VIRTANEN, HELI MNSc, RN; LEINO-KILPI, HELENA PhD, RN; LEINONEN, KEIJO BEng; PUUKKA, PAULI MSocSc; WÖNTSÖ, JARKKO BEng; SALANTERÄ, SANNA PhD, RN
An empowering discourse is an essential part of patient education1,2 and should therefore be part of nurse education. In Europe, empowering patient education is considered important enough to be recognized in a joint educational policy and to be part of the interpersonal competencies that must be achieved in nurse education.3 Autonomy in the construction and implementation of nursing curricula exists among European countries and among nursing schools in individual countries.4 For example, in Finland, 23 Finnish and Swedish polytechnics offer a wide variety in nurse education.5
Because of the complex scenarios that nurses encounter in practice, a constructive approach rather than an operant knowledge-acquisition approach6 is required when learning empowering discourse skills. Nowadays, many opportunities exist for the facilitation of constructive learning through the use of educational technology and multimedia learning methods.
Student control is a critical factor when multimedia learning methods are evaluated from the perspective of learning7,8 and the perspective of the pedagogical usability of a learning method as related to learning objectives.7 Student control is defined as an instructional strategy for students to regulate their own learning9 and to choose how to use a learning method.10 It is suggested that student control can be facilitated by using a computer simulation as a learning method owing to the availability of personal choices11–16 and the students’ active engagement.14–20 The use of computer simulation as a learning method in nursing education offers students an opportunity to experience some of the elements of real situations before their encounters with patients17,21 and suits different types of learners.21 The type of learner can be matched to the personal meanings that students give to studies. More specifically, students vary in the way they learn, based on different study orientations.22,23 A study orientation is a combination of different features of learning.22,24 The most common study orientations are meaning and reproduction25: meaning orientation consists of personal knowledge construction and self-regulation, and reproduction orientation consists of rote memorization and external regulation.24 The study orientation can be described also from the point of view of the student’s interest in studying,26,27 that is, whether the student is capable of active and productive study.27
The application of student control can enable learning the technique of empowering discourse by supporting the students’ own goals and enabling them to progress at their own pace.7 Without an appropriate learning method, learning empowering discourse is difficult because it requires a systematic structure and multidimensional content, composed of different aspects of patient empowerment (Figure 1).2
The structure of empowering discourse involves three phases: (1) initiation of the discourse, including the creation of an appreciative atmosphere and negotiation of the patient’s health problems and the goal of the discourse; (2) progression of the discourse, including an awareness of the patient’s existing knowledge and knowledge needs and supporting the patient’s active participation in the discourse; and (3) conclusion of the discourse, including an assessment of the achievement of the discourse’s goal.2 The content of an empowering discourse consists of biophysiology (eg, disease and treatment), functionality (eg, moving and daily activities), social (eg, social network and social support), experiential (eg, feelings, emotions, and coping), ethical (eg, patient’s rights and participation), and financial issues (eg, costs of care and financial benefits).28,29 Some methods for learning the elements of empowering discourse are online courses,30 classroom simulation,31 preparation of patient education material,32 and the health educator’s role.33 However, there is no reported learning of empowering discourse through the use of computer simulation programs.
In the higher education field, student control has been studied along with the development of educational technology and multimedia learning methods34–36 but not when using a computer simulation program as a learning method in nursing education. Computer simulations have been used, however, in several nursing areas, including problem-solving skills,19,20 critical-thinking skills,15 medication administration,11 diabetes care,18 cardiovascular assessment skills,37 resuscitation,38 electrocardiogram skills,13 intravenous catheter insertion,39 the human respiratory system,40 the management of critical care,12,14 and the management of preoperative and postoperative care.16 Although these studies have highlighted student control and issues such as the freedom to choose content and training methods using computer simulation,11–16 the evaluation of computer simulations has occurred mainly from the perspective of technical usability, including productive use of time,12 ease of navigation,12,13 flow and comprehensiveness of material,12 clarity of instructions,13 and technological access.15
The current study focused on the evaluation of student control when using a computer simulation program for learning the technique of empowering discourse. By assessing educational technologies for learning empowering discourse, one can better understand how to support this learning from the perspectives of constructive learning6 and pedagogical usability.7,41 Previous studies in other fields have indicated that some sociodemographic factors34,36 as well as a student’s study orientation35,36 could be associated with the student’s ability to control the learning process. In nursing education, research into students’ study orientation is scant26,42,43 and no previous studies have used computer simulation as a learning method for empowering discourse.
