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High tech cheating
Nurse Education in Practice (2006) 6, 364–371
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
High tech cheating Mary G. Harper
*
University of Central Florida, Orlando, Florida Hospital Memorial System, Ormond Beach, FL, 1832 South Central Avenue, Flagler Beach, FL 32136, USA Accepted 20 July 2006
KEYWORDS
Summary The use of technology has enhanced the convenience, flexibility, and efficiency of both preparatory and continuing education. Unfortunately, academic dishonesty, including plagiarism, has shown a positive correlation with the increased use of technology in education. A review of the literature related to unintended outcomes of the use of technology in nursing education and continuing education was conducted to determine the ethical implications for the nursing profession. Although nursing research dealing with academic and professional misconduct is sparse, evidence suggests that academic dishonesty is a predictor of workplace dishonesty. Given this correlation between unethical classroom behavior and unethical clinical behavior, efforts to staunch academic dishonesty may help allay professional misconduct. A combination of high tech and low tech methods may be used to minimize unethical behaviors among students and practicing professional nurses in order to maintain the integrity of the profession. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 672–679 and Nurse Education in Practice Vol. 6, No. 6, pp. 364–371.
Technology; Education; Academic dishonesty; Professional misconduct
Introduction The use of technology abounds in generic nursing programs as well as in staff development and continuing education. For example, simulation, web-based and web-enhanced classes, use of Personal Digital Assistants (PDAs), Computer Assisted Instruction (CAI), video, and webcasting are some technological innovations that may be used in the * Tel.: +1 386 615 4270; fax: +1 386 676 6115. E-mail address: [email protected].
community college or university setting (Jeffries, 2005). In addition, teleconferencing, videoconferencing, computer conferencing, web-based training, and use of organizational intranets are a few alternatives for staff development and/or continuing education program delivery (Buhmann, 2001). Furthermore, manufacturers have produced computer simulators that allow for certification in Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) without attending a live class. The advantages of the utilization of technology for education, such as convenience, flexibility, efficiency,
1471-5953/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
High tech cheating immediate feedback, and electronic completion tracking are widely recognized (Brownson, 2005; Smith, 2002). The outcomes of web-based, web-enhanced, and computer assisted education have been positive in acquisition of new knowledge and participant satisfaction (Bata-Jones and Avery, 2004; Buckley, 2003; Cobb, 2004). However, unintended outcomes, such as plagiarism and other types of academic dishonesty, may have also resulted from the proliferation of technology and warrant investigation by the profession. The purpose of this paper is to provide a review of the literature related to unintended outcomes of the use of technology in nursing education and continuing education in order to determine the ethical implications for the nursing profession. In addition, methods to minimize the unintended outcomes of the use of educational technology in both the academic and clinical setting will be explored along with implications for nursing research.
Academic dishonesty Cheating is defined as ‘‘breaking the rules to get ahead academically, professionally, or financially’’ (Callahan, 2004). The prevalence of cheating has burgeoned over the past few decades. Research indicates that from 40% to 80% of college students have cheated at least once (Brown, 2002; Callahan, 2004; Chaput de Saintonge and Palovic, 2004; Dawkins, 2004; McCabe et al., 2001; Underwood and Szabo, 2003). In a survey of 253 baccalaureate and associate degree nursing students, Brown (2002) found that from 61% to 94% of the students had seen their peers cheat while 8–39% reported that they had cheated themselves. The increased prevalence of academic misconduct is commonly attributed to technology which has facilitated cheating (Chaput de Saintonge and Palovic, 2004; Kennedy et al., 2000; Smith et al., 2005; Szabo and Underwood, 2004).
Use of technology A quick perusal of popular magazines and newspapers readily provides information on both the prevalence and use of technology for academic dishonesty (Heyman et al., 2005; Walker, 2004). New methods of using technology to cheat are discovered daily as evidenced by the recent Texas Instrument recall of a calculator after a sixth grader learned to manipulate the calculator to convert decimals into fractions (Sampson, 2005). An example of a high tech cheating device is the ‘‘KeyKat-
365 cher’’, a small device that records keystrokes on a personal computer (KeyKatcher: The Easiest Way to Monitor Your PC). It may be used to obtain an instructor’s computer password in order to access his/her files (Heyman et al., 2005). The KeyKatcher is available online for $69. Other examples of high tech cheating devices include PDAs which may be used to store notes for quizzes (Read, 2004) and cell phones, which are readily available and may be used for text messaging and calculations. Camera phones are used to take photographs of notes for reference during tests or to photograph tests to give to other students. Cell phones may also be used to access the internet to obtain answers to questions. The advent of wireless internet technology has provided further opportunities for accessing the internet to search for answers (Walker, 2004).
