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The challenges of online nursing education
Internet and Higher Education 12 (2009) 98–103
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Internet and Higher Education
The challenges of online nursing education Glenn Gordon Smith a,⁎, Denise Passmore b, Timber Faught c a b c
University of South Florida, 4202 E. Fowler Avenue, EDU 162, Tampa, FL 33620-5650, United States University of S. Florida, 12901 Bruce B. Downs Blvd., MDC22, Tampa, FL 33612-4766, United States University of S. Florida, 3418 Winder Dr. Holiday, FL 34691, United States
a r t i c l e
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Keywords: Online instruction Nursing Healthcare e-learning Distance learning
a b s t r a c t To meet the current critical need for qualified nurses, many colleges have initiated online programs, primarily aimed towards registered nurse (RN) to BS students. Despite the growing number of online nursing programs, there is little research on instructor views of online learning. This study used interviews to investigate nursing instructor experiences in online learning. Results revealed instructor concerns with identifying the most effective assessment methods to judge students' ability to apply their lessons in realworld settings. Online nursing exhibits unique challenges, such as providing nursing students with online authentic learning experiences that relate to real-world nursing situations, which comprise both high-stake medical and interpersonal elements. Results also indicated that providing support and ensuring that the faculty have sufficient time to develop effective courses, with adequate assessment for the students, is necessary to ensure the quality of online nursing education. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Currently, there is a healthcare crisis in the United States due to the shortage of qualified, professional nurses (Stotts, Smith, EdwardsSchafer, Schmidt, & Smith, 2002). Nurses with Bachelor's and Master's degrees on average have better critical thinking skills than their peers with Associate's degrees and hospitals that employ more nurses with higher level degrees tend to have lower mortality rates (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Therefore, hospitals strongly encourage their RNs to return to school to obtain Bachelor's and Master's degrees. Online programs provide a cost effective option for both institutions and students, enabling registered nurses (RNs) who may not have access to traditional academic settings to pursue a baccalaureate degree (Bolan, 2003; McAlpine, Lockerbie, Ramsay, & Beaman, 2002; Ostrow & DiMaria-Ghalili, 2005). However, despite the growth of online programs, there is little research on the disciplinespecific challenges that online nursing instructors face in the delivery of their courses. The purpose of this study was to identify particular challenges and issues that the online nursing faculty might face in the delivery of their particular discipline online. 1.1. Review of literature It is simplistic to point out that teaching online and teaching faceto-face are different. They obviously have different platforms of delivery, but the depth of the difference is surprisingly broad and ⁎ Corresponding author. Tel.: +1 813 974 7922; fax: +1 813 974 3837. E-mail addresses: [email protected] (G.G. Smith), [email protected] (D. Passmore), [email protected] (T. Faught). 1096-7516/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.iheduc.2009.06.007
deep. Teaching online demands not only an understanding of the content, but also an understanding of how to present the content, provide a learning environment using technology (Conceição, 2006), and take advantage of the unique learning affordances of online learning environments. O'Neil and Fisher (2008) described differences in experiences for nursing students who were taking an online course versus a traditional face-to-face course, despite both courses being taught by the same professor. Students in the online class felt that they worked harder, but also felt like they were more part of a group. Although the technology presented a barrier and was sometimes challenging, they were able to revisit lessons online at any time and felt the asynchronous nature of the course was beneficial. These students were often placed in small groups for discussion online, helping to promote the social interaction of the course. This is particularly interesting since students often talk about feeling alone or lost when they are in an online environment (Trenholm, 2007). Assessment can also provide certain challenges in online learning. Challenges include verifying identity (e.g., is the person taking the test the person signed up for the course?) (Trenholm, 2007), the use of non-allowed outside materials, and alignment of the assessment with the learning outcome (e.g., the tendency online to assess at a lower level than the learning outcome). Many of the methods used by professors in face-to-face classes cannot be employed in an online class. Teachers in online situations cannot think exclusively of themselves and their students, as they are also interdependent on other agencies and individuals, including instructional design and technical support and faculty peers who have also created online courses. These changes have also increased the workload of many faculty who were not expecting technology to be central to their careers (Hartman, Dziuban, & Brophy-Ellison, 2007; Passmore, 2000). The differences
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between online classes and face-to-face classes are real and must be considered. However, different disciplines lend themselves better or worse to online learning, an important consideration in the instructional design of online learning. Each discipline has unique demands, which may require unique online learning solutions. There is a voluminous body of research about online learning. However, the vast majority of such research tacitly assumes homogeneity between disciplines. For example, common theoretical constructs, such as community of inquiry (Rourke, Anderson, Garrison, & Archer, 1999) and social presence (Short, Williams, & Christie, 1976; Rourke et al., 1999) are typically discussed without regard to disciplinary differences. Social presence in online courses has been strongly correlated with satisfaction with online distance learning (Gunawardena & Zittle,1997), and is thus often suggested in the design of online courses. One might wonder whether feeling socially connected would matter in an online physics class as much as in an education course. A small but growing number of scholars have started to research online learning through the disciplines paradigm, exploring the disciplinary effects in online learning. Instructors of mathematics and mathematics-related courses are significantly less satisfied with online learning and course management tools than are their peers teaching non-mathematics-related courses (Smith, Ferguson, & Gupta, 2004; Trenholm, 2006; Trenholm, 2007). Online mathematics instructors often create their own technical solutions to overcome the failure of online course management systems to meet the unique needs of mathematics (Smith et al., 2004). Attrition is significantly higher in mathematics-related online courses than in non-mathematics-related courses (Smith & Ferguson, 2005), a difference that does not exist in equivalent face-to-face courses. Since assessment of online courses is problematic, some experts recommend proctored examinations (Trenholm, 2007). Arbaugh (2005) has also researched similar disciplinary questions in the context of online business education, as have Hornik, Saunders, Li, Moskal, and Dzuiban (2008), who have shown that student grades are significantly higher and withdrawal rates lower for courses with high paradigm (hard discipline) development (e.g., Biology, Computer Science) than for courses with low paradigm (soft discipline) development (e.g., Sociology, English) (Smith et al., 2008). Despite these disciplinary differences, it is important to understand that there are many salient features of the online learning experience that are common across disciplines, while there are also important differences between disciplines (Smith, Heindel, & TorresAyala, 2008). The differences have important implications for instructional design of online learning. The challenge of the discipline-specific online learning research paradigm is to differentiate what is common to all online learning, and what is unique to specific disciplines. Since participants in studies of online learning may have only been involved in one discipline, they may have no idea about what is unique to their discipline, nor how these differences may interact with the online modality (Smith et al., 2008). Differences between online and the traditional face-to-face modes of learning may be much more salient to people immersed in one discipline. Therefore, it is important to conduct research about online learning across disciplines, sorting out what is unique to specific disciplines and how the unique challenges of disciplines interact with online learning (Fig. 1). One way to understand the differences in the different disciplines relevant to online learning is Biglan's taxonomy, which divides up academic disciplines along two dimensions: hard versus soft and pure versus applied. Hard disciplines, such as chemistry, have an agreedupon, ordered, seemingly objective knowledge base, while soft disciplines, such as sociology, have knowledge bases relatively more open to interpretation and different schools of thought (Neumann, Perry, & Becher, 2002). The pure versus applied dimension is based on whether the discipline implicitly involves real-world application of the
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Fig. 1. Biglan's taxonomy of academic disciplines. (Smith et al., 2008).
