JULIANI, CARMEN MARIA CASQUEL MONTI PhD; CORRENTE, JOSÉ EDUARDO PhD; DELL'ACQUA, MAGDA CRISTINA QUEIROZ PhD
Computerized technological resources have become essential in education, particularly for teaching topics that require the performance of specific tasks. These resources can effectively help the execution of such tasks and the teaching-learning process itself.
Many of our social, economic, and professional daily actions involve technological procedures and a communication network, of which we are not always fully aware. In this scenario of the so-called information society, deep changes have occurred in the way people relate to one another, in the way people relate to knowledge, and in the way knowledge relates to the forms of organization and power in society. Such transformations make us think about what significant changes will take place in education, and despite our attempts to predict them, we will never know for certain how far reaching they will be.
For millions of years, people had little need for communication media because they lived near one another. A countryman spent all his life in an area of approximately 25 miles around his place of birth. With the advent of fax machines, global publications, and computers in particular, relationships were no longer restricted to time and place, since we have become members of global communities. On the other hand, new difficulties have also arisen as people are forced to face an encompassing power, considering that from five to 10 corporations control most of the major publications, radio and TV stations, movie-producing companies, information networks, and large Internet portals.1
The term cyberspace designates the universe of digital networks as a site for encounters and adventures, a territory of conflicts, and the new economic and cultural frontier.2 It is a new communication medium that arises from the worldwide interconnection of computers. The term specifies not only the material infrastructure of digital communication, but also the human beings who browse in and feed this universe. As regards the neologism "cyberculture," it refers to the set of techniques, practices, attitudes, ways of thinking, and values that develop simultaneously with the growth of cyberspace.3
Studies in the North American literature show innumerable advantages and advancements from the application of information technology in nursing care, administration, teaching, and research. However, Brazilian nursing is still far behind in relation to its use when compared with North American institutions. Hence, if nurses intend to play a leading role in nursing care, computerized instruments will have to be used in their work processes.4
According to Peres et al,5 computerized resources open new perspectives in education by enabling us to individualize teaching and rethink the nature of learning; however, they must not be limited to programs that teach students only how to use computers, but should also be instruments that can facilitate/potentiate the teaching-learning process.
The Internet increases students' motivation, since it is a novelty and provides endless research possibilities. It develops flexibility because most of the sequences are unpredictable and open, and the repetition of the same browsing sequence is unlikely. We have also developed new forms of communication, particularly written. We write in a more open, hypertextual, connected, multilinguistic fashion, thus bringing text and image together.6
Students must not be seen merely as information recipients, but should become responsible for the construction of their knowledge by using computers, among other resources, to search for, select, and interrelate significant information in the exploration, reflection, representation, and depuration of their own ideas, according to their way of thinking.
Although digital exclusion is still a reality in Brazil, proposals involving technology tend to "push" for measures so that educational structures can be prepared to absorb them, thus improving access resources for students. In this scenario, a Web site (www.escala.fmb.unesp.br) was designed for the undergraduate nursing program of the Department of Nursing, Botucatu School of Medicine, São Paulo State University, with the purpose to teach the topic, nursing staff scheduling, as part of human resources management. This resource is utilized as a teaching aid,7 and for this reason, we consider it to be relevant to compare students' learning performance with and without its use.
Human resources management is one of the key aspects in nurses' professional performance as nurses play a leading role on nursing teams consisting of other nurses, nursing technicians, and auxiliaries. Hence, nurses have acquired competence to coordinate activities, guide teams, plan and supervise healthcare provision, and ultimately administer nursing services.
With regard to nurses' administrative functions, the Brazilian Law for Professional Nursing Practice8 provides that they should be responsible for directing nursing departments in healthcare institutions as well for planning, organizing, coordinating, executing, and evaluating nursing services.
According to Kurcgant,9 it is a nurse's duty to incorporate knowledge from various sciences into his/her professional training. Among them, the science of administration contributes to the management of nursing personnel. Also, the incorporation of computer technology, similarly to what has occurred in other fields of human action, is pointed out.
Female nurses predominate, and shift work is another strong characteristic of their activities, since they provide care provision around the clock, particularly in hospitals.
Costa et al,10 in a survey of professionals working alternate shifts at a university hospital, concluded that, according to that group's perception of the effects of shift work, their health is mainly affected by neuropsychic, cardiovascular, and gastrointestinal disorders. Hence, social life is also negatively affected, first because of interference in personal and family relationships, second because of restriction to social activities, and third because of the difficulty in planning one's life. All these variables, among others that compose the complexity of healthcare institutions, and hospitals in particular, must be taken into account by nurses when a nursing staff schedule is designed.
