Introduction
How Can Health Professionals Learn Online?
An Approach to Understand Online Learnersâ Efforts
Members of the lay public often have questions about how health professionals could possibly learn the knowledge they need to practice competently in their discipline in online classrooms. How could nurses, dental hygienists, physical therapists and occupational therapists master hands on skills? How could psychologists master counselling skills? And beyond skill development, how could online environments provide health care professionals with opportunities to integrate the knowledge, skills and attitudes they need to provide safe care to their patients and clients?
Through a process of seeking answers to these and other questions, colleagues and I from the Faculty of Health Disciplines at Canadaâs Open University, Athabasca University (http://www.athabascau.ca/) have worked to establish and re-vitalize post-basic programs for health professionals who were already qualified in their discipline, but who wanted to upgrade their education. For example, one program provides nurses previously educated at college or vocational institutes
Similarly, another program provides nurses, dental hygienists, physical therapists, occupational therapists, dietitians and other university educated health professionals with opportunities to earn a masterâs degree. Professional counsellors and counselling psychologists have opportunities to earn graduate degrees in counselling. While some of the Athabasca University programs require students to attend face-to-face practicums in clinical settings, others are offered entirely online.
A common thread that our faculty group weaves throughout the programs and courses is our belief that our students are self-directed, reflexive practitioners who can already think critically. Our goals include extending and building on these strengths. As we designed and implemented different levels of learning experiences, we were guided by our universityâs mission statement. As Canadaâs Open University, Athabasca Universityâs mission is dedicated to removing the educational, geographical, financial, social, cultural and other barriers that often limit access to post-secondary achievement. In doing so, AU guarantees access to university-level study to a broad range of non-traditional students (Athabasca University, n.d.).
We also grounded our thinking in our universityâs mandate, which highlights how Athabasca University, as a distance education university, provides seamless and responsive advanced education, flexibility for lifelong learners who cannot or choose not to undertake residential post-secondary education and offers learners the opportunity to interact with students across Canada and around the world (Athabasca University, n.d.).
Given the commitment to understand and support learnersâ own efforts inherent in the universityâs mission and mandate, taking advantage of university wide opportunities already in place was an important consideration as we designed programs for health professionals. Athabasca University implements ongoing research with current and former students. For example, a recent survey indicated that over 90 per cent of AU students study year round, balancing their studies with work, family or community responsibilities; 81 per cent work while they study and 63 per cent support dependents (AU at a Glance, n.d.). The average undergraduate student is 29; the average graduate student is 37 and 67 per cent are women (AU at a Glance, n.d.). 74 per cent of AU graduates are the first in their family to earn a university degree.
Knowing that AU students are generally working adults who could find it difficult to accommodate traditional university terms and class schedules, the university makes every effort to incorporate this understanding of student needs with unique learning opportunities. Many Athabasca University courses are self-paced and students are not limited to typical university term registration times. They can register at the beginning of any month and may take a year or longer to complete courses. Transfer credit is given whenever possible.
Students also have opportunities to take the initiative to challenge non-required courses. They are invited to reflect on and document the valuable experiential
Online classrooms at Athabasca University use a variety of learning management systems to facilitate interaction among faculty and students. For example, the Faculty of Health Disciplines currently use the moodle learning platform (moodle, n.d.). Moodle allows faculty and students to interact asynchronously in secure discussion forums and to exchange e-mail within their courses. Conferencing software such as Adobe Connect (Adobe connect, n.d.) is also used to provide opportunities for synchronous interaction and the real-time sessions can be recorded for later use by students.
Courses are instructed by both full time continuing faculty and tutors who are employed on a contract basis. Both groups of instructors maintain toll free telephones. Students can log in to their courses on their computers or Smartphones anytime or anywhere and faculty are only a telephone call away. Students are encouraged to engage faculty in their learning by emailing or calling them throughout their program.
Autonomy Support
As faculty at AU consider approaches that can support online studentsâ own efforts to learn and autonomy, existing research provides important guidance. Autonomy support is defined as âthe interpersonal behaviour one person provides to involve and nurture another personâs internally locused, volitional intentions to act, such as when a teacher supports a studentâs psychological needs (e.g., autonomy, competency, relatedness), interests, preferences and valuesâ (Reeve & Jang, 2006, P. 210). In online learning environments, the construct of autonomy support involves teaching actions that support studentsâ towards becoming more self-determined, independent, intrinsically motivated and engaged (Lee, Pate & Cozart, 2015).