knowledge (Neumann et al., 2002). Engineering, an applied field, is the application of pure knowledge bases such as mathematics and physics. Biglan's taxonomy provides a useful lens for analyzing disciplinary differences in online courses. For example, a study spanning five years that analyzed Blackboard tool-usage patterns, student attrition rates, and student course evaluations suggests that online learning in pure disciplines has become more commoditized, while online learning in applied disciplines has become more oriented to community practice and more diversified (Smith et al., 2008). The lead author of the current publication has written publications on the discipline-specific effects of mathematics, a hard-pure discipline, in online learning. In Nursing, a soft-applied discipline, the lead author has made a deliberate choice of a discipline that is opposite along both dimensions of Biglan's taxonomy. Online nursing education delivers applied information in a human interactive environment. This means that the knowledge learned in the discipline is applied to people and is therefore unpredictable and requires critical thinking skills to be used by the students. Nursing is a high-demand field with highly specific needs for the students. The issues of nursing are in many ways different than the issues of other disciplines and thus require the online delivery to be modified in unique ways. By understanding the issues within the domain, the online education of nursing can be more productive. Beyond the content, Frith and Kee (2003) contend that withdrawal due to technical issues can be devastating to online nursing programs. It is vital that online curriculum is supported by sound instructional design to foster critical thinking and clinical decision-making paramount to nursing education and practice (Bolan, 2003). Providing nursing students with a well-constructed online course that targets their needs is part of a coordinated curriculum. This, plus responsive technical support, allows assessment to be provided in a timely manner, thereby creating a course with higher completion rates (Frith & Kee, 2003). Successful online courses for nurses provide frequent, short assignments and discussion forums centered around thoughtprovoking questions that integrate course content as well as illustrate the student's individual experience (Spangle, Hodne, & Schierling, 2002). An online nursing course should create an environment that fosters reflection and increases critical thinking about practice by allowing time for the students to develop cohesive written responses (Ali, Hodson-Carlton, & Ryan, 2004). By doing this, the students can share their personal experiences supported by research, helping not only to solidify their own learning, but also to bring more experiences to their fellow students who may face similar situations once they are in the field. 1.2. Gaps in the research literature More research on a soft-applied discipline would be helpful for this research paradigm, discipline-specific effects on e-learning. With its real-world consequences for practitioners, nursing is an appropriate choice. Further, with the rising demand for nursing associated with the aging of the U.S. population and the rapid growth of online nursing
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programs, an examination and dissemination of critical online needs of nursing could help instructional designers implement better online solutions for nursing programs. Since the stakes of nursing education are so high, it is vital to make sure online nursing is effective. Thus, the current exploratory study asked the main research question: In the perception of online nursing instructors and instructional designers, what are the unique challenges of teaching nursing courses online? 2. Method Participants for this study were seven instructors and two instructional designers within colleges of nursing at major research universities in the states of Florida and New York. Individuals were invited to participate if they had taught, or were teaching, one or more online classes or were involved in the design of online classes. All faculty interviewed had taught online nursing for more than two years. This qualitative, descriptive, multisite study consisted of open-ended questions designed to motivate the participants to reflect upon experiences associated with teaching and development of online nursing courses. Interviews were conducted face-to-face or by telephone. The interviews were conducted to uncover the most pressing differences between traditional face-to-face and online courses. Interviewers asked five initial questions focusing on issues such as the unique challenges of teaching nursing in the online environment versus face-toface. Following the answer to each question, the interviewers often asked follow-up questions addressing issues that the interviewee seemed to emphasize as important. The four initial questions included: 1) What are the unique challenges of teaching your discipline across all teaching modalities (whether face-to-face, e-learning, or point-to-point distance, etc.)? 2) How do instructors in your discipline address the unique challenges and pedagogy in the e-learning environment? 3) What unique learning opportunities for your discipline does the elearning modality afford, which are not available face-to-face? 4) What critical insights into teaching your discipline via e-learning were not covered by the preceding questions? Interviews averaged approximately 45 minutes in length. All interviews were taped, transcribed, segmented and coded independently by two research assistants with an interrater-reliability of 84.6%. The codes were analyzed with the whole interview as the unit of analysis (IUA), i.e., which codes occurred at least once in the interview. Multiple occurrences of a code in one interview did not add to its frequency. IUA frequency was counted by the number of interviews in which a code appeared once or more. 3. Results Table 1 shows the most common codes and their frequencies. The code names are italicized in the results reported below so the reader can read about the common themes in a prose context. A careful examination of the interviews revealed that assessment was not just the most common theme, but also ran through all the other
Table 1 Nursing—frequency of codes/themes using interview as unit of analysis. Code
Frequency
Percentage
Assessment Delivery method Tools Academic integrity Blended Feedback Interaction Authenticity CMS Research skills Student attributes
9 8 8 7 7 7 7 6 6 6 6
100% 89% 89% 78% 78% 78% 78% 67% 67% 67% 67%
common themes. Online nursing instructors discussed delivery methods, tools and academic integrity in the context of their concerns about assessment. Assessment issues permeated all of the interviews with online nursing instructors. Creating authentic assessments was a significant concern to participants. Most discussion of delivery method and tools was ultimately related to how these factors were utilized in the implementation of assessments. One of the most commonly utilized forms of assessment in online learning is testing. Testing in an online environment, however, provides unique challenges and opportunities not always encountered in classroom testing. One instructor discussed the advantage of providing computerized testing: “In Florida, RNs must take a rigorous computerized test in very secure conditions. They need opportunities to prepare for that.” The online testing experience gives students a chance to practice with this mode before having to sit for state board exams. Academic integrity is always a concern with online tests. Though one instructor permitted students to use notes and textbooks, other concerns were expressed about groups of students taking tests together: “You wonder who is in the room when they are taking the test.” Instructors discussed ways in which they attempt to minimize cheating such as randomized test pools and time limits. One instructor described her experience with a test pool that she began creating during her very first semester: “That test pool is still being used after five years.... The students are still scoring 65% to 100%. They have not gotten the answers out there.” It was expressed that “mature students will handle it well. Students with high integrity.” However, there was a definite concern for those students who do not fall into that category. One of the disadvantages mentioned in online testing was the lack of statistics provided by the Blackboard Course Management System (CMS), which was the system used by most of the participants in this study. Faculty asked for “more options for analysis with testing,” specifically a method for “the breakdown of information on the items for each test.” Without these tools, it was difficult for the faculty to compare online test results with live tests. Online nursing instructors discussed both desires for more tools within Course Management Systems, as well as teaching opportunities afforded by their Course Management System. Writing assignments were one of the most frequently mentioned forms of online assessment. In fact, one instructor stated that it was preferable to assess writing online: “Much of the interaction for writing and publication is appropriate on paper, such as critiques. exchange of manuscripts on Blackboard is efficient. Papers are easily shared.” Others expressed