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Telecommunications and nursing education
Telecommunications and Nursing Education ROSALEE C.
YEAWORTH,RN, PHD,* REBA A. BENSCHOTER,PHD,t
ROBIN METER, BA,$ AND SANDRa BENSON, MA§
Telecommunications are becoming increasingly important to nursing educators. At the University of Nebraska Medical Center College of Nursing, communication by two-way television, computers, facsimile machines, and telephone conferences is essential to the administration and operation of a school with four divisions located across 500 miles. Two-way television is available through one system that uses satellite and fiberoptic technology and another that uses telephone lines. The four campuses of the college share classes, administrative meetings, and conferences through television. Faculty members teaching via TV are oriented to designing instructional material for transmission and to the minor quirks of the technology. Students in TV classes must be aware of their responsibility for active involvement in learning. Studies have found no significant differences in the grades of students in "live" classrooms and those in TV classrooms, but both faculty and students prefer the face-to-face situation. The College of Nursing uses computers extensively on an internal network linking the four campuses for E-mail, file transfer, computer-assisted instruction, and administrative information sharing. Another computer network, Synapse Health Resources Online, links the college and the Medical Center with health professionals in rural areas throughout the state. (Index words: Computers; Nursing education; Telecommunications; Television.) J Prof Nurs 11: 227-232, 1995. Copyright © 1995 by W.B. Saunders Company
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E L E C O M M U N I C A T I O N S - e l e c t r o n i c communications over long distances-are becoming more and more essential to nursing educators as they extend programs and services into regions beyond the *Dean Emeritus & Professor, The University of Nebraska Medical Center, College of Nursing, Omaha, NE. tDirector, Biomedical Communications, and Associate Dean, School of Allied Health Professions, The University of Nebraska Medical Center, Omaha, NE. $Synapse Supervisor, Computing Services, The University of Nebraska Medical Center, Omaha, NE. §Assistant Professor, Biomedical Communications, School of Allied Health Professions, The University of Nebraska Medical Center, Omaha, NE. Address correspondence and reprint requests to Dr. Yeaworth: The University of Nebraska Medical Center, College of Nursing, 600 South 42nd Street, Omaha, NE 68198-5330. Copyright © 1995 by W.B. Saunders Company 8755-7223/95/1104-000853.00/0
Journal of ProfessionalNursing, Vol
traditional nursing school campus. Telecommunications are now used both for administrative purposes and for offering credit courses and continuing education programs in locations previously inaccessible to learners. As Nursing Centers are developed, electronic technology will likely be used for information and billing systems. The U n i v e r s i t y of N e b r a s k a Medical C e n t e r (UNMC) and its College of Nursing have been pioneers in using telecommunications to share education and services with areas of the state far from the Medical Center in Omaha. During the past three decades, the College of Nursing has grown to cover the entire state, and early efforts at telecommunication have evolved into today's system, which incorporates technology ranging from basic telephone and facsimile machine connections to sophisticated satellite television networking and computer access to nationwide resources.
Background The U n i v e r s i t y of N e b r a s k a , the only statesupported university in Nebraska, includes the Medical Center in Omaha, along with general campuses in Omaha, Lincoln, which is 55 miles from the Medical Center, and Kearney, which is 180 miles distant. Part of the Medical Center's mission is to provide education leading to degrees in health professions for citizens of the entire state. The challenge inherent in that charge is to make educational programs available not only in the cities of Omaha and Lincoln, but also in remote, primarily rural areas in a state that spans more than 500 miles from east to west. The Medical Center was active in the early days of telecommunications. In 1964, it established the nation's first long-distance two-way television system dedicated to medical uses (Benschoter, 1967). The system linked the Nebraska Psychiatric Institute in Omaha with the Norfolk State Mental Hospital, 110 miles away. In 1968, a second two-way TV network was formed, connecting Nebraska's Veterans Administration (VA) hospitals in Omaha, Lincoln, and
11, No 4 (July-August), 1995: pp 227-232
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Grand Island with the Medical Center (Wittson & Benschoter, 1972). Among the uses of the VA network was the transmission of continuing education programs to nurses and other professionals in the VA hospitals and surrounding communities. Such courses as "Update and Review of Pharmacology" and "Introduction to Diagnosis Related Groups," provided by the UNMC colleges of nursing and pharmacy, were especially popular because professionals could participate and earn continuing education units from the hospitals where they worked. Nursing education was evolving during those years, too. In the early 1970s the UNMC's Board of Regents asked Nursing Dean Rena E. Boyle to submit a proposal to establish a division of the College of Nursing at the University of Nebraska-Lincoln. One of Dean Boyle's requirements in that proposal was the availability of two-way television (TV) between the proposed Lincoln campus and the Omaha campus. The first students were admitted to the Lincoln division in 1974, and by the fall of 1976, when upper division nursing courses were to be offered, the TV system was ready. It used a combination of Nebraska