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=Virtual Families as the instructional strategy in undergraduate nursing curriculum.=

Amy Hilbelink, PhD Director of Curriculum, School of Nursing Kaplan Higher Education

Elaine Garofoli, MAT, MEd, MS Educational Technologist, Sawyer School of Business Suffolk University

Introduction
Kaplan University (KU), a private, for-profit university, accredited by the Higher Learning Commission (HLC) and a member of the North Central Association of Colleges and schools (NCA) offers over 100 academic programs and serves over 48,000 online and on-ground students, Kaplan University is part of Kaplan Higher Education, serving 75,000 students on-line and through 70 campus-based schools across the United States and in Europe (Kaplan University press releases, 2/4/2008). Kaplan University employs instructional methods based on adult learning theory and works to development each student’s intellectual, analytical, and critical thinking abilities. Techniques incorporated into the online classroom are meant to encourage active student participation and may include group discussions and projects, demonstrations, web field trips, guest speakers, and lectures. Kaplan University is an online university that uses the eCollege Course Management System. Unlike traditional classroom instruction, Kaplan University courses are fully developed before the first lesson takes place. Every assignment and activity in a course is planned, selected and evaluated against the course’s specific learning outcomes. (catalog 2007-2008)

The Course
The School of Nursing at Kaplan University currently offers three online nursing programs, an A.D.N. (launched in 2008), a BSN and an MSN (launched late in 2007). The A.D.N. program is a hybrid program; whereas the BSN and MSN programs are completely online. The oldest program, the BSN, was originally developed over 5 years ago and many of the courses are now outdated in terms of content and approach. It is for this reason that all BSN courses are currently undergoing major revision. One course within that revision schedule is NU304; Health/Wellness Assessment and Strategies. Learning outcomes for this course focus on patient health histories, determining health assessments, outlining communication strategies and creating effective health promotion strategies in a variety of settings, with a variety of patients and families. Within the original course, developed five years ago, it was determined that the health assessments often were superficial, inaccurate or incorrect. In addition, students registered for the RN-BSN completion program already had an RN and therefore had already learned the basics of a physical assessment. The need and the focus of the re-designed course was to reinforce proper health assessment that could be evaluated within the online course; which resulted in the approach using virtual families.

Literature Review
Because this course was to be delivered and evaluated in an online environment, the developers needed to design the course in such a way that students could learn how to conduct a culturally-appropriate holistic health assessment without actually working with real patients. Because this course was offered early in the program of study, it was important also to engage the students. This was done by creating authentic learning experiences (Choo, 2007). This approach focused on using common examples, in this case, families, which could be developed into more complex situations (Merrill, 2007). Complexity was achieved by offering more and varied health histories and cultural information for the individuals within the virtual families. These scenarios served to provide interactive activities for students within a socio-cultural context (Jonassen and Rohrer-Murphy, 1999).

Strategy for Course Design
The course revision process was a team effort consisting of a subject matter expert (SME) and an instructional designer (ID). The Kaplan adjunct faculty member chosen as the subject matter expert (SME) for this project was a registered nurse with years of assessment experience. She also had experience creating online courses in the field of nursing. The ID was a consultant who had worked as an instructional designer with a number of different schools within Kaplan over a number of years, and was familiar with Kaplan processes and technology.

This course redesign project began with a virtual meeting of the Director of Curriculum for Nursing, the Dean of the School of Nursing and the SME and ID to review changes to the overall course outcomes (if any). A working schedule was agreed to and roles clarified; the SME was responsible for the actual content of the course, while the ID was responsible for working with the SME and content to suggest teaching strategies that would best facilitate students achieving the course learning outcomes by the conclusion of the course. After this initial meeting, the SME and the ID met weekly via Skype at a time mutually convenient. The standard meeting was an hour in length, but could be extended or made more frequent, given the need based on the schedule.

We knew at the outset of the redesign project, based on feedback from both faculty and students of previous iterations of the course, that we wanted to reduce the emphasis on the actual health assessment portion of the course because students came into the course as an RN and already possessed these skills. We decided instead, to focus on the implementation of health assessment results and health promotion. Secondly, we knew we wanted to increase the amount of interaction in the course; student-student, student-content, and student-instructor, as recommended by the Sloan-C Consortium.

