Indiana University      Research & Creative Activity      April 1999 Volume XXII Number 1

Nurse Education, Hyperlearning, and the Virtual Clinic
by Deborah Galyan

When Pamela Jeffries, assistant professor at the IU School of Nursing at Indiana University-Purdue University Indianapolis, looks out on the seventy-three faces in her Introduction to the Discipline of Nursing class, she sees seventy-three individuals with different backgrounds, goals, and learning styles. Her class is fully engaged as she introduces a series of crucial concepts about nursing theory and practice. She calls on the students by name, an impressive feat in so large a class, and frequently asks them to take stock of their progress. "Are you with me?" she asks. "Can we move on?" The students seem fresh and excited, yet clearly a little nervous about the challenges to come. "She understands what it's like to be us," one young student confides after class. "She operates on our level."

Pamela Jeffries, assistant professor, Indiana University School of Nursing, Indiana University-Purdue University Indianapolis, designs courses that use technology to bring the clinic into the classroom. --credit

Fortunately for her students, Jeffries has never allowed herself to stop imagining what it feels like to be a first-year nursing student. That intuition is, in part, what makes her a scholarly teacher. Nursing is a complex profession that requires its practitioners to theorize, analyze, and solve problems, and to possess a large repertoire of clinical skills from surgical handwashing to calculating dosages of medications, and other complex patient interventions. For many years, schools of nursing have relied on a traditional model of lecture and demonstration to introduce these crucial clinical skills.

"Unfortunately, this model requires everyone to learn in the same order and at the same pace, regardless of learning styles and capacities," Jeffries says. "It makes students dependent on their instructors to learn skills that they must be able to perform independently in a hospital setting. I've observed students in clinical settings select less challenging patients to work with because they don't want to make a mistake in front of their instructors."

In the early '90s, while working on her doctorate in nursing, Jeffries followed with interest the discourse advocating a paradigm shift from teacher-centered to student centered learning. The literature confirmed what Jeffries already understood from years of teaching experience--she has taught nursing skills and theory courses at IUPUI since the early '80s. "I thought, this is exactly what we need to do in nursing education- give students control over their own learning without compromising the learning process."

Using the analogy of "hypertext," a computer-based concept in which text and images can be organized and manipulated in a nonlinear fashion, Jeffries developed a "hyperlearning" model on which she and other faculty members based a series of fifteen self-study modules for teaching clinical nursing skills. As an integral part of its foundation, Jeffries incorporated a series of teaching-learning principles of good practice in education that were first proposed by Chickering and Gamson in 1987. The principles are student-faculty contact, cooperation among students, active learning, prompt feedback, efficient time on task, high expectations, and respect for diverse talents. According to Jeffries, research shows these principles contribute to student performance and satisfaction when universities consistently apply them. "In my mind, they are crucial to the teaching-learning process," she explains. "My model is threaded with them."

The use of multimedia and a nonlinear approach are also key components of Jeffries' hyperlearning model. Equally important are a series of "dimensions" that she devised to describe and organize the complex body of knowledge needed to master each clinical skill. "The concept of 'dimensions' is critical," she explains. "It organizes knowledge into categories, so that students can learn it in the order that makes the most sense to them. I think all learners deserve that kind of control."

Jeffries has developed an interactive, multimedia CD-ROM to teach beginning nursing students about how to administer medication. The software was developed based on a "hyperlearning model" developed and tested by Jeffries. The CD contains a self-directed program so a student can stop and take notes, review the videos repeatedly, or go through the complete program as many times as needed. The program includes five dimensions: general principles, process, client teaching, critical thinking, and a pre/post test. --credit

With a growing sense of the potential in computer-based technologies for teaching hands-on clinical skills, Jeffries set out to create interactive CD-ROMs of her self-study modules. "I saw how we could bring nurse education alive with this technology," she says. "Not only could we do a better job of teaching a specific skill like dose calculation with an interactive CD-ROM, but we could also create a virtual clinical setting, where students could practice the skill and experience all the real-life complexity that it involves without any negative real-life consequences."

In the summer of 1997, with an IUPUI Network of Excellent Teaching (NET) grant, Jeffries went to work on her project, beginning with a module she had designed and written on oral and EEN (ears, eyes, and nose) medication administration. "When we got the grant, I thought: this will be a piece of cake. I was wrong." Jeffries assembled a production team, and hundreds of hours and thousands of decisions later, they completed the first CD-ROM. Three more are now in various stages of production. "I felt like Steven Spielberg at first," she laughs. "Each day there were new problems outside the realm of my experience. The camera person would walk in and ask: 'How do you want this shot--wide angle or close angle?'" Jeffries played a variety of roles during production, including content expert and director. She found herself rounding up volunteer actors, even persuading her father to serve as one "virtual patient." "He was a good sport," she laughs.

The CD-ROM on administering oral medications has been incorporated into the IUPUI nursing skills laboratory course, and more computer modules will soon be included. Jeffries and her team took full advantage of the CD-ROM format's amazing capacity to present material in nonlinear and graphic terms, enabling nursing students to see anatomy and physiology in three-dimensional graphics, to watch skills demonstrated on video, and to practice performing the skills on their own. In a nearly completed module on performing twelve-lead electrocardiogram (ECG), for example, students will use a computer mouse to place each electrode in the correct position on a virtual patient lying in a breathtakingly realistic virtual hospital room.

"This technology allows teachers and students to share control of the learning process," Jeffries observes. "I control it by including everything I think they need to know about a given skill. They control it by manipulating the material to fit their own learning needs and styles."

Preliminary tests showed that students using Jeffries' module had significantly more cognitive gains and higher satisfaction than students who learned the same material through lecture. "Research is a crucial element," Jeffries explains. "Why incorporate technology if it doesn't work? The outcomes are good so far, but more research is necessary."

Her research and commitment to student-centered learning and applicable technologies have made Jeffries an integral figure in a series of major curriculum developments and revisions currently under way at IU School of Nursing. Jeffries hopes that eventually her hyperlearning model will stand as a framework for nursing educators around the country to use developing multimedia technology.

Jeffries' experience illustrates one way teachers must rethink and recast their roles as the paradigm continues to shift to learning-centered instruction. "We are going to have to think of ourselves more as instructional designers. It takes planning, teamwork and good communication," she observes. "But, now that I've seen what I can do with technology, I no longer feel comfortable with the traditional model of lecture and demonstration. Now we can really bring these courses to life."

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