The aim of this descriptive, comparative study was to evaluate student control when using a computer simulation program to facilitate learning about empowering discourse. The following research questions were posed:
* How do nursing students use an empowering discourse computer simulation program?
* Does use of the computer simulation program differ among nursing students with different sociodemographic backgrounds and study orientations?
Our hypothesis was that students can control the use of the empowering discourse computer simulation program regardless of their sociodemographic factors and study orientation.
A sample of nursing students was recruited from graduating nursing students in 20 Finnish polytechnics that represented the east, north, south, and west of Finland. In Finland, a bachelor-level nursing degree requires 3½ years to complete44 and includes basic and professional studies, optional studies, clinical placement, and a diploma project consisting of 210 European Credit Transfer System credits.45
One polytechnic with more than 5000 students and another with fewer than 5000 students from each geographical area were randomly selected for the study, resulting in the inclusion of eight polytechnics. Nursing students were included in the study if they followed the curriculum schedule, were not exchange students from outside Finland, and were not on maternity leave.
Development of the Computer Simulation
The empowering discourse computer simulation program was developed by one researcher (H.V.) in collaboration with two nursing science researchers (H.L.K. and S.S.) and two information technology developers with expertise in multimedia and DVD technology (K.L. and J.W.). Macromedia Flash (Adobe Systems, San Jose, CA) was the main program tool; Adobe Photoshop, dpsVelocityQ (Harris Corporation, Melbourne, FL), and Soundforge (Sony Creative Software, Middleton, WI) programs were used to create the multimedia material; and ActionScript (Adobe) and PHP (an open source software available through http://www.php.net) were used as the programming languages.
) were used as the programming languages.
In the development process, the content and technical usability of the computer simulation program were evaluated. The content was evaluated by a panel of two experts in empowering patient education and nine PhD students of nursing science. Technical usability (focusing on the functionality of the pages), user activities, and the feedback system were evaluated by two multimedia and DVD technology experts. In addition, the computer simulation was pilot tested in May 2007 by graduating nursing students (N = 5) who used the program at home through the Internet. The pilot study showed that students needed some technical support to complete the simulation.
Using the Computer Simulation
The computer simulation was an interactive multimedia learning program based on the ideas of constructivism and students’ active engagement in learning.6 The aim of the empowerment discourse program (Figure 1) was to facilitate learning through a familiarization with the common structures and content in empowering discourse.
The computer simulation program contained orientation and instruction pages, a learning objective page, and a simulated discourse between a virtual female patient, admitted to the hospital for a knee arthroscopy as a day case, and a nurse. The program included 12 pages of information on empowering discourse based on scientific nursing literature.2,28,29 The simulated discourse case had six content areas in three sections. The use of the simulation program was facilitated by setting individual learning objectives and by training for empowering discourse through a multiple-choice method, an open-ended method, or both.
When using the multiple-choice method, the student chose answers to the virtual patient’s questions and comments from statements presented one by one, in random order, on the computer screen. As a result, the discourse is different each time the simulation is used. For example, when the virtual patient said the following about her activities after the operation:
An ambulatory operation is an easy way to get rid of my knee trouble and it’s good that I will be able to lie down at home. It’s nice to get an extra break,
the nurse’s choices of response were as follows:
Right, I would like to hear how you think you will manage at home after the operation (empowering response), or
Right, I’ll take care of the preparation of your operation. There is another nurse in an operating room that is waiting for you, but first, you need to go to the shower. Do you need information about washing and dressing before the operation? (nurse-centered response), or
Right! Let’s complete the Surgery and Anaesthesia Form and I will shave you. You may not eat and drink before the operation, and after the operation, you will be told what happens next (command-oriented response).
Overall, the simulated discourse provided 123 different responses by the nurse to 41 questions or comments by the patient. The student evaluated the empowering effect of each response on a dichotomous (yes or no) scale and, on request, received feedback about these responses on a dichotomous (correct or incorrect) scale.
When using the open-ended method, the student wrote the nurse’s responses to the virtual patient. For example, one comment by the patient about an ethical issue was as follows:
I have read about patient’s rights and malpractice.
The student nurse’s written response might have been the following:
There is a patient ombudsman in the hospital. If you want further information, you can contact her.
After the discourse, the student self-evaluated his/her responses in terms of model responses that have an empowering effect.
The main outcome—student control—was evaluated by measuring students’ learning objectives, students’ work with empowering discourse phases, and finally, students’ work with empowering discourse content areas. The learning objectives were acquired by asking the students to set their learning objectives for the session. Work with phases (six items: initiation, progression, and conclusion phases, each with a multiple-choice and an open-ended method) and content areas (12 items: biophysiological, functional, social, experiential, ethical, and financial areas, each with a multiple-choice and an open-ended method) were evaluated using a feedback tool in the program, which was developed for this study. The 18 items were scored using a dichotomous scale: 0, not used, and 1, used.
