Editorial Educational Strategies in the NICU

Education and Learning: What’s on the Horizon? Jobeth Pilcher, EdD, RN Disclosure The author has no relevant financial interest or affiliations with any ­commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.

Abstract Numerous organizations have called for significant changes in education for health care professionals. The call has included the need to incorporate evidence-based as well as innovative strategies. Previous articles in this column have focused primarily on evidence-based teaching strategies, including concept mapping, brain-based learning strategies, methods of competency assessment, and so forth. This article shifts the focus to new ways of thinking about knowledge and education. The article will also introduce evolving, innovative, less commonly used learning strategies and provide a peek into the future of learning. Keywords: learning; education; innovation; disruptive change; presentation software; audience response systems; whiteboards; e-learning tools; MOOC; gamification

I

n the 2003 r eport Health Professions

Accepted for publication January 2013.

Education: A Bridge to Quality, the Institute of Medicine (IOM) specif ied that education for health care professionals was in need of a major overhaul because of the ever-increasing medical knowledge, changing health care expectations, shifting demographics, and availability of new technologies. With the goal of improving the quality of patient care, the IOM described a vision to be achieved as follows: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”1(p3) In the more recent report, Redesigning Continuing Education in the Health Professions, the IOM voiced concern regarding the current continuing education (CE) model. 2 The report addressed concerns related to the effectiveness of CE, how outcomes of CE are measured, the limitations associated with activities that are primarily didactic in nature, and the fragmentation of CE among the different health care disciplines. The IOM recommended a move away from the traditional CE model and toward a continuing professional development (CPD) model that incorporates innovative, alternative, and evidence-based learning methods;

focuses on patient-centered quality care and outcomes; encourages lifelong learning among hea lt h ca re professiona ls ; and promotes interprofessional learning opportunities. Similarly, the Association of American Med ica l Col leges a nd t he A mer ica n Association of Colleges of Nursing developed a collaborative report, Lifelong Learning in Medicine and Nursing, also known as the Macy report. 3 The Macy report called for a change in education for health care professionals. In particular, the Macy report included recommendations as follows: • New, innovative, interactive, and more effective CE models designed to promote lifelong learning and impact patient outcomes. • Increased interprofessional education, as opposed to each discipline continuing to learn and practice in silos. • Changes designed to promote lifelong learning as a competency for health care professionals, and including such skills as follows: “understanding of evidence-based healthcare and critical appraisal, familiarity with informatics and literature search and retrieval strategies, practice-based learning and improvement methods, self-reflection and assessment, and other skill sets related to knowledge management.”3(p49)

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• Workplace learning with embedded lifelong learning opportunities including “formative assessment of performance and continuous learning.”3(p49) • Enhanced point of care/just in time learning options and documentation. All of these organizations specified a need for change because traditional approaches are not meeting the current needs. Both the IOM report and the Macy report indicated the need for significant transformation, or specifically for a disruptive change.2,4 Use of the term disruptive indicates that the learning needs of health professionals working in today’s complex health care environment cannot be met by merely fixing pieces or small components of the current approach to health professionals’ CE. Reflecting this disruptive approach, the panel suggested that sizable efforts be undertaken.3(p21) This disruption may include various creative and innovative learning options. The next section of the article includes examples of current and upcoming innovative approaches. Although not all the examples will be used for formal CE, they provide insight into lifelong learning options for today and for the future.

INNOVATION AND LEARNING

When the term learning is mentioned, it may promote thoughts of academia and attending lectures. One of the concerns regarding traditional education is that participants may not remember information presented in school or during lectures. This leads to the following questions: If it is not remembered, was it actually learned? Is the information part of our knowledge base? We need to think differently about learning and about knowledge. The current trend is to move away from traditional lecture formats and provide participants with opportunities to construct their own knowledge by being active participants in the learning process. This active process promotes memorable learning. 5 Creativity and innovative thinking on the part of the health care educator can result in various active learning experiences for both the traditional classroom and the virtual learning environment.

