A clinical practice teaching and learning observatory: The use of videoconferencing to link theory to practice in nurse education
Article Outline
- Abstract
- Introduction/background
- Literature review
- Method
- Discussion
- Limitations and further research
- Conclusion
- Acknowledgements
- References
- Copyright
Abstract
This paper discusses the implementation and evaluation of an innovative approach using videoconferencing to help student nurses to link theory to practice. A Clinical Practice Teaching and Learning Observatory (CP-TLO) was established to provide a synchronous learning opportunity for students in a university classroom observing and interacting with a specialist nurse, patients and carers in a diabetes clinic. Thirty eight students on a BSc/Diploma in Nursing course in the United Kingdom participated in the project which involved partnership working between lecturers, clinical and management staff, IT personnel and patients and their relatives. Student evaluations described the CP-TLO as an enjoyable and valuable learning experience. It is concluded that whilst the project focussed on nurse education and a diabetes clinic, videoconferencing between clinical placements and a classroom has the potential to strengthen links between theory and practice in other areas of nursing and health and social care professions.
Keywords: E-Learning, Videoconferencing, Theory–practice links, User and carer involvement
Introduction/background
This paper describes an innovative approach using videoconferencing to connect students in a university classroom in the United Kingdom (UK) with service users, carers and nurses in a clinical area, through what we have called a Clinical Practice Teaching and Learning Observatory (CP-TLO). The gains as well as the difficulties are discussed and although applied here to nurse education in the UK, the CP-TLO has potential use for interprofessional learning internationally, to enhance opportunities for all health and social care students who need to link theory to practice.
The project described is supported by the University of Nottingham, School of Nursing, Midwifery and Physiotherapy, Division of Nursing, and the Visual Learning Laboratory (VLL). The VLL is a learning, teaching and research centre supporting a range of projects across the University of Nottingham in the UK. The VLL was established in the School of Education in 2007 as one of the Centres for Excellence in Teaching and Learning (CETL) funded by the Higher Education Funding Council for England (HEFCE) to support innovations in visual learning.
Literature review
Three main areas of literature pertinent to our project are reviewed briefly; linking theory to practice, user and carer involvement and the use of videoconferencing to facilitate learning.
Linking theory to practice
The existence of a ‘theory–practice gap’ within nursing has been much debated over the years (Gallagher, 2004) and questions have been raised about the ability of nurse education to address the issue (Rolfe, 1996). There have been numerous suggestions on how student nurses can link theory to practice, for example, through reflection on practice (Benner, 1984, Johns, 2000), through Problem based learning (PBL) (Boud and Feletti, 1998) and Enquiry-Based Learning (EBL) (Ashby et al., 2005), all of which focus on practice experiences. Students’ exposure to service users in the classroom has also been put forward as a way of bridging the ‘theory–practice gap’ (Hopton, 1996, McGarry and Thom, 2004) and the patients in Twinn’s (1995) study saw their role in student learning as a way of overcoming the phenomenon. However, there appears to be no published literature to show how theory can be linked to practice through the use of videoconferencing. This paper addresses that omission.
Service user and carer involvement
The involvement of service users and carers in nurse education is supported at a national level by the Department of Health (2006) and the Nursing and Midwifery Council (HSLP 2009). The University of Nottingham (2009) has embraced the concept in the Divisions of Nursing and Midwifery by involving service users and carers in curriculum development and programme delivery. In this way, service users and carers take an active part in nurse education, in contrast to the more passive role they take as patients in clinical areas where student nurses gain practical experience (Rush, 2008).
Research into the involvement of service users in nurse education has revealed some positive results. For example, Wood and Wilson-Barnett (1999) found that students who had been exposed to service users in the classroom were less likely than others to use jargon and were more able to empathise with clients’ experiences of distress. Morgan and Sanggaran (1997) similarly found that the assessment of students by clients was beneficial to student learning. However, the study also found one student stating that service users’ opinions were not significant. More recently, Rush’s (2008) research gave examples of how student nurses had made positive changes to their practice following mental health service user involvement in the classroom. There appear to be no published studies on involving service users in nurse education through the medium of videoconferencing; a further gap in the literature that this paper addresses.
