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W201061194 abstract "INTRODUCTION The Way We Were … A lot has changed over the years since I was a student in physical therapy school, as I began my clinical practice, and since I entered academia. As students, we walked to class (when living in the dorm on campus), attended face-to-face classes, took notes based on the statements made by the “sage on the stage,” read textbooks, and viewed slides projected on the screen (or wall!). We studied in groups in dorms or in the library or Student Union Building (SUB), and researched for hours in the “stacks” in the library—using a card catalog to find books. We took tests that were copied on mimeographed paper (and left purple ink on our hands). We registered for classes by going to tables setup in a gymnasium, standing in lines to wait our turn, and paid by check at the “last table.” A lot has changed over the years since I began my clinical practice. As a young clinician, I wore the “dress code” of my facility: brown pants and a white zippered top with the American Physical Therapy Association (APTA) patch on the sleeve (as a student, I also wore a university pin on my lapel); scrubs were only worn by MDs in surgery. I wrote assessments and progress notes by hand. I communicated with other health care providers by mailed letters and a desk phone. I expanded my knowledge and clinical expertise by watching colleagues and attending continuing education courses. Word-of-mouth and personal testimonies of “what works” were all the “proof” we needed to change our interventions and techniques. A lot has changed over the years since I entered academia. As a new faculty member, I taught exclusively face-to-face in classrooms, asked questions of individual students in class, posted grades by students' social security number outside my office door to maintain confidentiality. I purchased VHS tapes to show in labs so that students could see a movement pattern or a child with a particular medical condition. I had slides made from pictures in textbooks. I made transparencies for overhead projectors and saved them in a paper file folder so I didn't have to recreate them in future classes. I expected students to attend my class and take notes; classroom interruptions were limited to fire drills or small discussions that might occur among students. I wrote lecture outlines and exams in longhand and gave them to a departmental administrative support person (secretary) to be typed. I did not have a computer in my office to serve as a word processor; none of the faculty did. Do I want to go back to those times? No. So many things have changed and for the most part, they are advances, but life was a bit simpler then, it seems. I want to spend some time looking at some of the changes in the technology used in health care education and how these changes impact our teaching and mentoring of students/clinicians and our patient education, and review what the literature has revealed to us about those technological changes. It seems our vocabulary has changed dramatically since those days: Laptops? Podcasts? Blogs? (Figure). Certainly, students have changed. Today's students are no longer the people that our education system was designed to teach. Another way to think of this might be to sort ourselves into “Digital Natives” or “Digital Immigrants,” terms coined by Marc Prensky about 10 years ago.1Figure. Current Terms in AcademiaDigital Natives, Digital Immigrants Digital Natives are today's students, K through college, which represent the first generations to grow up with these new technologies. They have spent their entire lives surrounded by and using computers, videogames, digital music players, video cams, cell phones, and all the other toys and tools of the digital age. Our students today are all “native speakers” of the digital language of computers, video games, and the Internet. Digital Natives are used to receiving information really fast. They like to parallel process and multi-task. Digital Immigrants are all of the rest of us. As instructors, we are Digital Immigrants and must learn to adapt to our environment. Prensky feels that the single biggest problem facing education today is that our Digital Immigrant instructors, who speak an outdated language (that of the pre-digital age), are struggling to teach a population that speaks an entirely new language. Digital Natives often can't understand what the Immigrants are saying. What does “dial” a number mean, anyway? As Digital Immigrants learn—like all immigrants, some better than others—to adapt to their environment and accept this new culture, they retain, to some degree, their “accent,” that is, their foot in the past. Some find it harder than others to leave their “comfort zone.”1 Most educators are aware of the body of literature regarding learning styles and have heard that teachers, overall, tend to teach others in the style that they most like to learn new material themselves, assuming that this works for others. With experience, we recognize that there are different learning styles, and our goal is to present information in various ways so that students with learning styles different from our own will be able to master the material we present.2 But what happens when the instructor's teaching style is from a different age (ie, the pre-digital age?) than the student's learning style? Basically, that is what is happening now (and has been for a number of years): Digital Natives versus Digital Immigrants. Federal Policies and Legislation Related to Technological Literacy Let's look at the federal policies and legislation that have facilitated our society's adoption of technology. In the 1983 federal report, A Nation at Risk, it was recommended that all high school graduates have mastery of the 5 new basics: English, math, social studies, science, and computer science.3 Some of us graduated from high school before 1983, so our “mastery” of computers has been achieved at work or in our homes. Consequently, we have more