The distribution of nursing personnel is a complex activity that takes time and requires knowledge of clients' needs, the unit's dynamics, the nursing staff's characteristics, and labor laws.11 Management, in its prescriptive, normative, explanatory, and descriptive approaches, deals with the planning, organization (structuration), direction, and control of all activities differentiated by the work division occurring within an organization, and in doing so, management is no more than the rational conduction of activities.12
With the purpose of contributing to nursing students' education, the idea of designing the Web site, "nursing staff scheduling," was conceived. This Web site provides a simulation in addition to content per se. Hence, this study aimed at comparing students' development during the teaching-learning process involving the topic "nursing staff scheduling," with and without the use of such technological resource.
The comparison was carried out by selecting two groups of undergraduate students: a case group and a control group. The names of the students who were to participate in the groups were randomly drawn.
Control-case studies are fast and inexpensive when compared with other types. However, cases, controls, and data must be carefully selected as they may be sources of bias.13 These studies are more frequently used in the healthcare field to analyze diseases, which is not the case in this study.
In control-case studies, two groups of individuals are observed: one group has a disease (the cases), whereas the other does not (the controls). The proportion of individuals exposed to a possible cause for a disease is then calculated for each group, and results are compared.13 Hence, by extending the example above, we considered the group of students exposed to the use of technological resources during the teaching-learning process to be the case group (GI), and that nonexposed to the use of such resources to be the control group (GM), thus enabling the comparison of results in the teaching-learning process.
Study Site and Population
The Botucatu School of Medicine (FMB) of São Paulo State University (UNESP), located in the city of Botucatu, São Paulo state, Brazil, offers two undergraduate programs, one in medicine and one in nursing. The undergraduate nursing program has a minimum duration of 4 years, and credits are achieved from completion of annual courses by the students.
This study was conducted in the undergraduate nursing program of FMB-UNESP, in the course of nursing administration, which is taken by students in the fourth year and when they are taught the topic, nursing staff scheduling.
Data were collected from 2003 to 2005 by means of a form especially designed for that purpose and following approval by the local research ethics committee.
The students were advised about the ethical and legal precepts of the study; that is, they were invited to participate and informed that they were free to withdraw their participation consent at any time. They were also made aware of the objectives of the study and assured of confidentiality and anonymity before they signed the free consent term.
After providing their consent, the students were separated into two groups. Their names were randomly drawn in their classroom and in the presence of all class members. The control group was taught the subject without support from the technological resource, and the case group was taught with its utilization.
Hence, the case group should design a nursing schedule via the Web site (Internet), and the control group should design a manual schedule. Both groups handed their work in to their teacher. It is noteworthy that the students in the case group were allowed to hand in their schedules manually in case they faced any problems related to the technological resources.
At the end of the investigation, an evaluation was performed to compare the outcomes in both groups. It is important to emphasize that the result of such evaluation was not part of the course's final grade, but instead, it was a specific evaluation designed to meet the objective of this study.
RESULTS AND DISCUSSION
The results herein presented indicate the effects of the use of technology in teaching. Although the study was carefully conducted, the previously mentioned effects cannot be generalized since it is not possible to state that all the variables involved in the teaching-learning process were controlled. Additionally, technological problems, such as access speed and connection crashes due to the fact that many users did not have high-speed Internet access at the time, occurred, which may have interfered with such control.
The target group in the study consisted of 91 students in the fourth year of the undergraduate nursing program in 2003, 2004, and 2005; however, only 80 of such students effectively participated, which corresponded to 88% of the population. We point out that GI (case group) represents the group organized to perform the activity by using the Web site, and GM (control group) represents the group designated to perform the activity manually (Table 1).
Students were allowed to perform the scheduling exercise manually in case any technology-related problem emerged. The group designated to work on the Internet was exposed to the technological resource and accessed the Web site for their studies. Some of them chose to do the exercise manually. The researchers' choice was to allow total freedom as to that aspect, since they were aware of the students' conditions and access difficulties. Another reason for having offered this choice to students was the fact that technical problems could occur during equipment use.
The evaluation itself is divided into two items: motivation evaluation and learning verification. Our choice was to present the data year by year.
Of the 25 students (78%) who answered the research form in 2003, only three were males. They were 21 to 27 years old, and their mean age was 23 years. All of them reported a computer and Internet access, and five pointed out that such access was provided by the university. Only two students reported they did not have regular access to the Internet. All of the students denied having previous experience in designing a nursing staff schedule; therefore, that was their first opportunity.