Our initial SME, Michelle Winter, originally mentioned that she had taught a class that used the notion of virtual families. She did not know the technology that made it possible, but she liked using it an an instructor. Unfortunately, Michelle became ill and unable to complete the project, and in her stead, Lanette Anderson, another Kaplan faculty member assumed the role of SME until completion of the course. We want to acknowledge the efforts of both faculty, without whom the course would not be what it is today.  Knowing that we wanted to make use of virtual families in some way, but cognizant of the need to be sensitive to our student base who is not particularly technologically savvy, we knew creating the course in any kind of virtual world was impossible. Whereupon we enlarged our team to work with two gifted multimedia managers. The Director of Curriculum, ID, SME, and the two multimedia individuals again met virtually via conference calls to clarify what we were looking for, how it might be implemented throughout the course, and how it could be built as efficiently as technically possible yet still with the necessary polish and professional look.

Once we agreed upon the look and feel of the virtual families, the SME and ID together created the notion that each of the 10 courses unit would be considered an element of time in which a variety of health events happened to any number of individuals in virtual families. We plunked the course location in Middletown, USA, and had all of the six families reside in the same city, although in different neighborhoods. From a mechanical perspective, students were assigned to a family by the first initial of their last name. For instance, If your last name begins with letter A – D, you will work with the Gordons; If E – I, you will work with the Lins. If there were more in some families and none in the others, then the faculty member re-assigned students to families as necessary. See Figure 1 for the Family interaction tool.

Figure 1. Family interaction tool The virtual families were from many different cultures, ethnicities, and sexual orientation. In the previous course design, students worked with a person who lived near them so that they could practice the conducting health assessments on their volunteer. This method naturally limited the exposure of students to people different from themselves and their volunteer. All courses at Kaplan University are created before any faculty actually teaches the course. All assignments, projects, readings and discussion questions are prepared by faculty for faculty. Faculty are expected to add their particular experience to the individual course via discussion boards, synchronous seminars and project evaluations. Therefore, NU304 was also created prior to faculty teaching the course and has run for two terms to date.

Results
 The result of the re-design was a totally new course with a different focus for the student. Students learned a more holistic approach to assessment of clients. They had to learn how to assess the entire family as well as the effects external situations had on the individual client. From this course, students were given the opportunity to assess individuals from a variety of families and life situations; much more than if they were to simply do a head to toe physical assessment of a friend.

Overall faculty comments were positive, with some offering that the use of the virutal families resulted in greater perspectives in the issues surrounding culture. Other faculty felt that the use of virutal families created good discussion between the students. It was felt during the first term of the course that project instructions needed more definition and clarify for the students. It was felt, by at least one faculty member, that students needed more guidance early in their course work. The health history assignment mid-way through the course seemed to cause some degree of frustration for faculty and students alike as not all information was provided. Students were purposely given incomplete health information for members of their families and were tasked with determining how best to get the appropriate health information. Some areas of the health history form were therefore left incomplete, and one faculty member requested more information on the specific families. One student inquired as to whether or not they should just make up additional information. Students were also asked to complete a cultural self-assessment survey from the National Center for Cultural Competence in order to determine where their strengths and weaknesses were when it came to cultural awareness. One faculty mentioned that students felt that they didn't know enough on this topic and that after the self-assessment felt "culturally incompetent". She requested that we push this assignment to much later in the course so that students would be better able to handle their results.

Based upon both formative and summative survey results from both faculty and students, a few changes were implemented in the course. Additional guidance was given on how to complete assignments, but more health history was not provided. Faculty were instructed to assist students to the length that they could and that students needed to do the work to assess and to begin to feel comfortable not knowing or not being given all the health history answers. The course has successfully run for two complete terms, and has been seen as successful overall by both faculty and students. Students appear to be engaged in the discussions and it has brought cultural issues to the forefront of the minds of many students and faculty.

Challenges
 Our challenges were plentiful as we sought to create an effective course for our audience of adult learners that addressed all outcomes appropriately and creatively. The development process was initially hindered by our need to switch SME's halfway into the course time line, which put us behind in our delivery schedule. Inherent in a collaborative effort such as the model used by Kaplan is the need for all parties to be responsible to their duties and timeline. It also helps tremendously if all parties are able to work together from a personality perspective. Secondly, the multimedia talent with whom we worked were not specific to the School of Nursing, and consequently, we only had a limited amount of their time and corresponding limited budget with which to conform.