educational TV microwave equipment, cable installed on the Lincoln campus, and telephone lines. TV was used to share courses and administrative meetings between the two campuses. From either location, participants could both see and talk with those at the other site. The college also used TV in packaging courses for registered nurses (RNs) throughout the state who wished to earn the bachelor of science degree in nursing. In 1977, the Kellogg Foundation funded a program which allowed the College of Nursing to deliver an off-campus baccalaureate program for RNs. The first delivery methods were videotapes, telephone conferences, learning packets, and faculty travel for supervision of clinical experiences. The program has recently been incorporated into a Rural Health Education Network established by the entire Medical Center. RNs now have access to courses via live TV at the four nursing campuses. In 1985, the Nebraska legislature provided funds for the College of Nursing to phase in its baccalaureate program in Scottsbluff, on the Wyoming border 500 miles from the Medical Center. Again, TV was an important component. A microwave system carried TV pictures from Omaha to Scottsbluff, while telephone lines provided two-way sound communication. The College of Nursing added another unit in 1991, when Kearney State College became the University of Nebraska-Kearney. Kearney State College's
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Department of Nursing then became the UNMC College of Nursing-Kearney Division. By that time, the College of Nursing was using the NEB~SAT system, described below, to connect its various components. As each of the college's divisions has been added, one of the first major expenditures it made has been to establish telecommunication connections, equip class and conference rooms, and find or train technicians to operate the systems. Telecommunications is, in fact, the key to operating four far-flung divisions as a single college. During the 1992-1993 academic year, the College of Nursing used TV a total of 498 hours for classes and 172 hours for administrative and faculty meetings.
Telecommmunications Today Television The UNMC College of Nursing currently participates in a statewide TV system called NEB~SAT, which uses satellite and fiberoptic technology. NEB~SAT began operations on February 1, 1990, using a transponder on satellite Spacenet III. Originally, the state leased the transponder, but in 1991 the legislature appropriated $6,500,000 for its purchase. The system is intended for use by the Nebraska ETV network, all campuses of the University of Nebraska, state colleges, technical colleges, elementary and secondary school systems, the State Department of Education, and public radio. NEB~SAT provides capability for simultaneous broadcasting of three "networks." Network 1 is a broadcast-quality channel used for the state's educational TV and public radio. Network 2, also a highquality broad-band channel, allows statewide distribution of distance learning and continuing education for all educational institutions. Network 3 has narrow-band channels for compressed video transmission. Network 3 can accommodate 16 one-way or eight two-way interconnections between origination and reception sites at educational institutions that have the required hardware. UNMC primarily uses the compressed video of Network 3. The medical center also has access to Network 2, which can reach many more sites, but provides only one-way video (Benschoter & Benson, 1992). In compressed video, selected elements of each TV image are digitized and transmitted. At the receiving site, the signals are decoded and converted to standard TV. The hardware consists of an antenna or large dish, a transceiver, and a codec. The codec is a corn-
TELECOMMUNICATIONS AND NURSING
puter-controlled unit which digitizes and compresses the information for transmission and which decodes the compressed signals from other locations. The total hardware expense for each site is about $91,000. At present, 15 sites in Nebraska have the necessary equipment and can thus participate in Network 3 (Fig 1). The major advantage of compressed video is its ability to squeeze many channels onto a given space on the satellite transponder, thus permitting simultaneous transmission of more than one program. Compressed video also provides a certain amount of privacy because it can be received only by those with the necessary equipment. The primary disadvantage is some loss of picture quality for some types of images, particularly those which contain fast motion. The images are adequate for most class and meeting uses, but they would not be desirable for exercise demonstrations or sports programs. In a compressed video presentation, the speaker must limit walking, gesturing, and other quick movements, and the technician should avoid sudden camera movements. Synchronization between picture and sound may also be a problem if adjustments are not precise. The College of Nursing also has access to another two-way video system, the Nebraska Video Conference Network. This system uses telephone lines to carry compressed video and audio to 12 sites in communities throughout Nebraska. Each participating community has a viewing room with automated transmission/reception equipment which can be operated by users of the system. Any or all sites may be connected for a conference. The automatic switching equipment makes it possible for all sites to see and hear each location as it presents information. Because transmission is by telephone lines, confidentiality is assured, an important consideration for case conferences or discussions of student applicants for admission. Scheduling of the Nebraska Video Conference Network is based on established priorities and availability. •
Collegeof
B ok go NorthPlatte I' I i . ~ [ - - 7 ~ - F ~ , Omaha I I * Granld/lsla'nd I I'~ ~ M C /
Figure 1. Location of NEB*SAT Compressed Video Receptor sites and College of Nursing divisions.
