Full Paper

Alison Russell

alison.russell@flinders.edu.au

Department of Speech Pathology

Flinders University of South Australia

Jennifer Oates

j.oates@latrobe.edu.au

School of Human Communication Sciences

La Trobe University

A prototype of the program has been trialed with students from La Trobe and Flinders Universities and the student responses from the focus groups suggest that the aims of the package to encourage active and self directed participation in clinical decision making have been met. The students enjoyed using the program and indicated that they were motivated to go back and use it again, as the program was realistic, had a high level of interactivity and was flexible enough to meet their own learning needs. Evaluation of A Sound Judgement by speech pathology students indicates that it is likely to be a valuable tool in teaching perceptual voice analysis.

An important outcome of education for speech pathologists is the ability to perceptually analyse voices. This ability to listen to normal and impaired voices and make judgements about impairment and its physiological basis is crucial for diagnosis and treatment of patients with voice disorders. Clinicians also need to be able to describe the perceptual attributes of voices to facilitate communication with other professionals such as otolaryngologists and voice teachers, and to ensure that they and their clients share a common frame of reference (Gerratt, Kreiman, Antonanzas-Barroso, & Burke, 1993; Kempster, Kistler, & Hildenbrand, 1991).

Although there is general agreement that perceptual analysis of voice is important in speech pathology practice the clinical and research literature is replete with suggestions that the task of perceptually evaluating voices is complex, particularly for inexperienced students and novice clinicians (Bassich & Ludlow, 1986; Fex, 1992; Gelfer, 1988; Gerratt, et al. 1993; Kempster, et al. 1991; Kreiman, Gerratt, Kempster, Erman, & Berke, 1993; Kreiman, Gerratt, Precoda & Berke , 1992; Laver & Hanson, 1981).

Educational research indicates that students will develop effective learning strategies if they are given the opportunity to actively engage in higher levels of cognitive activity such as decision making, reflective thinking, and problem-solving in a real world context (Hedberg & Harper B, 1996; Laurillard, 1993; Lebow, 1993; Ramsden, 1992). Further, we now know that learning is enhanced when students apply their knowledge in solving patient problems, when they are shown their misconceptions and helped to conceptualise in better ways, when they are able to choose between linear and more flexible ways of approaching problems, and when they are free to learn at their own pace (Coles & Grant, 1985; Laurillard, 1993; Marton & Ramsden, 1988). It is clear that current approaches to teaching speech pathology students how to analyse voices perceptually rarely incorporate such pedagogical principles. The result is that many of our students are likely to develop a superficial and passive approach to the task of evaluating voices (Freeman, Syder, & Nicolson, 1996). It is not surprising then, that their skills are not at a high level, that students find it difficult to integrate perceptual features of voice with underlying laryngeal physiology, and that they are anxious about learning and maintaining perceptual analysis skills.

The project described in this paper developed from our interest in improving the perceptual voice analysis skills of speech pathology students and in increasing their confidence in their voice evaluation abilities. Our task was to create a learning package that would redress many of the educational deficiencies of the ways in which students are currently taught to evaluate voices perceptually. Our aim was to present the task of perceptual voice evaluation in the context of real clinical cases where students are encouraged to be active and self-directed participants in clinical decision-making. We also aimed to facilitate students' ability to link perceptual components of voice with physiological principles and to provide them with feedback and cues which would help them conceptualise the task more effectively.

The overall aim of A Sound Judgement is to increase students' skill, consistency and confidence in perceptual voice analysis. The specific learning objectives are for students to learn to perceptually discriminate between the pitch and quality aspects of the voice, to make judgements about which aspects of particular voices are impaired, to judge the severity of vocal impairments, and to explain the probable laryngeal physiology underlying the perceptual features of the voice. A Sound Judgement was also designed to assist students in understanding that the perception of a particular voice feature may be confounded by the presence of other features and that perceptual analysis of voice is a complex task which can be approached from several perspectives and requires ongoing development throughout an individual's career.

An interactive multimedia design was selected as the instructional platform for this project. Interactive multimedia seemed ideal because of its capacity to support the variety of different media which would best represent the complex process of clinical voice evaluation and because it would allow us to apply current educational theory and practice to the project. Multimedia materials can support a wide range of media forms including sound, animations, photos, dynamic images, text and diagrams. These media forms can be arranged in many different structures and sequences which are vastly different from those which can be provided by the library or teacher (Hedberg & Harper B, 1996; Oliver, 1996). Multimedia platforms also permit presentation of an authentic and relevant context for learning which in turn is likely to enhance student learning, motivation, and interest (Hedberg & Harper B, 1996; Keller & Keller, 1993; Oliver, 1996). Interactivity is the other important aspect of instructional platforms; it describes the options that users have for navigating through the package as well as program characteristics which elicit decision making, problem solving, and reflection, and provide feedback and cuing. The interactivity aspects of multimedia packages, if well designed, can promote active rather than passive involvement of the learner, encourage higher levels of cognitive activity, enhance the learner's motivation, and allow learners to explore their interests and choose between linear and more flexible ways of dealing with problems (Hedberg & Harper B, 1996; Keller & Keller, 1993; Laurillard, 1993; Oliver, 1996).

