Authentic eLearning in Nurse Training for the Australian Outback

TheMaryAnnMartinHospitalProject
APaperpresentedtoEdMedia2012

Chris Sutton CEO, Educational Designer and Consultant eLearn Australia.com.au Pty Ltd (eLearn Australia) Nambour, Qld, Australia

Abstract: With enrolments falling across the Kimberley and many students failing to complete their courses because of barriers of distance and culture, the University of Notre Dame in Australias School of Nursing in Broome had to find a better way of engaging the trainee nurses of the outback. The "Maryanne Martin Hospital" provides students with an authentic virtual hospital environment, problems and tasks; promotes reflective practice; employs collaborative tools and diverse learning pathways and equally engages both on-campus and remote students. Faculty members have developed new ways of teaching. Students are becoming independent learners, using sources of learning and information provided by government and professional organizations outside of and complimentary to the resources provided by teachers and lecturers. In so doing, they are developing lifelong professional learning skills. This paper examines the way in which applying the nine principles of Authentic eLearning design has improved student engagement and educational outcomes.

Introduction
...the principal challenge has been for the course designers to think beyond the content of the course itself to the authentic use of the knowledge developed in the course. To think deeply about how professionals use knowledge and to query when and where such knowledge will be useful, is a most demanding part of task design. Herrington (2005) In this paper I will consider how the eLearn Australia and the University of Notre Dame in Australias School of Nursing in Broome have risen to the challenge of Authentic eLearning to design and develop an approach to training enrolled nurses in some of the remotest areas of our continent. At the University of Notre Dame in Australia, the Diploma of Nursing is a pathway to the Bachelor of Nursing conversion program. The course focuses on practical demonstration and practice of skills so that students are competent in a clinical environment. They need to be practice ready for when they attend clinical placement as they are often placed in the regional health services hundreds of kilometres away from the Universitys Broome or Fremantle Campus where the courses are available. The University had worked with students and industry to come up with a serviceable model of delivery to suit all stakeholders including those who live in the remote regions of the Kimberley in small communities and towns thousands of kilometres from University campuses. The course structure prior to the development of the current elearning strategy was an 18 month full time (1320 hours in total) program divided into 3 semesters with 15 weeks of clinical placement in Health Centres or hospitals interspersed throughout the program. There are 21 units of competency (16 compulsory 5 electives) organised into an off- the- job training program with on-the-job components. The course was organised so that students were provided with theory based learning, simulated practical sessions and practical placements in a hospital or health care organisation/service. The approach involved some block components of study on the campus as well as distance learning. However, most student interest came from remote communities in the Kimberley and students could not always leave home and their communities to live in Broome. Block release of five weeks per Semester was used but proved an impossible model for sustainability. Five weeks was too long for these learners to be away from their family and their community and employers were unable to fill a gap of that length. Other strategies were sought. The University commenced using Blackboard

Collaborate (then Elluminate Live!) to work with students in a traditional distance program, and used it extremely effectively; however it was evident from the number of student withdrawals that a better solution was needed. Sally Clark, Dean of Nursing at UNDAs Broome Campus approached eLearn Australia to work with UNDA Broome to develop an elearning strategy and resource for the enrolled nurse training at the University. The foundations were laid for the Mary Ann Martin Hospital. Every construction needs a strong foundation and for any learning resource that foundation is a sound educational theory. In the case of the elearning resources and strategies that we develop at eLearn Australia there are two theories that form the foundation of our design approach, authentic eLearning and Multiliteracies.