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Teaching and Learning by Television Orientation. Some orientation is important for faculty, students, and TV technicians who are unaccustomed to participating in televised courses. Faculty need information on designing instructional material so that it will transmit well. Occasionally faculty request that some of their non-televised classes be videotaped so that they can review and critique themselves before going "live" in televised courses. Such previews can make them aware of distracting gestures or unnecessary walking. Instructors also need to prepare well in advance, so that handouts and other materials can be sent to the remote campuses in time for the class. Faculty also must be aware of compressed video's slight delay of sound. When several locations are involved in a course or meeting, persons in two or more places may begin to speak simultaneously. To persons in the originating location, this can sound like interruptions. But with push-to-talk microphones, when someone in a location is talking, others in that location cannot hear incoming speech from the other sites. The "time-out" sign can indicate to the other locations what is happening. Then the teacher or facilitator can ask for comments or questions from each site individually. If possible, the teacher or chair of a meeting should address participants by name. Students also should be given some orientation before their first TV courses. They should have a discussion of expectations and have the opportunity to try out the push-to-talk microphones. Students must be aware of their responsibility to be actively involved in learning and to come prepared to discuss and ask questions about assigned material. Both students and faculty should use large name cards which can be seen on TV, until everyone has had the opportunity to learn names in the other sites. The TV technician is another important element of successfu] TV courses. The technician does much more than turn on the camera, adjust the monitors, and regulate sound. He or she can assist the faculty in deciding where to sit or stand, familiarize participants with equipment, and provide suggestions and general assistance. The technician must focus the camera in on the persons speaking and should move the camera periodically so that all participants can be seen. Like any technology, the compressed video system sometimes fails, and faculty and students must be prepared for these occasions. The College of Nursing usually videotapes classes so that if transmission is interrupted, the tapes can be sent to the various sites
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for later viewing. Before videotape recordings are made, the teaching faculty member is asked to sign a permission form which clearly states how the tape will be used and how long it will be retained. As additional coverage in case of interruption, when a graduate assistant or faculty member is going to be present in a remote site, that person should have some discussion questions or learning activities planned for use in case of technical difficulties. Brief interruptions of sound can be handled by writing on the board or on overhead transparencies. Evaluation of TV Teaching and Learning. A good outcome measure for evaluation is always the students' course grades. Formal studies at the College of Nursing have found no significant differences in the grades of students watching a course live and those receiving it by TV. However, students have been found to differ in aspects other than grades. A study by Rheiner (1991) involved 61 undergraduate senior students in three of the college's divisions. She found that students in the live classroom spoke 3.5 times more frequently than students in the T V classrooms. More student-tostudent talking occurred in the rooms receiving TV, which at times interfered with students' hearing the instructor. Students in the live classroom believed that the teacher's questions were directed equally to all students, but the majority of those in the TV classrooms thought that questions were directed more to the live classroom. Likewise, the majority of students in the live classroom believed they got to know the teacher, but the TV students did not. Because both faculty and students do not like TV courses as well as the traditional face-to-face interaction in classrooms, the College of Nursing faculty make an effort to have some classes of each course taught live in every participating location. Sometimes the faculty member travels to another location to present a class and interact live with the students. The 500 miles between Omaha and Scottsbluff make West Nebraska a difficult site for faculty travel, but sometimes classes are taught by a faculty member from the west division, so that all the students can feel they get some live classes in each course, and that all other students are participating via TV. Often faculty members are reluctant to teach by TV out of concern that they or their courses will receive less-positive evaluations from students who receive instruction by TV. This was especially a concern in the early days of compressed video use, when technical problems were frequent and both students and faculty had high levels of frustration. However, Rheiner's
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study (1991) showed that the students in a classroom with one-way video gave highest evaluations to the teacher. There were no statistically significant differences in the live and TV classroom evaluations of the course. In the final analysis, satisfaction relates to students' expectations of a course. Students who know that TV or other technology provides opportunities that would not otherwise be available are the most appreciative. Those who seem to do best with TV courses are graduate students in seminars, who expect to participate actively with faculty and other students and to take responsibility for their own learning. Undergraduate students who anticipate small classes in traditional classrooms with a great deal of faculty interaction are less satisfied. But for classes at all levels, wellfunctioning equipment and prepared faculty and students help to improve satisfaction.
Advantages and Disadvantages of TV Use Some of the advantages of using TV for teaching is that it allows us to make courses accessible to areas where there are no qualified faculty. It is certainly a more economical use of faculty time to have one faculty member in one division prepare for a class rather than have four faculty members preparing and teaching live in the four divisions. In this way, it is possible to take advantage of the faculty member with the greatest expertise to do a presentation. When faculty from all divisions are viewed as a total faculty, the College presents a stronger picture with more diversity and more depth in various areas of expertise. When the College has a consultant or presentation from a guest expert, faculty and students from all divisions can benefit by using television. State Board of Nursing or National League for Nursing accreditation visits are simplified and more faculty and students can participate in the evaluation process. Some of the disadvantages of using TV have already been mentioned. Faculty and students do not like TV teaching/learning as well as the traditional face-to-face interaction. The cost of equipment, satellite or line time, and technician time is no small consideration. As greater use is made of TV for teaching by all levels of education, competition for time has created scheduling difficulties. Courses must be scheduled well in advance and schedule flexibility is limited.
