OLNT'90 Proceedings: Hawley and Spice 'From the mountains to the sea'

"From the mountains to the sea"

Georgina Hawley and Chris Spice
School of Nursing
Curtin University of Technology

Introduction

The renewal of General Registration nursing programme originated from the Canadian Nurse Credentialling or Nursing Refresher programme. The School of Nursing, Curtin University of Technology, purchased the copyright of the computer program from Grant MacEwan College, Edmonton Canada in 1987. Subsequent changes have been made to meet the style and needs of nurses in Western Australia. To facilitate the administration of the programme, computer technology for testing, scoring tests, giving feedback and maintaining records is used. Hence the term computer managed learning or CML.

The mainframe computer used for the CML system is the VAX 11/750. The computer software was purchased from Computer Based Training Systems (CBTS), in Melbourne.

The programme begins with pretesting, then each student pursues an individualised route through 23 modules of theory until mastery level has been obtained. Computer testing is done through an objective specific test bank (updated for each module yearly). Finally, the student completes preparation for registration with a four week supervised clinical practicum. Many students complete the process in 3 to 6 months, with others taking up to 12 months.

An operations manual forms an essential part of the printed materials which accompany the system. Roles and functions for all those involved in the instructional process are delineated and step by step student progress through the system is described. Each of the components has its own course outline in booklet form and for preceptors, a separate manual is provided to guide evaluation.

Purpose of the programme

The renewal of General Registration nursing programme was designed to meet the needs of registered nurses who have been out of the practice for a minimum of five years and who wish to renew their knowledge and skills in preparation for returning to practice. Because these students differ widely in the amount and type of "renewing" required, an individualised, student paced, mastery oriented learning system has been designed to provide each student with the learning experiences needed by that student in both the theory and clinical areas.

Conceptual framework

From the inception of nursing until the late 1960s, nursing practice was based on a model which emphasised causes of diseases and treatment based on doctors' orders. As early as 1960, nursing leaders demonstrated that nursing has a unique function based on a solid knowledge foundation and characterised by specialised expertise. Nursing also broadened its dimensions to include promotion of health and prevention of illness as well as care during illness. The realisation of the uniqueness of nursing gave rise to nursing models.

This programme is based on a model which describes the context of nursing. The recipient of nursing care is a person, and the nurse's goal is to help this person achieve optimal health. Nursing interventions are directed towards the critical periods in an individual's life. The sources of these critical periods are

stages of growth and development;
lifestyle (patterns of living in response to environmental and organismic forces);
unanticipated events (disorders or occurrences unexpected by the individual).

These three sources of critical periods are interrelated and cannot be viewed independently because a person functions as an integrated whole. When giving care, a nurse reinforces appropriate modes of adaptation by preventing, supporting or altering stimuli. In order to determine the correct action, the nurse must identify the source of the stimuli. In other words the nurse does a nursing assessment, the first step of the nursing process.

Planning of an appropriate mode of adaptation is enhanced by the nurse's physiological, psychosocial and legal ethical knowledge base. With this broad knowledge base the nurse has the capacity to organise interactions systematically and to demonstrate his or her competence.

There are four exemplary characteristics of a practising nurse.

Nurses are guided by a mental image which identifies the focus for the independent practice of nursing.
Nurses systematically implement, communicate, validate records and update all steps of the nursing process in conjunction with the client or patient.
Nurses establish the helping relationship as the basis for client nurse interaction.
Nurses fulfil professional responsibilities in their independent, interdependent and dependent functions.

This model of nursing permeates the study materials which the students in this programme use.

Overview of instructional system

The students come from a variety of different backgrounds, and have been out of practice for differing numbers of years. They are a very heterogeneous group. It is therefore necessary to make pretesting available to each student so that the existing level of competency can be recognised and rewarded.

Following pretesting on the theory component, students decide in which order they would like to do the modules. This is done in conjunction with the instructor. The student then pursues an individualised route through the learning materials available, and is allowed to do so at a self determined pace. Extensive print materials are available to the student as needed. Additional learning resources and audiovisual materials are available in a local learning centre, which the student can access at predetermined hours. All students are assigned to a staff member at Curtin School of Nursing who monitors their progress and is available for advice and guidance.

In both testing and learning activities, the student works from the known to the unknown, in order to maximise motivation. Students who have been away from learning for some years need, a few success experiences at the beginning of their programme in order to encourage them and maintain their motivation. The programme is designed to reorient them in both theoretical knowledge and clinical practice.