Self-regulation is essential for student success in online learning environments, and autonomy support can make an important difference in studentsâ feelings of ownership and responsibility for their work (Chen & Jang, 2010). Autonomy support can help students feel more emotionally connected to their teachers (Ryan, LaGuardia, Solky-Butzel, Chirkov, & Kim, 2005). When studentsâ feel that their own efforts to learn are supported, their engagement, concentration, time management and self-regulation can improve (Reeve, Jang, Carrell, Jeon, & Barch, 2004).
Lee, Pate and Cozart (2015) summarized three overarching guidelines for providing autonomy support to online students. First, provide choices; second, provide rationale; and third, provide opportunities for personalization. Providing choices, such as inviting students to choose among several options for assignments and activities offers a variety of different ways for students to demonstrate expected
Understanding the Learning Needs of Three Health Professions Students
Life circumstances of the health professionals who upgrade their education through online courses at Athabasca University can be expected to be different than those of traditional university students. A traditional university student, particularly at the undergraduate level, could be single without dependents; live at home or in lower cost student housing; and could work in a non-professional job. However, an AU student typically supports children, elders or other family members; lives in a home with significant associated costs; and works at least one professional job. As adult learners, AU students juggle family and work responsibilities in addition to their studies. Many are the first in their family to earn a university degree. In the Faculty of Health Disciplines, the majority of students are women with children.
Learning online can be a lifeline for health professionals. Shift work, unpredictable employment schedules, childrenâs activities, family commitments and unexpected events make attending brick-and mortar classrooms challenging. In this section, I share the stories of three students from the Faculty of Health Disciplines (without using their real names) as a way of illustrating how health professionals can learn online.
Kim
Kim is a Licensed Practical Nurse LPN (known in other jurisdictions as Licensed Vocational Nurse LVN, Enrolled Nurse EN, or Registered Practical Nurse RPN) who began her career as a Nursing Assistant. Kim did not graduate from high school. After completing six weeks of Nursing Assistant training, Kim worked in a care home for the elderly and later bridged into an LPN program. She continued working in the care home and completed the needed upgrades to gain admission into the Athabasca University Post Basic LPN to BN program. Earning a Bachelor of Nursing (BN) degree will allow Kim to write the qualifying examinations required to practice as a Registered Nurse RN in Canada.
I met Kim, as a student during a two-week required clinical practicum I instructed. To complete this practicum, students and faculty travel to a specified clinical setting
One of the most poignant memories I have of learning with Kim throughout her practicum was her tenacity. Kimâs newborn baby was just two months old and she was still breastfeeding. In order to complete her practicum within the timeframe she set for herself, Kimâs mother and her baby travelled with her to the practicum site and stayed with the billet family as well. Kimâs mother took unpaid leave from her own job. Kim attended the clinical course each day and her mother brought the baby in every three hours to feed.
After completing her practicum, Kim returned home and continued with the online portion of her program. If and when she needed extra help understanding concepts or perhaps an extension for an assignment, faculty and tutors were there to help and accommodate her needs.
Kim received ongoing support for the actions she was taking on her own to learn. For example, one of the assignment choices Kim selected in her public health course required students to create a health teaching plan for a new mother. Kimâs tutor listened carefully to Kimâs recent experiences as a new mother and then customized the assignment to include some of the non-assigned readings and experiential learning Kim had been doing on her own to understand her new role. In another instance, during a telephone call with Kim, her tutor became aware that Kimâs verbal skills seemed stronger than her written work, and that her practice background was working in a care home for the elderly. In response, this tutor invited Kim to create an audio-recording explaining a topic she had experience with in her workplace. This recording was used as a foundation and Kimâs tutor helped her build and extend the assignment to also include written work that integrated reviews of relevant literature.
Anna
Anna is a health professional earning a graduate degree. Under difficult conditions, she left an Asian country and arrived in Canada as a young girl with her parents. Learning English as a second language posed a continuing challenge for her.