the comparability to live courses: “Assessment is similar to face-to-face. They write papers. They get credit for their weekly discussions.” One instructor, who taught a class of adult students returning to college, used writing assignments to help students get comfortable with the process of being a student and utilizing the electronic features that enabled sharing papers back and forth: “I had a lot of formative and summative papers for them.” The use of formative papers enabled students to gain familiarity with the system, getting feedback prior to submission of the actual final paper. Using word processing simplified the task of giving feedback and additionally gave students an opportunity to improve their computer skills. The use of writing assignments was described as an alternative to the issues found in online testing, assuming of course that students are writing the papers they submit. Using plagiarism detection tools is one way to prevent issues with cheating. However, the use of writing assignments is negatively impacted by the number of students: “Our classes vary from a minimum that is supposed to be thirty, but some instructors will take 60 to 70 students and say they have to use multiple choice questions to assess the student.” Authenticity was a major concern to online nursing instructors. Nursing is fundamentally a human care-giving activity. There is always the danger that didactic courses, particularly e-learning courses, seem too theoretical and not closely related, in an authentic way, to real
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nursing situations. The following is an example of a case study used to relate online nursing education to the human values of a real nursing situation: According to three of the nursing instructors, one of the human relations difficulties that nurses face every day is the diversity of cultural attitudes about medical situations. Not only is healthcare a technical profession where medical professionals take care of patients, but there is also a psycho-social component that is equally important, and it involves the cultural diversity of both the patient and the care provider. Therefore, teaching people to be culturally sensitive when they come from different cultural backgrounds with different cultural norms and expectations is a challenge. This exchange works both ways; it is not just teaching American-born, American-raised kids to deal with people from different cultures. Nursing instructors teach people from all over the world how to deal with people from all over the world. It is a great challenge teaching someone who comes from a culture where health care is based on science (United States or the European Union) how to appreciate a patient who requests something spiritual as part of the healing process. One nursing instructor brought this example from her own practice into her teaching as a case study: We had a family whose child was very sick and dying in the emergency room. The family wanted to do a prayer circle around the child who at that point, based on modern medicine, required a lot of medical intervention. In order to allow the family of six or eight people, where only two people are allowed to visit, we had to get special permission in a timely fashion because we had a really sick patient, to allow this family to do this prayer ritual, when the majority of the staff would rather have given another dose of medication. In the medical arena, there is a constant tension between the rules, cultural beliefs and providing the best comprehensive care for the patient. This is a major challenge in teaching nursing. Most nursing instructors have students from all over the world. The students come with their own cultural beliefs and norms and they have to accept the patient's cultural beliefs and norms. A major theme that emerged in the data upon analysis was the use of appropriate delivery method and tools to develop nursing courses consistent with national curriculum standards. One instructor stated that “we need to design assignments that help [them] students get to higher level thinking and skill development.” The assessments must also be applicable to real life because, as one instructor stated, “nursing is a practice-oriented field.” Instructors spoke of the challenge of “getting that application and synthesis” available in face-to-face courses to the same level of assessment into the online nursing courses. The question becomes what technology is available to create an interactive assessment for students that will allow the students to face real-world situations and prove they understand the concepts being taught in the class. One of the participants in the study stated, “You really need the students to apply the theory to the patient in that particular situation. They are dealing with people who are having illnesses, health care crises and so on. The students need to do more than just learn the theory that teaches you how to do it, they have to actually be able to do it.” The online learning environment can provide this by being adaptable to multiple situations and creating a multi-tiered program in which reactions to situations lead to a positive or negative result for the student. However, a critical concern “is that if everything goes into this cyberspace world, and we are trying to teach a profession [where] human contact is the nuts and bolts of it. Keeping the human contact piece going is the critical element.” One of the ways to keep the humanity in online learning environment is to work with other students in small cohorts or in synchronous chat sessions with other students. The use of discussion boards allows students to work with other students, comparing their own experiences to the experiences of others. One of the nursing professionals interviewed explained how discussion boards worked in one class: “They have to bring the experience with their patients into the discussion and then they have
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to reflect on whether they would do it different next time.” The use of synchronous chat sessions was discussed but “with nursing there is not a time that someone is not working. They work 24/7 so there is no time that all students would be available.” These methods do two things for the students: they incorporate the human or soft element into the course and give them a sense of community, which broadens their knowledge of the nursing community. Without appropriate tools, the ability to deliver authentic assessments is impaired. This was important to all participants in addressing the content-management system (CMS) used to deliver content, other tools used to enhance the course, or student ability and support. Use of a CMS usually dictates the delivery of online assessments. Another faculty member described problems with this system: “We do not have any standards in the college of nursing as to how we do testing online. And there is rampant sharing of tests from students in one semester to students in another.” However, not all individuals interviewed agreed that students were cheating. Even with the concern of test sharing, the consensus is that online testing also provides other benefits for nurses preparing careers in hospitals that are completely computerized. Today, even giving a patient an aspirin is logged immediately into a computer system, often by scanning the patient's bracelet and then the code for the aspirin. This familiarity with the online environment will be priceless in the new computerized hospital setting. Ultimately, none of these online tools are effective if students do not use what is available. Although some instructors insist on weekly deliverables to ensure that students are keeping up, others relied on the student's self-directedness. However, they discovered a correlation between time online and grades. “Some students do not check in for 2 weeks at a time. It shows the total times and hits. It seems to be related to the grades that they earn. Students with high grades put in many more hours and many more hits within the course than those with lower grades.” This is important to the field of nursing, where dedication is priceless to success and patient well being. When asked what would make their course, which was hosted in a Course Management System, but supplemented with additional webbased tools supplied by instructional designers—more effective, one instructor asked for a method that would allow students “more interaction between themselves.” Despite inconveniences and lacks, one faculty stated, “I think we are looking forward to more and more high quality tools being available online and can give the student the visualization of what is going on but also be able to get some manipulation that goes along with that.” The assessment of these methods might help resolve part of this issue, and give students more time to interact with other students in the nursing program. Technical support was mentioned as being important to the success of both nursing students and faculty. Several instructors mentioned having a support organization within the college, including an instructional designer and technical support, to supplement what is offered by the university. In this sense, online nursing instructors are much better off than online instructors in other colleges. Healthcare related colleges, such as nursing and public health, typically have more resources to support the development and delivery of online courses. Both instructional designers mentioned that, although the online nursing courses were officially online courses, many online nursing instructors created blended classes by adding one or two face-to-face class meetings at the end of the semester for final presentations or testing: “Even though it is not merely a web-based course, some faculty will require towards the end of the semester a meeting where students will present papers and projects and so on.” Both of the instructional designers and most of the online nursing instructors mentioned the lack of immediate real-time interaction between students and instructor, and thus the need to design in a vehicle for students to get feedback on questions about assignments: “You don't have the feedback that is useful from seeing them face-toface,” “They really want to have feedback from the instructor,” and