Computers Computers also provide communication, both within the traditional campuses of the College of Nursing, and beyond, in rural areas.
TELECOMMUNICATIONS AND NURSING
Internal Systems
Personal computers are available throughout the College's learning centers, faculty and staff offices, and research facilities. A few older machines are not connected to any network and are used primarily for word processing. Most personal computers, however, are either directly connected to the Medical Center's mainframe for data analysis or are networked within and across the College's divisions. The networks are used for diverse purposes. For basic messages, E-mail has saved a tremendous amount of time and paper. The ability to transfer files allows faculty members on more than one campus to work on different sections of grant proposals, or secretaries to combine efforts to work on course syllabi. A doctoral student who lives in Kearney can use a campus computer to send her dissertation proposal to committee members in Omaha; the committee members can then either read the proposal on the computer or print copies for use. All of the College's divisions have computer access to the University of Nebraska libraries on all campuses and to the National Library of Medicine. Computer~assisted instruction (CAI) is used by students in learning resource centers at each division. Commercially produced CAI packages are used, and one faculty member has developed a CAI unit on Lyme disease. Plans are under way for additional faculty-developed materials, and for use of CAI in continuing education. Computer links with the student information system on the Medical Center campus are especially important to the West Nebraska Division of the College of Nursing, which does not have a University of Nebraska student services center for registration, billing, and student information. The West Nebraska student services advisor can enter registration data on the computer system, and billing can then be done from the Medical Center. Both the West Nebraska and Omaha divisions use the computerized UNMC student information system extensively for registration, billing, and student advising. The Lincoln and Kearney divisions work through their local campus student services offices. The College has established a nursing center in the South Omaha Neighborhood Association building. The center provides a primary care practice site for faculty and students and is a source of care for underserved populations. This site has computer connections with the physicians' billing service and with the Medical Center's mainframe, which allows nurse prac-
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titioner faculty access to E-mail. The College of Nursing also operates a Mobile Nursing Center (MNC) for providing primary care services to vulnerable and underserved populations in the eastern half of the state. The MNC can keep billing records on disk for handling later by the billing service. Decisions about a computerized patient information system for the nursing centers are pending. At present, the Internal Medicine Clinic uses COSTAR (Computer Stored Ambulatory Record, Massachusetts General Hospital), which is also used by Omaha College of Nursing community health faculty and students who provide home services. The University Hospital is implementing a system called PHAMIS (Public Health Automated Medical Information System, Phamis Inc, Seattle, WA), which will contain information on inpatients and outpatients, as well as billing and assistance with clinical decision-making. In the future, it may connect to the planned Community Health Information Networks. As other divisions of the College of Nursing develop nursing centers, a standardized system of billing and patient information will become increasingly important. Services to Rural Areas
A key component of the Medical Center's information systems is called Synapse Health Resources Online (University of Nebraska Medical Center Computer Network). Synapse provides access to oncampus and external databases through a menu-driven software telecommunications program. Its major thrust is providing health information for professionals in rural areas. At present, timely health information at UNMC is available to more than 200 sites in an eight-state area through personal computers, modems, telephone lines, and Synapse software. Participants have access to E-mail (including the Internet and Bitnet), medical decision support information, continuing education, patient education materials, and comprehensive medical literature databases. Other services include access to patients' clinical information, practice parameters, and clinical quality guidelines, plus such office management functions as accounts payable, coding, Medicaid eligibility databases, and electronic claims.
Summary Telecommunications are a critical component of administering a school with several divisions or campuses. Computers permit the coordination of admin-
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istrative activities and services and provide efficient communication. Televised courses and continuing education offerings can make education much more accessible, particularly in rural areas. Televised courses and other distance teaching and learning methods have been proven effective as measured by students'
grades. Students and faculty are most satisfied by distance teaching and learning activities when they can be assured of equipment that functions properly and when both students and faculty are well-prepared for the learning experience.
References Benschoter, R. A. (1967). Multi-purpose television. Annals of the New York Academy of Sciences 142, 471-78. Benschoter, R. A., & Benson, S.J. (1992). Satellite System Addresses Rural Health Problems..journal of Biocommunication I9 (4), 26-30. Rheiner, J. G. (1991). Teaching nursing by interactive
television: Interaction and evaluation. Unpublished doctoral dissertation, University of Nebraska, Lincoln, NE. Wittson, C. L., Benschoter, R. A. (1972). Two-way television: Helping the medical center reach out. American .Journal of Psychiatry I29, 136-39.
