expert met with the program designer, who assisted in the formulation and development of the program ideas and decided what media elements would best convey each concept. Other tasks in this phase addressed the following considerations:
When the design process is complete, everyone involved should have a "map" of what they need to do - content, media, interface, or programming - and how it fits into the project as a whole. The lead designer, who usually, but not always, acts as the project manager, is an integral part of the success of the project. The project manager must be current on all aspects of the project. Furthermore, since many phases of a project are dependent on other phases being completed, the project manager must ensure that the project continues smoothly throughout the design, development, and deployment phases. B. The Development Process
C. Pre-Production Process It is common to want to begin shooting video and recording audio somewhat randomly in hopes of capturing that unique or spontaneous moment. Although this type of shooting may have some advantages, overshooting becomes impossible to avoid without a script. The reality is that it takes hours of pre-production planning to come out on the other end with anything useful or educational. Preparation is the key to success. Regardless of the media used, there are certain commonalities of preparation. Media were planned out on paper first, using suggestions from the team. Discussion addressed how we could best present the information and whether it should be in video, audio, photo, or graphic form. Once we made those decisions, we drew up itemized lists of exactly what had to be produced so that during the programming phase, all the pieces would be there to incorporate into the work. The quality of media depends on factors such as money, equipment, and time. Whatever the medium, the content must be presented in a clear and concise way. If, for instance, you are not able to record audio clips that are of good volume and have little background noise, then material needs to be presented by use of another medium or perhaps by outsourcing the audio component to a recording studio. Producing Video ClipsVideo clips can provide a visual experience as good as or better than that in the traditional classroom, with each learner having a virtual "front row seat" when a new technique is being demonstrated. Close-up shots can facilitate understanding of detailed procedures and visibility of small pieces of equipment. They become essential when the finished size of the video clip is about 240X180 pixels. A 240X180 size allows enough room on the screen for text to accompany the clip, yet keeps the file size small enough to play back at full motion (30 frames per second) and still fit onto the CD. Before we shot the video segments, we made a list of shot locations and descriptions including the specific procedures to be captured (documents known as a shooting schedule and shot list). Next, we wrote the scripts. A script does not necessarily include dialogue and need not be formal: rather, it comprises a detailed list of all the things needing to be accomplished. If a procedure is being shown, the script should describe the specific actions making up that procedure. Scripting ensures that the director captures and includes close-ups of the specific steps involved and also that overshooting is avoided, saving time during the shoot and editing process. When shooting with a single camera, parts of several "takes" will be used together. The actor must perform the actions exactly the same way each time for the takes to edit properly. This becomes even more important when the actors have verbal content to convey. Scripts will not only ensure that the actors say exactly the same words for each take, thus enabling easy editing, but will also guarantee that the course content is presented in a factual and complete way that meets the goals of the instructional designer. It is important to determine in advance exactly what shots are needed. For one thing, video production involves the time of many people, and a room full of people waiting for the director or subject matter expert to make decisions wastes that time. Also, it makes editing easier to have exactly what is needed. Searching through two hours of videotape to find a 10-second close-up shot can be even more time consuming than having to re-shoot a missed scene. Proper documentation will help in finding small segments on a videotape. Keeping the shot list handy and writing down how many takes there were in each segment, as well as what close-ups and wide shots were captured, is critical. This will not only be useful when searching through footage during editing, but will help during the shoot so that the director can check the footage against the shot list and know instantly if each item has been recorded. It takes a minimum of two people for a production crew. The carrying of equipment alone requires two persons. The camera operator should be able to concentrate on capturing the video, leaving the microphones and lighting to another. Ideally, a crew would consist of four persons: 1) a director, 2) audio engineer, 3) lighting technician, and 4) camera operator. For our project, there were only two: a director/cameraman and a lighting/audio engineer. The video was shot using a Sony Digital Video camera to get the best possible image for the equipment we had available. After the footage was shot, it was digitized onto a Macintosh computer using Adobe Premier to edit the segments and "render" the movies. The average amount of time spent for each segment (varying in length from 30 seconds to two minutes) totaled around 3 hours, including the video shoot, editing, and rendering onto a movie file. At least that much time, if not more, went into the scheduling of actors, locations, and scripting of each shoot. Our experience demonstrated that arranging the logistics of location, crew, actors, and equipment can be a monumental challenge Creating Audio ClipsAudio clips, when coupled with a still photograph, can sometimes be as effective as a movie clip and will have a much smaller file size. We also used audio clips and sound effects to keep the learner engaged. Users have become accustomed to on-screen buttons making a click or pop when pushed or short music