Students’ sociodemographic factors and study orientations were evaluated as background variables. The students’ sociodemographic factors were gathered using a questionnaire designed for this study. The chosen factors were age, basic education, vocational education, healthcare education, patient education experience and the type of patient education studies, information technology study experience, use of computer learning programs, and self-evaluated patient education and computer skills.
The students’ study orientation was measured using part of the shortened version of the Task Booklet of Learning (27 items23,46 adopted from the Inventory of Learning Styles47 and the Dualism Scale48) and part of the Inventory of General Study Orientations (10 items).49 The Task Booklet of Learning portion measured two summative variables (construction of learning and self-regulation of learning, for a total of nine items) that formed a second-tier variable of meaning orientation and measured four summative variables (intake of learning, external regulation of learning, lack of regulation, and dualistic conception of knowledge, a total of 18 items) that formed a second-tier variable of reproduction orientation.24 The scale of the second-tier variables varied from 1 (low orientation) to 5 (high orientation). Students who considered learning as a construction of knowledge and self-regulated their learning were called meaning-oriented learners. Students who perceived learning as rote memorizing, either allowed the teacher to regulate their learning or did not regulate their learning, and perceived knowledge as a set of clear, absolute, and unchanging facts were called reproduction-oriented learners.24 All 10 items of the Inventory of General Study Orientations49 measured students’ levels of interest in studying on a scale from 1 (fully disagree) to 5 (fully agree).
Data were collected during a 4-month period (September–December) in 2007. One researcher (H.V.) arranged the data collection sessions with the polytechnic teachers through e-mail and acted as a supervisor and technical expert for the students during the sessions. At the beginning of each computer simulation session at the individual polytechnics, the supervisor introduced the computer simulation to the students both orally and with written orientation information and provided each student with a username and password. The students then participated in a 90-minute empowering discourse computer simulation session through the Internet, under supervision. During the session, log files were saved automatically to the researcher’s (H.V.’s) electronic mail.
Permission to carry out this study was received from the executives of each of the six polytechnics, and permission to use the instruments was received from the developers of the instruments. All students were informed about the purpose and processes involved in the study, both orally and in writing, before the intervention. The study posed minimal risks of harm to the students; hence, students gave their informed consent only orally. Attendance at the computer simulation session and the completion of the questionnaire were taken as indications of voluntary participation.
Data for evaluating student control were based on quantitative content analysis and statistical tests using SAS release 9.1 (SAS Inc, Cary, NC). Quantitative content analysis was used to analyze the students’ learning objectives. Each objective was categorized inductively. Descriptive statistics were used for the evaluation of the students’ work with the phases and content areas of the empowering discourse. The paired t test was used to test the differences associated with using the multiple-choice and open-ended learning methods.
Descriptive statistics were used to analyze students’ sociodemographic factors and study orientations. Three summative variables representing students’ study orientations were formed by combining the nine items of the meaning orientation variable, the 18 items of the reproduction orientation variable, and the 10 items of the level of interest variable. Descriptive statistics (mean, standard deviation, median) were used for the summative variables, and a Cronbach’s α coefficient was calculated for each summative variable to test the internal consistency of the measures.
Differences associated with sociodemographics were tested using the χ2 test. To test the differences associated with the different study orientations, a k-cluster analysis (three-cluster model) was performed to find extreme groups represented by the meaning-oriented and reproduction-oriented students. Differences between the study orientation groups were then tested using the χ2 test.
To test the differences associated with the computer simulation and the level of interest in studying, a summative variable was categorized into three groups, using tertiles. Only the first and last groups were used. The first group represented students with interest in studying and the third group represented students with the highest lack of interest. Differences between these two groups were tested with the Fisher exact test. In all tests, P < .05 was considered to be statistically significant.
Students’ Background Factors
Students’ background factors were described in terms of sociodemographic factors and study orientations.
Students’ Sociodemographic Factors
The study criteria were fulfilled by 348 students. However, time scheduling difficulties prevented data collection in one southern and one northern polytechnic, so data were collected from only six polytechnics and 242 eligible students. Before the study, polytechnic teachers introduced the students to the purpose of the study and asked them to participate. Of the 242 students, 141 decided not to participate. The responses of 32 other students had to be excluded because of technical problems in saving the information from the computer simulation, leaving a total of 69 students, or 29% of invited students.
