Web-based distance continuing education: a new way of thinking for students and instructors

Abstract

As people have more difficulty taking time away from work to attend conferences and workshops, the idea of offering courses via the Web has become more desirable. Addressing a need voiced by Medical Library Association membership, the authors developed a Web-based continuing-education course on the subject of the librarian's role in evidence-based medicine. The aim of the course was to provide medical librarians with a well-constructed, content-rich learning experience available to them at their convenience via the Web. This paper includes a discussion of the considerations that need to be taken into account when developing Web-based courses, the issues that arise when the information delivery changes from face-to-face to online, the changing role of the instructor, and the pros and cons of offering Web-based versus traditional courses. The results of the beta test and future plans for the course are also discussed.

INTRODUCTION

Health information professionals have come to recognize that change is a constant force in today's working environment. To continually maintain adequate knowledge and competence in the field and to keep up with the best current ideas and techniques, professional survival depends on lifelong learning. Often, the on-the-job demands of the profession outweigh the time available to devote to learning. Methods of acquiring continuing education without the inconvenience of leaving the work area and incurring travel expenses are becoming more popular as professionals strive to remain current with both their daily duties and professional concerns. Innovative ways of delivering education are being developed to meet these needs and provide health information professionals with quality, cost-effective alternatives to traditional continuing-education courses.

Increasingly, the trend across all professions is to deliver professional development activities through distance education. Distance education refers to a formal learning experience that takes place when a student and instructor reside in different locations throughout the majority of the learning process. Components of distance education include the physical separation of the instructor and student, the use of some technology to unite the instructor and the student, and the provision of two-way communication [1].

Although distance education and traditional education offer similar content, educators have realized that distance education requires a transformation in thinking for both instructors and students [2]. This requirement is especially true with Web-based distance education. Several factors need to be considered to create an online environment conducive to teaching and learning. Many of the practices that are taken for granted as part of the educational process disappear when education is taken out of the classroom. Creative ways of addressing these processes within the course will determine whether the educational experience is a success for the instructors and the students.

BACKGROUND

Distance education is not a new phenomenon. Since the 1800s, universities have worked to broaden the availability of instruction through distance education. Organized correspondence courses, where instructors and students communicated through letters, were the first form of distance education [3]. Correspondence courses provided a mechanism for instructors to teach through writing and students to learn through reading and providing written responses. The educational material came to the students and was transferred back to the instructor via the postal service, thus providing students with a more convenient learning opportunity. Drawbacks to this approach included the slow response time of communicating through the mail, the restriction to the written word, and the lack of student-student interaction.

As audiovisual technology developed, distance education began taking on new forms. Educators experimented with instructional radio, instructional television, and microwave networks in delivering distance education [4]. These methods introduced visual and audio aspects to the educational experience but still only concentrated on the instructor-student relationship and asynchronous (not occurring at the same time) communication. The development of telecommunication technology began to provide for interactivity between distance education students. Two-way voice and two-way video classrooms allowed for instructor-student interactions as well as opportunities for small group discussion, where student-student relationships could form [5]. A disadvantage to this model was that students had to travel to a designated broadcast site, at a specific time, where the education took place.

In the early 1980s, the introduction of personal computers and communication networks, such as Telenet and Tymnet, provided increased advantages for distance education. Electronic mail (email) could now be used to accelerate the pace of communication for correspondence courses. Though students and instructors were back to a written model, information could now be shared between the instructor and student the same day. In addition, students could email each other and build peer relationships.

The Internet, and more specifically the Web, is the newest and most versatile distance-education vehicle. The Web has the potential to provide the best of all distance-education worlds. It incorporates multimedia and self-paced learning, and offers multiple opportunities for communication, both asynchronous and synchronous (occurring at the same time) between and among instructors and students. The Web is location independent, so students and instructors can participate whenever and wherever it is most convenient [6].