clips that play while media are being loaded. We used the introductory music and button sound effects to assure the user that the software has not suddenly stopped or crashed while they wait. Most audio clips and "voiceover" recordings for these kinds of programs can be done with a good microphone and a small, quiet room. Again, it is imperative that scripts be written so that no course content gets left out and so that audio edits can be made easily. Just as videotapes are logged, so too are audio segments. Using a copy of the script to mark where segments begin and end and which takes are best as the audio is being recorded will greatly reduce the time spent editing. We used Macromedia Sound Edit 16 for the audio clips. Creating them took varying amounts of time, depending on the length of the script and the ability and talent of the person performing the voiceover. Shooting PhotographsThe old adage "a picture is worth a thousand words" is true. Since screen space is at a premium and reading large amounts of text from a computer screen is tiring, sometimes a picture is all that is needed. Each photo that needs to be taken should be listed and broken into categories, like a video shoot, according to the location. Without a clear idea of exactly what is needed, time and film will be wasted returning to previous locations for pictures, and some photos will likely be missing later when the whole program is being put together. We took most of the photographs for our program with a 35mm camera and then scanned the negatives into a computer using a Polaroid Sprint Scanner. Adobe Photoshop became a necessary tool when converting file types and when resizing or cropping photographs and correcting for hue/contrast/saturation. Creating Graphic ElementsGraphic elements are very important since they give the product its look and feel. The graphical user interface should be easy to read and understand, with navigational buttons near where they are needed so that the user is not constantly running the mouse from one end of the screen to the other. Users have become accustomed to highly polished and slick graphics from TV, movies, and the Internet and may understandably assume that a poor-looking product is of less value than a good-looking one. A checklist of each graphic needed should be made. Use of a good graphics tool such as Adobe Illustrator or another vector-based art program for drawings and illustrations will enable art to be re-sized and manipulated in a variety of ways while maintaining the integrity of the original work. In summary, media production is mostly about thorough preparation. If a good foundation is made during pre-production, then the rest of the program development has a better chance of running smoothly. Planning may seem like a lot of work up front, but the ability to organize all of these things will bring success. By the end of making the medication administration CD, we had hundreds of video, audio, graphic, and picture files, not including the hundreds of text files. Each was identified with either a number and a log sheet for cross reference or a meaningful file name so that the programmer could find the files easily. Pilot TestingWe evaluated the different aspects of the program using various instruments. We used an instructor-made pre/post test included in the CD ROM to measure cognitive gains of the student learner and a skills competency check that was performed in the learning lab environment to measure the psychomotor skill level of administering medications. Additionally, we used a Student Satisfaction Scale and a Scale derived from the Flashlight item bank - a survey item bank of the Annenberg/CPB Project under the guidance of Dr. Steven Ehrmann at the American Association of Higher Education (Ehrrman, 1995) - to test the hyperlearning model that was embedded in the CD ROM for principles of good practice in teaching (Chickering and Gamson, 1987). In October of 1997, the team’s subject matter expert Jeffries worked with a focus group of 29 volunteer bachelor’s of science in nursing students from the fundamentals nursing course to pilot test the medication software for content clarity, ease of navigating through the program, and overall "debugging" of the software product (Jeffries, 1997). Pre- and post-test scores were obtained on these students since the testing was built-into the interactive program. Overall, the instruction design problems were minimal. ApplicationsMultimedia programs have numerous potentially valuable applications. Once a multimedia program is developed, subsequent teacher preparation is minimized and professional role development for the learner is enhanced. The program can also make it easier to compare the performance of one student with that of another, since the learning experience is exactly the same for all students, unlike a classroom where one class might differ from another, and one student might affect the learning of another student during a class. Comparisons of student performance outcomes will of course be needed to validate this as a viable mode of teaching. Health science schools are being mandated to make courses more versatile, cost-effective, self-paced, and learner-centered. Using multimedia is one way to meet these goals. Students, professionals, technicians, and other learners can use this learning modality for acquiring particular skills quickly and without dependence on the physical presence of the instructor. The program provides an efficient method of delivering repetitive content to a large number of learners. The use of interactive multimedia computer programs, already apparent in many disciplines, will continue to evolve and to become more sophisticated as the technology and access improve. Failure to investigate and plan for the integration of this multimedia environment will leave many health science programs unprepared for the outcomes that technology has to offer (Hudston-Carlton, 1996). RecommendationsBased on our experience designing a multimedia program, we offer the following recommendations for other educators considering the use of this teaching method:
Table 1. Benefits of using Interactive Multimedia for Teaching Medication Administration
Figure 1. The Hyperlearning Model
Figure 2. Example Story BoardUsed for mapping content flow and screen design
References
|