Plagiarism While accessing the internet to search for answers to test questions may be commonplace, perhaps the most alarming trend in internet use is plagiarism, the failure to reference another’s work (Tanner, 2004). Cyberplagiarism is a relatively new term that refers to use of information obtained from the World Wide Web (WWW) without proper citation (Eysenbach, 2000). The cut and paste function of computers turns copying a vast amount of information into a few keystrokes, making plagiarism easier than ever (Smith et al., 2005; Szabo and Underwood, 2004; Underwood and Szabo, 2003). A device called the Super Pen Professional that resembles an oversized pen advertises that it can scan and ‘‘store up to 1000 pages of information and transfer to a PC or PDA’’ (SkyMall, 2003). While it is conceivable that an author may inadvertently fail to cite properly, the opposite extreme of cyberplagiarism is the downloading of entire papers from the internet, either for free or for a nominal fee (Smith et al., 2005; Tanner, 2004). A Google search of ‘‘term paper’’ yields 44,400,000 results, the first page of which contains 16 different sites from which to purchase term papers. Some even advertise being non-plagiarized. In an investigation of student attitudes toward using the internet for plagiarism, Szabo and Underwood (2004) found that 20% of the 291 university students surveyed in the United Kingdom (UK) would ‘‘definitely resort to plagiarism to escape failing a module’’ (p. 188). Another 34% signified they would ‘‘probably’’ plagiarize, leaving less than half of the students who would accept failing. In fact, nearly one-third of the respondents acknowledged having plagiarized from the internet. The investigators posit that accessibility of
366 information on the internet is one factor that promotes ‘‘cybercheating.’’ The Assessment Project conducted by the Center for Academic Integrity (CAI) reported that the self-reported incidence of internet plagiarism among university students is 40% (McCabe, 2005). In addition, 77% of the students surveyed reported that cutting and pasting small amounts of information from internet sources is not a ‘‘serious issue’’. McCabe states that students lack clear understanding of appropriate use of the internet. A Cumulative Index of Nursing and Allied Health Literature (CINAHL) database search of the terms plagiarism and nursing returned 14 sources from 2000 forward. Of these, only three were research reports. While there appears to be consensus that plagiarism is a problem among nursing students (Bellack, 2004; Tanner, 2004), there is a paucity of nursing research that addresses the issue. Bailey (2001) investigated the perceptions of 160 faculty and 197 deans in baccalaureate nursing schools in the United States regarding what constitutes academic misconduct. Her report focused on the component of the study that investigated whether actual incidences of academic misconduct were ‘‘positive experiences’’ that followed institutional policies or ‘‘negative experiences’’ in which policy proved to be ineffective. Overall study findings supported previous research that indicates that plagiarism is an area of academic misconduct among college students. However, data concerning prevalence were not presented. In a qualitative study to explore the perceptions of 10 nursing students and eight faculty in a Canadian university, Paterson et al. (2003) found that plagiarism is perceived ‘‘primarily as a student problem caused by moral breakdown or ignorance’’ (p. 147). They also discovered that faculty response to suspected or actual plagiarism varies based on the individual faculty’s perception of student motivation in committing the academic misconduct. No data were collected to determine the prevalence of the problem.
Distance education The proliferation of internet distance education over the past decade has created a new realm for academic misconduct. Kennedy et al. (2000) investigated the views of 172 students and 69 faculty from a Midwestern United States university about cheating in distance education. The majority of both groups perceived that cheating is facilitated by distance learning. Participants indicated that in addition to traditional classroom cheating methods, the possibility exits for individuals other than the student to
M.G. Harper complete assignments and take tests. The implication of this study is that as distance education expands, academic misconduct will also increase. Baron and Crooks (2005), in their review of the literature of academic misconduct in internet based distance education, state that there is currently no data to support the implication that academic misconduct will increase with distance education. However, the investigators do not describe their review method, stating only that there is an ‘‘absence of quantitative data’’ (p. 40). They cite 12 references dating back to 1998 and relate six cases ‘‘of academic dishonesty in web-based courses reported in the distance education literature’’ (p. 40). They identified no other documented cases of academic dishonesty in their review. The scarcity of data related to academic misconduct in distance education is also reflected in the nursing literature. A CINAHL search of combinations of the terms ‘‘distance education’’, e-learning, ‘‘web-based education’’, ‘‘online education’’, nursing, dishonesty, and cheating produced no citations.
Staff development/continuing education Scant information is found concerning any form of negative outcomes related to use of technology with staff development or continuing education in nursing. However, the use of on-line delivery methods has been shown to provide opportunity for someone other than the registrant to complete the course material (Smith, 2002). In an evaluation of cheating with online continuing education for Emergency Medical Services (EMS), Eastham and Zietlow (2004) found that in addition to having another person complete the online education, Emergency Medical Technicians (EMT) reported answer-sharing, collaborating on exams and ‘‘hitting the back button at just the right moment after submitting an online quiz, allowing the cheater to change an answer just marked wrong’’ (p. 89). I am personally aware of staff collaboration to complete ACLS certification on a computer simulator. Such evidence indicates that using technology for educational dishonesty is not limited to the academic setting. In Florida, professional misconduct related to reporting of continuing education is an issue. According to Dan Coble, Executive Director of the Florida Board of Nursing, an audit of 1500 nurses’ continuing education records, revealed that onethird had not completed the required continuing education for licensure renewal even though an attestation is signed on the renewal application. Of those, approximately 100 had completed no
High tech cheating continuing education at all (personal communication, June 6, 2005).
Determinants of academic dishonesty The motivation behind the decision to engage in academic dishonesty has been the subject of significant research (Eisenberg, 2004; Love and Simmons, 1998; McCabe et al., 2001; Underwood and Szabo, 2003; Wajda-Johnston et al., 2001). Typically, the motivators are categorized as individual and contextual (Love and Simmons, 1998; McCabe et al., 2001). Early research with technology based academic misconduct indicates that the motivators are similar (Szabo and Underwood, 2004).
Individual determinants In their review of the past decade of research, McCabe et al. (2001) determined that younger, first and second year university students are more apt to cheat. Cheating was found to be more prevalent among men. These findings were supported by Szabo and Underwood’s (2004) study of plagiarism and the internet. Other individual factors that have demonstrated a correlation with academic dishonesty include low grade point averages, involvement in college athletic programs, desire and pressure to do well, indolence, irresponsibility, lack of integrity, and incompetence (Harding et al., 2004; Love and Simmons, 1998; McCabe et al., 2001).
Contextual determinants McCabe et al. (2001) determined that contextual factors are more significant than individual factors in the decision to engage in academic misconduct. Love and Simmons (1998) conducted a qualitative study with six graduate students to determine influences to cheat or plagiarize. Pressure to make good grades, lack of adequate time to complete assignments, and failure of professors to address academic dishonesty issues were identified by the participants as factors that contribute to cheating. Other studies demonstrate a strong positive correlation between peer behavior and academic misconduct (Eisenberg, 2004; McCabe et al., 2001; Wajda-Johnston et al., 2001). Contextual restraining factors identified in McCabe et al.’s (2001) review include institutional use of an honor code, fear of being reported, and penalties. No research that specifically investigated the correlation between contextual factors and academic dishonesty in web-based distance education was reviewed.