Authentic eLearning
Authentic eLearning has its foundations in the theory of situated learning that arose in the 1991 with the work of Lave and Wenger. Situated Learning proposes the notion of learning knowledge and skills in contexts that reflect the way the knowledge will be useful in real life. It argued that many of the activities that learners undertake are quite different from the ordinary activities that people meet in their real workplace. In the 1990s we saw the development of simulated work environments and courseware that emulated the workplace. However, further research carried out by Jan Herrington, Oliver and Reeves from 2000 has shown that creating a simulated environment is not enough to bring learning into a context that reflects the workplace and the tasks and problems that make up the ordinary activities of the worker. In 2003 Ron Oliver and Jan Herrington were at Edith Cowan University. They had just published, together with Tom Reeves, from the University of Georgia, a piece of research entitled Authentic activities and online learning. That was the year of my Australian Flexible Learning Leader research grant and it was in the course of my research that I met and interviewed both Ron and Jan. Their research rang many bells for me. Together with some research into Multiliteracies for a Digital Age that I had undertaken it formed an approach to elearning design and development that I believed would lead to deeper and more effective learning and a higher level of engagement and completion in students. An Authentic elearning resource is designed to create ill-defined problems that replicate the types of problems that students will confront in the workplace. It puts the emphasis on the mode of discovery, not the answer, helping students develop the critical thinking skills necessary to reach a conclusion. Students learn how and where to look for information or seek out collaborations. Our challenge as educational designers was to discover what knowledge professionals need in the hospital environment and create an environment and tasks that would allow students to learn and put into practice the professional knowledge and behaviours they need before they graduate. Rising to that challenge involved working very closely with the lecturers at the University of Notre Dame in Australias Broome Campus. In their latest publication A Guide to Authentic eLearning, Herrington, Reeves and Oliver (2009) refine and condense authentic elearning into nine characteristics. I will consider each of these in turn and look at how we applied them in the design of the Mary Ann Martin Hospital resource.

The Characteristics of Authentic eLearning

1. Provide authentic context that reflect the way the knowledge will be used in real-life; When we designed the interface for the hospital we placed the learning in a highly complex context that is recognisable as real. As one of the problems that have been identified by UNDA was the need to spend valuable time inducting the students into environment at the Broome campus, it also reflects the teaching laboratory at UNDA Broome where the students complete their block release. It allows the learner to identify and function as they would at work by working through the virtual environment and exploring how the skills and knowledge that theyre acquiring will be used. Within the hospital there are all the facilities that a nurse would expect to find a ward, a dispensary, an operating theatre, pre and post operative areas. There is a staff room where access to professional development tools can be found and discussions of a formal and informal nature can be carried out and where appointments can be made to meet with their nurse tutor.

Figure 1:

The ward at the Mary Ann Martin Hospital

In the ward are all the usual sources of information that a nurse in a Western Australian bush hospital will use; patient notes, clinical references and workbooks, patient charts and forms that are required for completion at various times. The forms and documents provided are those that are used in real hospitals throughout the state. Students complete them and use them as they would in the real world. 2. Provide Authentic Tasks The tasks in the Mary Ann Martin Hospital are complex. They have real world relevance. Students are very good crap detectors; if a task is contrived and simplified they will quickly lose interest and disengage. They need to be presented with tasks that have all the complexities of definition, of identifying the subtask that have to be carried out and of having to go out and search for information and determine what information is and is not relevant. Tasks are integrated across the learning, across subject areas, so that anatomy and physiology for example will permeate all other skills areas from medication to palliative care. Of course this entire approach means that time is needed for investigation and research. No quick tick and flicks here.

Figure 2: Tasks are contained within patients case study, notes and records. A patient is provided for each of the body systems. When the learner clicks on the patients photo at the top of the screen he/she appears in the central bed. The patients chart hangs on the end of the bed. By clicking on the patient the learner enters the case study information and as they work through it complete a number of tasks relating to interpreting the charts and patient information, understanding the doctors diagnosis and notes, creating care plans, and caring for the patient and, sometimes, the family. In the dispensary are the tools that a nurse uses to calculate dosages and dispense medication together with medical supplies. The same information sheets are available that are required to be used in all hospitals. There is

also a me edication calc culator availab ble. Students carry out the e normal tasks s of calculatin ng dosage and d dispensing medicatio on for patients s. The medica ation tasks flow w naturally fro om the patients case notes a and case study y.

Figure 3: Th he dispensary replicates faci ilities, supplies and equipme ent usually fou und in hospita als. W have not a We abandoned co ontent, but content is no lon nger King. Fo or each of the U Units of Comp petency that have been n developed th hus far we ha ave created a w workbook con ntaining inform mation and int teractive learn ning objects. These are e accessed from the booksh helf at the nurs ses station in n the ward. Th hey can be accessed and us sed over and over again n as needed an nd are available no matter w what UOC the student is com mpleting.