Two categories of Web-based courses are tutorials and simulations (independent self-paced or interactive). One method is independent self-paced tutorials where feedback is automated and scripted. These tutorials offer no interaction with an instructor or other people taking the tutorial. Often these independent tutorials are created to teach a simple skill or train a user to perform tasks, such as navigating through the Web. Information is presented, but little critical thinking is required to complete the tutorial. Interactive courses present a different approach. This type of course is usually offered over a longer period of time and may contain some self-paced information combined with discussion among instructors and other students learning the material. Interactive courses may introduce students to complex subject matter, thus requiring individualized, not scripted, feedback. In either Web-based course model, text may be combined with other media, such as video and sound, to illustrate principles.

Fueled by demands from the membership, the Medical Library Association's (MLA's) Continuing Education (CE) Committee has been encouraging instructors to develop self-study courses. This interest was heightened in 1998 as the CE Committee developed its “Centennial Distance Learning Program” in celebration of MLA's centennial anniversary. The topic of evidence-based health care was the focus of this program. The year-long effort concentrated on delivering continuing education using a variety of learning tools. In addition to holding a teleconference, providing continuing education at annual meetings, and encouraging the creation of journal clubs on the topic, the committee also wanted to offer a Web-based course to the membership. In response to this interest, the authors developed a Web-based course entitled “Evidence-Based Medicine (EBM) and the Medical Librarian.”

The purpose of developing the “EBM and the Medical Librarian” Web-based course was twofold. The first objective was to provide introductory information about evidence-based medicine and roles medical librarians could undertake in educating health professionals about the concepts of EBM. The second goal was to ascertain what was involved in developing a Web-based course and to test the effectiveness of delivering MLA CE through this medium. If this course was successful, it could become a model for developing future Web-based, MLA continuing-education courses.

PROCESS

The task of creating a Web-based CE course requires instructors to rethink significant parts of how education is delivered. The traditional way of teaching provides students and instructors with a physical space to gather together and sets the time and structure for the course. In the case of CE, the course often takes place at an organized professional meeting. This face-to-face gathering provides a venue for verbal communication and a means of engaging student attention and monitoring their understanding and progress throughout the course. The framework for awarding course credit is based on whether or not students come to the course. If students come and stay the required number of hours, they receive credit. All of these measurable phenomena are no longer true when providing continuing education over the Web.

In using this new mode of offering education, developing a different model for dealing with these processes was necessary. In order to conceptualize this model, the instructors started by asking themselves a series of questions that addressed the following issues: student expectations, content, content presentation, teaching components, interaction between students and instructors, and course delivery.

What are the students' expectations?

One of the hardest questions to answer was that of student expectations. Hypotheses were made based on the instructors' experiences teaching and developing traditional adult education and their experiences as Web-based course students. The instructors anticipated that students would expect the same high-quality course that would be offered to them in a traditional classroom setting. This included clear and logical presentation of information, interactivity with the other students and the instructors, and adequate instructor feedback regarding students' understanding of the material. In addition to these traditional classroom criteria, students would select a Web-based alternative because of the flexibility to complete the course at their own pace, without the inconvenience and expense of travel. The students also would expect the educational environment to be easy to use and navigate. Although some of these expectations may seem simplistic, it proved useful to articulate them and to continually keep them in mind as the course was developed.

What content to include in the course?

The course would be designed to teach librarians the concept and process of practicing evidence-based medicine to prepare them to participate in the process. The content would cover the steps involved in EBM and identify the areas where librarians could participate in training and supporting health care professionals. The course would emphasize developing a well-built clinical question, MEDLINE search strategies, and basic criteria for judging the validity of studies dealing with diagnosis, prognosis, therapy, and harm issues. In addition to learning these skills, students would be expected to walk away from the course having some ideas about how their library could contribute to EBM initiatives in their institutions (Appendix A).

How to present the content?