Videoconferencing in higher education
The use of videoconferencing, to connect learners from distant sites to a main campus has been described in relation to a wide range of courses. For example, Parker et al. (1999) in High Energy Astrophysics; Pounder (2004) in an Organisational Theory class and Lewis and Coursol (2007) in teaching career counsellors. Norum and Jordhoy (2006) researched the feasibility of videoconferencing for clinical and educational support between oncologists at two hospitals in Norway and in continuing medical education Karlinsky et al. (2006) showed that videoconferencing and online training were at least as effective as traditional programmes in increasing the knowledge of physicians relating to injury management. However, students in a School of Textiles in Scotland were seen to be less participative than usual when videoconferencing was introduced to their sessions (Brown et al., 1999).
In nurse education there are a number of studies describing the use and advantages of videoconferencing for enhancing learning. Some difficulties have also been described. Lehna et al. (2005) discuss its use in making links between institutions in Texas and Houston to enable the sharing of expertise and effective networking among paediatric nurses on a continuing education programme. The authors cite increased recruitment, the sharing of expertise and savings in time and travel costs as positive, but conferencing scheduling as a challenge: the link to one site was delayed because the preceding conference ended late. A further negative point was that some attendees had difficulty seeing the off-site speaker. Martin and Klotz (2001) describe the ambitious provision of a full nurse education programme using videoconferencing to provide a flexible course for student nurses living 45 miles from the main campus of the University of Texas with no access to public transport. The researchers found an advantage of videoconferencing was that students with families who would be likely to stay in a given area could have access to a Baccalaureate degree, which would have been less likely under the provision of traditionally taught courses, due to travelling and time difficulties. However, this study also identified a number of difficulties, including the expense of setting up the course, communication breakdowns, anxiety levels in students at the remote site when they did not have the same course material as those at the main campus and the advance preparation needed by lecturers. Reinhert and Frybeck (1997) describe a nurse education outreach programme to Palestine which highlighted a concern about student socialisation associated with distance learning and the need for nursing students to develop appropriate values, attitudes and beliefs related to the nursing profession. They emphasise the need for students at remote sites to have mentoring and support. On the basis of the published literature, bearing in mind the possibility of publication positive results bias, the benefits of videoconferencing in an educational context appear to outweigh the difficulties.
Training and preparation to ensure the correct set up and delivery of videoconferenced teaching sessions ensures positive gains for the students. Haythornthwaite and Rees (2004) provide guidelines on the use of videoconferencing in telepsychology that can be transferred to other professions. Zalon (2000) advocates careful attention to course planning, television techniques and the presentation of course materials. Birden and Page (2005) describe how to start using videoconferencing for educational purposes and suggest certain protocols, such as ensuring participants at remote sites have the same information available to them as those at the host site and muting the microphone when not speaking, to name just two, to ensure a satisfactory experience for learners. Similarly, Gill et al. (2005) offer twelve tips for using videoconferencing in higher education and Lehna et al. (2005) suggest resources that need to be in place for successful videoconferencing, such as rooms with telecommunications capabilities, accessibility to phone lines, site coordinators and a budget for staff time and transmission. Waldman (2006) presents a comprehensive help sheet based on information from generic literature and research. All papers offering guidance emphasise the need for knowledge and adherence to videoconferencing protocols and importantly, the need for technical support, good planning and coordination in order to enhance the learning experience.
Aim
The aim was to use videoconferencing technology to investigate the feasibility of setting up a Teaching and Learning Observatory (TLO) which Coyle (2006) had first initiated to link student teachers in a university classroom with experienced teachers in state schools in the UK. We developed the concept further with its application in a clinical setting to facilitate the learning of student nurses on a Diploma/BSc in Nursing course. If successful this approach provides students with more opportunities to interact with patients and clinicians in real time leading to enhanced learning by addressing the theory–practice gap.
Objectives
Method
The method describes the setting up of a CP-TLO in a diabetes clinic.
Participants
Access to participants and preparation of students
Permission was gained from senior managers in the local NHS Trust, the partner organisation in the initiative. NW contacted a diabetes specialist nurse who facilitated group education for service users and carers to provide information and peer support regarding various aspects of type 2 diabetes. At the initial individual appointment the nurse ensured that the patients had adequate capacity in terms of understanding and the dexterity for insulin administration. It was also established that they were willing to engage in group education.
A letter was sent to the patients, offering group education on insulin initiation and explaining the Trust’s links with the University of Nottingham. The prospective group members were invited to participate in the CP-TLO and an information sheet was included to describe the process. A consent form was enclosed for signing which stated that participants could withdraw at any time. The letter explained that if the person did not wish to be involved in the CP-TLO, an alternative appointment could be made. Everyone invited to the clinic agreed to take part.