Fig gure 4: An ex xample of a wo orkbook page from the Med dications Work kbook 3. vide access to expert perfor rmances and th he modelling o of process; Prov T apprentice/master mod The del is really im mportant in the e context of au uthentic learn ning. It is also o an integral part of nu ursing. Traine ee nurses learn rn from more e experienced n nurses and from m their nurse supervisor. I In designing the hospi ital we needed to provide access to exp perts, expert t thinking and modelling in a variety of ways for example, we created Jill, the nurs se supervisor, to express pr rofessional op pinion and adv vice and prov vided access he tearoom t to journal arti icles, videos an nd websites. through th

T use of Bl The lackboard Col llaborate allow ws for guest s speakers and contact with other students s at varying levels of expertise an nd gives opportunities throu ugh live inte eractions to be e able to share e stories and n narrative and to learn a at the feet of t the mentor, th he UNDA lect turer/trainer. 4. Prov vide multiple roles r and pers spectives I the workpla In ace we are me et with differin ng opinions o of how things ought to be do one. This is n no less so in the hospit tal environment. Health pro ofessionals ca an provide con nflicting opinio on on how car re needs to be given, what medicatio ons are effectiv ve and how best to look aft ter the welfare e of the patien nt. We needed d to provide ac ctivities that give the learner access s to differing opinions, opp portunities to assess these and look at how h one migh ht outweigh n certain circu umstances yet n not in others. another in

Figur re 5: Guest sp peakers in Col llaborate provi ide sources of f multiple pers spectives

T They need to b be provided w with multiple p problems to ex xamine and to which they can apply know wledge from different perspectives. No right an nswer problem ms are impor rtant. This is snt possible unless the fo ormat of the resource i is non-linear. The Mary An nn Martin Hos spital allows le earners to mov ve backwards and forwards through the many res sources and w workbooks, to look again work w carried o out in previou us units and lo ook at it from m a different perspectiv ve. 5. Supp port collabora ative construct tion of knowle edge; A Although this is a difficult thing to achi ieve where there is not a c cohort of stude ents going thr rough at the same tim me, authentic elearning need ds to have acti ivities and a design d that has tasks that ar re completed in pairs and groups, an nd a structure that encourag ges the whole group g to achie eve. T use of discussion boar The rds, wikis and d Collaborate tutorials allow ws for collabo orative learnin ng. Coming together at a Block Rele ease as a grou up that has me et virtually ov ver a few weeks or months has allowed for a higher level of collaborative le earning. Teac chers have fou und that as a re esult of the Blackboard Coll laborate group p sessions, it er in collabora ation than it t took when lea arning was via a traditional takes far less time for the group to come togethe correspondenc ce methods. distance/c

6.

mote reflection n to enable ab bstractions to b be formed Prom R Reflection is a an important p part of learning its also an n extremely im mportant part of a nurses working w life. Nurses ar re encouraged as part of thei ir professional l life to contin nually reflect o on their practic ce and weigh t the pros and cons of d differing opinio on and care ch hoices. We ne eeded to ensur re that the res source provide es a context an nd tasks that require decision makin ng and then an n opportunity y for students to reflect on their decision ns and make c comparisons between them and exp perts, they and role models s and they an nd other stude ents. This ag gain requires a non-linear ion of materials and resou urces that mak kes it easy fo or them to mo ove back and d forth up and d down and organisati sideways if desired. T Tasks that requ uire reflection n on choices m made or case study s problem ms resolved are built in as forum response es and the kee eping of a jour rnal. Wiki or fo

7.

mote articulat tion to enable tacit knowledg dge to be made e explicit Prom R Reflection go oes hand in h hand with arti iculation an nd by that I dont mean a articulating in nto a higher qualificat tion I mean talking and writing! w We n needed to provide complex x tasks that cre eated a need to t say it out loud and talk about it, not simply pr rompt a verbal l response. To oo often we re ely on questio ons to prompt articulation, need is to crea ate situations w where the stud dent needs to have somethin ng say. Often n the saying or r the writing what we n of argume ents and ideas s enables the k knowledge to be made muc ch clearer. Di iscussions, de ebates, semina ars presented by the st tudent, group discussion, th he making of f videos and d digital stories all promote articulation. In taking a blended a approach of on nline resource e, Collaborate tutorials and Block B Release e allow for the e widest possible range of verbalisat tion even thou ugh we are in a technology b based solution n.