The mean age of participating students was 25 years (range, 21–48 years). The students’ sociodemographic factors are described in detail in Table 1. The 69 students graded their patient education skills, on average, as 3.35, on a scale from 1 (poor) to 5 (good). Most grades were 3 (51%, n = 35) or 4 (39%, n = 27). The students graded their skills in information technology as 3.38 on a scale from 1 to 5. Most grades were, again, 3 (45%, n = 31) or 4 (45%, n = 31).
Students’ Study Orientations
In their studies, about one quarter of the students were meaning oriented (28%, n = 19) and slightly fewer were reproduction oriented (26%, n = 18), measured on a scale from 1 (low orientation) to 5 (high orientation). All students (n = 69) were quite interested in studying (mean [SD], 2.19 [0.70]; median, 2.10) measured on a scale from 1 (interest) to 5 (lack of interest). Students’ study orientations are described in Table 2.
Student control is described in terms of the students’ learning objectives, work with the phases of empowering discourse, and work with the content areas of empowering discourse.
Students’ Learning Objectives
Nearly half of the students (49%, n = 34) set their own learning objectives, which consisted of six groups. Students wanted to learn about patient education (11 students), learn about empowering patient education (seven students), learn about supporting patients’ empowerment (seven students), and rehearse the use of the computer simulation of empowering discourse (three students). Additionally, the students wanted to evaluate their own patient education skills (three students) and understand patient empowerment (two students).
Students’ Work With the Phases of Empowering Discourse
About three quarters of the students using the multiple-choice method completed all phases of the simulated discourse (initiation, progression, and conclusion), compared with more than half of the students using the open-ended method (Table 3). About half of the students used the initiation and progression phases of empowering discourse in both learning methods. More than one third of the students used the concluding phase of empowering discourse in both methods.
Almost all students (87%, n = 60) selected the multiple-choice method in the computer simulation. Just fewer than three quarters (70%, n = 48) selected the open-ended method, and more than half of the students (59%, n = 41) used both methods. Around one quarter of the students used only the multiple-choice method (28%, n = 19), and a few students used only the open-ended method (10%, n = 7).
Students’ Work With the Content Areas of Empowering Discourse
Nearly all students (n = 68) used at least one of the content areas of empowering discourse (biophysiological, functional, social, experiential, ethical, and financial) and worked with the multiple-choice method, the open-ended method, or both (Table 3). When using the multiple-choice method, around two thirds of students (61%, n = 42) trained with the “coping with everyday life activities and rehabilitation” section, and around one third of the students trained with the other content areas. When using the open-ended method, more than one third of the students (36%, n = 25) trained with the “coping with everyday life activities and rehabilitation” section, and only a few students rehearsed discussions in other content areas. When using both learning methods, one quarter of the students (25%, n = 17) trained with the “coping with everyday life activities and rehabilitation” section. Only around 10% of the students trained in empowering discourse in other content areas, with the exception of financial issues.
The use of the computer simulation was also evaluated by considering how the students used the program as a whole (Figure 2). This evaluation revealed that 25% (n = 17) of the students used three content areas with both learning methods. Students using the multiple-choice method worked with several content areas, whereas those using the open-ended method used between one and three content areas. All eight content areas were used by 15% (n = 10) of the students working in the multiple-choice method but only 4% (n = 3) of the students working in the open-ended method. Analysis of these results showed that students working with the multiple-choice method used more content areas (mean [SD], 3.74 [2.52]) than did those working with the open-ended method (mean [SD], 2.03 [2.12]; paired t test, P < .0001).
Differences Between Students’ Background Factors and Their Use of the Computer Simulation
The differences between students’ background factors and their use of the computer simulation are reported in terms of (1) the students’ sociodemographic factors and their work in the content areas of the simulation and (2) the students’ study orientations and learning methods.
Students with different sociodemographic backgrounds used the simulation program in similar ways, with few statistically significant differences. The students who had not studied patient education during their first school year (n = 25) used the content area concerning patients’ daily functions more than did students who had completed these studies during their first year (n = 17, χ2 test = 4.51, P = .034). The students who had not studied patient education in their last school year (n = 30) used the content area concerning patients’ daily functions more than did the students who had completed these studies during their last year (n = 12, χ2 test = 6.42, P = .013).
The differences between the study orientations and the learning methods used are presented in Figure 3. The extreme groups are reported here because it was expected that these groups would differ from each other. The reproduction-oriented students used the program in more ways than the meaning-oriented students did. Of the students who showed interest in learning, a larger proportion used the open-ended version of the program than did those whose scores showed a lack of interest in learning. Both groups used the multiple-choice method equally.