A Sound Judgement is an interactive multimedia package with six main components which can be accessed by students in any sequence they choose. Students are able to move freely between components of the program at any time. The six components are as follows:

This component of the package introduces students to their 'clinical supervisor' who guides them through all later sections the package. It also allows them to explore the learning objectives of the package, prior knowledge requirements, the main perceptual components of voice, alternative methods of navigating through the package, and expected learning outcomes.

A party hosted by the clinical supervisor allows students to listen to a range of voices by selecting from 20 photos of people on the screen. The voices of the guests represent a range of normal male and female voices as well as a wide range of impaired voices. When students have listened to a voice, they are asked to decide whether the voice is normal or impaired and, if the voice is impaired, the student can then compare that impaired voice with a corresponding normal voice of a person of the same age and gender. Feedback is given by the supervisor for each of the studentsí decisions. The student has access to a text description of the probable laryngeal physiology underlying each impaired voice.

The 'Clinic' component presents 10 real clients with vocal impairments at three levels of complexity. The increasing levels of complexity are represented as three separate voice clinic rooms, 'Beginners' 'Intermediate' and 'Advanced'. For each of the three clinic rooms, the student can evaluate the voices of one or more of the clients who are seated in the waiting room. Students are able to make their own choice of which client to listen to, the number of clients they wish to evaluate in each clinic room, and the level of complexity they wish to work on.

Each clinical case has a videoed interview with the client, endoscopic views (with continuous and stroboscopic light) and animations of the client's larynx, and written case history reports from a speech pathologist and an otolaryngologist. Students see and hear the speech pathologist interviewing the client about their voice problems and have the option of reading the case history reports and viewing the endoscopies and animations of the client's larynx. The speech pathologist then asks the student to make perceptual ratings of the client's voice on an evaluation format designed specifically for this package and feedback is provided using ratings made by expert speech pathologists. Student ratings which are within one rating point of the average of the experts' ratings are considered to be correct. The voice rating format was developed by the project team specifically for this project. It incorporates terminology and definitions which were as universally accepted as possible, reflects current knowledge of the relationships between perceptual features and vocal physiology, is comprehensive enough to include the majority of features of impaired voices, and is sufficiently clear and of appropriate complexity for speech pathology students. Lastly, an otolaryngologist asks the students to describe the probable laryngeal physiology underlying the client's perceptual voice features. Students answer using a multiple choice format for the 'Beginners' and 'Intermediate' clinics and by constructing their responses from a list of phrases in the 'Advanced' clinic. Feedback on their answers is provided by the otolaryngologist.

The 'Test Clinic' component provides students with a summative assessment of their voice evaluation skills and has a similar structure to the 'Clinic' component described above. Students make perceptual judgements of the voices of two clients and describe the probable laryngeal physiology which contributes to the client's voice characteristics. When the student has completed the evaluation of the two clients in this clinic, their performance on both perceptual analysis and understanding of laryngeal physiology is assessed against pre-set criteria. Feedback is provided by the speech pathologist and a certificate of achievement is awarded if the student has met the criteria for successful completion of the package. If the student does not meet criteria, he or she is encouraged to revise earlier components of the program, to seek assistance from their peers and instructors, and to return to the 'Test Clinic' at a later time.

A glossary of terms can be accessed at any time and from any part of the package. The glossary takes the form of a scroll-down menu with perceptual, anatomical and physiological terms of relevance to the package and includes text, diagrams, photos and where relevant, dynamic endoscopic views of laryngeal functioning.

The Quicktime movies and images used within this interactive multimedia package were produced with a Radius 8100/110 Power PC and an Avid Media Composer 1000. The Quicktime movies and still images were digitised from video using a Radius Videovision capture card and Digidesign sound card. The Quicktime movies were composited in Adobe Premiere version 4.2 and compressed with Movie Cleaner Pro. Still images were modified and composited in Photoshop version 3.05 and QuarkXPress. Animations were produced with Macromedia Director version 5.0. The project was undertaken using Macromind Director on a Macintosh 9500/120 Power PC.