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“What works the best is I often set up times during the second week so that all students who have issues can come.” Student attributes such as technical ability were important to nursing instructors. Nursing students' technical ability has long been a challenge. However, one instructor remarked that “it gets easier annually as people get more computer literate.” It was noted that “health care is traditional and not computer oriented,” indicating that nursing students are not as “knowledgeable in technology as other disciplines.” Because of this, one instructor listed another advantage to e-learning, “it does expose the nurses to other kinds of technology; searching literature bases; communicating in groups and networking with people across the country and across the globe to get expert input and advice.” Finally, as one faculty member advised, “the instructor has to maintain a level of competency in the new technology... that requires updates in training through journals, clinical practice, conferences, meetings, in-services.” This becomes even more important as nursing moves into a computerized era where multiple tools are used to connect patient, nurses and doctors. Instructors also discussed using tools to supplement the options available on CMSs. Several mentioned using iPods and synchronous software such as Elluminate. One instructor said, “I am using Captivate [an Adobe multimedia development program] to supplement the PowerPoints and the students are really enjoying that modality.” Although one instructor thought these kinds of tools were helpful for faculty, there was a concern: “we need the tools, but we also need the time for it.” One issue that came up from discussion with the instructional designers, but was only implicitly hinted at in the instructor interviews, was the notion of core, or clinical, versus non-core nursing courses. At the undergraduate level, core clinical courses are typically not taught online, for the obvious reason that nurses need to learn procedural medical skills, which have life and death implications, in the context of face-to-face supervision and feedback. On the other hand, there is an increasing demand for nurses to keep abreast of the changing medical field by conducting research online to keep their knowledge current. Thus a lot of online nursing courses, particularly, graduate courses, emphasize research skills: “We do a lot as far as assigning them to go and find articles on those types of topics... and then analyze it, summarize it, and that type of thing.” “We have a big focus on evidence-based practice, which means basing your practice on what evidence tells us.” 4. Discussion Results showed that nursing instructors were concerned with authentic assessment of e-learning. The ability to assess nursing students in an online environment offered both positive and negative issues for students, but overall it seems weighted toward the positive. Many of the face-to-face aspects of the courses which are not available online are able to be replaced by technology that is available to students 24/7. Discussion boards were mentioned by most instructors as one of the more effective methods of assessing students. In addition to simulations of real-life situations, students had opportunities to interact with each other on the boards, and through these discussions brought their own experiences into the classroom situation. This allowed for learning from peers as well as from the instructor, thereby creating an interactive assessment model. Papers, journals, and case studies were also utilized by many of the faculty as a way of encouraging students to develop critical thinking skills regarding what they were learning. Diversity was mentioned by the participants as being particularly important. Incorporating multi-culturalism in an online curriculum requires not only an understanding of one's own cultural background and biases, but the ability to be aware and sensitive to students' needs and beliefs. Another area of significance to nursing is that students must apply the information they learn to real-life situations. Instructors must find ways to assess whether the knowledge taught online can actually be
applied by students. Assessment methods include discussions of case studies, group projects that simulate real-life situations and journals that describe how students apply theory to practice. Course Management Systems were challenging, in some respects, to all faculty either in their limitations, unreliability, lack of support, or due to a prevalence of nursing students who tend to be less technically adept than students in other disciplines. Faculty described how the CMSs could either further them towards or deter them from their objectives. There were numerous methods for creating online assessments, and faculty even stated that there were advantages, particularly in the areas of journaling and discussions. The lack of real-time interaction between students was seen as a disadvantage in CMSs. Results of the current study are consistent with previous research. Many nursing students, especially for those coming from community colleges, have little or no experience with online courses (Chaffin & Maddux, 2004). Also, many nursing students complain that online courses consume more time than traditional face-to-face classes. In addition, nursing students often experience extra stress through a struggle with the technology (Kozlowski, 2004). But even with those challenges, it is important to recognize that offering tests online gives students an opportunity to prepare for state boards that are all computer-based (McAlpine et al., 2002). Most students also felt that despite these challenges the ability to work asynchronously made the challenges worthwhile (Udod & Care, 2002). From the instructor's point of view, the challenge of preventing cheating worried instructors and increased their reluctance to offer online testing. Other methods of assessment were considered at least as effective as testing. However, the number of students enrolled limits the instructor's ability to grade and provide timely feedback to each student when using some of these alternate assessments such as research papers. 5. Conclusion When viewed through the lens of research on discipline-specific elearning, online nursing courses exhibit both similarities and differences in relation to other disciplines. Although nursing is a soft-applied discipline, while mathematics is a hard-pure discipline, instructors in both disciplines express concern with academic integrity in assessment. However, online nursing does exhibit its own unique set of challenges, such as providing nursing students with online learning experiences that relate to real-world nursing situations, which comprise both high-stake medical and interpersonal elements. Online discussions, case studies, and research papers potentially provide such authentic learning experiences and the means of assessing them. In terms of solutions, online nursing education is consistent with other soft-applied disciplines taught online (Smith et al., 2008) in that online nursing instructors and instructional designers customize their courses by using community-oriented pedagogy. References Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA: The Journal of the American Medical Association, 290(12), 1617–1623. Ali, N. S., Hodson-Carlton, K., & Ryan, M. (2004). Students' perceptions of online learning: Implications for teaching. Nurse Educator, 29(3), 111–115. Arbaugh, J. B. (2005). How much does “subject matter” matter? A study of disciplinary effects in on-line MBA courses. Academy of Management Learning & Education, 4(1), 57–73. Bolan, C. M. (2003). Incorporating the experiential learning theory into the instructional design of online courses. Nurse Educator, 28(1), 10–14. Chaffin, A. J., & Maddux, C. D. (2004). Internet teaching methods for use in baccalaureate nursing education. CIN: Computers, Informatics, Nursing, 22(3), 132–142. Conceição, S. C. O. (2006). Faculty lived experiences in the online environment. Adult Education Quarterly, 57(1), 26–45. Frith, K. H., & Kee, C. C. (2003). The effect of communication on nursing student outcomes in a web-based course. Journal of Nursing Education, 42(8), 350–358. Gunawardena, C. N., & Zittle, F. J. (1997). Social presence as a predictor of satisfaction within a computer-mediated conferencing environment. American Journal of Distance Education, 11(3), 8–26.