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Academic dishonesty and professional dishonesty Nonis and Swift (2001) evaluated the extension of academic misconduct into the workplace. They surveyed 1051 undergraduate and graduate business students at six universities who have held part- or full-time jobs in the past five years. Their hypothesis that cheating in college was positively correlated to cheating at work was supported. The investigators reported that a ‘‘disturbing’’ finding was that over 10% of the students indicated that over half of the behaviors were ‘‘definitely not’’ or ‘‘probably not’’ illustrations of cheating. Similarly, in a survey of 130 engineering students, Harding et al. (2004) found that academic misconduct is a positive predictor of dishonesty in the workplace. Qualitative analysis of the data revealed common elements in the decision-making process about dishonesty at school and in the workplace. The investigators posit that students who cheat in high school or college are likely to make similar decisions in the workplace. Research conducted in the 1980s demonstrated a correlation between academic dishonesty in nursing students and their propensity to engage in unethical behaviors in the clinical setting (Hilbert, 1985, 1987, 1988). In a survey of 101 baccalaureate students in their final month of nursing school (Hilbert, 1985), and in a subsequent survey of 210 nursing students in their final semester at four universities in the United States (Hilbert, 1987), significant, positive correlations were found between unethical clinical actions and academic dishonesty. Unethical clinical behaviors included actions such as taking hospital property, lying about being sick, discussing patients in inappropriate locations, falsifying documentation, and reporting for duty under the influence of drugs and/or alcohol.
Implications for the nursing profession While technology has expanded the flexibility and accessibility of education, academic misconduct has been an unanticipated outcome of its use. The ease and frequency of use of technology for academic dishonesty has been demonstrated in the literature. The seeming acceptance of such unethical behavior has tremendous implications for the nursing profession. If academic misconduct is a precursor of professional misconduct as the literature indicates, it is imperative that the nursing profession take immediate action to ensure that
368 the ethical fabric of the profession is maintained. These implications extend to many facets of the profession including education, practice and research.
Implications for nursing education Given the correlation between unethical behavior in the classroom and the clinical setting, efforts to staunch academic dishonesty may help allay unethical clinical actions. As stated earlier, research has demonstrated that contextual factors, such as peer behavior and penalties, are more significant than individual factors in the decision to engage in cheating (McCabe et al., 2001). Contextual factors including the presence of honor codes, likelihood of being reported, and perception of significant penalties for cheating have been found to be inversely related to academic misconduct (McCabe, 2005; McCabe et al., 2002). In spite of this evidence, the CAI Assessment project, in its survey of over 10,000 university faculty, found that nearly half had failed to report known cheating (McCabe, 2005). It is incumbent upon academic institutions to promote a culture where academic misconduct is not tolerated. While the implementation of technology is thought to promote academic dishonesty, a combination of low and high tech methodologies may be used to stem the increased incidence of cheating among students. For example, in the low tech arena, honor codes have been shown to reduce cheating by one-third to one-half and plagiarism by onequarter to one third (McCabe, 2005). Institutional resources for self-evaluation and development of honor codes are available at the CAI website www.academicintegrity.org. In addition, McCabe and Pavela (n.d.) have developed ten faculty principles of academic integrity that include stressing the expectation of academic integrity, maintaining an environment of trust, communicating clear expectations, challenging occurrences of academic misconduct, and supporting university standards for academic integrity. An environment in which a student recognizes not only a high risk of discovery but the likelihood of significant corrective action is necessary (Smith et al., 2005). Faculty must acknowledge and penalize academic misconduct immediately upon its discovery. The use of technology to restrain those who may be tempted to cheat includes the use of internet plagiarism search sites such as ‘‘Turnitin’’ at www.turnitin.com or Essay Verification Engine (EVE) at http://www.canexus.com/eve/ to discover plagiarized documents (Heberling, 2002; Smith et al., 2005). These sites require a paid sub-
M.G. Harper scription. They also require that student papers are available electronically which is easily accomplished by having students submit assignments using e-mail or course software. Internet search engines such as Google (www.google.com), Dogpile (www.dogpile.com), or Yahoo (www.yahoo.com) may help in the discovery of plagiarism by searching phrases that appear inconsistent with the student’s writing style (Baron and Crooks, 2005; Heberling, 2002; Smith et al., 2005). Techniques that may be employed to promote academic integrity in the distance learning environment also include a combination of high and low tech mechanisms (Baron and Crooks, 2005; Olt, 2002). For example, on-line testing log-ins may be changed for each assessment and distributed just prior to testing. All tests should be an open-book format with a pool of randomized questions so that students do not receive the same set of questions. Tests should be designed to require critical thinking as opposed to simply information retention (Fulton and Kellinger, 2004). As an alternative to testing, projects (Baron and Crooks, 2005) or case studies may be assigned (Fulton and Kellinger, 2004). Assignments that promote collaboration among students may also promote academic integrity. Frequent interaction with the student through discussions and e-mail will give faculty a sense of the student’s writing style and ability, enhancing the instructor’s ability to recognize deviations from style that may indicate plagiarism (Baron and Crooks, 2005; Olt, 2002). Finally, course assignments may be modified each term to prevent students from sharing assignments (Baron and Crooks, 2005). Fulton and Kellinger (2004) recommend a code of ethics for on-line nursing education. They maintain that an ethics framework promotes values based ethical decision-making focusing on internal determinants as described by McCabe et al. (2001). Issues that must be addressed in the proposed internet education code of ethics include content quality, security, and outcome assessment. To be effective, both students and faculty must accept the honor code.