of a patchwork of computer skills: e-mails, maybe rudimentary searching capabilities, word-processing skills, etc. We may or may not use computers for documentation in our employment settings. Nearly 20 years after the A Nation at Risk report, the No Child Left Behind4 legislation in 2001 recommended that all eighth-grade students have the ability to use computers to communicate with others, to locate and manage information for personal and professional use, and to use these tools to support learning the content of “the other basics”—in other words, to gain technological literacy. So there was an expectation in 1983 that twelfthgraders be computer literate; in 2001, it was expected that eighth graders have technology literacy. Outcomes of Technological Literacy It looks as if these policies and legislation have been effective. In 2007-2008, about 4.3 million undergraduate students, or 20% of all undergraduates, took at least 1 course through distance education. About 800,000, or 4%, of all undergraduates took their entire program through distance education. In addition to these undergraduate students, about 800,000, or 22%, of all postbaccalaureate students took distance education courses in 2007-2008.5 Literature Review of Technology in the Education of Health Care Professionals and Their Patients/Clients Let's see what the literature tells us about the use of technology in the classroom, online programs, clinical education, continuing education, and clinical/patient education. See Table 1 for a list of the uses of technology in the classroom. In 1986 (the year I joined the University of Texas Medical Branch (UTMB) faculty), Phelps and Abedor6 suggested the cutting-edge ideas of using “microcomputers” to create course syllabi, exams, handouts, spreadsheets for course grades, etc.6 We've come a long way in those 25 years! In the mid 1990s, Sanford et al7 investigated the use of videodisc for independent study of clinical findings in arthritis for occupational and physical therapist (PT) students, comparing the performance of 2 groups of students. The videodisc group had significantly higher scores on the slide (graphic) questions.Table 1: Uses of Technology in the ClassroomHybrid, also known as “blended,” distance courses have been utilized in professional physical therapist education programs for a number of years. In response to a rural health initiative, the University of Kentucky developed an innovative distance learning program of physical therapy instruction in the early 1990s that combined classroom lecture and discussion via compressed video technology with laboratory experiences. The authors describe the development of a distance learning course in pathomechanics for the master's-degree physical therapist students.8 In 2008, Maring et al9 reported the use of distance education technology in the delivery of a pathophysiology course to 96 physical therapist students. Each student received half the course instruction in traditional format and half using distance education. Most recently, Bayliss and Warden11 created a hybrid course in cardiopulmonary. Half of a module (3 classes) was presented in traditional lecture format; the other half comprised of electronic lectures and small-group, problem-solving activities. Students did significantly better on test questions related to material presented in the hybrid classes.11 Web-based tutorials have been developed for occupational therapist students to offer interactive instructional strategies, allowing for self-directed learning. When comparisons of performance outcomes before and after the tutorial were developed, it was found that fewer occupational therapist students fell below the class average on exams after using the tutorial.11 Goldman et al12 reported on small seminar blogs used in a course with graduate students in public health. A majority of the students reported that blog participation enriched their learning; 60% found it easier to write on the blog than to speak in class. The authors concluded that small seminar blogs offer opportunities for increased student participation, interaction, and learning.12 Audience Response Systems (ARS) and clickers (think “poll the audience” in various TV game shows) have been used in classroom settings. Wait et al13 reported that second-year Doctor of Physical Therapy (DPT) students served as tutors or lab assistants and created ARS quizzes and administered them at the beginning of weekly peer-teaching study sessions for first-year students. Both sets of students were surveyed for their impressions. Students felt that the use of clickers provided first-year students with instant feedback, plus they allowed the “teachers” to know if the students were getting the concepts. Caudle et al14 discussed computer-based testing (CBT) in a distance education program for graduate nursing students. A post-CBT survey captured students' opinions of the experience. Home-based CBT brings a unique set of challenges, ranging from test security to the institutional response (help desk able to help? timely?) to student issues during the test-taking period. Test-taking is a stressful activity for students; the addition of a new technology for test-taking may increase some students' level of anxiety.14 Even on-campus CBT can be challenging, getting the technology to work. Last, podcasts and “class capture” are scrutinized in an article by Allen and Katz.15 The authors studied dental students' use of podcasts in courses and found that the podcasts were preferred over lecture transcript when studying for exam, reviewing an attended lecture, and especially when reviewing a missed lecture. However, the students didn't want to give up the transcript service; they wanted both learning supports. Further, it was found that younger students tended to listen to the podcasts at 1.5 to 2 times the real-time speed15: Digital Natives! There are other ways that faculty are using technology in classes. An October 2011 PT in Motion article16 revealed interviews with several physical therapy