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Contents lists available at ScienceDirect
Internet and Higher Education
The challenges of online nursing education Glenn Gordon Smith a,⁎, Denise Passmore b, Timber Faught c a b c
University of South Florida, 4202 E. Fowler Avenue, EDU 162, Tampa, FL 33620-5650, United States University of S. Florida, 12901 Bruce B. Downs Blvd., MDC22, Tampa, FL 33612-4766, United States University of S. Florida, 3418 Winder Dr. Holiday, FL 34691, United States
a r t i c l e
i n f o
Keywords: Online instruction Nursing Healthcare e-learning Distance learning
a b s t r a c t To meet the current critical need for qualified nurses, many colleges have initiated online programs, primarily aimed towards registered nurse (RN) to BS students. Despite the growing number of online nursing programs, there is little research on instructor views of online learning. This study used interviews to investigate nursing instructor experiences in online learning. Results revealed instructor concerns with identifying the most effective assessment methods to judge students' ability to apply their lessons in realworld settings. Online nursing exhibits unique challenges, such as providing nursing students with online authentic learning experiences that relate to real-world nursing situations, which comprise both high-stake medical and interpersonal elements. Results also indicated that providing support and ensuring that the faculty have sufficient time to develop effective courses, with adequate assessment for the students, is necessary to ensure the quality of online nursing education. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Currently, there is a healthcare crisis in the United States due to the shortage of qualified, professional nurses (Stotts, Smith, EdwardsSchafer, Schmidt, & Smith, 2002). Nurses with Bachelor's and Master's degrees on average have better critical thinking skills than their peers with Associate's degrees and hospitals that employ more nurses with higher level degrees tend to have lower mortality rates (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Therefore, hospitals strongly encourage their RNs to return to school to obtain Bachelor's and Master's degrees. Online programs provide a cost effective option for both institutions and students, enabling registered nurses (RNs) who may not have access to traditional academic settings to pursue a baccalaureate degree (Bolan, 2003; McAlpine, Lockerbie, Ramsay, & Beaman, 2002; Ostrow & DiMaria-Ghalili, 2005). However, despite the growth of online programs, there is little research on the disciplinespecific challenges that online nursing instructors face in the delivery of their courses. The purpose of this study was to identify particular challenges and issues that the online nursing faculty might face in the delivery of their particular discipline online. 1.1. Review of literature It is simplistic to point out that teaching online and teaching faceto-face are different. They obviously have different platforms of delivery, but the depth of the difference is surprisingly broad and ⁎ Corresponding author. Tel.: +1 813 974 7922; fax: +1 813 974 3837. E-mail addresses: [email protected] (G.G. Smith), [email protected] (D. Passmore), [email protected] (T. Faught). 1096-7516/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.iheduc.2009.06.007
deep. Teaching online demands not only an understanding of the content, but also an understanding of how to present the content, provide a learning environment using technology (Conceição, 2006), and take advantage of the unique learning affordances of online learning environments. O'Neil and Fisher (2008) described differences in experiences for nursing students who were taking an online course versus a traditional face-to-face course, despite both courses being taught by the same professor. Students in the online class felt that they worked harder, but also felt like they were more part of a group. Although the technology presented a barrier and was sometimes challenging, they were able to revisit lessons online at any time and felt the asynchronous nature of the course was beneficial. These students were often placed in small groups for discussion online, helping to promote the social interaction of the course. This is particularly interesting since students often talk about feeling alone or lost when they are in an online environment (Trenholm, 2007). Assessment can also provide certain challenges in online learning. Challenges include verifying identity (e.g., is the person taking the test the person signed up for the course?) (Trenholm, 2007), the use of non-allowed outside materials, and alignment of the assessment with the learning outcome (e.g., the tendency online to assess at a lower level than the learning outcome). Many of the methods used by professors in face-to-face classes cannot be employed in an online class. Teachers in online situations cannot think exclusively of themselves and their students, as they are also interdependent on other agencies and individuals, including instructional design and technical support and faculty peers who have also created online courses. These changes have also increased the workload of many faculty who were not expecting technology to be central to their careers (Hartman, Dziuban, & Brophy-Ellison, 2007; Passmore, 2000). The differences
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between online classes and face-to-face classes are real and must be considered. However, different disciplines lend themselves better or worse to online learning, an important consideration in the instructional design of online learning. Each discipline has unique demands, which may require unique online learning solutions. There is a voluminous body of research about online learning. However, the vast majority of such research tacitly assumes homogeneity between disciplines. For example, common theoretical constructs, such as community of inquiry (Rourke, Anderson, Garrison, & Archer, 1999) and social presence (Short, Williams, & Christie, 1976; Rourke et al., 1999) are typically discussed without regard to disciplinary differences. Social presence in online courses has been strongly correlated with satisfaction with online distance learning (Gunawardena & Zittle,1997), and is thus often suggested in the design of online courses. One might wonder whether feeling socially connected would matter in an online physics class as much as in an education course. A small but growing number of scholars have started to research online learning through the disciplines paradigm, exploring the disciplinary effects in online learning. Instructors of mathematics and mathematics-related courses are significantly less satisfied with online learning and course management tools than are their peers teaching non-mathematics-related courses (Smith, Ferguson, & Gupta, 2004; Trenholm, 2006; Trenholm, 2007). Online mathematics instructors often create their own technical solutions to overcome the failure of online course management systems to meet the unique needs of mathematics (Smith et al., 2004). Attrition is significantly higher in mathematics-related online courses than in non-mathematics-related courses (Smith & Ferguson, 2005), a difference that does not exist in equivalent face-to-face courses. Since assessment of online courses is problematic, some experts recommend proctored examinations (Trenholm, 2007). Arbaugh (2005) has also researched similar disciplinary questions in the context of online business education, as have Hornik, Saunders, Li, Moskal, and Dzuiban (2008), who have shown that student grades are significantly higher and withdrawal rates lower for courses with high paradigm (hard discipline) development (e.g., Biology, Computer Science) than for courses with low paradigm (soft discipline) development (e.g., Sociology, English) (Smith et al., 2008). Despite these disciplinary differences, it is important to understand that there are many salient features of the online learning experience that are common across disciplines, while there are also important differences between disciplines (Smith, Heindel, & TorresAyala, 2008). The differences have important implications for instructional design of online learning. The challenge of the discipline-specific online learning research paradigm is to differentiate what is common to all online learning, and what is unique to specific disciplines. Since participants in studies of online learning may have only been involved in one discipline, they may have no idea about what is unique to their discipline, nor how these differences may interact with the online modality (Smith et al., 2008). Differences between online and the traditional face-to-face modes of learning may be much more salient to people immersed in one discipline. Therefore, it is important to conduct research about online learning across disciplines, sorting out what is unique to specific disciplines and how the unique challenges of disciplines interact with online learning (Fig. 1). One way to understand the differences in the different disciplines relevant to online learning is Biglan's taxonomy, which divides up academic disciplines along two dimensions: hard versus soft and pure versus applied. Hard disciplines, such as chemistry, have an agreedupon, ordered, seemingly objective knowledge base, while soft disciplines, such as sociology, have knowledge bases relatively more open to interpretation and different schools of thought (Neumann, Perry, & Becher, 2002). The pure versus applied dimension is based on whether the discipline implicitly involves real-world application of the
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Fig. 1. Biglan's taxonomy of academic disciplines. (Smith et al., 2008).