The scholarly writing requirements of graduate study seemed overwhelming. Despite working two part-time jobs in busy clinical agencies and caring for young children and aging parents, Anna attended supplemental writing workshops offered by both Athabasca University and a community college in her area. She sought help from one of her childrenâs school teachers and employed a freelance editor to review her assignments before submitting them.
Kelly
Kelly is also a health professional earning a graduate degree. His practice is in the military and online learning provided the flexibility he needed to further his career whether he was stationed at home or deployed abroad. During one period of his studies, Kelly was on active duty in a war zone. For security reasons, at times he was unable to access the internet and complete required assignments. He worked around this hurdle by letting his instructors know about times he might not be available and made every effort to complete and submit his assignments well before they were due. In many instances, without contact with his instructors, this self-directed approach increased the difficulty of course requirements for him, but despite this, he succeeded in completing his degree.
Online faculty and tutors became aware of Kim, Anna and Kellyâs unique circumstances through posts they made in the âIntroductionâ forums of their classes. All courses in the Faculty of Health Disciplines at Athabasca University provide âIntroductionâ forums where students are invited to post thoughtful introductions. Reading studentsâ introductions carefully and gently probing for further information at the beginning of online courses can encourage students to share relevant information about their learning strengths, needs and barriers.
From her posts in the course introductory forum, Kimâs tutor learned that she had a new baby. Further discussion revealed that Kim had been reading about the role and responsibilities of new mothers. So, her tutor used this knowledge to help Kim integrate her personal experiences into an assignment. Similarly, Annaâs introductory posts revealed that she was struggling with English as a second language and scholarly writing. She hoped attending supplemental writing workshops would help. Knowing this, Annaâs tutor could build on what Anna was learning in activities beyond the classroom. Finally, Kellyâs introductory posts explained how he was in the military and could suddenly be denied access to the internet. In response, Kellyâs tutor was more than willing to be flexible with deadlines. Programs that consistently provide introductory forums, where teachers and students can get to know one another, are an important tool for teachers seeking to understand and support online studentsâ own efforts to learn.
Instructorsâ Strategies to Understand Studentsâ Own Efforts to Learn
In the Faculty of Health Disciplines, most instructors ground their teaching approaches in the belief that students themselves are making efforts to learn. While instructors may be aware of some of the kinds of efforts students are making,
When students introduce themselves to their instructors, some details of their circumstances become apparent. However, it is also likely that instructors are unaware of many of the less obvious learning efforts students are undertaking. One effective way to consider some of the actions learners themselves are taking to learn is to ask them directly. Inviting learners to share their experiences opens the door to recognizing and supporting their work.
Strategies That Support Learnersâ Efforts
Research exploring studentsâ online learning experiences offers direction and helps instructors begin to recognize learnersâ own efforts. In Kimâs program, for example, recognizing her efforts was particularly useful to successfully support her in her studies. A qualitative descriptive study with Post LPN to BN students revealed that they valued affirmation of both the unique challenges they faced and the strategies they were implementing to overcome these challenges (Melrose & Gordon, 2008). A longitudinal study exploring LPN to BN transitions revealed that this group of students set their own personal learning goals and that it was these self-determined goals that sustained and motivated them when learning became difficult (Melrose & Gordon, 2011).
One strategy that this non-traditional group of adult learners found useful was turning to workplace mentors for help applying what they were learning online (Melrose & Gordon, 2011). As a way of recognizing and supporting these efforts, course designers developed assignments that involved discussing course concepts in learnersâ own workplaces and then reporting on these discussions.
In Anna and Kellyâs graduate program, an action research project highlighted how learners were seeking help from their family, friends and co-workers (Melrose, Shapiro, & LaVallie, 2005). Course designers recognized this important source of help by building in assignments that invited learners to adapt coursework for immediate use in learnersâ lives and workplaces.