Implications for nursing practice The correlation between academic misconduct and professional misconduct presents an area of grave concern for the nursing profession (Bailey, 2001; Bellack, 2004). A search of CINAHL, Pre-CINAHL, Health Source: Nursing/Academic Edition, PsychINFO, and Academic Search Premier electronic databases for ‘‘professional misconduct’’ and ‘‘nursing’’ produced 719 items. A scan of titles
High tech cheating indicated professional misconduct issues such as medication errors, sleeping on duty, failure to sterilize equipment between patients, lack of competence, working under the influence of alcohol, inappropriate delegation, and inaccurate documentation. No current research conducted with practicing clinical nurses was found. The dearth of nursing research related to this issue may be an indication of ignorance or a failure to acknowledge its prevalence. The nursing profession must address misconduct in the practice setting as well as in the academic setting. As previously stated, the correlation between academic misconduct and professional dishonesty seems to indicate that dealing with academic dishonesty may have a long term effect on reducing professional misconduct. Furthermore, mechanisms used in the academic setting to reduce cheating may be effective in practice settings as well. For example, a professional code of ethics, similar to an academic code of honor, may promote a practice environment that values integrity. In their description of a total healing environment, Taylor and Keigbron (2004) describe their organization’s transition from ‘‘one of mistrust, blame, and fear to one of trust, respect, integrity, commitment and quality’’ (p. 242). The organizational value of integrity requires consistency between talk and action. Hardingham (2004) posits that individual integrity is influenced by contextual factors and that a ‘‘moral community’’ is necessary. Kerfoot (1999) asserts that this is only possible in a ‘‘culture of courage and an environment that drives fear out of the workplace’’ (p. 238). The American Association of Critical Care Nurses has sponsored a white paper, ‘‘Silence Kills,’’ that calls for promotion of a culture that makes confrontation safe as a priority for health care leaders (Maxfield et al., 2005). Clearly, it is incumbent upon nursing leadership to create a culture that promotes honesty and integrity and supports those who confront professionals who are not modeling those values. As in academia, technology provides a mechanism for monitoring professional misconduct in the workplace. A hospital risk manager recently told me that nurses were falsifying blood glucose results to avoid initiation of an insulin drip and its concomitant monitoring. The falsification was technologically confirmed by using the blood glucose machines to validate actual results. The use of monitoring equipment that interfaces with electronic medical records will further enhance accurate documentation and deter falsification. Plagiarism is another aspect of unethical behavior among practicing nurses who publish, both clini-
369 cians and academicians (Bellack, 2004; Logue, 2004). Dimensions of Critical Care Nursing reported that plagiarism was identified in five percent of its manuscripts in a two year period (Cronin, 2003). Logue (2004) states, ‘‘The practice of putting your name to a piece of work when you have had little or no input is so extensive in academic and research communities that it is often regarded as the norm’’ (p. 41). While both Cronin and Logue posit that plagiarism by nurses may be attributed to ignorance of proper citation, it remains unethical (Tanner, 2004). As with student papers, internet resources are available to test for plagiarism prior to acceptance or publication of manuscripts. In the arena of continuing education, both high tech and low tech mechanisms have been implemented to deal with professional misconduct. Russell (2004) reports that the American Nurses Credentialing Center’s Commission on Accreditation altered requirements for verification of completion of continuing education programs due to technological changes such as self-learning or web-based programs. As a result, Urologic Nursing implemented a short essay evaluation method to determine what the participant learned and how he/she would apply the knowledge to practice. Initial evaluation indicated ‘‘insightful’’ and ‘‘thoughtful’’ responses. In an effort to deal with professional misconduct related to false reporting of continuing education, Florida has legislated continuing education reporting to an online database, CE Broker, by all continuing education providers. A mechanism remains, however, for self-reporting for continuing education obtained from providers outside the state of Florida. Failure to complete competency based programs such as ACLS and BLS computer simulators may impact a nurse’s ability to respond in an emergency situation. A representative of a company that produces a computer based ACLS selflearning module acknowledges that the system lends itself to completion by others in addition to or in place of the registered participant. Suggestions for preventing such unethical behavior include a separate skills evaluation by an ACLS or BLS instructor or proctored completion of the computer program.
Implications for nursing research The paucity of current research into the negative outcomes of the use of technology in nursing
370 education provides ample opportunities to expand the profession’s knowledge of this phenomenon. In the academic setting, current descriptive studies are needed to determine the prevalence, methods and attitudes of academic misconduct among nursing students. While some students do not perceive cheating as a moral issue, both students and faculty perceive different levels of wrongdoing among cheating behaviors (Lewenson et al., 2005; Tanner, 2004). Determining student and faculty perceptions of what constitutes unethical behavior is necessary to determine strategies for correction. The effectiveness of mechanisms to hinder all types of academic misconduct, including factors that influence faculty willingness to address cheating (Simon et al., 2003), in nursing warrants investigation. Research is also indicated to determine if the increase in academic dishonesty among nursing students has resulted in an increase of professional misconduct. While self-report mechanisms may provide some insight into the prevalence of misconduct, board of nursing complaints may also yield important information about reported professional misconduct. Investigation into the motivating and restraining factors for dishonesty in the clinical setting and the effectiveness of preventive actions is required. One challenge of conducting research in the area of academic and professional misconduct may be the reluctance of students and professionals to self-report, even if anonymity is ensured. Investigators must take this challenge into consideration in the design of studies.
Summary While the use of technology has enhanced the convenience, flexibility, and efficiency of both generic and continuing education, the unintended outcome of academic dishonesty, including plagiarism, has shown a positive correlation with the increased use of technology. Since academic dishonesty is a predictor of dishonesty in the workplace, it ‘‘has special relevance for those preparing to become professionals trusted with caring for and safeguarding the public’’ (Bellack, 2004, p. 527). The implementation of methods to curtail dishonesty in the academic arena may prove to be instrumental in disrupting future professional misconduct. In the meantime, interventions are necessary to restrain the practicing professional from engaging in unethical behaviors if the integrity of the profession is to be maintained.