knowledge (Neumann et al., 2002). Engineering, an applied field, is the application of pure knowledge bases such as mathematics and physics. Biglan's taxonomy provides a useful lens for analyzing disciplinary differences in online courses. For example, a study spanning five years that analyzed Blackboard tool-usage patterns, student attrition rates, and student course evaluations suggests that online learning in pure disciplines has become more commoditized, while online learning in applied disciplines has become more oriented to community practice and more diversified (Smith et al., 2008). The lead author of the current publication has written publications on the discipline-specific effects of mathematics, a hard-pure discipline, in online learning. In Nursing, a soft-applied discipline, the lead author has made a deliberate choice of a discipline that is opposite along both dimensions of Biglan's taxonomy. Online nursing education delivers applied information in a human interactive environment. This means that the knowledge learned in the discipline is applied to people and is therefore unpredictable and requires critical thinking skills to be used by the students. Nursing is a high-demand field with highly specific needs for the students. The issues of nursing are in many ways different than the issues of other disciplines and thus require the online delivery to be modified in unique ways. By understanding the issues within the domain, the online education of nursing can be more productive. Beyond the content, Frith and Kee (2003) contend that withdrawal due to technical issues can be devastating to online nursing programs. It is vital that online curriculum is supported by sound instructional design to foster critical thinking and clinical decision-making paramount to nursing education and practice (Bolan, 2003). Providing nursing students with a well-constructed online course that targets their needs is part of a coordinated curriculum. This, plus responsive technical support, allows assessment to be provided in a timely manner, thereby creating a course with higher completion rates (Frith & Kee, 2003). Successful online courses for nurses provide frequent, short assignments and discussion forums centered around thoughtprovoking questions that integrate course content as well as illustrate the student's individual experience (Spangle, Hodne, & Schierling, 2002). An online nursing course should create an environment that fosters reflection and increases critical thinking about practice by allowing time for the students to develop cohesive written responses (Ali, Hodson-Carlton, & Ryan, 2004). By doing this, the students can share their personal experiences supported by research, helping not only to solidify their own learning, but also to bring more experiences to their fellow students who may face similar situations once they are in the field. 1.2. Gaps in the research literature More research on a soft-applied discipline would be helpful for this research paradigm, discipline-specific effects on e-learning. With its real-world consequences for practitioners, nursing is an appropriate choice. Further, with the rising demand for nursing associated with the aging of the U.S. population and the rapid growth of online nursing
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programs, an examination and dissemination of critical online needs of nursing could help instructional designers implement better online solutions for nursing programs. Since the stakes of nursing education are so high, it is vital to make sure online nursing is effective. Thus, the current exploratory study asked the main research question: In the perception of online nursing instructors and instructional designers, what are the unique challenges of teaching nursing courses online? 2. Method Participants for this study were seven instructors and two instructional designers within colleges of nursing at major research universities in the states of Florida and New York. Individuals were invited to participate if they had taught, or were teaching, one or more online classes or were involved in the design of online classes. All faculty interviewed had taught online nursing for more than two years. This qualitative, descriptive, multisite study consisted of open-ended questions designed to motivate the participants to reflect upon experiences associated with teaching and development of online nursing courses. Interviews were conducted face-to-face or by telephone. The interviews were conducted to uncover the most pressing differences between traditional face-to-face and online courses. Interviewers asked five initial questions focusing on issues such as the unique challenges of teaching nursing in the online environment versus face-toface. Following the answer to each question, the interviewers often asked follow-up questions addressing issues that the interviewee seemed to emphasize as important. The four initial questions included: 1) What are the unique challenges of teaching your discipline across all teaching modalities (whether face-to-face, e-learning, or point-to-point distance, etc.)? 2) How do instructors in your discipline address the unique challenges and pedagogy in the e-learning environment? 3) What unique learning opportunities for your discipline does the elearning modality afford, which are not available face-to-face? 4) What critical insights into teaching your discipline via e-learning were not covered by the preceding questions? Interviews averaged approximately 45 minutes in length. All interviews were taped, transcribed, segmented and coded independently by two research assistants with an interrater-reliability of 84.6%. The codes were analyzed with the whole interview as the unit of analysis (IUA), i.e., which codes occurred at least once in the interview. Multiple occurrences of a code in one interview did not add to its frequency. IUA frequency was counted by the number of interviews in which a code appeared once or more. 3. Results Table 1 shows the most common codes and their frequencies. The code names are italicized in the results reported below so the reader can read about the common themes in a prose context. A careful examination of the interviews revealed that assessment was not just the most common theme, but also ran through all the other
Table 1 Nursing—frequency of codes/themes using interview as unit of analysis. Code
Frequency
Percentage
Assessment Delivery method Tools Academic integrity Blended Feedback Interaction Authenticity CMS Research skills Student attributes
9 8 8 7 7 7 7 6 6 6 6
100% 89% 89% 78% 78% 78% 78% 67% 67% 67% 67%
common themes. Online nursing instructors discussed delivery methods, tools and academic integrity in the context of their concerns about assessment. Assessment issues permeated all of the interviews with online nursing instructors. Creating authentic assessments was a significant concern to participants. Most discussion of delivery method and tools was ultimately related to how these factors were utilized in the implementation of assessments. One of the most commonly utilized forms of assessment in online learning is testing. Testing in an online environment, however, provides unique challenges and opportunities not always encountered in classroom testing. One instructor discussed the advantage of providing computerized testing: “In Florida, RNs must take a rigorous computerized test in very secure conditions. They need opportunities to prepare for that.” The online testing experience gives students a chance to practice with this mode before having to sit for state board exams. Academic integrity is always a concern with online tests. Though one instructor permitted students to use notes and textbooks, other concerns were expressed about groups of students taking tests together: “You wonder who is in the room when they are taking the test.” Instructors discussed ways in which they attempt to minimize cheating such as randomized test pools and time limits. One instructor described her experience with a test pool that she began creating during her very first semester: “That test pool is still being used after five years.... The students are still scoring 65% to 100%. They have not gotten the answers out there.” It was expressed that “mature students will handle it well. Students with high integrity.” However, there was a definite concern for those students who do not fall into that category. One of the disadvantages mentioned in online testing was the lack of statistics provided by the Blackboard Course Management System (CMS), which was the system used by most of the participants in this study. Faculty asked for “more options for analysis with testing,” specifically a method for “the breakdown of information on the items for each test.” Without these tools, it was difficult for the faculty to compare online test results with live tests. Online nursing instructors discussed both desires for more tools within Course Management Systems, as well as teaching opportunities afforded by their Course Management System. Writing assignments were one of the most frequently mentioned forms of online assessment. In fact, one instructor stated that it was preferable to assess writing online: “Much of the interaction for writing and publication is appropriate on paper, such as critiques. exchange of manuscripts on Blackboard is efficient. Papers are easily shared.” Others expressed the comparability