Prior to commencing clinical practice in the hospital, a student attends a workshop, to practice common psychomotor skills. During the first week of clinical practice, an initial assessment of the student's skills is conducted. Based on the strengths and weaknesses identified in this process, the student and the preceptor agree on a plan of action to accomplish the student's objectives. The student's evolving clinical competencies are assessed on a regular basis, according to a predetermined schedule, until such time as the preceptor judges the student's clinical skills to be satisfactory. Clinical assessment covers not only individual skill assessment, but also the student's ability to integrate all of the competencies into total nursing care.

Components of the delivery system

Delivery of the renewal of General Registration programme involves three agencies. First there is the central office located at Curtin School of Nursing. Its main functions are overall control, troubleshooting and lending support to local operations. Second there are the remote or local learning centres in the country, whose main function is to provide individual students with access to examinations, learning resources and to provide support during the theory component. In some instances they also provide the clinical skills workshop for the student, prior to the clinical component. Third are the health care agencies, whose main function is to provide clinical learning experiences for students upon completion of the theory section. The responsibilities of the central office are mostly administrative. For example the central office

coordinates overall functioning of the programme;
selects and establishes the local or remote learning centres;
selects and orients tutors to their role;
orients preceptors;
receives applications from students and verifies their eligibility with the Nurses' Board of WA;
prepares and disseminates study materials;
troubleshoots problems for tutors, students and preceptors;
monitors performance of the system as a whole and revises as necessary.

In other words, the central office in every way supports the activities of the local or remote learning centres. The central office personnel consists of the programme head and support staff. The main function of the local or remote learning centres is the face to face contact with students. Each local learning centre is be staffed by an educational instructor. Generally speaking, educational instructors

monitor student learning contracts;
monitor, score and give feedback for difficult concepts;
contact the central office if problems arise;
maintain personal contact with students in order to motivate and pace students, eg set deadlines for and with students;
operate a lending system for resource materials, textbooks and audiovisual materials housed in the local learning centre;
maintain records of student progress;
answer questions regarding routine administrative matters for students.

Certain physical requirements are necessary in order to establish a local learning centre in either a hospital or a college. A designed space is necessary. Since print and audiovisual resources are housed there, shelving and required playback equipment must be available. Provision must be made for individualised work and an effort made to minimise distractions. The local learning centre should not only provide a space for individual student instructor contact, but should also provide space for student to student contact and a secure space for test writing. The local support staff may or may not be housed within the local learning centre.

Clinical learning experiences are provided by cooperating health care agencies. These agencies also provide preceptors to carry out one to one tutorial duties during the clinical portion of the programme. Staff of the health care agency

assess students' clinical competence using guidelines provided by the central office;
set up individual plans of action for the clinical experience;
arrange for and monitor learning experiences in the clinical area;
contact the central office for unresolved problems;
conduct formative and summative assessments on each student.

These three components are not always physically separated by distance. For example, the metropolitan learning centre is situated at Curtin, University, in the same building as the central office. However, in most cases it is necessary for the central office and the local learning centres to be connected by a direct communications link by telephone and computer.

Variations and examples

The delivery system for the nursing renewal of General Registration programme can be conceptualised as variations on a theme. Generally speaking, the delivery system provides administrative, tutorial and support functions for every student who goes through the programme. The particular configuration of these components varies, depending on the location of the student and the facilities available in that student's local community. The three most common patterns are described here.

Student in Perth

For students who live in the Perth area, the focus of their activity during the theory section is the Curtin School of Nursing. The administrative, tutorial and support functions are all carried out by School of Nursing staff. The programme head receives applications and verifies eligibility with the Nurses' Board of WA. Registration and orientation of these students is handled at Curtin. Once students are oriented to the system, they are asked to self evaluate prior to pretesting. Selected pretests are then administered, monitored and marked by computer support staff. Upon completion of the pretests, the tutor interprets the results and provides feedback to the student as soon as possible. The instructor's role thereafter is to motivate, advise and tutor the students as they work through the study materials in the order prescribed in the learning contract. At the completion of each module the student is tested by answering 25 multichoice questions. This is done at Curtin under the supervision of support staff.

Upon completion, the student either moves on to the next module or continues to study the current one. It is the job of the instructor to motivate and pace the students and, if necessary to set with and for them short term deadlines for the achievement of each of the topics listed in the learning contract. It is the job of the support staff to monitor test taking, to facilitate the marking by the computer of tests and to serve as a liaison between individual students and their instructor.