In preparation for the CP-TLO, students were asked to complete a workbook focusing on a patient’s journey through diabetes (type 2), epidemiological factors and the nurse’s role. A lead lecture included emphasis on diabetes management, the efficacy of group education in clinical practice and the importance of user and carer involvement. The CP-TLO concept and process was explained to the students and they were asked to think of questions to ask the participants in the clinic. The IT technician had prepared the equipment and was available for technical support.
Technical specification
A Tandberg 990MMX Codec system with two Audio Technica boundary microphones were used with an NEC 42 inch plasma television and a data projector which was fitted in the classroom. The portable system used in the clinic was a Toshiba A100 laptop running IPContact videoconference software (www.bnisolutions.com), a Sony TRV265 camera and a BeyerDynamic MPC70 boundary microphone.
Classroom – clinic link
At the appointed time, a videoconferencing link was made between the classroom and the clinic. Participants in the clinic and the classroom could see and hear each other and greetings were exchanged. Participants were asked if they understood what was about to happen and everyone was willing to proceed. The microphone and camera in the classroom were then turned off and those in the clinic remained on so that the students could see and hear the activity in the clinic. At the same time as the patients were viewing the insulin ‘pens’ handed round by the nurse, the students had access to identical equipment in the classroom and so were learning alongside the patients. At the end of the clinic, the microphone and camera were switched on in the classroom and the students were invited to ask questions.
Examples of questions asked by the students were:
“How do you think you will cope with this change in your lifestyle?”
“Do you have a needle phobia?”
“How did you feel about us watching you?”
In response to the question about a needle phobia, the nurse was able to tell the student that if anyone had such a fear, an individual appointment would have been made rather than asking the person to attend group education. The last question was asked by a student who had initially felt uncomfortable about the process. When the patients all said that they had been pleased to help and had “forgotten that the camera was there”, the student was reassured. Service users and carers were thanked for their input and the video link was ended.
Results/student evaluations
Results for two cohorts (n = 16 and n = 22) are reported and where there is concordance between the two cohorts, the data have been combined. Where there is disagreement between the cohorts, these will be reported separately.
All students (n = 38) strongly agreed or agreed that they were well prepared for the session, felt encouraged to be involved and that they achieved the aims of the session. Four students from cohort 1 and just 1 from cohort 2 did not enjoy learning this way and felt unable to ask questions during the session. There were differences between the cohorts in terms of being able to hear the remote site (Fig. 1) and the qualitative responses below:
“The sound quality affected this learning experience. But it was a good way to learn and remember details from the session” (Cohort 1)
“Session was good. Able to see how patients behaved during their diabetes induction. Sound quality was not so clear” (Cohort 2).
Fig. 1
Hearing the Speaker
In response to the negative comments by cohort 1, the microphone was changed resulting in an improvement in the feedback for cohort 2. This may have been a factor in the response of cohort 1 when asked if they wanted to take part in another videoconferenced session (In cohort 1, 25% said not compared to 0% of cohort 2). Cohort 2 were very positive about the TLO experience:
“I learnt a lot from this session and can take the knowledge into practice, particularly understanding that patients can be taking medication for conditions that they may have little understanding of”.
“A valuable educational experience of real life”.
“The screen was a little blurred. However it was a breath of fresh air to receive a different method of teaching. The nurse was teaching the patients and students individually. Very dynamic!”
“Really enjoyed session. Great way to learn from clinical setting in School. Respectful and ethical way for observed learning. Good balanced discussion… professional but relaxed rapport”.
Fig. 2 shows the question ‘The presence of cameras and technical equipment hindered my learning’ produced the most varied response with 25% of all the students feeling the technology hindered their learning – most were from cohort 1.
Fig. 2
The presence of cameras affecting learning
Discussion
It is apparent from the feedback above that the majority of students found the experience of linking theory to a practice setting via videoconferencing, a valuable learning experience. It is therefore pertinent to consider some reasons for implementing a CP-TLO in a practice area. From a practical perspective, it is not possible for students to experience all clinical areas. Furthermore, it is not feasible for several students to be present in a small clinic during consultations. The CP-TLO enabled the business of the clinic to be conducted without the distraction of having students physically present and addressed the space issue.
It is possible that the skills of the specialist diabetes nurse may be demonstrated through role play in the classroom. Role play can be a valuable learning tool (Ellington, 2004) but the student evaluations in this project and in other research involving service users (Rush, 2008) has shown that the ‘reality’ of the situation is considered to be beneficial to their learning. Whilst some students enjoy the challenge of role play, others will argue that it is not ‘real’ and therefore not helpful.