to live courses: “Assessment is similar to face-to-face. They write papers. They get credit for their weekly discussions.” One instructor, who taught a class of adult students returning to college, used writing assignments to help students get comfortable with the process of being a student and utilizing the electronic features that enabled sharing papers back and forth: “I had a lot of formative and summative papers for them.” The use of formative papers enabled students to gain familiarity with the system, getting feedback prior to submission of the actual final paper. Using word processing simplified the task of giving feedback and additionally gave students an opportunity to improve their computer skills. The use of writing assignments was described as an alternative to the issues found in online testing, assuming of course that students are writing the papers they submit. Using plagiarism detection tools is one way to prevent issues with cheating. However, the use of writing assignments is negatively impacted by the number of students: “Our classes vary from a minimum that is supposed to be thirty, but some instructors will take 60 to 70 students and say they have to use multiple choice questions to assess the student.” Authenticity was a major concern to online nursing instructors. Nursing is fundamentally a human care-giving activity. There is always the danger that didactic courses, particularly e-learning courses, seem too theoretical and not closely related, in an authentic way, to real
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nursing situations. The following is an example of a case study used to relate online nursing education to the human values of a real nursing situation: According to three of the nursing instructors, one of the human relations difficulties that nurses face every day is the diversity of cultural attitudes about medical situations. Not only is healthcare a technical profession where medical professionals take care of patients, but there is also a psycho-social component that is equally important, and it involves the cultural diversity of both the patient and the care provider. Therefore, teaching people to be culturally sensitive when they come from different cultural backgrounds with different cultural norms and expectations is a challenge. This exchange works both ways; it is not just teaching American-born, American-raised kids to deal with people from different cultures. Nursing instructors teach people from all over the world how to deal with people from all over the world. It is a great challenge teaching someone who comes from a culture where health care is based on science (United States or the European Union) how to appreciate a patient who requests something spiritual as part of the healing process. One nursing instructor brought this example from her own practice into her teaching as a case study: We had a family whose child was very sick and dying in the emergency room. The family wanted to do a prayer circle around the child who at that point, based on modern medicine, required a lot of medical intervention. In order to allow the family of six or eight people, where only two people are allowed to visit, we had to get special permission in a timely fashion because we had a really sick patient, to allow this family to do this prayer ritual, when the majority of the staff would rather have given another dose of medication. In the medical arena, there is a constant tension between the rules, cultural beliefs and providing the best comprehensive care for the patient. This is a major challenge in teaching nursing. Most nursing instructors have students from all over the world. The students come with their own cultural beliefs and norms and they have to accept the patient's cultural beliefs and norms. A major theme that emerged in the data upon analysis was the use of appropriate delivery method and tools to develop nursing courses consistent with national curriculum standards. One instructor stated that “we need to design assignments that help [them] students get to higher level thinking and skill development.” The assessments must also be applicable to real life because, as one instructor stated, “nursing is a practice-oriented field.” Instructors spoke of the challenge of “getting that application and synthesis” available in face-to-face courses to the same level of assessment into the online nursing courses. The question becomes what technology is available to create an interactive assessment for students that will allow the students to face real-world situations and prove they understand the concepts being taught in the class. One of the participants in the study stated, “You really need the students to apply the theory to the patient in that particular situation. They are dealing with people who are having illnesses, health care crises and so on. The students need to do more than just learn the theory that teaches you how to do it, they have to actually be able to do it.” The online learning environment can provide this by being adaptable to multiple situations and creating a multi-tiered program in which reactions to situations lead to a positive or negative result for the student. However, a critical concern “is that if everything goes into this cyberspace world, and we are trying to teach a profession [where] human contact is the nuts and bolts of it. Keeping the human contact piece going is the critical element.” One of the ways to keep the humanity in online learning environment is to work with other students in small cohorts or in synchronous chat sessions with other students. The use of discussion boards allows students to work with other students, comparing their own experiences to the experiences of others. One of the nursing professionals interviewed explained how discussion boards worked in one class: “They have to bring the experience with their patients into the discussion and then they have
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to reflect on whether they would do it different next time.” The use of synchronous chat sessions was discussed but “with nursing there is not a time that someone is not working. They work 24/7 so there is no time that all students would be available.” These methods do two things for the students: they incorporate the human or soft element into the course and give them a sense of community, which broadens their knowledge of the nursing community. Without appropriate tools, the ability to deliver authentic assessments is impaired. This was important to all participants in addressing the content-management system (CMS) used to deliver content, other tools used to enhance the course, or student ability and support. Use of a CMS usually dictates the delivery of online assessments. Another faculty member described problems with this system: “We do not have any standards in the college of nursing as to how we do testing online. And there is rampant sharing of tests from students in one semester to students in another.” However, not all individuals interviewed agreed that students were cheating. Even with the concern of test sharing, the consensus is that online testing also provides other benefits for nurses preparing careers in hospitals that are completely computerized. Today, even giving a patient an aspirin is logged immediately into a computer system, often by scanning the patient's bracelet and then the code for the aspirin. This familiarity with the online environment will be priceless in the new computerized hospital setting. Ultimately, none of these online tools are effective if students do not use what is available. Although some instructors insist on weekly deliverables to ensure that students are keeping up, others relied on the student's self-directedness. However, they discovered a correlation between time online and grades. “Some students do not check in for 2 weeks at a time. It shows the total times and hits. It seems to be related to the grades that they earn. Students with high grades put in many more hours and many more hits within the course than those with lower grades.” This is important to the field of nursing, where dedication is priceless to success and patient well being. When asked what would make their course, which was hosted in a Course Management System, but supplemented with additional webbased tools supplied by instructional designers—more effective, one instructor asked for a method that would allow students “more interaction between themselves.” Despite inconveniences and lacks, one faculty stated, “I think we are looking forward to more and more high quality tools being available online and can give the student the visualization of what is going on but also be able to get some manipulation that goes along with that.” The assessment of these methods might help resolve part of this issue, and give students more time to interact with other students in the nursing program. Technical support was mentioned as being important to the success of both nursing students and faculty. Several instructors mentioned having a support organization within the college, including an instructional designer and technical support, to supplement what is offered by the university. In this sense, online nursing instructors are much better off than online instructors in other colleges. Healthcare related colleges, such as nursing and public health, typically have more resources to support the development and delivery of online courses. Both instructional designers mentioned that, although the online nursing courses were officially online courses, many online nursing instructors created blended classes by adding one or two face-to-face class meetings at the end of the semester for final presentations or testing: “Even though it is not merely a web-based course, some faculty will require towards the end of the semester a meeting where students will present papers and projects and so on.” Both of the instructional designers and most of the online nursing instructors mentioned the lack of immediate real-time interaction between students and instructor, and thus the need to design in a vehicle for students to get feedback on questions about assignments: “You don't have the feedback that is useful from seeing them face-toface,” “They really want to have feedback from the instructor,” and