M.G. Harper
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Nurse Education in Practice www.elsevierhealth.com/journals/nepr
High tech cheating Mary G. Harper
*
University of Central Florida, Orlando, Florida Hospital Memorial System, Ormond Beach, FL, 1832 South Central Avenue, Flagler Beach, FL 32136, USA Accepted 20 July 2006
KEYWORDS
Summary The use of technology has enhanced the convenience, flexibility, and efficiency of both preparatory and continuing education. Unfortunately, academic dishonesty, including plagiarism, has shown a positive correlation with the increased use of technology in education. A review of the literature related to unintended outcomes of the use of technology in nursing education and continuing education was conducted to determine the ethical implications for the nursing profession. Although nursing research dealing with academic and professional misconduct is sparse, evidence suggests that academic dishonesty is a predictor of workplace dishonesty. Given this correlation between unethical classroom behavior and unethical clinical behavior, efforts to staunch academic dishonesty may help allay professional misconduct. A combination of high tech and low tech methods may be used to minimize unethical behaviors among students and practicing professional nurses in order to maintain the integrity of the profession. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 672–679 and Nurse Education in Practice Vol. 6, No. 6, pp. 364–371.
Technology; Education; Academic dishonesty; Professional misconduct
Introduction The use of technology abounds in generic nursing programs as well as in staff development and continuing education. For example, simulation, web-based and web-enhanced classes, use of Personal Digital Assistants (PDAs), Computer Assisted Instruction (CAI), video, and webcasting are some technological innovations that may be used in the * Tel.: +1 386 615 4270; fax: +1 386 676 6115. E-mail address: [email protected].
community college or university setting (Jeffries, 2005). In addition, teleconferencing, videoconferencing, computer conferencing, web-based training, and use of organizational intranets are a few alternatives for staff development and/or continuing education program delivery (Buhmann, 2001). Furthermore, manufacturers have produced computer simulators that allow for certification in Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) without attending a live class. The advantages of the utilization of technology for education, such as convenience, flexibility, efficiency,
1471-5953/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
High tech cheating immediate feedback, and electronic completion tracking are widely recognized (Brownson, 2005; Smith, 2002). The outcomes of web-based, web-enhanced, and computer assisted education have been positive in acquisition of new knowledge and participant satisfaction (Bata-Jones and Avery, 2004; Buckley, 2003; Cobb, 2004). However, unintended outcomes, such as plagiarism and other types of academic dishonesty, may have also resulted from the proliferation of technology and warrant investigation by the profession. The purpose of this paper is to provide a review of the literature related to unintended outcomes of the use of technology in nursing education and continuing education in order to determine the ethical implications for the nursing profession. In addition, methods to minimize the unintended outcomes of the use of educational technology in both the academic and clinical setting will be explored along with implications for nursing research.
Academic dishonesty Cheating is defined as ‘‘breaking the rules to get ahead academically, professionally, or financially’’ (Callahan, 2004). The prevalence of cheating has burgeoned over the past few decades. Research indicates that from 40% to 80% of college students have cheated at least once (Brown, 2002; Callahan, 2004; Chaput de Saintonge and Palovic, 2004; Dawkins, 2004; McCabe et al., 2001; Underwood and Szabo, 2003). In a survey of 253 baccalaureate and associate degree nursing students, Brown (2002) found that from 61% to 94% of the students had seen their peers cheat while 8–39% reported that they had cheated themselves. The increased prevalence of academic misconduct is commonly attributed to technology which has facilitated cheating (Chaput de Saintonge and Palovic, 2004; Kennedy et al., 2000; Smith et al., 2005; Szabo and Underwood, 2004).
Use of technology A quick perusal of popular magazines and newspapers readily provides information on both the prevalence and use of technology for academic dishonesty (Heyman et al., 2005; Walker, 2004). New methods of using technology to cheat are discovered daily as evidenced by the recent Texas Instrument recall of a calculator after a sixth grader learned to manipulate the calculator to convert decimals into fractions (Sampson, 2005). An example of a high tech cheating device is the ‘‘KeyKat-
365 cher’’, a small device that records keystrokes on a personal computer (KeyKatcher: The Easiest Way to Monitor Your PC). It may be used to obtain an instructor’s computer password in order to access his/her files (Heyman et al., 2005). The KeyKatcher is available online for $69. Other examples of high tech cheating devices include PDAs which may be used to store notes for quizzes (Read, 2004) and cell phones, which are readily available and may be used for text messaging and calculations. Camera phones are used to take photographs of notes for reference during tests or to photograph tests to give to other students. Cell phones may also be used to access the internet to obtain answers to questions. The advent of wireless internet technology has provided further opportunities for accessing the internet to search for answers (Walker, 2004).