In order to meet the assumed student expectations and convey the information clearly, presentation of the content in the Web-based course had to be considered carefully. The process of EBM builds on a series of steps; therefore, the course content needed to be sequential. To accomplish this, the authors decided to employ a traditional course model that included fixed beginning and end dates. Because evidence-based medicine, by definition, required critical thinking skills and tended to be open to interpretation, feedback had to come from the instructors and could not be automated and scripted. In addition, offering the course within the structure of fixed dates allowed the instructors to schedule exercises at fixed intervals. This structure would give students the opportunity to practice each step, turn in an exercise, and receive feedback before they would be expected to move forward in the process (Appendix A).

What teaching components to utilize?

Once the content and structure had been decided, the next step was to determine what components should be included in the course. In order to balance the assumed student expectations with the need to present the content clearly, the instructors decided that the course should contain a series of independent modules to be completed in a specific order and within a general timeframe. The course modules were divided into weekly segments. During the first three weeks of the course, the students would be expected to complete the readings for the scheduled module and to complete the accompanying exercises. At the end of each week, there would be a required, pre-scheduled thirty-minute online chat. This approach would provide students with an opportunity to learn material on their own, practice, receive feedback from instructors, and then share experiences with other students before moving on to the next module. The last week was designed as a review of concepts learned in the previous three weeks. Instead of readings and exercises, the students would be required to do a final project that incorporated all the skills they learned. In order to receive the eight MLA-approved credit hours, students would need to submit all the exercises and attend three of the four chats.

One major concern for the instructors was how teaching material from a distance would affect their ability to evaluate whether or not students understood the course information. Instructors would have no way of picking up on nonverbal cues, such as students' facial expressions, to determine whether a concept was understood. This issue was resolved by requiring the students to complete two exercises for each module. The first exercise was a series of multiple-choice questions that would act as a course review and provide students with immediate, scripted feedback. The immediate feedback would allow the students to see if they understood the concepts of the module before moving on to a more difficult, short-answer exercise. The second exercise was short-answer and was developed with a similar design as the first exercise, but instead of immediate feedback, the answers would be submitted to the instructors for individualized feedback. In general, feedback from the second exercise would be given before the scheduled chat, so that the students would have the opportunity to discuss confusing issues during the half-hour, online discussion.

The final project, to be completed during the fourth week of the course, was designed to give students an opportunity to practice all EBM steps learned in the previous weeks. The exercise was intended to simulate how a librarian or clinician would respond when encountering a real clinical question within the EBM framework. To build confidence in their ability to execute all EBM steps independently, students would be given a choice of two scenarios, which would then be used to develop a clinical question. Using the clinical question they developed, the students would then be required to complete the EBM process, which included searching MEDLINE, selecting an article, and evaluating the validity of the article based on criteria learned in the course. Because students could create several different clinical questions from one given scenario as well as evaluate a range of articles, the final exercise would require considerable effort on the part of the instructors. Before presenting students with feedback, the instructors would have to complete their own MEDLINE searches and read the selected articles. However, the instructors felt structuring the final exercise in this manner was necessary to simulate an actual situation.

How would students contact the instructors if they had questions?

The instructors provided several ways in which students could contact them during the course. These included scheduled office hours for phone contact, email links embedded throughout the course documents, and general contact through email and phone. Because the material was complex and the format was untested, the instructors aspired to be available at the students' point of need.

How to deliver this course over the Web?

The easiest and most efficient way to deliver the course was to use a commercial Web-based training product. Creating hypertext markup language (HTML) templates would have taken more time and skills than the instructors had readily available. Classroom (now called CourseInfo), from Blackboard (http://www.blackboard.com), was chosen for several reasons. It created a relatively straightforward environment for student navigation, while maintaining a professional look. The learning curve for using Classroom was relatively flat, both for the instructors and the students. It was fairly simple for instructors to input information, track students, and create assessments. No scripts or HTML had to be written. The software had all the features needed to create independent modules, produce assessments, and hold chat sessions without requiring students to have extra plug-ins or helper applications to participate fully. In addition, Blackboard allowed instructors to create and offer one course on their Website at no charge, so it required no up-front financial investment to create the course.