YEAWORTH,RN, PHD,* REBA A. BENSCHOTER,PHD,t
ROBIN METER, BA,$ AND SANDRa BENSON, MA§
Telecommunications are becoming increasingly important to nursing educators. At the University of Nebraska Medical Center College of Nursing, communication by two-way television, computers, facsimile machines, and telephone conferences is essential to the administration and operation of a school with four divisions located across 500 miles. Two-way television is available through one system that uses satellite and fiberoptic technology and another that uses telephone lines. The four campuses of the college share classes, administrative meetings, and conferences through television. Faculty members teaching via TV are oriented to designing instructional material for transmission and to the minor quirks of the technology. Students in TV classes must be aware of their responsibility for active involvement in learning. Studies have found no significant differences in the grades of students in "live" classrooms and those in TV classrooms, but both faculty and students prefer the face-to-face situation. The College of Nursing uses computers extensively on an internal network linking the four campuses for E-mail, file transfer, computer-assisted instruction, and administrative information sharing. Another computer network, Synapse Health Resources Online, links the college and the Medical Center with health professionals in rural areas throughout the state. (Index words: Computers; Nursing education; Telecommunications; Television.) J Prof Nurs 11: 227-232, 1995. Copyright © 1995 by W.B. Saunders Company
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E L E C O M M U N I C A T I O N S - e l e c t r o n i c communications over long distances-are becoming more and more essential to nursing educators as they extend programs and services into regions beyond the *Dean Emeritus & Professor, The University of Nebraska Medical Center, College of Nursing, Omaha, NE. tDirector, Biomedical Communications, and Associate Dean, School of Allied Health Professions, The University of Nebraska Medical Center, Omaha, NE. $Synapse Supervisor, Computing Services, The University of Nebraska Medical Center, Omaha, NE. §Assistant Professor, Biomedical Communications, School of Allied Health Professions, The University of Nebraska Medical Center, Omaha, NE. Address correspondence and reprint requests to Dr. Yeaworth: The University of Nebraska Medical Center, College of Nursing, 600 South 42nd Street, Omaha, NE 68198-5330. Copyright © 1995 by W.B. Saunders Company 8755-7223/95/1104-000853.00/0
Journal of ProfessionalNursing, Vol
traditional nursing school campus. Telecommunications are now used both for administrative purposes and for offering credit courses and continuing education programs in locations previously inaccessible to learners. As Nursing Centers are developed, electronic technology will likely be used for information and billing systems. The U n i v e r s i t y of N e b r a s k a Medical C e n t e r (UNMC) and its College of Nursing have been pioneers in using telecommunications to share education and services with areas of the state far from the Medical Center in Omaha. During the past three decades, the College of Nursing has grown to cover the entire state, and early efforts at telecommunication have evolved into today's system, which incorporates technology ranging from basic telephone and facsimile machine connections to sophisticated satellite television networking and computer access to nationwide resources.
Background The U n i v e r s i t y of N e b r a s k a , the only statesupported university in Nebraska, includes the Medical Center in Omaha, along with general campuses in Omaha, Lincoln, which is 55 miles from the Medical Center, and Kearney, which is 180 miles distant. Part of the Medical Center's mission is to provide education leading to degrees in health professions for citizens of the entire state. The challenge inherent in that charge is to make educational programs available not only in the cities of Omaha and Lincoln, but also in remote, primarily rural areas in a state that spans more than 500 miles from east to west. The Medical Center was active in the early days of telecommunications. In 1964, it established the nation's first long-distance two-way television system dedicated to medical uses (Benschoter, 1967). The system linked the Nebraska Psychiatric Institute in Omaha with the Norfolk State Mental Hospital, 110 miles away. In 1968, a second two-way TV network was formed, connecting Nebraska's Veterans Administration (VA) hospitals in Omaha, Lincoln, and
11, No 4 (July-August), 1995: pp 227-232
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Grand Island with the Medical Center (Wittson & Benschoter, 1972). Among the uses of the VA network was the transmission of continuing education programs to nurses and other professionals in the VA hospitals and surrounding communities. Such courses as "Update and Review of Pharmacology" and "Introduction to Diagnosis Related Groups," provided by the UNMC colleges of nursing and pharmacy, were especially popular because professionals could participate and earn continuing education units from the hospitals where they worked. Nursing education was evolving during those years, too. In the early 1970s the UNMC's Board of Regents asked Nursing Dean Rena E. Boyle to submit a proposal to establish a division of the College of Nursing at the University of Nebraska-Lincoln. One of Dean Boyle's requirements in that proposal was the availability of two-way television (TV) between the proposed Lincoln campus and the Omaha campus. The first students were admitted to the Lincoln division in 1974, and by the fall of 1976, when upper division nursing courses were to be offered, the TV system was ready. It used a combination of Nebraska educational TV microwave equipment, cable installed on the Lincoln campus, and