F Figure 6: Scaf ffolding, colla aboration and articulation a in n an online session

vide coaching g and scaffoldi ing by the teac cher at critical l times Prov A Authentic eLe earning canno ot happen wit thout a teache er although the role of t that teacher m may be very rtunities for different to the role th hey traditiona ally held. Go ood design ma akes it impera ative for ther re to be oppor ble students t to assist in sca affolding and c coaching learn ners. teachers and more ab A Again the use of Blackboard d Collaborate has made scaf ffolding and c coaching easier for the remo ote student. In the Tea a Room there is the facility for a student t to click and m make an appoin ntment for a on ne on one Collaborate session w with their teach her. This is we ell used. The water cooler i in the Tea Roo om is clickable e to open a for rum that is student to o student comm munication an nd is not used by b teachers at all. This enab bles peer coac ching and scaff ffolding and encourage es collaborativ ve learning. In fact, the ex xperience of te eachers, traine ers and lecturer rs working wi ith these learni ing designs ha as been that h in a complet tely different w way. They devote considera ably more tim me than previou usly - and a sig gnificant they teach amount of time in the course c to coa aching and sca affolding and f far less time in n lecturing in n fact lectures s and slide presentati ions have gone from their pr ractice. 8. vide for authentic assessmen nt of learning within the tas sks Prov tic elearning design require es that assessment offers s students oppor rtunities to cr raft polished Good authent tasks effective ely within the assessment task itself, that assessment tasks are real world w tasks. products and perform t nd effort and will usually b be completed in collaborati ion with other rs as well as i individually. These will take time an ould be integr rated into the e learning act tivities and h have multiple indicators tha at the learnin ng has been They sho effective. Most of the e authentic as ssessment in t the UNDA bl lended approa ach is within t the Block Release where practice i is observed wi ithin the labor ratory. Forma al written asse essment happe ens in the LMS S environmen nt and is less c as it has to meet m the requi irements of sta atutory auditor rs and the organisation. authentic 9.

F Figure 7: Ass sessment of learning within the UNDA Br roome laborat tory

S Sometimes, of ften because th he organisatio on has not mov ved beyond old practice, o or because of requireme ents of regulat tion and/or aud dit, assessmen nt sits out alon ne and while it t looks authent tic, and feels a authentic, it really isnt and gives lit ttle true indica ation of the stu udents ability y to operate in the workplace e. A we can do All o is our best, by providing non-formal assessment that i is seamless wi ithin the activi ities and use those as a an indicator to o competence, followed up by b the formal requirements r o the organisa of ation.

Multilit teracies
T There is more e to our appr roach than the e authentic learning enviro onment, activities, tasks, pr roblems and assessmen nts. We also take t into consideration the i implications o of Multiliteraci ies for the targ get audience. I everything we do in life we need to be In e literate in a n number of dif ffering langua ages some sp poken, some written an nd some under rstood. A nur rse needs at lea ast the followi ing literacies; The common language in T n Australia th his is usually English. E In or rder to work i in a hospital a anywhere in A Australia a good knowledge e of written an nd spoken Eng glish is essentia al. If from a non I n-English back kground, the l learners first language. In the case of m many of the n nurses in the K Kimberley, Northern Territory and Centr ral Australia th heir first language is one of a number of f Indigenous l languages, an advantage in areas where th he patients the emselves are In ndigenous firs st speakers. The language of the workpl T lace hospita al terminology y and common n speak inclu uding acronym ms - Wards, T Theatres and D Dispensaries, Inpatients, Ou utpatients, Del livery Ward, Intensive I Care e, High Dependency, ICU, H HDU, Admiss sions, Discharg ge (several me eanings) - no wonder its co onfusing. Medical langu M uage and term minology if you get these e wrong, live es may be in danger as it includes i the d dosages of m medicines, how w they are ad dministered an nd where; sub bcutaneous, I IV, oral, optic cal - not to m mention the de escriptions of illnesses, anat tomical names s, physiological terms. Nurse langu uage the lang guage that has s been created d by the nursin ng profession for f itself; nurs se specialist, r registered nur rse, enrolled n nurse, nurse s supervisor, gra aduate nurse, nursing unit manager, nurs se educator, g graduate nurse e, CN, RN, NU UM, EDNS, E EN Government H G Health Depart tment languag ge including g acronyms can vary from m state to sta ate A3GP, A A&E, AAQHC C, CATSIN in fact there i is a published d glossary of th housands of A Acronyms that are used by t Commonw the wealth Govern nment Departm ment of Health h and the Ageing (DoHA) al lone. If working with specific cultural groups the language I ure. This has b been found to be essential e of that cultu i the outback in k where medical professiona als are working g with Indigen nous patients.

Technology the language of the computer and other technologies that are in use drug dispensing equipment, monitoring equipment, patient records, even some beds are technology controlled and have a language of their own.