Perhaps of most concern was the challenge of overcoming resistance to change in the form of a different type of course design. This was applicable to both existing Kaplan School of Nursing faculty and to the students in the course. Heretofore, all courses in the RN-BSN program has a similiar standard design and formt, which even though they did include video clips, were mostly text-based. Our efforts to create a course that was potentially more engaging as a result of using virtual families and weaving events and a type of story in time throughout the ten weeks was a radical departure for both faculty and students. Fortunately, the individual who was the SME for this course has taught it the first two times it has been offered, and even though Kaplan students are enrolled in a totally online program, they are not overly technically savvy. We were ever conscious about creating our student-content interaction so that it was easy to move around the various course elements such as; from the Discussion Board, to their virtual family, take a virtual field trip, and then to navigate to the the virtual families, and chat synchronously online. Students are not required to have computers with processors and memory necessary to support abundant multimedia experiences, so we also needed to be mindful that our design would not overly tax students' hardware.Students and faculty alike seemed to need more direction on expectations than in previous courses. After two terms, faculty asked that more information be supplied to both students and themselves so that they could assist students and understand better what needed to be evaluated.

Conclusion
Faculty noted that this was an innovative course and unlike any they had taught before. Students appeared to be more engaged in the course, as evidenced by more frequent postings to the discussion boards. Students also worked well in collaborative groups when discussing their families. The evaluation of the course outcomes demonstrated that the majority of students did achieve what the course was designed to achieve. Students learned how to conduct holistic assessments and learned how to ask culturally appropriate questions of their diverse clients. They also came to realize that there was more they needed to learn about cultural sensitivity. The course design has been shared with others in Kaplan University and most express interest in incorporating similar approaches to situational learning environments. Within the School of Nursing we are currently evaluating creating a similar approach within the Bachelor of Science in Nursing capstone course.

References

Choo, C. (2007). Activity-based approach to authentic learning in a vocational institute. //Educational Media International,// 44(3), 185-205.

Herrington, J., Oliver, R., Reeves, T., (2002). Patterns of engagement in authentic online learning environments. Retrieved April 24, 2009, from []

Jonassen, D.A., and Rohrer-Murphy L. (1999). Activity theory as a framework for designing constructivist learning environments. //Educational Technology Research and Development//, 47(1). 61-79.

Kaplan University press releases, 2/4/2008.

Merrill, M.D. (2007) A Task-Centered Instructional Strategy. //Journal of Research on Technology in Education,// 40(1), 33-50.

Biographical Sketches
Amy Hilbelink, Director of Curriculum, KHE School of Nursing, has presented twice before at the Annual Conference on Distance Teaching & Learning in Madison. She received her undergraduate degree from Marshall University in Huntington, West Virginia in 1983, and completed her master’s degree in biological sciences at the University of South Florida in 1986. Her doctoral degree is from the School of Education at the University of South Florida and her dissertation involved the effectiveness of desktop 3D imaging in online human anatomy courses. Dr. Hilbelink’s research interests include outcomes assessment, the incorporation of appropriate technology into online health/medical education courses, and online faculty competencies.

Address: Kaplan Higher Education 605 Crystal Grove Blvd. Lutz, Florida, 33548 E-mail: ahilbelink@kaplan.edu Phone: (813) 205-2628 Fax: 1-800-735-4516

Elaine Garofoli, President and Owner of SparkFireLearning, has presented at regional, national and international conferences and workshops throughout her 30 year professional career, most recently on topics including: Facilitating Collaborative Learning, Making Web 2.0 Tools Work for You, and Effective Presentations: No More Bullets. Her research interests include institutional use of personal learning environments, connectivism, connected knowledge and collaboration, and techniques to increase faculty presence in online learning. Elaine worked as the Instructional Designer on this project, and is currently the Educational Technologist at Suffolk University's Sawyer Business School in Boston.

Address: Suffolk University Sawyer School of Business 8 Ashburton Place Boston, MA. 02108-2770 E-mail: egarofoli@suffolk.edu Phone: (617) 973-1112 Fax: 1(617) 573-8704