telephone lines. TV was used to share courses and administrative meetings between the two campuses. From either location, participants could both see and talk with those at the other site. The college also used TV in packaging courses for registered nurses (RNs) throughout the state who wished to earn the bachelor of science degree in nursing. In 1977, the Kellogg Foundation funded a program which allowed the College of Nursing to deliver an off-campus baccalaureate program for RNs. The first delivery methods were videotapes, telephone conferences, learning packets, and faculty travel for supervision of clinical experiences. The program has recently been incorporated into a Rural Health Education Network established by the entire Medical Center. RNs now have access to courses via live TV at the four nursing campuses. In 1985, the Nebraska legislature provided funds for the College of Nursing to phase in its baccalaureate program in Scottsbluff, on the Wyoming border 500 miles from the Medical Center. Again, TV was an important component. A microwave system carried TV pictures from Omaha to Scottsbluff, while telephone lines provided two-way sound communication. The College of Nursing added another unit in 1991, when Kearney State College became the University of Nebraska-Kearney. Kearney State College's
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Department of Nursing then became the UNMC College of Nursing-Kearney Division. By that time, the College of Nursing was using the NEB~SAT system, described below, to connect its various components. As each of the college's divisions has been added, one of the first major expenditures it made has been to establish telecommunication connections, equip class and conference rooms, and find or train technicians to operate the systems. Telecommunications is, in fact, the key to operating four far-flung divisions as a single college. During the 1992-1993 academic year, the College of Nursing used TV a total of 498 hours for classes and 172 hours for administrative and faculty meetings.
Telecommmunications Today Television The UNMC College of Nursing currently participates in a statewide TV system called NEB~SAT, which uses satellite and fiberoptic technology. NEB~SAT began operations on February 1, 1990, using a transponder on satellite Spacenet III. Originally, the state leased the transponder, but in 1991 the legislature appropriated $6,500,000 for its purchase. The system is intended for use by the Nebraska ETV network, all campuses of the University of Nebraska, state colleges, technical colleges, elementary and secondary school systems, the State Department of Education, and public radio. NEB~SAT provides capability for simultaneous broadcasting of three "networks." Network 1 is a broadcast-quality channel used for the state's educational TV and public radio. Network 2, also a highquality broad-band channel, allows statewide distribution of distance learning and continuing education for all educational institutions. Network 3 has narrow-band channels for compressed video transmission. Network 3 can accommodate 16 one-way or eight two-way interconnections between origination and reception sites at educational institutions that have the required hardware. UNMC primarily uses the compressed video of Network 3. The medical center also has access to Network 2, which can reach many more sites, but provides only one-way video (Benschoter & Benson, 1992). In compressed video, selected elements of each TV image are digitized and transmitted. At the receiving site, the signals are decoded and converted to standard TV. The hardware consists of an antenna or large dish, a transceiver, and a codec. The codec is a corn-
TELECOMMUNICATIONS AND NURSING
puter-controlled unit which digitizes and compresses the information for transmission and which decodes the compressed signals from other locations. The total hardware expense for each site is about $91,000. At present, 15 sites in Nebraska have the necessary equipment and can thus participate in Network 3 (Fig 1). The major advantage of compressed video is its ability to squeeze many channels onto a given space on the satellite transponder, thus permitting simultaneous transmission of more than one program. Compressed video also provides a certain amount of privacy because it can be received only by those with the necessary equipment. The primary disadvantage is some loss of picture quality for some types of images, particularly those which contain fast motion. The images are adequate for most class and meeting uses, but they would not be desirable for exercise demonstrations or sports programs. In a compressed video presentation, the speaker must limit walking, gesturing, and other quick movements, and the technician should avoid sudden camera movements. Synchronization between picture and sound may also be a problem if adjustments are not precise. The College of Nursing also has access to another two-way video system, the Nebraska Video Conference Network. This system uses telephone lines to carry compressed video and audio to 12 sites in communities throughout Nebraska. Each participating community has a viewing room with automated transmission/reception equipment which can be operated by users of the system. Any or all sites may be connected for a conference. The automatic switching equipment makes it possible for all sites to see and hear each location as it presents information. Because transmission is by telephone lines, confidentiality is assured, an important consideration for case conferences or discussions of student applicants for admission. Scheduling of the Nebraska Video Conference Network is based on established priorities and availability. •
Collegeof
B ok go NorthPlatte I' I i . ~ [ - - 7 ~ - F ~ , Omaha I I * Granld/lsla'nd I I'~ ~ M C /
Figure 1. Location of NEB*SAT Compressed Video Receptor sites and College of Nursing divisions.