Plagiarism While accessing the internet to search for answers to test questions may be commonplace, perhaps the most alarming trend in internet use is plagiarism, the failure to reference another’s work (Tanner, 2004). Cyberplagiarism is a relatively new term that refers to use of information obtained from the World Wide Web (WWW) without proper citation (Eysenbach, 2000). The cut and paste function of computers turns copying a vast amount of information into a few keystrokes, making plagiarism easier than ever (Smith et al., 2005; Szabo and Underwood, 2004; Underwood and Szabo, 2003). A device called the Super Pen Professional that resembles an oversized pen advertises that it can scan and ‘‘store up to 1000 pages of information and transfer to a PC or PDA’’ (SkyMall, 2003). While it is conceivable that an author may inadvertently fail to cite properly, the opposite extreme of cyberplagiarism is the downloading of entire papers from the internet, either for free or for a nominal fee (Smith et al., 2005; Tanner, 2004). A Google search of ‘‘term paper’’ yields 44,400,000 results, the first page of which contains 16 different sites from which to purchase term papers. Some even advertise being non-plagiarized. In an investigation of student attitudes toward using the internet for plagiarism, Szabo and Underwood (2004) found that 20% of the 291 university students surveyed in the United Kingdom (UK) would ‘‘definitely resort to plagiarism to escape failing a module’’ (p. 188). Another 34% signified they would ‘‘probably’’ plagiarize, leaving less than half of the students who would accept failing. In fact, nearly one-third of the respondents acknowledged having plagiarized from the internet. The investigators posit that accessibility of
366 information on the internet is one factor that promotes ‘‘cybercheating.’’ The Assessment Project conducted by the Center for Academic Integrity (CAI) reported that the self-reported incidence of internet plagiarism among university students is 40% (McCabe, 2005). In addition, 77% of the students surveyed reported that cutting and pasting small amounts of information from internet sources is not a ‘‘serious issue’’. McCabe states that students lack clear understanding of appropriate use of the internet. A Cumulative Index of Nursing and Allied Health Literature (CINAHL) database search of the terms plagiarism and nursing returned 14 sources from 2000 forward. Of these, only three were research reports. While there appears to be consensus that plagiarism is a problem among nursing students (Bellack, 2004; Tanner, 2004), there is a paucity of nursing research that addresses the issue. Bailey (2001) investigated the perceptions of 160 faculty and 197 deans in baccalaureate nursing schools in the United States regarding what constitutes academic misconduct. Her report focused on the component of the study that investigated whether actual incidences of academic misconduct were ‘‘positive experiences’’ that followed institutional policies or ‘‘negative experiences’’ in which policy proved to be ineffective. Overall study findings supported previous research that indicates that plagiarism is an area of academic misconduct among college students. However, data concerning prevalence were not presented. In a qualitative study to explore the perceptions of 10 nursing students and eight faculty in a Canadian university, Paterson et al. (2003) found that plagiarism is perceived ‘‘primarily as a student problem caused by moral breakdown or ignorance’’ (p. 147). They also discovered that faculty response to suspected or actual plagiarism varies based on the individual faculty’s perception of student motivation in committing the academic misconduct. No data were collected to determine the prevalence of the problem.
Distance education The proliferation of internet distance education over the past decade has created a new realm for academic misconduct. Kennedy et al. (2000) investigated the views of 172 students and 69 faculty from a Midwestern United States university about cheating in distance education. The majority of both groups perceived that cheating is facilitated by distance learning. Participants indicated that in addition to traditional classroom cheating methods, the possibility exits for individuals other than the student to
M.G. Harper complete assignments and take tests. The implication of this study is that as distance education expands, academic misconduct will also increase. Baron and Crooks (2005), in their review of the literature of academic misconduct in internet based distance education, state that there is currently no data to support the implication that academic misconduct will increase with distance education. However, the investigators do not describe their review method, stating only that there is an ‘‘absence of quantitative data’’ (p. 40). They cite 12 references dating back to 1998 and relate six cases ‘‘of academic dishonesty in web-based courses reported in the distance education literature’’ (p. 40). They identified no other documented cases of academic dishonesty in their review. The scarcity of data related to academic misconduct in distance education is also reflected in the nursing literature. A CINAHL search of combinations of the terms ‘‘distance education’’, e-learning, ‘‘web-based education’’, ‘‘online education’’, nursing, dishonesty, and cheating produced no citations.
Staff development/continuing education Scant information is found concerning any form of negative outcomes related to use of technology with staff development or continuing education in nursing. However, the use of on-line delivery methods has been shown to provide opportunity for someone other than the registrant to complete the course material (Smith, 2002). In an evaluation of cheating with online continuing education for Emergency Medical Services (EMS), Eastham and Zietlow (2004) found that in addition to having another person complete the online education, Emergency Medical Technicians (EMT) reported answer-sharing, collaborating on exams and ‘‘hitting the back button at just the right moment after submitting an online quiz, allowing the cheater to change an answer just marked wrong’’ (p. 89). I am personally aware of staff collaboration to complete ACLS certification on a computer simulator. Such evidence indicates that using technology for educational dishonesty is not limited to the academic setting. In Florida, professional misconduct related to reporting of continuing education is an issue. According to Dan Coble, Executive Director of the Florida Board of Nursing, an audit of 1500 nurses’ continuing education records, revealed that onethird had not completed the required continuing education for licensure renewal even though an attestation is signed on the renewal application. Of those, approximately 100 had completed no
High tech cheating continuing education at all (personal communication, June 6, 2005).
Determinants of academic dishonesty The motivation behind the decision to engage in academic dishonesty has been the subject of significant research (Eisenberg, 2004; Love and Simmons, 1998; McCabe et al., 2001; Underwood and Szabo, 2003; Wajda-Johnston et al., 2001). Typically, the motivators are categorized as individual and contextual (Love and Simmons, 1998; McCabe et al., 2001). Early research with technology based academic misconduct indicates that the motivators are similar (Szabo and Underwood, 2004).
Individual determinants In their review of the past decade of research, McCabe et al. (2001) determined that younger, first and second year university students are more apt to cheat. Cheating was found to be more prevalent among men. These findings were supported by Szabo and Underwood’s (2004) study of plagiarism and the internet. Other individual factors that have demonstrated a correlation with academic dishonesty include low grade point averages, involvement in college athletic programs, desire and pressure to do well, indolence, irresponsibility, lack of integrity, and incompetence (Harding et al., 2004; Love and Simmons, 1998; McCabe et al., 2001).
Contextual determinants McCabe et al. (2001) determined that contextual factors are more significant than individual factors in the decision to engage in academic misconduct. Love and Simmons (1998) conducted a qualitative study with six graduate students to determine influences to cheat or plagiarize. Pressure to make good grades, lack of adequate time to complete assignments, and failure of professors to address academic dishonesty issues were identified by the participants as factors that contribute to cheating. Other studies demonstrate a strong positive correlation between peer behavior and academic misconduct (Eisenberg, 2004; McCabe et al., 2001; Wajda-Johnston et al., 2001). Contextual restraining factors identified in McCabe et al.’s (2001) review include institutional use of an honor code, fear of being reported, and penalties. No research that specifically investigated the correlation between contextual factors and academic dishonesty in web-based distance education was reviewed.