can include having participants solve a case study, write a one-minute paper, complete mini-surveys, or participate in reflective brainstorming or hands-on exercises. Within the lecture itself, educators often use PowerPoint, Keynote, or similar presentation software. The use of the software can enhance delivery of content if they include pictures, videos, and imbedded activities. Alternative presentation tools can add diversity to the learning situation. Some alternatives to PowerPoint are listed in Table 1. Note that those listed are not recommendations but simply examples. Some of the examples can be used for both the traditional classroom and for online presentations. Additional examples can be found by performing an Internet search using the search phrase “alternatives to PowerPoint.” Many of the technological innovations designed for the traditional classroom are those aimed at increasing interactivity. Audience response systems provide one example. These systems allow all class attendees to respond individually to questions posed during a presentation by using a wireless Table 1  n  Examples of Alternatives to PowerPoint Alternative

Description

Website

Brainshark

An online tool designed to turn PowerPoint presentations into videos

http://www.brainshark.com/

Flair

A desktop app that can be used to produce Flash-based presentations and animations

http://www.wildform.com/ products/flair/

FlipSnack

Provides the ability to turn PowerPoint presentations into online books

http://www.flipsnack.com/

Google Docs

A free online alternative to PowerPoint

https://docs.google.com

Impress

A free software option with features similar to PowerPoint

http://www.openoffice.org/ product/impress.html

Prezi

A cloud-based app that uses Adobe Flash to create presentations that allow zooming and various degrees of animation

http://prezi.com/

SlideRocket

A Web-based app that offers advance animations and transitions

http://www.sliderocket.com/

Xtranormal

An online tool that allows you to turn presentations into 3D animated movies

http://www.xtranormal.com/

Zoho Show

An online documentmanagement software option, which includes presentation software

https://www.zoho.com/ docs/#4

LEARNING TOOLS AND STRATEGIES FOR THE TRADITIONAL CLASSROOM

Technological advances and the Internet have afforded individuals and educators with a wealth of resources. Although online learning is gaining increased recognition, face-to-face education in the traditional classroom continues to be one of the primary means of formal learning. However, various creative strategies and technological tools are changing the landscape of the traditional classroom. Although lecture has received criticism in recent years, it remains a beneficial method of introducing new knowledge and explaining difficult concepts. Increasing research has demonstrated the importance of interspersing learning activities at least every 20 minutes during learning. 5 Examples

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TABLE 2  n  Examples of Varied Audience Response Systems System

Description

Website

Poll Everywhere

Allows audience to answer using smartphones

http://www.pollyevery where.com

Socrative

Allows audience to answer using tablets, smartphones, or laptops

http://www.socrative.com

LectureTools

A presentation tool with audience response

http://www.lecturetools.com

Mindmeldr

A web-based presentation and audience response tool

http://www.mindmeldr.com

range from intravenous catheter insertion devices to devices that enable users to practice surgical procedures. Research has demonstrated use of these devices can increase confidence and skills of health care professionals.8 Similarly, high-fidelity simulators provide learners the opportunity to learn and practice high-risk activities, as has been described in a previous issue of this column.

E-LEARNING TOOLS AND STRATEGIES

keypad (also known as clickers) to enter their answers. The aggregate answers can then be graphically displayed for all participants. Research has demonstrated that these systems can promote learner engagement, reflection, and perceived learning.6,7 The initial systems included computer software, a receiver that could attach to a computer, and the keypads. Newer options for audience responses accept responses from various devices including smartphones. The more recent systems are also allowing for responses beyond the simple true/false and multiple-choice question and answer options. Table 2 provides a list of some of the available audience response systems. More can be found through an Internet search using the search phrase “audience response system.” Interactive whiteboards offer another innovation for the traditional classroom. These computerized displays incorporate touch recognition, whiteboard activities, and embedded software to enhance the learning experience. As the name implies, the whiteboards were designed to allow more interactivity among the participants. A video example of interactive whiteboards can be viewed at http://www.youtube.com/ watch?v=DjdNPMZJbLs or http://www.youtube.com/ watch?v=0U05WeXPGlk. Similar options are available for individual and small group learning with tablet computers and smartphones. Examples of whiteboard applications (apps) include Educreations, Twiddla, ShowMe, Scribblar, Sketch Swap, Splashtop, and others, which can be found using the store for smartphone or tablet apps. For learners, tablet computers also offer note-taking apps, which allow the learner to type notes, take pictures and add them to their notes, and send notes via e-mail. Examples of note-taking apps include Notability, Evernote, ColorNote, GNotes, Notes Plus, and others. Haptic devices and high-fidelity simulators have revolutionized the learning of skills. Haptic devices are tools that make it possible for learners to touch and manipulate virtual objects. The devices measure touch, force, vibration, and motion, thus allowing for a more realistic learner experience. Examples