We chose to present these results according to the graphic expressions used on the form. GI corresponds to the group that worked on the Internet, and GM is the group that did not use the World Wide Web. After presenting the absolute and relative figures in the tables, we show the statistical tests for comparison of years 2003, 2004, and 2005 (Tables 2 and 3). In Table 2, it is observed that motivation for the study was high both in the case group and in the control group, as only one student showed a negative attitude in relation to the item concerning the simulated exercise, that is, the manual design of the schedule. A less positive evaluation was observed for the item simulation in both groups. This fact is related to the schedule-designing task, which poses difficulty to students due to its complexity, as it requires concentration and time for execution.
Most of the students presented a positive evaluation (75%), and no significant difference was observed between the two groups. One hundred percent agreement was observed among the students in relation to the usefulness of studying the topic to professional practice, which reinforces the need for it to remain as one of the items in curricular content.
Similarly to our results, research carried out in other countries reports that there is no significant difference between distance and conventional on-site learning as regards relational/dialogic aspects or results.14,15 We understand that these findings are favorable to distance-learning experiences, since similar results to those in conventional on-site learning are achieved. In addition to the use of computers and software, the apprehension of these processes enables students to open new perspectives in the construction of their knowledge and in the articulation of resources that surpass technology handling and contribute to the teaching-learning process.
As to the 2004 group, of the 24 students (86%) who answered the research form, 100% were females from other municipalities in São Paulo state. They were 21 to 28 years old, and their mean age was 23.5 years. All of them reported having computers and Internet access. Only one student reported no regular access to the Internet. All of the students denied having previous experience in designing a nursing staff schedule; therefore, that was their first opportunity.
Table 4 shows the motivation variables considered (interest in the topic, teacher-student relationship, usefulness of the simulated exercise to professional practice, and content quality and amount) for the year 2004. Table 5 is a comparison of statistics on motivation for the 2004 groups.
Repeating what had occurred in the previous year, only one student showed a negative attitude in relation to the simulated exercise, and also similarly, agreement concerning the usefulness of the topic to professional practice and a less positive evaluation of the simulated exercise were maintained. In both groups, evaluation was positive in 77% of the answers, and, for this class, the positive evaluation concerning interest was greater for the group working on the Internet (46%) than for that working on the schedule manually (25%).
Other similar experiences with the use of virtual environments in teaching show that they awake the interest of students since they support and acknowledge such tools as important resources in the teaching-learning process.16-18
In 2005, 31 students (100%) answered the research form. They were all females aged 21 to 27 years, therefore with a mean age of 22.8 years. All of them reported having a computer and Internet access, and seven reported that such access was provided by the university. Only two students reported that they did not have the habit of accessing the Internet. All of the students denied having previous experience in designing nursing staff schedules; therefore, that was their first opportunity (Tables 6 and 7).
Similarly to previous years, in 2005 only one student showed a negative attitude and, again, in relation to the simulated exercise, although the evaluation of such activity was better for this class. Agreement in relation to the usefulness of the topic to professional practice can also be again observed. A less positive evaluation concerning the simulated exercise remained. The evaluation was positive for both groups; it increased to 80% of the answers, and for this class, interest was greater in the group working manually, which differed from previous years.
For a realistic comparison, statistical tests were performed by considering only the two first evaluation values (Symbol 1 and Symbol 2). As the third value (Symbol 3) was inexpressive, its inclusion in the tests was not justified (Table 8).
Learning verification comprised a few questions related to the content involved in the topic, nursing scheduling, such as the practical aspects of carrying out the activity, and some more relevant and common questions concerning labor law. The questions were designed in the form of multiple answer-choice questions, and students could check more than one correct alternative whenever possible. The answers were considered to be correct only when the student checked all the correct alternatives for the situation presented. The questions without answers were considered to be incorrect. The students were given such question-answering information when they received the research form.
The data are conjointly presented; that is, the total percentage of correct answers was considered, and therefore, each one of the six questions are not individually shown. Instead, the total number of correct answers for each year has been provided by separating students in GI from those in GM.
Performance was similar in the two groups under study (GI and GM), which was confirmed by means of statistical tests of significance. The results indicated no significant differences between the groups' performances, as shown in Tables 9 and 10.
Overall, the results are in agreement with those from other studies14,15 that reported no great difference in performance between on-site and distance learning. With the expansion of online learning, the quality standards that have been studied and proposed for distance learning are based on the experience and conclusions already pointed out for conventional modalities.14,15,19
Kennedy19 reports that online learning is growing; however, it is not a new phenomenon. Most of the times, it is associated with distance learning, but it also comprises on-site learning, in the form of a "mixed" modality. The technological changes occuring interfere more with the form and media available and less with the teaching-learning process, which is based on the affective relationship, guidance, and clarity of objectives between teachers and students, in addition to the availability of content and meaning that they present to students.