faculty using the following: Interactive computer programs to assist students with developing skills in differential diagnosis Flip© camera in class to capture a specific movement for further analysis, then post on YouTube© Flip© camera to capture a demonstration and download video to iPhones© so that the students can compare their movements to instructors iTunes University® to post class lecture and PowerPoint slides so that students can view it prior to class, allowing more time in class devoted to lab instruction and hands-on practice There's no doubt that these creative uses of technology in the classroom are exciting to students, and I agree with one person interviewed that if it is more fun, students will spend more time with it. I encourage all of us to provide the “evidence” that these new technologies are giving us the learning outcomes that we expect. Learning Outcomes Using technology just to be “current” is not our goal as educators. Students report that whether in traditional face-to-face courses or distance delivery, it is the quality and effectiveness of instructor and instruction, not the technology, that is associated with satisfaction. The use of technology in any capacity does not guarantee academic success, but indications from some studies suggest that it does not necessarily have any significant negative effects, and may benefit some learners (Table 2).Table 2: Learning OutcomesSome studies have focused on the question of whether differences exist in learning between traditional classes and online courses. Wegner et al17 studied 2 groups of students in a graduate education curriculum and instruction course. The students self-selected into a traditional class or a web-based class. There were no significant differences between the 2 groups on final exam scores, and no significant differences in student evaluations between the 2 courses. In 2003, Cook and Merrifield18 reported on the use of distance education in the preparation of entry-level physical therapist students in the 1990s. One cohort of students was located on the main campus, with another at a satellite campus in another town. Many lectures were simultaneously presented using closed-circuit television; laboratory classes were held on the individual campuses. No statistically significant differences in grade point averages or dropout rates were found in the student groups regardless of which campus the students graduated, suggesting that the hybrid distance education program was effective in the academic preparation of entry-level PT students. It's been argued that students need to be in a “community” in order to develop their professional identity, and some question if this could be done in distance courses. Rush et al19 examined self-reported professional development among nursing students enrolled in an online program. The students revealed that they “evolved as professionals along many dimensions”19(p288) during the online program. The role of interaction in the attainment of professional socialization appears to be satisfied in a graduate program offered through distance education. Bonnel20 reported that students in online programs become more active participants and learners. In online courses, students take on new roles, have more responsibilities, and are more active participants providing feedback through discussions and group projects and assignments. They become more active learners and refine critical thinking skills.20 In the Maring et al study mentioned earlier, where distance education technology was used in the delivery of a pathophysiology course to PT students, the students scored significantly better on questions based on material presented in the distance format, but the students reported preferring the traditional course format. Another study involved students in an occupational therapist education program.21 All 6 courses in the first semester of an occupational therapist education program were offered to small number of students using only distance education. Students in the experimental group completed the semester with comparable grades to those in the traditional program, successfully completing the occupational therapist program. These last studies focus on discussion boards, which can be helpful in face-to-face classes, too. Discussion boards are critical to course interaction among online students. We offer an online DPT program in a transition format at the University of Texas Medical Branch (UTMB), and I have found that experienced PTs are not shy about posting their opinions, questions, or impressions on course discussion boards. Picciano22 studied graduate students enrolled in an administration course. The authors investigated the number of postings and students' perception of learning and perceived interaction. Findings revealed that actual student interaction as measured by the number of postings on the discussion board had no relationship to performance on the examination, but it did have a relationship to the written assignment. Authors found a strong relationship between students' perceptions of interaction and perceived learning.22 In a study by Barnett-Queen et al,23 participants in a distance education majors program indicated that online discussions facilitated interactions more than a traditional classroom. Authors found the quantity and quality of student input was greater online than in the traditional classroom. Some critics have questioned if a sense of community can be achieved in online courses. To investigate this, Gallagher-Lepak et al24 reported the results of qualitative research obtained from online nursing students. In focus groups, students shared their perceptions of “community” in online courses. Among the themes identified, those that assisted in developing the sense of community were: (1) class structure (course activities such as discussion boards); (2) required participation (requiring students to post a response to a discussion board question or respond to classmate posting; in face-to-face classes, some students