Online learning has the benefit of being able to reach more learners and has 24/7 availability. In health care, innovative educators have moved unit-based journal clubs to an online format so that nurses from all shifts, and even from multiple units or hospitals, can easily participate. Similarly, professional organizations are beginning to offer online poster sessions so that participants can access posters long after a conference has ended. Various organizations have developed online learning options for health care workers, including websites that offer professional collaboration such as blogs and listservs, along with sites and apps for both CE and lifelong learning opportunities. Table 3 provides a list of examples of educational websites regarding neonatal topics. Electronic portfolios, also known as ePortfolios or digital portfolios, offer individuals a way to record both learning and

TABLE 3  n  Examples of Online Collaborative and Learning Websites Learning Format

Website

Professional blogs and forums

99nicu: http://www.99nicu.org/forum World Association of Perinatal Medicine: http://www.wapm.info/WAPMForums/ tabid/148/view/topics/forumid/2/Default.aspx NICU-Net: To join, send an e-mail message to [email protected] Healthy Newborn Network: http://www.healthynewbornnetwork.org/blog

Educational websites

Neonatal and pediatric case studies: http://www.virtualpediatrichospital.org/ Neonatal x-rays: http://www.hawaii.edu/medicine/pediatrics/ neoxray/neoxray.html Anatomy and physiology animations: http://bio-alive.com/animations/anatomy.htm Health sciences educational resources http://healthsciences.merlot.org/

Games and simulations

Blood typing game: http://www.nobelprize.org/educational/ medicine/bloodtypinggame/game/index.html Newborn Jeopardy: http://www.wisc-online.com/objects/ ViewObject.aspx?ID=NUR6004 Simulation software: http://anesoft.com/shop. aspx?p=13141&k=Neonatal-Simulator-2 List of online games for health care: http://healthcaregames.wisc.edu/inventory/ browse-inventory.php

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accomplishments. Digital portfolios provide a benefit over traditional paper resumes in that the content does not have to be static. ePortfolios can contain electronic files, pictures, recordings, multimedia, links, and more. Resumes and portfolios of the future will not simply be used as an adjunct tool for job applicants. Portfolios have the potential for providing a holistic picture of the individual and have many unforeseen uses. Several professions are making the shift from text-based and paper resumes to digital portfolios as a way to demonstrate competency and to promote communication and networking.9 With increasing expectations for digital literacy skills and the changing health care landscape, digital portfolios can also be used by health care professionals as a method of documenting ongoing professional competence.10 Various free and low-cost tools are currently available for individuals to develop digital portfolios such as Googlios, Carbonmade, FolioSpaces, ZEN Portfolios, and others. An Internet search using the term “free ePortfolio” can yield additional currently available websites. At the time of this writing, professional networks such as LinkedIn are beginning to expand, allowing some of the multimedia and advanced ePortfolio capabilities. It is also anticipated that a central network and repository will be developed for health care professional ePortfolios in the future. Massive Open Online Courses (MOOCs) provide a different way of thinking about learning. In these courses, learners decide what they want to learn and how they will go about achieving their goals, and they also determine when their goal has been met. Within the courses are numerous learning options for the person to choose from to help her reach her goal. Among the options may be blogs, websites, lectures, problem-solving activities, tweets, and more. The initial MOOCs focused on participatory learning; however, newer MOOCs are available for individual and self-directed learning, such as Udacity, Khan Academy, Sophia, Google Online Courses, and others. In some cases, such as Sophia, the information learned can be used to gain college credit. However, the original purpose of the MOOC was to promote lifelong learning.11 A video describing a MOOC can be found at http://www.youtube.com/watch?v=eW3gMGqcZQc. Additional resources are available for neonatal nurse educators to help enhance the development of online and virtual learning experiences. Websites such as TED Talks, Lynda. com, merlot.org, Edutopia.org, Digital-Tutors, and http:// creatingthefuturetoday.com provide educators with knowledge and training regarding teaching strategies and digital tools. Websites such as Zorap, Cim Cim, Elluminate Vroom, Skype, Second Life, and others provide options for virtual learning spaces. Educators can plan collaborative learning activities such as WebQuests using websites such as Filamentality, zWebQuest, and TeacherWeb. Wiki’s are another option for collaborative learning. A video describing Wikis can be found at https://www.youtube.com/watch?v=-dnL00TdmLY. Wiki development websites include Wikispaces, MediaWiki,