EVALUATION

The instructors decided to conduct an evaluation of the course for a number of reasons. Because the assumptions about student expectations could have been incorrect, a thorough course evaluation needed to be completed to determine what worked and what required improvement. The instructors were too familiar with the material to judge impartially whether the information was presented clearly and logically and wanted others to scrutinize the material closely. The overall flow of the course also needed to be examined. To ensure quality and investigate these assumptions, a beta test was conducted before offering the course to the membership at large.

Beta testers were recruited based on several characteristics. The instructors looked for librarians with varying degrees of subject knowledge. Students with a breadth of knowledge in evidence-based medicine were needed to help identify flaws in the course material. They would already understand the concepts and could focus on the quality of the information being presented. EBM novices were the target audience of the course, so librarians who were interested in learning more on the topic were recruited as well. Novices would test whether the information was too complex or too simple for a beginner. In addition, both groups would help identify areas where the information was not clear or where more explanation was needed.

Familiarity and comfort with technology, especially Web technology, was another factor in selecting beta testers. To identify technical problems using Classroom, as well as barriers that could confuse students during the class, beta testers with a range of technical abilities were sought. By mixing the technically savvy in with the novices, determining whether a problem was user error or a technical glitch would be easier. Beta testers from both hospital and academic settings were also selected to test the success of the class from different types of Internet connections (i.e., dial-in or direct connection), as well as to determine if the content was slanted toward one audience or the other.

The most important criteria by far was a willingness to critically evaluate the course in regards to content, design, usability, and general syntax. An honest perspective with respect to the quality of the material and its presentation, as well as the interaction with the instructors and fellow students would be a basis for judging the course. Beta testers were also asked to be flexible in adapting to any changes or improvements the instructors might implement throughout the course.

The number of beta testers was kept relatively small. In the end, six librarians were identified, five of whom agreed to participate. Three librarians were from academic settings, and two were in hospital environments. In addition to completing all of the exercises and participating in the chats (like anticipated students), the beta testers were asked to fill out a weekly feedback questionnaire (Appendix B), with an emphasis on the presentation and content, about the individual modules. The weekly feedback was used to determine how successful the module was, to identify parts of the course the students liked, and to detect areas that needed improvement. In addition, beta testers were asked to keep track of the number of hours they spent completing each week's readings and exercises to determine whether the weekly workload was too heavy or too light.

BETA TEST OBSERVATIONS

The beta test proved to be extremely informative. As the course progressed, key factors in delivering Web-based continuing education, such as clarity of the written material, became clear. The beta test reinforced some of the instructors' beliefs and pointed out the course's strengths. More importantly, it also identified areas for improvement.

During the course of the beta test, it quickly became evident that the clarity of the written information was essential. When the instructor was not physically present to assist students in digesting the information or to add oral clarification, the written content must stand on its own. “Chunking” the content into absorbable pieces helped keep students from feeling overwhelmed and provided them with the essential information for completing the exercises and grasping the concepts without exhausting them with too much written content. Students appreciated when supplemental information was complementary, not repetitive. When the links to supplemental pages did not yield unique information, students felt the reading was a waste of their time. In more than one case, students were also confused by the supplemental material, unsure how much of the information was needed to complete the exercises.

Though the information was rigorously proofread several times, errors were discovered during the beta test. One of the scripted responses in the first review exercise was incorrect. When several students objected to the answer during a chat session, the error was discovered. There were also places where the text was misunderstood. Information that the instructors intended to serve as a guide was perceived by students to be prescriptive. The students also had difficulty with the way instructor feedback was presented. Only one of the three instructors provided all feedback. As EBM was a somewhat subjective topic, especially as regards developing a search strategy, the beta testers would have preferred receiving feedback from all three instructors for each exercise.