never comment); and (3) opportunities for informal discussions via a “chat” area so that students can ask each other about children, weather, job experiences, etc. At UTMB, this is called the UTMB café. In a recent study by Wong and Abbruzzese,25 3 clinical cases were developed in a physical therapist education program—orthotics, gait analysis, and soft tissue mobilizations—that required collaborative learning activities in online communities. Some used “wiki” space, where students could share information; some required videostreaming; and others required the students to use teamwork and peer feedback. At least threefourths of the students voted to keep or expand the collaborative activities. Many physical therapist education programs now offer a transitional Doctor of Physical Therapy degree (entry-level degree to DPT) for experienced physical therapists using online technology, whether blended or completely online. But, what is needed for an online program to be successful for both the faculty and students? What Faculty Need to Teach Online Teaching online requires more than just posting PowerPoint files to a course management system. It requires a new way of thinking of the course content and knowing how to best convey the important concepts to others when they can't hear the intensity and excitement in your voice (Table 3). Faculty need time to think of alternative ways to present material.26 The use of CAI (computer-aided instruction) or distance education requires a different way of thinking about the material (and how it will be presented, studied, and compartmentalized) than what the instructor may have done in face-to-face courses.Table 3: What Faculty Need to Teach OnlineIt is not enough to just post a PowerPoint or handout on a classroom management system, or e-mail it to students. You must really think about how the material will be consumed by the learners, and how you need to guide them to get out of the course material what you wanted them to get out of it. The role of the instructor becomes one of preparing the instructional environment, anticipating the needs of the students in advance, and providing contingencies.17 We are no longer the “sage on the stage” but the “guide on the side.” Faculty also need time to provide continued presence in the course.20,27 It is suggested that faculty provide weekly bulleted feedback to the learning community on what has been accomplished; posing prompting and questioning techniques that elicit further student reflection on course material.20,27 In online courses, faculty are not able to answer questions at end of a class, so they need to monitor how things are going on discussion boards and be available to troubleshoot when technology hiccups. Several authors have discussed the need for faculty teaching online to have institutional support. Knowledgeable personnel need to orient faculty to the technology and provide suggestions on adapting course materials to the technology; they need to determine that the technology will work as expected and be there when it doesn't. Remember, faculty members are Digital Immigrants!21,25,26,28 Finally, a distance education coordinator is recommended to facilitate the creative and educational theory process for distance course development, serve as a central contact for communications for all to assure there is well-developed technological support, and coordinate logistical details for issues as they arise.21,29 What Students Need to Learn Online Students, too, need additional characteristics and supports to be successful in online courses (Table 4). Students need to be organized and skilled in time management.9,26 As noted earlier, Maring et al9 used distance education technology in the delivery of a pathophysiology course to physical therapist students. The students in this study reported increased reading/research in the online course, a tendency to procrastinate, and difficulty being organized. Students need to be active learners and participate in required course activities.26 This is a consistent finding in the literature review summarized by these authors: Students “get out of it what they put into it.”Table 4: What Students Need to Learn OnlineStudents need to be comfortable with technology; they need to have available reliable technology and support.21,30,31 Caison et al30 reports on the use of the Technology Readiness Index32 to examine the technology readiness of nursing and medical students. Rural nursing students were more insecure with technology than their urban counterparts, male medical students had a higher overall technology readiness attitude than female medical students, and (medical students older than 25 have a negative technology readiness score compared to those under 25 who had a positive score30; again, they were Digital Immigrants. At UTMB, on our website, students can assess their readiness for online learning using a self-administered, confidential survey like Washington Online.33 Dorrian and Wache31 caution that flexible delivery techniques, including online technologies, can be used to cater to the differing needs of students, but also can cause anxiety in students who are unfamiliar with the online environment. Strong student support services should be in place for those institutions that are going to utilize distance education.34 Students need access to tech help and library resources. Campus administrative offices need to be aware that some students don't come to campus and brainstorm how to serve these students differently. Similarly, students need an orientation to the online course and instructor expectations.20 Experienced online course instructors will not immediately jump into course content in the first week of class, but will allow some time for technology issues to be resolved. They will design the first few exercises to familiarize the students with the technology and its functionality. They will use grading rubrics for assignments so that students know what is expected of them. Last, students need a variety of modes of