Asynchronous e-learning methods are well established in Higher Education Institutions as part of a blended approach to learning, but as Jones et al. (2006) note, synchronous methods have been less reported. Videorecording of clinical skills enables playback as many times as needed to aid student recall. In contrast, videoconferencing is a synchronous learning method, a live broadcast enabling students to interact with the participants through questions and discussion. Practitioners and/or service users and carers might be more willing to participate in videoconferencing, knowing that their words will not be scrutinised at a later date as in a videorecording. In this way participants are more likely to ‘act naturally’ rather than being self-conscious about their behaviour.
The inclusion of service users and carers in nurse education has become accepted as a good practice in the UK. However, since students have contact with patients and their relatives in practice placement, the validity of their involvement in a CP-TLO needs to be considered. Ramon and Sayce (1993) made the point that service users are always in the role of ‘helped’, whereas students are in the role of ‘helper’ when in practice. Consequently, students do not always feel able to ask questions of patients in practice to enhance their learning because they see their role as helping patients and not being helped by them. When service users enter the classroom to teach students, the roles are reversed, so that the former help the latter. The power positions are reversed and students learn from service users, rather than learning about them in practice (Rush, 2008).
A CP-TLO has some advantages over direct contact with service users in both placements and the classroom in terms of the student experience and that of the service users. Students in a CP-TLO can observe the skills of the practitioner and interact with the patients in a learning context rather than in the role of ‘helper’ or ‘nurse’. The service user gains from the experience of being ‘helped’ by the practitioner in relation to their medical condition and then in a reversal of roles is able to help the students by responding to their queries and demonstrating expertise of the subject in question, from their personal perspective. In this way the voice of the service user is heard and there is a change in the power relationship. Students can learn the value of partnership working in this way and the importance of listening to the patient. In practical terms, service users can share their experiences of health problems and health services in a CP-TLO without having to travel to a classroom and without having to prepare lesson plans. The value of learning from service users’ experiences cannot be overestimated.
From our description of the CP-TLO it might appear that the implementation was a straightforward matter with benefits for all. However, whilst we are keen to emphasise the positive aspects of the project, we also need to explain some of the difficulties encountered. Initially we thought that the main problem in establishing a CP-TLO would be recruiting service users to participate. In fact, engaging service users posed no problem. All those requested to take part willingly did so and appeared to enjoy the experience. Similarly, senior managers in the partner Trust were very supportive. The overriding difficulty was a technical one. At first, we had to resort to a direct wired data connection between the classroom and the nearby diabetes clinic because the data points in the university and the Trust were incompatible. Through negotiation between technicians in the Trust and University, it became possible to use the Trust data points to link the classroom with the clinic to open up the possibility of implementing CP-TLOs over long distances.
Limitations and further research
It is acknowledged that this pilot study has captured the reactions of the students to their immediate learning experience. We do not know the extent to which the CP-TLO has impacted on the students’ practice. A further follow-up study could shed light on this unknown area. In addition, an evaluation comparing CP-TLOs in different clinical areas could provide information on the mechanisms required to ensure successful implementation and so increase the possibilities for the sustainability of good practice.
Conclusion
From our initial investigation, it appears that whilst the time, effort and commitment required to implement a CP-TLO should not be underestimated, the difficulties were outweighed by the benefits to learning as reported by the students. A CP-TLO has the potential to combine the advantages of observing an experienced nurse with hearing the real experiences of service users and so giving the patient a voice in nurse education. It can enable greater partnerships to develop between educators in higher education and practitioners in healthcare settings, demonstrating to the students the value of partnership working and the importance of learning from the patient’s perspective. The CP-TLO will not replace face-to-face teaching and learning methods but it can provide a blended approach using the expertise of educators, health practitioners and patients, as well as providing opportunities for students to think critically by having the opportunity to interact with the subjects of the CP-TLO and their peer group. Finally, the CP-TLO has the potential to facilitate links between theory and practice and thus enhance learning in nurse education and other health and social care professions.
Acknowledgements
The authors thank the participating service users and carers, the students and nurses who engaged in the CP-TLO, senior staff and IT personnel in the East Midlands Trust and the Visual Learning Lab, CETL, who funded the study.
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PII: S1471-5953(10)00090-9
doi:10.1016/j.nepr.2010.06.001
© 2010 Elsevier Ltd. All rights reserved.