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Academic dishonesty and professional dishonesty Nonis and Swift (2001) evaluated the extension of academic misconduct into the workplace. They surveyed 1051 undergraduate and graduate business students at six universities who have held part- or full-time jobs in the past five years. Their hypothesis that cheating in college was positively correlated to cheating at work was supported. The investigators reported that a ‘‘disturbing’’ finding was that over 10% of the students indicated that over half of the behaviors were ‘‘definitely not’’ or ‘‘probably not’’ illustrations of cheating. Similarly, in a survey of 130 engineering students, Harding et al. (2004) found that academic misconduct is a positive predictor of dishonesty in the workplace. Qualitative analysis of the data revealed common elements in the decision-making process about dishonesty at school and in the workplace. The investigators posit that students who cheat in high school or college are likely to make similar decisions in the workplace. Research conducted in the 1980s demonstrated a correlation between academic dishonesty in nursing students and their propensity to engage in unethical behaviors in the clinical setting (Hilbert, 1985, 1987, 1988). In a survey of 101 baccalaureate students in their final month of nursing school (Hilbert, 1985), and in a subsequent survey of 210 nursing students in their final semester at four universities in the United States (Hilbert, 1987), significant, positive correlations were found between unethical clinical actions and academic dishonesty. Unethical clinical behaviors included actions such as taking hospital property, lying about being sick, discussing patients in inappropriate locations, falsifying documentation, and reporting for duty under the influence of drugs and/or alcohol.
Implications for the nursing profession While technology has expanded the flexibility and accessibility of education, academic misconduct has been an unanticipated outcome of its use. The ease and frequency of use of technology for academic dishonesty has been demonstrated in the literature. The seeming acceptance of such unethical behavior has tremendous implications for the nursing profession. If academic misconduct is a precursor of professional misconduct as the literature indicates, it is imperative that the nursing profession take immediate action to ensure that
368 the ethical fabric of the profession is maintained. These implications extend to many facets of the profession including education, practice and research.
Implications for nursing education Given the correlation between unethical behavior in the classroom and the clinical setting, efforts to staunch academic dishonesty may help allay unethical clinical actions. As stated earlier, research has demonstrated that contextual factors, such as peer behavior and penalties, are more significant than individual factors in the decision to engage in cheating (McCabe et al., 2001). Contextual factors including the presence of honor codes, likelihood of being reported, and perception of significant penalties for cheating have been found to be inversely related to academic misconduct (McCabe, 2005; McCabe et al., 2002). In spite of this evidence, the CAI Assessment project, in its survey of over 10,000 university faculty, found that nearly half had failed to report known cheating (McCabe, 2005). It is incumbent upon academic institutions to promote a culture where academic misconduct is not tolerated. While the implementation of technology is thought to promote academic dishonesty, a combination of low and high tech methodologies may be used to stem the increased incidence of cheating among students. For example, in the low tech arena, honor codes have been shown to reduce cheating by one-third to one-half and plagiarism by onequarter to one third (McCabe, 2005). Institutional resources for self-evaluation and development of honor codes are available at the CAI website www.academicintegrity.org. In addition, McCabe and Pavela (n.d.) have developed ten faculty principles of academic integrity that include stressing the expectation of academic integrity, maintaining an environment of trust, communicating clear expectations, challenging occurrences of academic misconduct, and supporting university standards for academic integrity. An environment in which a student recognizes not only a high risk of discovery but the likelihood of significant corrective action is necessary (Smith et al., 2005). Faculty must acknowledge and penalize academic misconduct immediately upon its discovery. The use of technology to restrain those who may be tempted to cheat includes the use of internet plagiarism search sites such as ‘‘Turnitin’’ at www.turnitin.com or Essay Verification Engine (EVE) at http://www.canexus.com/eve/ to discover plagiarized documents (Heberling, 2002; Smith et al., 2005). These sites require a paid sub-
M.G. Harper scription. They also require that student papers are available electronically which is easily accomplished by having students submit assignments using e-mail or course software. Internet search engines such as Google (www.google.com), Dogpile (www.dogpile.com), or Yahoo (www.yahoo.com) may help in the discovery of plagiarism by searching phrases that appear inconsistent with the student’s writing style (Baron and Crooks, 2005; Heberling, 2002; Smith et al., 2005). Techniques that may be employed to promote academic integrity in the distance learning environment also include a combination of high and low tech mechanisms (Baron and Crooks, 2005; Olt, 2002). For example, on-line testing log-ins may be changed for each assessment and distributed just prior to testing. All tests should be an open-book format with a pool of randomized questions so that students do not receive the same set of questions. Tests should be designed to require critical thinking as opposed to simply information retention (Fulton and Kellinger, 2004). As an alternative to testing, projects (Baron and Crooks, 2005) or case studies may be assigned (Fulton and Kellinger, 2004). Assignments that promote collaboration among students may also promote academic integrity. Frequent interaction with the student through discussions and e-mail will give faculty a sense of the student’s writing style and ability, enhancing the instructor’s ability to recognize deviations from style that may indicate plagiarism (Baron and Crooks, 2005; Olt, 2002). Finally, course assignments may be modified each term to prevent students from sharing assignments (Baron and Crooks, 2005). Fulton and Kellinger (2004) recommend a code of ethics for on-line nursing education. They maintain that an ethics framework promotes values based ethical decision-making focusing on internal determinants as described by McCabe et al. (2001). Issues that must be addressed in the proposed internet education code of ethics include content quality, security, and outcome assessment. To be effective, both students and faculty must accept the honor code.