When students finish the theory section, each begins a placement experience in a health care agency. Here, the preceptor adopts a role similar to that of the instructor in the theory section. During the first week, an initial assessment of the student's competencies is done. Based on this assessment, the student and the preceptor decide on a plan of action, which provides the student with the particular combination of learning experiences which that student needs. Using anecdotal records and the skills list, the preceptor conducts frequent formative evaluations of the student's progress and discusses these with the student. When the student has reached the criterion level, a summative assessment is completed. The result of this summative assessment is communicated to the student and to the School of Nursing.

Student living in a country town where a health agency or hospital has been designated as the learning centre

The learning centre provides the physical space for the computer and learning library. This means the student accesses the examination bank for all examinations without the need to come to Perth. The learning centre must nominate support staff to be responsible for this facility and to be available for students.

The agency also supplies the selected preceptors and the opportunity for clinical experience. Curtin School of Nursing will still be responsible for enrolment and for overall orientation to the programme. Orientation may occur at the local learning centre. Students will also have an instructor at Curtin School of Nursing, who will monitor the student's progress and liaise with preceptors and other staff.

Student living in the country but not in a town nominated as a local learning centre

There are also situations in which individual students in isolated communities need access to the programme. In these communities there may be no local learning centre and no institution able to broker the programme. The student must, however, be able to access a health care agency or hospital approved for the clinical experience. Since this student may be the only one in the community taking the programme, the student has all the necessary materials sent from the central office, and may or may not travel to a local learning centre for orientation.

Periodically, it is necessary to answer tests on each of the modules. For these students, tests are sent from Curtin to a person who supervises the student doing the tests and returns answers and tests to the instructional assistant at Curtin University. The instructor can analyse and interpret the results. For students in this category, much of the tutorial work is done by telephone, although students may choose to come to Perth to write their tests and obtain guidance. In this variation, it is necessary for the Perth based instructor and the student to maintain a communication link by telephone, in order to keep up to date on the student's progress and any problems that the student may be having. In this way, the student progresses through each of the modules in the theory section. Many of these students visit a local learning centre sometime during the programme, usually combining appointments and shopping in the city or town with the visit. During the visit the student is able to sit examinations at the computer terminal, thus combining both forms of testing to complete the programme.

The clinical experience is completed in a hospital or health care agency of the student's choice and approved by the Nurses Board. It may be at the nearest town with a local learning centre, or it may be in Perth.

In conclusion

The programme is now in its second year of operation, with students enrolled and progressing through the programme to successful registration at completion. It is apparent that using CML has a number of advantages.

Cheapness. The programme is cheap to set up and maintain, compared with other open learning systems, such as tutors travelling to the country areas to conduct the programme, or interactive video.
Standardised testing . All the questions are contained within test bank on the computer. This means that whether the student sits the test in Perth or Albany, it is of the same quality.
Suitability for courses which need to be updated frequently. When the theory is contained on computer disk, the instructor can modify and make changes before each print out if necessary. Similarly, the test bank can be edited.
The skill of the person operating the equipment in the learning centres does not have to be the same as the profession for which the programme is intended.

The disadvantages include those involved with any external programme for those students who can not access a learning centre. That is, there is minimal interaction between the instructor and student, as only telephone contact can be maintained. The main difficulty experienced has been the maintenance of the computer link between the local learning centres and the VAX mainframe computer on campus via Austpac.

To date enrolments have exceeded one hundred and there have been 57 graduates from the renewal of General Registration nursing programme. All of the current modules used in this programme have been modified for continuing education for the benefit of all registered nurses throughout the state. It is hoped these modules will become a valuable source of refreshing and updating nursing knowledge throughout Western Australia.

Successful implementation of CML in nursing is leading to further developments. It is anticipated that a CML Midwifery Renewal of Registration programme will be available in August 1990 and it is possible that Child Health and Mental Health nursing reregistration will be developed in this format.

Through the adaptation of CML and instructional support mechanisms, this programme reaches out from the mountains to the sea, from the Kimberley region to Albany, for all nurses in Western Australia.

Georgina Hawley is Director of the Computer Managed Learning Program in the School of Nursing at Curtin University of Technology. She commenced her nursing education in 1963 at Royal Perth Hospital and spent many years in nursing practice and higher education before entering academic life.
Chris Spice is instructional assistant for the CML programme and has responsibility of the day to day operation of the CML Laboratory. He is currently undertaking a degree in recreation studies at WACAE. Chris is also well known in hockey circles as a player of high calibre, coach and national umpire.
Please cite as: Hawley, G. and Spice, C. (1990). "From the mountains to the sea". In R. Atkinson and C. McBeath (Eds.), Open Learning and New Technology: Conference proceedings, 179-186. Perth: Australian Society for Educational Technology WA Chapter. http://www.aset.org.au/confs/olnt90/hawley.html

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