This research has also shown that another effective help-seeking strategy used by online learners is asking for help from fellow students in their classes (Melrose, 2008). Instructors can therefore build in opportunities for this kind of interaction to take place. In Open University settings, interactions and relationships with fellow students are increasingly being found valuable to student retention and
Creating Supportive Online Learning Environments
As the above discussion illustrated, at the university, program and course design levels, Athabasca University provides opportunities for faculty and tutors to recognize and support what learners themselves are doing to strengthen their upgrading experiences. However, the heart of creating genuinely supportive learning environments occurs at the instructional level in online classrooms. In order to understand the efforts Kim, Anna, and Kelly were putting into their studies, their classroom teachers needed to take special care to establish positive relationships with them and communicate genuine interest in their individual learning.
Developing Positive Relationships with and between Students
Affirming, supportive learning environments are grounded in strong relationships between students and teachers. In online classrooms, engaged supportive relationships with teachers have consistently been found to be critically important to online learners (Fedynich, Bradley, & Bradley, 2015; Marin, Martinez, Pecino, Rodriguez, & Melero, 2011; Wright, 2014). Positive teacher-student relationships set the stage for creating supportive environments where students are more willing to take responsibility for their own learning. Students can feel emotionally connected to teachers who support their autonomy and the actions they are taking on their own to learn (Ryan et al., 2005). Understanding the construct of instructional immediacy can help online teachers establish supportive relationships with their students.
Engaging in Instructional Immediacy
Instructional immediacy involves communicating availability, friendliness, and a willingness to connect in personal ways with students. The construct of immediacy was introduced in the 1960s by social psychologist Albert Mehrabian, who defined immediacy as an affective expression of emotional attachment, feelings of liking and being close to another person (Mehrabian, 1967, 1971; Wiener & Mehrabian, 1968). Thus, immediacy is a sense of psychological closeness.
In traditional face to face university classrooms, instructors express immediacy through nonverbal communication such as maintaining eye contact, leaning in closer, touching, smiling, maintaining a relaxed body posture, and attending to voice inflection (Andersen, 1979). They express immediacy verbally by using
In online learning environments, the experience of liking and feeling close to instructors also leads to positive effects in the classrooms (Chakraborty & Nafukho, 2015), higher interactivity (Fahara & Castro, 2015) and greater student satisfaction (Ghamdi, Samarji, & Watt, 2016; Woods & Baker, 2004) In essence, instructional immediacy online refers to the extent to which teachers are able to project a feeling of warmth and likeability in their communication with students (Melrose, 2009). During real-time synchronous conferencing sessions, instructors can demonstrate immediacy verbally and non-verbally in the same way instructors do in traditional classrooms. This process of modeling of immediacy can include invitations to students to imagine new ways of learning that extend beyond course requirements.
On the other hand, during asynchronous interactions, intentional word choices can be an effective way of expressing immediacy. For example, messages and posts with words that refer to âourâ class and indications that an instructor is willing to work âwithâ learners project interest in understanding studentsâ circumstances, their goals and their own efforts. Words that communicate a genuine interest in getting to know each class member as a unique individual can create a feeling of safety within the teacher-student relationship. Learning in health professions programs can be expected to be a high stakes endeavour and feeling safe can make it easier to take risks and try integrating new ways of thinking.
Research exploring online graduate studentsâ perceptions of instructional immediacy highlighted that learners value instructional behaviours that model engaging and personal ways of connecting; that maintain collegial relationships; and that honour individual learning accomplishments (Melrose & Bergeron, 2006). Examples include instructors posting self-introductions that include pictures and appropriate personal and professional information, creating a course document incorporating biographical information for each member of the class, and choosing words with gentle connotations (Melrose & Bergeron, 2006).
Instructional immediacy can help establish instructor-student relationships that encourage students to share their circumstances, their goals and the learning activities they are initiating on their own. Modelling immediacy during interactions with students can help emphasize the value of autonomy, self-regulation and taking responsibility for oneâs own learning. In turn, knowing what students themselves are tackling and the risks they are taking, instructors can respond to these efforts and offer further guidance and suggestions. Additionally, instructors can create affirming supportive online environments by connecting students with one another and establishing expressions of immediacy in class groups.