OpenWikiNG, and PBwiki. Further websites that allow learners to be involved in creating and sharing knowledge include YouTube, Xtranormal, Animoto, and Moviestorm. Educators and learners can create their own avatar using Voki or Blabberize or comic strips using Pixton. Additional resources are continuously being developed, and thus some of those listed in this article may be outdated by the time of publication. However, one of the purposes of this article is to encourage nurse educators to actively seek out innovations that can promote learning. One way to do so is to look both within the health care education world as well as to monitor trends in general education.

NEW TECHNOLOGIES AND THE HORIZON REPORT

Every year, the New Media Consortium (NMC),12 in collaboration with the EDUCAUSE Learning Initiative, conducts research regarding emerging technologies and education trends and produces the Horizon Report. The reports include a description of emerging technologies that are likely to have a large impact on learning, teaching, and creative inquiry in higher education over three periods: one year or less, two to three years, and four to five years. Although the reports focus on time to adoption of these technologies in higher education, workplace learning is also impacted.

INNOVATIONS FOR RAPID ADOPTION

For the year 2012, mobile apps and tablet computing were listed as the technologies for one year or less time to adoption.12 By the end of 2012, the one-year predictions appeared to be approaching fruition. ABI Research estimated 36 billion apps downloaded by smartphone users in 2012.13 Similarly, tablets such as iPad, Samsung Galaxy, and Sony Tablet S entered the market with a bang. Within the first year, iPad users downloaded 3 billion applications.13 Many neonatal nurses have adopted a mobile learning pattern and have downloaded apps such as neonatal calculators, flash cards on neonatal knowledge, glossaries, bilirubin guides, and medication administration guides.

INNOVATIONS WITHIN A COUPLE OF YEARS

Game-based learning and learning analytics were predicted to be forerunners for the two- to three-year time-toadoption time frame.12 The report specified that educational games will include activities such as goal-oriented, problemsolving, role-playing, and other simulated experiences. Examples of online learning games for nurses include blood gas analysis, blood typing, and others. Gamification and serious games are new terms used to describe the use of games for the purpose of learning. With serious games, learning is reported to occur through the immersion of participants in experiences where they use knowledge to solve increasingly difficult problems and build on their understandings through cues and structured progression.14 In the

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neonatal world, LeFlore and associates reported increased knowledge acquisition, timeliness of caregiving, and overall achievement of learning outcomes when learning with a virtual neonatal simulated experience.15 Learning analytics in the virtual setting refers to the ability to monitor and analyze online learning activities of individual learners and groups of learners.16 A familiar example of analytics is how tracking occurs on the Internet to monitor site usage, anticipate and suggest similar sites, and optimize searching. Learning analytics are designed to optimize the virtual learning environment. Although learning analytics currently focus on the academic world, corporate education can also use this tool to measure and enhance learning.

INNOVATIONS ON THE HORIZON

Gesture-based computing and Internet of Things were listed in the four- to five-year time-to-adoption frame.12 Many smartphones, tablet computers, and interactive whiteboards use gesture-based input such as taps and swipes. The Nintendo Wii and Microsoft Kinect extend the gesture responses to hand, arm, and other body movements. Although the possibilities have not yet been fully realized, increasing numbers of gesture-based tools are being developed to assist in special needs situations.12 For example, some tools allow decreased dependence on keyboards, whereas others offer voice recognition and interpretation of body language (such as sign language). The Internet of Things refers to small objects with unique identifiers, data storage space, and ability to communicate with external devices.12 These may include advanced forms of the current radio-frequency identification devices (RFID) and barcodes. A current example includes quick response (QR) codes, which can be scanned with smartphones or tablet computers to direct learners to specific educational websites. Much of the concept related to the Internet of Things is still a vision. It may include aspects associated with augmented reality and other evolving immersive technologies.