In building a learning resource we have ensured that Multiliteracies are built in and that the language used in the resource is also real and reflects, and intentionally builds, literacy in the many languages of the workplace. It is in this area that we are in the process of expanding the Mary Ann Martin Hospital resource to ensure that Multiliteracies, as they apply to indigenous and international students, are well catered for. The indigenous nurse often moves between two sets of language and understanding of anatomy and physiology. Indigenous patients come into the outback hospitals with varying degrees of English and their first language. For some, English may be their 4th or 5th language. We believe we can overcome some of the barriers and challenges to achievement that have been identified as Multiliteracies issues amongst Indigenous students by creating a resource that bridges the gap between indigenous language and cultural understanding and anatomy and physiology medical terminology. For example, one doctor is using aboriginal art and drawings to encourage patients to describe their symptoms in a way that is familiar to them, using aboriginal terminology and cultural understandings of physiology. He is then able to bridge the gap between the official language of medicine and the language that the patient understands. As many of the indigenous graduates of the Diploma of Enrolled Nursing will work in Communities and hospitals where the majority of patients are Aboriginal, their understanding and ability to bridge the multiliteracies gap with their patients will be invaluable.

Conclusion
The Mary Ann Martin Hospital is a living resource. As we find more ways to make the learning authentic, and more audiences who need it the hospital grows and develops. In the next phase of development it will probably acquire a Maternity Section and an Aged Care facility. Whatever direction the curriculum takes it is a simple and easy thing to change content and text as we have built the resource to the Australian Flexible Learning Frameworks e-Standards for Training. It can be housed in any standards based LMS; it has been tested in Moodle and runs live in Blackboard. We believe that we are meeting the challenge that was set for us, that we are creating an authentic learning environment that prepares enrolled nurses well for the workplace. The Mary Ann Martin Hospital provides students with an authentic virtual workplace, with real workplace problems and relevant and appropriate workplace tasks. It promotes reflective practice, employs collaborative tools and diverse learning pathways and at the same time equally engages both on-campus and remote students. This is confirmed by perhaps the most important response to the Mary Ann Martin Hospital resource, that of the learners. They tell us that it is like going to work in a real hospital. They tell us that they feel they are being prepared for the real world of nursing. They tell us that they are more able to find information and resources for themselves and to think about their work and reflect on their choices. More of them are completing their course and going on to further study. Their excitement and enthusiasm led them to request that the name of the hospital be that of a renowned indigenous nurse from the region, Mary Ann Martin. Faculty members who deliver the training through the Mary Anne Martin Hospital Resource have developed new ways of teaching. They spend more time coaching, mentoring and scaffolding students and less time preparing lectures. Lectures have become a thing of the past, though past PowerPoint slides are part of the resources that are made available. Students are becoming independent learners. They are searching for and using sources of learning and information provided by government and professional organizations outside of and complimentary to the resources provided by teachers and lecturers. In so doing, they are developing lifelong profession learning skills.

Acknowledgements
The design and development of this approach has been a team effort involving personnel from both UNDA and eLearn Australia. The following people are the members of the Mary Ann Martin Project Team; from UNDA Sally Clark, Associate Dean of Nursing, Broome, Jennifer Farrell, Donnelle Perry (the lecturers) and from eLearn Australia Chris Sutton CEO and Educational Designer, Sarah Bock Instructional Designer and Leia Sidery, Graphic Artist.

References
Australian Flexible Learning Framework E-standards for Training V1.0 (2011) Commonwealth of Australia http://estandards.flexiblelearning.net.au/index.php Herrington, J., Reeves, T.C. and Oliver, R. (2009) A Guide to Authentic e-Learning. Routledge, New York. Herrington, J. Authentic tasks in e-learning designs. In Studies in Learning, Evaluation, Innovation and Development http://sleid.cqu.edu.au 2(2), pp. 18. 2005 Lave, J. & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press. Reeves, T., Herrington, J. & Oliver, R. (2002). Authentic Activities and online learning. In J. Herrington (Eds.) Proceedings of HERDSA. Joondalup: Edith Cowan University. http://elrond.scam.ecu.edu.au/oliver/2002/Reeves.pdf Sutton, Chris (2006) Literacy, e-literacy and multiliteracies: meeting the challenges of teaching online. In Allan Martin and Dan Madigan (Eds.) Digital Literacies for Learning, Facet Publishing