On-screen questionnaires which were completed as the student leaves each clinic level and again when the student completes the 'Test Clinic' ask students to rate the extent to which their experience in that clinic room developed their perceptual skills, their understanding of laryngeal physiology underlying voice features, and their confidence in their voice evaluation abilities. The questionnaire also asks students to rate the difficulty of the tasks presented in the clinic room, the value of the feedback provided, and the amount of interest the experience engendered. Additionally, in cases where the student completes only one client evaluation in a particular clinic room, the student is asked to explain why they left the clinic room at that stage. Five-point Likert-type equal appearing interval scales are used for all questions with the exception of the question for students who leave a clinic room early. For that question, students answer by selecting from a list of phrases.

Seventy eight second year students at LaTrobe university used A Sound Judgement as part of the requirements for their unit on voice disorders, however due to technical difficulties with this aspect of the program, the on-screen evaluation data is not available for a sufficient number of these students at this time. This aspect of the evaluation will be reviewed, and repeated with a different group of students in 1998.

Formal focus groups were conducted with 11 students from La Trobe University and 6 students from Flinders University. The interviews focussed on the strengths and weaknesses of the package and also asked students to comment on how the package could be improved.

The focus group interview responses indicated that A Sound Judgement was well received and had motivated students to understand perceptual voice analysis in depth. They all agreed that the high level of interactivity was a strength of the program. They were very positive about the reality of the program and felt they were participating in the interview process. The access to other information about the client including reports and endoscopy of the larynx added to this feeling of being involved with a real client.

Students made a number of suggestions for improvement of program. They suggested that the glossary could be improved by including audio examples of the different voice quality parameters and video clips of laryngeal endoscopies related to these parameters. In the ëPartyí and the ëRainbow Clinicsí, students wanted to be able to bypass instructions which they viewed as repetitive, and to navigate through some parts of the program more flexibly. This may reflect the sophistication of many of the student users, however it is important to recognise that all students do not share this level of expertise. One student felt her access to the depth of the program was limited by her poor computer literacy, and it will be important for educators incorporating the program into their teaching to be aware of the computer literacy of their students to ensure equitable access.

The students thought the program could be used best for individual learning, or learning in pairs rather than being used in a classroom situation. The opportunity to make perceptual judgements in a ìsafeî environment, where client management was not compromised, and peers could not be critical of incorrect answers, was valued by all of the students. They suggested the program may also meet learning objectives other than those stated in the program including being used as a means of revision for assessment or used by clinicians who wanted to maintain or update their perceptual voice rating skills, and in some parts could be used for client education.

Thirty nine students who used A Sound Judgement as part of their voice disorders unit at La Trobe University completed a questionnaire to evaluate the program. Students were asked to respond using 5 Likert-type equal appearing interval scales, with 1 being strongly disagree and 5 being strongly agree. As can be seen from their responses summarised in Table 1, there was a range of responses, however, the majority of the students were positive about their learning using A Sound Judgement. The responses to the open ended questions mirrored the comments from the focus groups.

Overall, the student responses from the focus group and the questionnaires suggests that the aims of the package to encourage active and self directed participation in clinical decision making involved in perceptual voice analysis have been met. The students enjoyed using the program and indicated that they were motivated to go back and use it again, as the program was flexible enough to meet their own learning needs. Evaluation of the package by speech pathology students indicates that A Sound Judgement is likely to be a valuable educational tool for Australian speech pathology students. Further evaluation by international experts is currently underway to determine the possible application of A Sound Judgement in speech pathology programs overseas.

Our efforts to follow the recommendations of recent research on methods for improving perceptual rating of voice (Gerratt et al. 1993; Fex, 1992; Hammarberg, 1986; Kreiman et al. 1992; Kreiman et al, 1993) and research on how student learning can be enhanced (Hedberg & Harper B, 1996; Laurillard, 1993; Lebow, 1993; Ramsden, 1992; Oliver, 1992) appear to have been successful. While recognising that it is difficult to compare the learning outcomes using different teaching methodologies and materials, we believe that the use of interactive multimedia has made a difference in studentsí learning of perceptual voice analysis. Students are more positive about learning these skills using multimedia than they have been about more traditional methods, and this is supported by their enthusiastic comments about the program: ì a fantastic learning experienceî, ìa more realistic way of learningî, ìas close to hands on experience as possibleî, ìa most valuable learning experience.î As teachers, the experience of developing this multimedia program has certainly encouraged us to pursue this approach to teaching and learning.

(c) Alison Russell and Jennifer Oates

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