SUMMARY

Technology and the Internet are changing the way we live and the way we learn. With the unrelenting increases in medical and nursing knowledge, it is imperative that nurses take advantage of available learning options and become lifelong learners, for professional growth and for the purpose of providing safe, evidence-based care for our patients. The purpose of this article has been to encourage neonatal nurses to begin thinking differently about knowledge and education. The article has provided examples of learning options that are available for all neonatal nurses as well as an introduction to evolving and innovative teaching and learning strategies for neonatal nurse educators.

REFERENCES

  1. National Academy of Sciences. Health professions education: a bridge to quality. http://www.nap.edu/catalog.php?record_id=10681. Accessed December 3, 2012.

 2. Institute of Medicine. Redesigning continuing education in the health professions. http://www.iom.edu/Reports/2009/Redesigning-ContinuingEducation-in-the-Health-Professions.aspx. Published December 4, 2009. Accessed December 6, 2013.  3. Association of American Medical Colleges & American Association of Colleges of Nursing. Lifelong Learning in Medicine and Nursing: Final Conference Report (Macy Report). Washington, DC: American Association of Colleges of Nursing; 2010. https://www.aamc.org/ download/92612/data/macy_report.pdf. Accessed December 3, 2012.   4. Institute of Medicine. The future of nursing: Leading change, advancing health. http://www.iom.edu/Reports/2010/The-future-of-nursingleading-change-advancing-health.aspx. Published October 5, 2010. Accessed December 6, 2013.   5. Willis J. Research-Based Strategies to Ignite Student Learning. Alexandria, VA: Association for Supervision and Curriculum Development; 2006.   6. Micheletto MJ. Using audience response systems to encourage student engagement and reflection on ethical orientation and behavior. Contemp Issues Educ Res. 2011;4(10):9-17.  7. Porter AG, Tousman S. Evaluating the effect of interactive audience response systems on the perceived learning experience of nursing students. J Nurs Educ. 2010;49(9):523-527.   8. Lyons MG, Kasker J. Outcomes of a continuing education course on intravenous catheter insertion for experienced registered nurses. J Contin Educ Nurs. 2012;43(4):177-181.   9. Kryder LG. ePortfolios: providing competency and building a network. Bus Comm Q. 2011;74(3):333-341. 10. Peacock S, Scott A, Murray S, Morss K. Using feedback and ePortfolios to support professional competence in healthcare learners. Res Higher Educ J. 2012;16:1-23. 11. Cormier D. What is a MOOC? http://www.youtube.com/ watch?v=eW3gMGqcZQc. Accessed December 3, 2012. 12. New Media Consortium. Horizon report: 2012 higher education edition. http://www.nmc.org/publications/horizon-report-2012-higher-ededition. Accessed December 3, 2012. 13. ABI Research. Practice areas: mobile devices. http://www.abiresearch. com/research/practice/devices-content-applications/. Accessed December 3, 2012. 14. Squire K, Giovanetto L, Devane B, Durga S. From users to designers: building a self-organizing game-based learning environment. TechTrends. 2005;49(5):34-42. 15. LeFlore JL, Anderson M, Zielke MA, et al. Can a virtual patient trainer teach student nurses how to save lives—teaching nursing students about pediatric respiratory diseases. Simul Healthc. 2012;7(1):10-17. 16. Brown M. Learning analytics: moving from concept to practice. Educause Brief. July 2012. http://net.educause.edu/ir/library/pdf/ELIB1203. pdf. Accessed December 3, 2012.

About the Author

Jobeth Pilcher, EdD, RNC-NIC, BC, has more than 20 years of NICU experience. She is currently a nurse education specialist for Baylor Health Care System in Dallas, Texas. She also serves as a parttime faculty member for Capella University. Dr. Pilcher gained her undergraduate nursing degree from Baylor University, her Master of Science degree from California College for Health Sciences and her doctorate in education from Northcentral University.

For further information, please contact: Jobeth Pilcher, EdD, RNC-NIC, BC E-mail: [email protected]

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