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“What works the best is I often set up times during the second week so that all students who have issues can come.” Student attributes such as technical ability were important to nursing instructors. Nursing students' technical ability has long been a challenge. However, one instructor remarked that “it gets easier annually as people get more computer literate.” It was noted that “health care is traditional and not computer oriented,” indicating that nursing students are not as “knowledgeable in technology as other disciplines.” Because of this, one instructor listed another advantage to e-learning, “it does expose the nurses to other kinds of technology; searching literature bases; communicating in groups and networking with people across the country and across the globe to get expert input and advice.” Finally, as one faculty member advised, “the instructor has to maintain a level of competency in the new technology... that requires updates in training through journals, clinical practice, conferences, meetings, in-services.” This becomes even more important as nursing moves into a computerized era where multiple tools are used to connect patient, nurses and doctors. Instructors also discussed using tools to supplement the options available on CMSs. Several mentioned using iPods and synchronous software such as Elluminate. One instructor said, “I am using Captivate [an Adobe multimedia development program] to supplement the PowerPoints and the students are really enjoying that modality.” Although one instructor thought these kinds of tools were helpful for faculty, there was a concern: “we need the tools, but we also need the time for it.” One issue that came up from discussion with the instructional designers, but was only implicitly hinted at in the instructor interviews, was the notion of core, or clinical, versus non-core nursing courses. At the undergraduate level, core clinical courses are typically not taught online, for the obvious reason that nurses need to learn procedural medical skills, which have life and death implications, in the context of face-to-face supervision and feedback. On the other hand, there is an increasing demand for nurses to keep abreast of the changing medical field by conducting research online to keep their knowledge current. Thus a lot of online nursing courses, particularly, graduate courses, emphasize research skills: “We do a lot as far as assigning them to go and find articles on those types of topics... and then analyze it, summarize it, and that type of thing.” “We have a big focus on evidence-based practice, which means basing your practice on what evidence tells us.” 4. Discussion Results showed that nursing instructors were concerned with authentic assessment of e-learning. The ability to assess nursing students in an online environment offered both positive and negative issues for students, but overall it seems weighted toward the positive. Many of the face-to-face aspects of the courses which are not available online are able to be replaced by technology that is available to students 24/7. Discussion boards were mentioned by most instructors as one of the more effective methods of assessing students. In addition to simulations of real-life situations, students had opportunities to interact with each other on the boards, and through these discussions brought their own experiences into the classroom situation. This allowed for learning from peers as well as from the instructor, thereby creating an interactive assessment model. Papers, journals, and case studies were also utilized by many of the faculty as a way of encouraging students to develop critical thinking skills regarding what they were learning. Diversity was mentioned by the participants as being particularly important. Incorporating multi-culturalism in an online curriculum requires not only an understanding of one's own cultural background and biases, but the ability to be aware and sensitive to students' needs and beliefs. Another area of significance to nursing is that students must apply the information they learn to real-life situations. Instructors must find ways to assess whether the knowledge taught online can actually be
applied by students. Assessment methods include discussions of case studies, group projects that simulate real-life situations and journals that describe how students apply theory to practice. Course Management Systems were challenging, in some respects, to all faculty either in their limitations, unreliability, lack of support, or due to a prevalence of nursing students who tend to be less technically adept than students in other disciplines. Faculty described how the CMSs could either further them towards or deter them from their objectives. There were numerous methods for creating online assessments, and faculty even stated that there were advantages, particularly in the areas of journaling and discussions. The lack of real-time interaction between students was seen as a disadvantage in CMSs. Results of the current study are consistent with previous research. Many nursing students, especially for those coming from community colleges, have little or no experience with online courses (Chaffin & Maddux, 2004). Also, many nursing students complain that online courses consume more time than traditional face-to-face classes. In addition, nursing students often experience extra stress through a struggle with the technology (Kozlowski, 2004). But even with those challenges, it is important to recognize that offering tests online gives students an opportunity to prepare for state boards that are all computer-based (McAlpine et al., 2002). Most students also felt that despite these challenges the ability to work asynchronously made the challenges worthwhile (Udod & Care, 2002). From the instructor's point of view, the challenge of preventing cheating worried instructors and increased their reluctance to offer online testing. Other methods of assessment were considered at least as effective as testing. However, the number of students enrolled limits the instructor's ability to grade and provide timely feedback to each student when using some of these alternate assessments such as research papers. 5. Conclusion When viewed through the lens of research on discipline-specific elearning, online nursing courses exhibit both similarities and differences in relation to other disciplines. Although nursing is a soft-applied discipline, while mathematics is a hard-pure discipline, instructors in both disciplines express concern with academic integrity in assessment. However, online nursing does exhibit its own unique set of challenges, such as providing nursing students with online learning experiences that relate to real-world nursing situations, which comprise both high-stake medical and interpersonal elements. Online discussions, case studies, and research papers potentially provide such authentic learning experiences and the means of assessing them. In terms of solutions, online nursing education is consistent with other soft-applied disciplines taught online (Smith et al., 2008) in that online nursing instructors and instructional designers customize their courses by using community-oriented pedagogy. References Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA: The Journal of the American Medical Association, 290(12), 1617–1623. Ali, N. S., Hodson-Carlton, K., & Ryan, M. (2004). Students' perceptions of online learning: Implications for teaching. Nurse Educator, 29(3), 111–115. Arbaugh, J. B. (2005). How much does “subject matter” matter? A study of disciplinary effects in on-line MBA courses. Academy of Management Learning & Education, 4(1), 57–73. Bolan, C. M. (2003). Incorporating the experiential learning theory into the instructional design of online courses. Nurse Educator, 28(1), 10–14. Chaffin, A. J., & Maddux, C. D. (2004). Internet teaching methods for use in baccalaureate nursing education. CIN: Computers, Informatics, Nursing, 22(3), 132–142. Conceição, S. C. O. (2006). Faculty lived experiences in the online environment. Adult Education Quarterly, 57(1), 26–45. Frith, K. H., & Kee, C. C. (2003). The effect of communication on nursing student outcomes in a web-based course. Journal of Nursing Education, 42(8), 350–358. Gunawardena, C. N., & Zittle, F. J. (1997). Social presence as a predictor of satisfaction within a computer-mediated conferencing environment. American Journal of Distance Education, 11(3), 8–26.
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