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Teaching and Learning by Television Orientation. Some orientation is important for faculty, students, and TV technicians who are unaccustomed to participating in televised courses. Faculty need information on designing instructional material so that it will transmit well. Occasionally faculty request that some of their non-televised classes be videotaped so that they can review and critique themselves before going "live" in televised courses. Such previews can make them aware of distracting gestures or unnecessary walking. Instructors also need to prepare well in advance, so that handouts and other materials can be sent to the remote campuses in time for the class. Faculty also must be aware of compressed video's slight delay of sound. When several locations are involved in a course or meeting, persons in two or more places may begin to speak simultaneously. To persons in the originating location, this can sound like interruptions. But with push-to-talk microphones, when someone in a location is talking, others in that location cannot hear incoming speech from the other sites. The "time-out" sign can indicate to the other locations what is happening. Then the teacher or facilitator can ask for comments or questions from each site individually. If possible, the teacher or chair of a meeting should address participants by name. Students also should be given some orientation before their first TV courses. They should have a discussion of expectations and have the opportunity to try out the push-to-talk microphones. Students must be aware of their responsibility to be actively involved in learning and to come prepared to discuss and ask questions about assigned material. Both students and faculty should use large name cards which can be seen on TV, until everyone has had the opportunity to learn names in the other sites. The TV technician is another important element of successfu] TV courses. The technician does much more than turn on the camera, adjust the monitors, and regulate sound. He or she can assist the faculty in deciding where to sit or stand, familiarize participants with equipment, and provide suggestions and general assistance. The technician must focus the camera in on the persons speaking and should move the camera periodically so that all participants can be seen. Like any technology, the compressed video system sometimes fails, and faculty and students must be prepared for these occasions. The College of Nursing usually videotapes classes so that if transmission is interrupted, the tapes can be sent to the various sites
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for later viewing. Before videotape recordings are made, the teaching faculty member is asked to sign a permission form which clearly states how the tape will be used and how long it will be retained. As additional coverage in case of interruption, when a graduate assistant or faculty member is going to be present in a remote site, that person should have some discussion questions or learning activities planned for use in case of technical difficulties. Brief interruptions of sound can be handled by writing on the board or on overhead transparencies. Evaluation of TV Teaching and Learning. A good outcome measure for evaluation is always the students' course grades. Formal studies at the College of Nursing have found no significant differences in the grades of students watching a course live and those receiving it by TV. However, students have been found to differ in aspects other than grades. A study by Rheiner (1991) involved 61 undergraduate senior students in three of the college's divisions. She found that students in the live classroom spoke 3.5 times more frequently than students in the T V classrooms. More student-tostudent talking occurred in the rooms receiving TV, which at times interfered with students' hearing the instructor. Students in the live classroom believed that the teacher's questions were directed equally to all students, but the majority of those in the TV classrooms thought that questions were directed more to the live classroom. Likewise, the majority of students in the live classroom believed they got to know the teacher, but the TV students did not. Because both faculty and students do not like TV courses as well as the traditional face-to-face interaction in classrooms, the College of Nursing faculty make an effort to have some classes of each course taught live in every participating location. Sometimes the faculty member travels to another location to present a class and interact live with the students. The 500 miles between Omaha and Scottsbluff make West Nebraska a difficult site for faculty travel, but sometimes classes are taught by a faculty member from the west division, so that all the students can feel they get some live classes in each course, and that all other students are participating via TV. Often faculty members are reluctant to teach by TV out of concern that they or their courses will receive less-positive evaluations from students who receive instruction by TV. This was especially a concern in the early days of compressed video use, when technical problems were frequent and both students and faculty had high levels of frustration. However, Rheiner's
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study (1991) showed that the students in a classroom with one-way video gave highest evaluations to the teacher. There were no statistically significant differences in the live and TV classroom evaluations of the course. In the final analysis, satisfaction relates to students' expectations of a course. Students who know that TV or other technology provides opportunities that would not otherwise be available are the most appreciative. Those who seem to do best with TV courses are graduate students in seminars, who expect to participate actively with faculty and other students and to take responsibility for their own learning. Undergraduate students who anticipate small classes in traditional classrooms with a great deal of faculty interaction are less satisfied. But for classes at all levels, wellfunctioning equipment and prepared faculty and students help to improve satisfaction.
Advantages and Disadvantages of TV Use Some of the advantages of using TV for teaching is that it allows us to make courses accessible to areas where there are no qualified faculty. It is certainly a more economical use of faculty time to have one faculty member in one division prepare for a class rather than have four faculty members preparing and teaching live in the four divisions. In this way, it is possible to take advantage of the faculty member with the greatest expertise to do a presentation. When faculty from all divisions are viewed as a total faculty, the College presents a stronger picture with more diversity and more depth in various areas of expertise. When the College has a consultant or presentation from a guest expert, faculty and students from all divisions can benefit by using television. State Board of Nursing or National League for Nursing accreditation visits are simplified and more faculty and students can participate in the evaluation process. Some of the disadvantages of using TV have already been mentioned. Faculty and students do not like TV teaching/learning as well as the traditional face-to-face interaction. The cost of equipment, satellite or line time, and technician time is no small consideration. As greater use is made of TV for teaching by all levels of education, competition for time has created scheduling difficulties. Courses must be scheduled well in advance and schedule flexibility is limited.