Implications for nursing practice The correlation between academic misconduct and professional misconduct presents an area of grave concern for the nursing profession (Bailey, 2001; Bellack, 2004). A search of CINAHL, Pre-CINAHL, Health Source: Nursing/Academic Edition, PsychINFO, and Academic Search Premier electronic databases for ‘‘professional misconduct’’ and ‘‘nursing’’ produced 719 items. A scan of titles
High tech cheating indicated professional misconduct issues such as medication errors, sleeping on duty, failure to sterilize equipment between patients, lack of competence, working under the influence of alcohol, inappropriate delegation, and inaccurate documentation. No current research conducted with practicing clinical nurses was found. The dearth of nursing research related to this issue may be an indication of ignorance or a failure to acknowledge its prevalence. The nursing profession must address misconduct in the practice setting as well as in the academic setting. As previously stated, the correlation between academic misconduct and professional dishonesty seems to indicate that dealing with academic dishonesty may have a long term effect on reducing professional misconduct. Furthermore, mechanisms used in the academic setting to reduce cheating may be effective in practice settings as well. For example, a professional code of ethics, similar to an academic code of honor, may promote a practice environment that values integrity. In their description of a total healing environment, Taylor and Keigbron (2004) describe their organization’s transition from ‘‘one of mistrust, blame, and fear to one of trust, respect, integrity, commitment and quality’’ (p. 242). The organizational value of integrity requires consistency between talk and action. Hardingham (2004) posits that individual integrity is influenced by contextual factors and that a ‘‘moral community’’ is necessary. Kerfoot (1999) asserts that this is only possible in a ‘‘culture of courage and an environment that drives fear out of the workplace’’ (p. 238). The American Association of Critical Care Nurses has sponsored a white paper, ‘‘Silence Kills,’’ that calls for promotion of a culture that makes confrontation safe as a priority for health care leaders (Maxfield et al., 2005). Clearly, it is incumbent upon nursing leadership to create a culture that promotes honesty and integrity and supports those who confront professionals who are not modeling those values. As in academia, technology provides a mechanism for monitoring professional misconduct in the workplace. A hospital risk manager recently told me that nurses were falsifying blood glucose results to avoid initiation of an insulin drip and its concomitant monitoring. The falsification was technologically confirmed by using the blood glucose machines to validate actual results. The use of monitoring equipment that interfaces with electronic medical records will further enhance accurate documentation and deter falsification. Plagiarism is another aspect of unethical behavior among practicing nurses who publish, both clini-
369 cians and academicians (Bellack, 2004; Logue, 2004). Dimensions of Critical Care Nursing reported that plagiarism was identified in five percent of its manuscripts in a two year period (Cronin, 2003). Logue (2004) states, ‘‘The practice of putting your name to a piece of work when you have had little or no input is so extensive in academic and research communities that it is often regarded as the norm’’ (p. 41). While both Cronin and Logue posit that plagiarism by nurses may be attributed to ignorance of proper citation, it remains unethical (Tanner, 2004). As with student papers, internet resources are available to test for plagiarism prior to acceptance or publication of manuscripts. In the arena of continuing education, both high tech and low tech mechanisms have been implemented to deal with professional misconduct. Russell (2004) reports that the American Nurses Credentialing Center’s Commission on Accreditation altered requirements for verification of completion of continuing education programs due to technological changes such as self-learning or web-based programs. As a result, Urologic Nursing implemented a short essay evaluation method to determine what the participant learned and how he/she would apply the knowledge to practice. Initial evaluation indicated ‘‘insightful’’ and ‘‘thoughtful’’ responses. In an effort to deal with professional misconduct related to false reporting of continuing education, Florida has legislated continuing education reporting to an online database, CE Broker, by all continuing education providers. A mechanism remains, however, for self-reporting for continuing education obtained from providers outside the state of Florida. Failure to complete competency based programs such as ACLS and BLS computer simulators may impact a nurse’s ability to respond in an emergency situation. A representative of a company that produces a computer based ACLS selflearning module acknowledges that the system lends itself to completion by others in addition to or in place of the registered participant. Suggestions for preventing such unethical behavior include a separate skills evaluation by an ACLS or BLS instructor or proctored completion of the computer program.
Implications for nursing research The paucity of current research into the negative outcomes of the use of technology in nursing
370 education provides ample opportunities to expand the profession’s knowledge of this phenomenon. In the academic setting, current descriptive studies are needed to determine the prevalence, methods and attitudes of academic misconduct among nursing students. While some students do not perceive cheating as a moral issue, both students and faculty perceive different levels of wrongdoing among cheating behaviors (Lewenson et al., 2005; Tanner, 2004). Determining student and faculty perceptions of what constitutes unethical behavior is necessary to determine strategies for correction. The effectiveness of mechanisms to hinder all types of academic misconduct, including factors that influence faculty willingness to address cheating (Simon et al., 2003), in nursing warrants investigation. Research is also indicated to determine if the increase in academic dishonesty among nursing students has resulted in an increase of professional misconduct. While self-report mechanisms may provide some insight into the prevalence of misconduct, board of nursing complaints may also yield important information about reported professional misconduct. Investigation into the motivating and restraining factors for dishonesty in the clinical setting and the effectiveness of preventive actions is required. One challenge of conducting research in the area of academic and professional misconduct may be the reluctance of students and professionals to self-report, even if anonymity is ensured. Investigators must take this challenge into consideration in the design of studies.
Summary While the use of technology has enhanced the convenience, flexibility, and efficiency of both generic and continuing education, the unintended outcome of academic dishonesty, including plagiarism, has shown a positive correlation with the increased use of technology. Since academic dishonesty is a predictor of dishonesty in the workplace, it ‘‘has special relevance for those preparing to become professionals trusted with caring for and safeguarding the public’’ (Bellack, 2004, p. 527). The implementation of methods to curtail dishonesty in the academic arena may prove to be instrumental in disrupting future professional misconduct. In the meantime, interventions are necessary to restrain the practicing professional from engaging in unethical behaviors if the integrity of the profession is to be maintained.
M.G. Harper
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