interaction. Distance learning is not just passive learning from posted PowerPoint files; activities should be included that allow for various types of interaction in the course. Thurmond and Wambach35 maintain 4 types of interaction are important in designing effective online courses. The first 3 listed below fit any course, even traditional ones: Learner-to-Content Interaction results from students examining the course content and participating in class activities (eg, reading a chapter or journal article; taking an online quiz; using the course syllabus to plan; reading a PowerPoint presentation.) Learner-to-Learner Interaction can take place between 2 students or between several students (eg, interactions that occur on a course discussion board or blog, or teamwork on group assignments). Learner-to-Instructor Interaction is intended to reinforce student understanding of course material and provide the student with feedback (eg, submitting a paper or exam to an instructor and receiving instructor comments/viewing ongoing grades in course grade book). Learner-to-Interface Interaction is unique to online, web-based courses and occurs between student and the technology employed (eg, computer hardware, software, internet connection). This is often a source of stress/anxiety for the student, especially the Digital Immigrant (eg, links that don't work, loss of internet connection). They assume that something is wrong with their computer. Benefits of Technology/Computer-Assisted Instruction (CAI) There are a number of benefits of technology to faculty members, institutions, and students (Table 5). Course interactivity fosters independence in student attainment and assimilation of content.17,36 This represents a paradigm shift: Teachers take on the role of “coach” rather than “instructor” in distance learning courses; students are in charge of their own learning and degree of success. Students have more responsibility and more accountability in online courses, providing feedback in discussions and group assignments.20 Online learning requires each student to respond. It changes the dynamic of some students who might formerly have relied on others in the group—they must now contribute individually. For institutions, the use of new technology is seen as a way to attract students; thus, increasing enrollment, improving teaching and learning at the institution, and making more efficient use of instructional and physical resources.26Table 5: Benefits of Computer-Assisted Instruction/Distance EducationResearchers have cited the following benefits of distance education for students: (1) it allows increased access to a variety of courses26; (2) it provides more convenience when scheduling course work and less disruption to personal and professional lives9,26; (3) it enables students to be more active learners and refine critical-thinking skills in online courses20; (4) it is cost-effective if not necessary to relocate to campus site9; and (5) it provides immediate feedback through interactive modules.11 The interactivity translates to no need for the student to wait for a faculty member to return papers or “log on” to give feedback. Use of Technology in Clinical Education I didn't find many articles that address the use of technology in the clinical setting when mentoring students for professional programs. Maybe some have used Skype© or other technology to “visit” students and clinical instructors at geographically distant clinical sites. I would encourage all of us to think of ways that we can—and have—used technology during clinical education experiences, and then submit those manuscripts to the Journal of Physical Therapy Education. Graf and Stebnicki37 reported on the use of e-mail for communications between rehabilitation counseling students and practicum supervisors in a clinical setting. The students reported the e-mails to be useful in between scheduled, periodic individual and group sessions, and that they provided them with much more support, resources, and reflection than they could have had with only face-to-face individual supervision. The authors noted that the e-mails were used in addition to, or to enhance, the supervisor/student interactions—rather than as a substitute for scheduled interactions. The use of a virtual learning environment in occupational therapy clinical fieldwork experiences is reported by Thomas and Storr.38 WebCT&copy discussion boards were utilized for 42 occupational therapist students on a 6-week clinical fieldwork placement. Authors reported that the majority of students liked it. Participation in WebCT discussion boards during fieldwork appears to have a beneficial effect on student learning and allows for peer learning. Ferenchick et al39 reported using Personal Digital Assistants with 95 medical students on 8-week internal medicine clerkships (the PDAs were used in lieu of fax or e-mail). All students were able to download the educational objectives and administrative tools and upload their logs with minimal technological problems. In addition, the students' logs were successfully used by directors to monitor and document their patient interactions. I'm sure this saved the instructor's e-mail inbox from having 95+ e-mails with attachments! Use of Technology in EBP/Continuing Education We'll spend a bit of time now looking at the use of technology in evidence-based practice (EBP) and continuing education venues. In Physical Therapy in 1997, authors Tassone and Speechley40 surveyed rural and urban physical therapists in Canada. At that time (14-15 years ago), the results indicated that conferences or workshops should be the primary delivery format of continuing education (CE) programs and that the use of CAI should be further developed and evaluated. More recently, in" @default.
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W201061194 title "Pauline Cerasoli Lecture 2012 Googling and Texting and Browsing, Oh My! Mentoring and Teaching in an Electronic Age" @default.
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