As is always the case when delivering instruction, pleasing everyone was impossible. Though several students found the chats indispensable for communicating with instructors and fellow students, others thought they were a waste of time. On the positive side, the chats were used effectively for asking questions about readings and exercises. Students had an opportunity to share their concerns, issues, and creative ideas with each other during these half-hour sessions. One of the major issues with the chat requirement was the delay in waiting for responses. It could take several seconds for a reply to appear after participants submitted their comments. Also, the technology did not always work. The chat software was unreliable, so not all students were able to participate each time.

The time involved, for instructors and students, was greater than anticipated. In some cases, students read all related materials, including the supplemental material provided via external Websites, so more time was required to complete the material. Some of the exercises also proved to be more challenging and required more time to complete than expected. Overall, most beta testers invested more than eight hours to complete the course. Instructors invested major amounts of time providing weekly individualized feedback to the students. Not only did the exercises have to be reviewed and critiqued, but instructors also blocked a weekly office hour out of their schedules and facilitated every chat.

The beta test provided valuable feedback that indicated modifications should be made to the course. Student feedback indicated that the duration of the course needed to be longer. Students felt one week was not enough time to complete certain exercises, especially the final exercise. In response, the instructors extended the course from four to six weeks to allow students more time to complete certain sections of the course. The requirements for receiving MLA continuing-education credit also needed to be reexamined to address technical issues. Initially, attendance at three of the four chats was required to receive CE credit. As mentioned previously, many obstacles, including some out of the students' control, made chat attendance difficult. Responses to the chat requirement were mixed and technological issues made chat problematic. To address these issues, the instructors planned to implement an electronic discussion list as an alternative means of communication for the next course offering. Students would be required to participate on the list to receive CE credit, and, for those who prefer synchronous communication, chat would remain an optional component.

Overall, both students and instructors judged this endeavor to provide a quality, distance-education course a success. Although there was room for improvement and enhancement, the students thought that the course was very valuable. All participants agreed that they acquired knowledge and skills they could use and that the course was well organized. Even the beta testers with previous content expertise in EBM learned new skills by participating in the course. Reading material, exercises, and conversation combined to make a successful continuing-education course.

CONCLUSION

Keys to the success of any Web-based educational experience are the design and planning behind the program. Though the students do not necessarily realize it, the instructor's creative thinking and organizational skills become even more important when there is no face-to-face interaction. The core content does not change, but new strategies as well as additional preparation time are required for developing effective communication techniques and building an environment conducive to learning from a distance [7]. Despite the fact that students have fewer encounters with the instructor, the instructor is still responsible for focusing on the learning objectives and determining the best ways to express the course concepts. The instructor must gauge student progress without any of the visual clues observed when working with a student face to face. To accomplish this, the instructor must construct the right combination of flexible, independent learning and guided instruction.

Incorporating communication and peer learning into the process is one of the instructor's greatest challenges. Students take continuing education courses to learn a new skill but also to learn from each other and to network with colleagues. Because of this, incorporating student-to-student communication and encouraging students to become active learners are integral to the delivery of successful Web-based instruction. Instructors should integrate a number of delivery systems to facilitate interactive communication, such as email, telephone “office” hours, electronic discussion lists, and chat discussions. In addition, instructors need to provide students with detailed comments on submitted exercises and return them to students in a timely manner [8].

In order for Web-based distance education to provide a beneficial learning experience, it is imperative that both the instructor and the students be self-motivated. It is easy to let workplace diversions interfere with the successful completion of a Web-based course. The instructor must remain involved with the students, returning feedback and answering questions promptly. If not, students will become uninterested in the course and find little benefit to the educational experience. Students must assume responsibility for completing the course as well. In addition to completing the exercises by the deadline, students must be proactive in contacting the instructor if they experience difficulties with a concept or exercise. In many ways, a Web-based course is more demanding of the instructor, as well as the students, than a traditional course.

As with any course, the quality is based on the organization of content and relevance of activities. Especially in an online environment, the instructor must continue to focus on goals, objectives, and outcomes. Many Web-based courses provide supplemental information, and, without the instructor present, students can all too easily become distracted by peripheral information. Because the instructor is not physically able to guide students or to emphasize particularly important points, it is imperative that the content be organized in a clear and logical manner and that the exercises emphasize the key concepts, or “take home points,” of the particular sections.