Laguardia et al20 also argue that special distinction must be given to the learner-tutor interaction so that users can experience teaching affectivity and satisfaction, which affects motivation and learning. It seems that students' greatest benefit lies in the diversity of media and the possibility of easy access to contents when they use technological resources in which such contents are available on the Internet, as in this case.
When questioned if they considered it important to maintain the nursing staff scheduling content available on a Web site, only one student answered negatively, and one did not answer at all. All the others considered it important to count on a Web site for reference.
Some comments made by the students in 2004 and 2005 are transcribed below. No comments are provided for 2003, since, as previously mentioned, that was the year when most of the problems involving the technology and Web site hosting occurred.
* A 3: "It is difficult to read."
* A 7: "Whenever a question arises, there is a place to look up the information."
* A 9: "It will make it easier to refer to labor laws whenever we need to."
* A 10: "Because it can make it easier to design schedules, however, a faster Web site is necessary."
* A 11: "This is a frequently addressed topic in nursing, and being available on a Web site will make access to it easier."
* A 13: "This topic is of great interest to nurses, who can now easily access this information anywhere."
* A 19: "As long as it facilitates the professional's work."
* A 20: "Because it is one of the nurse's main attributions. Nurses can be helped if they have a specific and easily accessible program to do it, since not all nurses know labor laws well enough."
* A 28: "Because there would be a Web site to access, since that subject is a little complicated in books."
* A 29: "To make the material available for students who were absent from class or for healthcare professionals."
* A 1: "Access is easier anywhere."
* A 3: "It makes life much easier, particularly due to the fact that the Internet is dynamic, and fast. Access to the information necessary for designing a schedule is easy, and once the schedule has been designed, all you have to do is print it."
* A 5: "Labor laws are available."
* A 7: "To facilitate and make it available for all, anywhere."
* A 10: "To remember all the information related to labor laws."
* A 11: "I can find it wherever I am and whenever I need it."
* A 13: "It is an important topic, and we can access the available site at any time."
* A 14: "It is easier to organize the work. I think that the manual schedule is easier, but the Web site's layout facilitates access."
* A 16: "To solve doubts more easily and promptly."
* A 19: "To facilitate the esthetic design, greater mobility, and agility."
* A 20: "I believe that, after the practice of designing a schedule, the computer helps, that is, it makes the work faster."
The comments show that the importance of counting on the resource is undeniable, and many students mentioned its easy access. Nevertheless, problems exist, and for technology to be well accepted, it needs to make work processes faster and easier; that is, it is well accepted only when it brings advantages in relation to manual processes. From our experience with students, we know that there are many aspects to be improved and, in particular, that it is necessary to improve the simulated exercise to adequately meet users' needs; however, the evaluation results have shown favorable conditions for maintaining the Web site.
Another study involving 53 nursing students who were enrolled full time in the cooperative nursing education program at Our Lady of Lourdes School of Nursing in Camden, New Jersey, and Camden County College in Blackwood, New Jersey, indicates that nursing programs will need to continue to provide accessible educational opportunities as the demand for nurses continues to increase.21
Education is and will always be an important aspect of informatics in nursing, and the use of technology has the purpose to facilitate access to information.22
Among the main considerations in the study, we found that
* the students were unanimous in acknowledging the importance of the topic nursing staff scheduling for their training and professional life;
* the students did not have previous experience in designing nursing staff schedules;
* among the proposed activities, the students' greatest difficulty was in doing the nursing staff scheduling exercise, whether manually or on the computer;
* there is no significant difference in performance results for learning verification when comparing the groups;
* easy access was a positive aspect pointed out by the students for maintaining the Web site; and
* the great advantage pointed out by the students was the fact that they could refer to labor laws anywhere and at any time.
We admit that uncontrolled variables could interfere in the evaluation, as for instance, in which group would the more dedicated and diligent students be? Nevertheless, because the composition of the groups was random, the result is significant, as no statistical difference was found in the results between the groups, which was corroborated by the findings in the studies cited. The culture of working with technology has not been totally incorporated, considering that traditional teaching modalities still predominate, but even so, students' acceptance of the resource was observed.
From our experience, in addition to improving the program, it is also necessary to advance its operationalization by, for example, extending its use to healthcare services.
© 2011 Lippincott Williams & Wilkins, Inc.