This study evaluated student control in the use of a computer simulation designed to facilitate learning about empowering discourse. The study showed that, overall, the students used all the opportunities presented in the simulation program. Additionally, the results show that different learners from different backgrounds are able to use this type of computer simulation to manage their own learning. This supported our hypothesis, which was based on previous studies about student control34–36 and the use of computer simulation.21
The study findings may suggest the pedagogical usability of the computer simulation program for empowering discourse. A novel learning method of empowering discourse that focuses on learning and pedagogy, not only on technical usability, is noteworthy, as indicated in the literature.7,8,41 Our results on the use of a computer simulation program established the idea of student control in a pertinent way.9,10 In this study, the students used the program in its entirety, indicating that the students found its variety useful for achieving their set learning goals. Individual students, however, used the program in their own ways.
Our study broadened the target of evaluation for computer simulation programs. Previous studies highlighted students’ opportunities to determine the pace and selection of alternatives, but this evaluation focused on students’ subjective feelings, for example, how competent students felt in relation to learning the skills and materials13 and technical usability of the program,12,13,15 not on student control based on their use of the simulation.
Our study showed that students chose the discourse about coping with everyday life activities and rehabilitation most frequently. On one hand, this result may indicate that students found this area the most interesting one for discussion, or they wanted to practice because they lacked knowledge in this area. This conclusion makes sense because previous studies have shown that nurses tend to discuss with patients biophysiology and functionality rather than the social, experiential, ethical, or financial aspects of care.29 On the other hand, this result may indicate that students considered working in this area the most suitable or the easiest. This latter conclusion can be considered an advantage because student control should not cause cognitive overload,34,36 but the area also cannot be considered too easy because not all students chose it.
Some students wanted to use the computer simulation of empowering discourse even though they had taken previous patient education courses and had work experience in this area. This might be because nurses and nursing students consider the management of empowering discourse challenging.2 The results showed an association between the student’s previous lack of education on patient education and their rehearsal of the content. This indicates that the learning of empowering patient education should be emphasized throughout undergraduate nursing studies.
Contrary to earlier studies evaluating the use of computer simulation programs,12,13,15 this study evaluated use in association with students’ study orientations to determine whether students who are oriented for learning in different ways are equally capable of using the program. Although the differences between students with different study orientations were not statistically significant, they do provide support for the use of the computer simulation to facilitate the learning of empowering discourse. The findings showed that the computer simulation program suited both students who waited for external regulation of the learning process and students who handled their own learning process. Students who were identified as reproduction oriented used both methods in the program more frequently than meaning-oriented students did. This result may be explained by the students’ high expectations about the external regulation of their learning,24 which may be organized using the program. Overall, however, students in the sample used all program possibilities despite their study orientation, which supports the pedagogical usability of the program.
Strengths and Limitations of the Study
This study had some limitations. The data were collected from all over Finland, but the generalization of the results was limited to the target group of students due to sampling problems. Also, the sample size was smaller than anticipated because of a technical problem with the user platform that prevented some students’ responses from being saved. The loss of students from the sample further limited the study and suggests that the technical quality of the computer simulation’s user interface needs further strengthening and testing. However, the sample size was reasonable compared with previous studies focusing on computer simulations in nurse education,12–16,18 where sample sizes varied from 14 to 77 and samples were drawn from only one education unit.
Another limitation of the study was the measurement of students’ study orientations from two perspectives: students’ meaning and reproduction orientation and students’ interest in studying. From the point of view of the constructive approach to learning6 and the use opportunities offered by the computer simulation program,11–16 however, it was important to evaluate how the students perceived learning and knowledge as well as the regulation of learning, and to compare how different students used the program. In addition, from the point of view of using a computer simulation program, it was important to evaluate students’ interest in studying. In the past, interest in studying has been connected to active and productive studying,27 which is important when using a computer simulation program.
A last limitation of the study was that the computer simulation was not tested as part of the approved student nurse curriculum, making the testing situation somewhat artificial. However, the study showed that nursing students with different study orientations could use and benefit from the computer simulation. The validity of this study is based on the literature, the use of the expert panel, and the pilot study. However, further validity testing is required through additional studies with nursing students and other healthcare students.
This study provided information on the use of computer simulation as a learning method in the management of empowering patient discourse. The findings show that nursing students in this study, regardless of their sociodemographic background and study orientation, were able to control their learning by using the simulation program. These indicators support the pedagogical usability of computer simulation in the management of learning about empowering patient discourse.
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