Although it is unlikely that Web-based instruction will ever replace classroom education completely, it appears to be a worthy alternative to traditional CE courses. One of the benefits of the Web-based approach is the flexibility of completing the exercises at the students' convenience. It is an excellent alternative for those who are seeking education but do not have the time or budgets to travel to a program. The Web offers instructors an innovative way to remove space and time constraints of a conventional classroom and allow learners more freedom in guiding their own educational course [9].

APPENDIX A

Course objectives, schedule, and outline

Course objectives

After completion of this class, participants should be able to:

1. identify and explain the concept, issues, and process of EBM

2. identify the parts of a well-built clinical question

3. identify and explain at least three basic criteria for judging the validity of studies on:

▪ diagnosis

▪ therapy

▪ prognosis

▪ harm/etiology

4. identify at least three roles that librarians can undertake in providing EBM training and support to health care professionals

5. suggest at least three ways to incorporate EBM training and support into what the library is already doing

Course schedule for beta test

Week 1: Introduction and question building

March 5: Begin Week 1

March 10: Complete and submit exercises 1 and 2 (to receive feedback before Friday Chat)

March 12: 2:00 p.m.–2:30 p.m. ET, Scheduled chat—Topic: The clinical question

Week 2: Selecting resources and conducting the search

March 13: Begin Week 2

March 17: Complete and submit exercise 3 (to receive feedback before Friday Chat)

March 19: 2:00 p.m.–2:30 p.m. ET, Scheduled chat—Topic: Teaching MEDLINE

March 20–26: No exercise or scheduled chat

Week 3: Critical appraisal of the evidence

March 27: Begin Week 3

March 31: Complete and submit exercise 4 (to receive feedback before Friday Chat)

April 2: 2:00 p.m.–2:30 p.m. ET, Scheduled chat—Topic: Critical appraisal

Week 4: Final project and wrap up

April 3: Begin Week 4

April 7: Complete and submit final project (to receive feedback before Friday Chat)

April 9: 2:00 p.m.–2:30 p.m. ET, Scheduled chat—All topics

Course outline

Week 1: Introduction

▪ What is EBM?

▪ Why is EBM important?

▪ Is it reasonable to expect evidence from the literature?

▪ What are the controversial issues surrounding EBM?

▪ What is the librarian's role in EBM?

▪ The EBM model

▪ Constructing a well-built clinical question

▪ Class review and exercise

Week 2: Selecting the resources and conducting the search

▪ Selecting resources

▪ Searching MEDLINE

▪ How to teach MEDLINE in context of EBM

▪ Class review and exercise

Week 3: Evaluating the evidence

▪ Appraising articles on diagnosis

▪ Appraising articles on therapy

▪ Appraising articles on prognosis

▪ Appraising articles on etiology/harm

▪ Class review and exercise

Week 4: Final project and wrap-up

▪ Final project

▪ Class evaluation

APPENDIX B

Weekly feedback email questionnaire for beta test

Please answer the questions below and send me your responses.

1. Did the course flow well this week? Please explain.

2. What would you have liked to see the instructors do differently?

3. Was the course documentation helpful? Please explain.

4. Did you understand the week's materials? Please explain.

5. Did you find the chat useful? Please explain.

6. Did you find this week's review and exercise assignments useful? Please explain.

7. Please let us know of any problems or issues you had while accessing the course this week.

8. Were these issues the instructor could have helped you with by providing better instructions or were they the result of external forces (e.g., Internet slow)? Please explain.

9. Please list any aspects of this week's course materials and assignments that you liked.

10. Please list any aspects of this week's course materials and assignments that you would like to see changed.

11. How many hours did you spend reading the course documentation and completing the reviews and exercises this week?

12. Please list any other comments you would like to include about the course.