Computers Computers also provide communication, both within the traditional campuses of the College of Nursing, and beyond, in rural areas.
TELECOMMUNICATIONS AND NURSING
Internal Systems
Personal computers are available throughout the College's learning centers, faculty and staff offices, and research facilities. A few older machines are not connected to any network and are used primarily for word processing. Most personal computers, however, are either directly connected to the Medical Center's mainframe for data analysis or are networked within and across the College's divisions. The networks are used for diverse purposes. For basic messages, E-mail has saved a tremendous amount of time and paper. The ability to transfer files allows faculty members on more than one campus to work on different sections of grant proposals, or secretaries to combine efforts to work on course syllabi. A doctoral student who lives in Kearney can use a campus computer to send her dissertation proposal to committee members in Omaha; the committee members can then either read the proposal on the computer or print copies for use. All of the College's divisions have computer access to the University of Nebraska libraries on all campuses and to the National Library of Medicine. Computer~assisted instruction (CAI) is used by students in learning resource centers at each division. Commercially produced CAI packages are used, and one faculty member has developed a CAI unit on Lyme disease. Plans are under way for additional faculty-developed materials, and for use of CAI in continuing education. Computer links with the student information system on the Medical Center campus are especially important to the West Nebraska Division of the College of Nursing, which does not have a University of Nebraska student services center for registration, billing, and student information. The West Nebraska student services advisor can enter registration data on the computer system, and billing can then be done from the Medical Center. Both the West Nebraska and Omaha divisions use the computerized UNMC student information system extensively for registration, billing, and student advising. The Lincoln and Kearney divisions work through their local campus student services offices. The College has established a nursing center in the South Omaha Neighborhood Association building. The center provides a primary care practice site for faculty and students and is a source of care for underserved populations. This site has computer connections with the physicians' billing service and with the Medical Center's mainframe, which allows nurse prac-
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titioner faculty access to E-mail. The College of Nursing also operates a Mobile Nursing Center (MNC) for providing primary care services to vulnerable and underserved populations in the eastern half of the state. The MNC can keep billing records on disk for handling later by the billing service. Decisions about a computerized patient information system for the nursing centers are pending. At present, the Internal Medicine Clinic uses COSTAR (Computer Stored Ambulatory Record, Massachusetts General Hospital), which is also used by Omaha College of Nursing community health faculty and students who provide home services. The University Hospital is implementing a system called PHAMIS (Public Health Automated Medical Information System, Phamis Inc, Seattle, WA), which will contain information on inpatients and outpatients, as well as billing and assistance with clinical decision-making. In the future, it may connect to the planned Community Health Information Networks. As other divisions of the College of Nursing develop nursing centers, a standardized system of billing and patient information will become increasingly important. Services to Rural Areas
A key component of the Medical Center's information systems is called Synapse Health Resources Online (University of Nebraska Medical Center Computer Network). Synapse provides access to oncampus and external databases through a menu-driven software telecommunications program. Its major thrust is providing health information for professionals in rural areas. At present, timely health information at UNMC is available to more than 200 sites in an eight-state area through personal computers, modems, telephone lines, and Synapse software. Participants have access to E-mail (including the Internet and Bitnet), medical decision support information, continuing education, patient education materials, and comprehensive medical literature databases. Other services include access to patients' clinical information, practice parameters, and clinical quality guidelines, plus such office management functions as accounts payable, coding, Medicaid eligibility databases, and electronic claims.
Summary Telecommunications are a critical component of administering a school with several divisions or campuses. Computers permit the coordination of admin-
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istrative activities and services and provide efficient communication. Televised courses and continuing education offerings can make education much more accessible, particularly in rural areas. Televised courses and other distance teaching and learning methods have been proven effective as measured by students'
grades. Students and faculty are most satisfied by distance teaching and learning activities when they can be assured of equipment that functions properly and when both students and faculty are well-prepared for the learning experience.
References Benschoter, R. A. (1967). Multi-purpose television. Annals of the New York Academy of Sciences 142, 471-78. Benschoter, R. A., & Benson, S.J. (1992). Satellite System Addresses Rural Health Problems..journal of Biocommunication I9 (4), 26-30. Rheiner, J. G. (1991). Teaching nursing by interactive
television: Interaction and evaluation. Unpublished doctoral dissertation, University of Nebraska, Lincoln, NE. Wittson, C. L., Benschoter, R. A. (1972). Two-way television: Helping the medical center reach out. American .Journal of Psychiatry I29, 136-39.