Encouraging Peer Engagement and Support
Creating and Using Innovative Podcasts
At AU, faculty embrace traditional activities for peer connections such as partnering during assignments and including peer evaluations whenever possible. Additionally, innovations such podcasts created by students are also being used to encourage student autonomy. In online classrooms, where most interaction is text-based, podcasts can be used to create opportunities for peers to literally âhear fromâ others in their program. For example, in some asynchronous self-paced courses in the undergraduate LPN to BN program, junior students work alone rather than in class groups. In an effort to decrease their feelings of isolation, senior students were asked to record brief podcasts that offered mentorship and advice. The podcasts were embedded in the moodle learning platform where their course was hosted (Gordon & Melrose, 2011). With the podcasts so readily available, students could click on the MP3 audio file any time of day or night and hear a mentoring tip from a peer who had successfully completed the course. Although the students did not know one another and no further interaction occurred, a connection was made. Senior students felt the process affirmed that actions they were taking on their own were important and worthwhile enough to record and share with others.
Podcasts created by students have also been used in the graduate programs at AU. Once again students further along in their programs were invited to share messages of encouragement with less experienced peers. The messages were collected on a telephone answering machine as MP3 files and then embedded in the moodle learning platform (Melrose & Swettenham, 2012). In this instance, the messages were not just available in a particular course, rather they were included in a graduate student orientation manual that students access throughout their program.
Organizing Group Work and Networking as Integral to the Course Experience
Group work can also provide opportunities where the actions students are taking on their own to learn can be affirmed and supported. All students in the Faculty of Health Disciplines at AU do have access to groups where they can interact with other students. For self-paced courses, participation in the groups may be optional. In paced courses, participation in class groups is required and graded. Just as in traditional learning situations, group work in online classes can foster supportive relationships among students and their teachers. Examples of group work include completing projects with peers, facilitating online seminars with others in a class and offering feedback on student papers.
In a three year qualitative research project AU faculty found that students believed meaningful learning in their online group work occurred for them in three different stages (Melrose & Bergeron, 2007). First, a, beginning/engagement stage; second, a middle/encouragement stage; and third, an ending/closure stage. Viewing the experience of group work through the eyes of the students, we heard our students say that in the beginning/engagement stage, they valued knowing their instructors were available âif you need meâ and that it was âsafeâ to contact them. When they felt that their instructors were present, they could risk sharing their concerns and any strategies they were implementing to overcome these concerns.
In the middle/encouragement stage, students said they appreciated personal help with networking. Again simply knowing their instructors were present and would help them manage any conflict that might emerge was helpful as they worked through issues. During this middle time of needing encouragement, students appreciated private feedback and prompt responses.
Lastly, in the ending/closing stage, students needed opportunities to debrief and reflect. Knowing about the needs that students can be expected to have at different stages of their group work can help instructors offer timely and meaningful support. As instructors model immediacy and recognition of student strengths and efforts in their discussions with student groups, the students are likely to extend this affirming way of interacting to their conversations with one another. For health professionals, who often interact with patients and clients from a strengths based approach, dialogue where individuals are recognized for their efforts can be expected to be a familiar and comfortable way of relating.
Creating Virtual Gathering Spaces for Students
Another innovation for establishing peer connections that faculty at AU implemented was creating program-wide virtual gathering spaces (Getzlaf et al., 2012). Here, graduate students from different health disciplines and programs were invited to
Access to these forums was not limited to course terms, so students could drop in throughout their program. Faculty members were welcome to attend and join any conversations underway, but they did not provide leadership or initiate activities. Participants in the virtual gathering spaces were free to share their experiences, seek and receive help from one another and exchange information about issues of common interest. The process of creating a space where students could gather and connect beyond their classes was another way faculty could indicate to students that their ideas and the actions they were taking to strengthen their learning were important and should be communicated.
Developing an E-Textbook for Online Health Professions Educators
In an effort to disseminate the innovative activities (such as those mentioned in the preceding discussion) that faculty and tutors at Athabasca University have been using with their students to create affirming environments, colleagues and I have collected these activities and presented them in an e-textbook. The e-textbook is titled: Teaching Health Professionals Online: Frameworks and Strategies (Melrose, Park, & Perry, 2013). Each chapter suggests creative challenging activities that educators in the health professions can readily implement in their online classes.
The activities were developed by the experienced faculty and tutors at AU. As these instructors come from various disciplines within the health professions, and live in different jurisdictions in Canada and internationally, a wide scope of perspectives is represented. As many health professionals begin their teaching career with strong clinical knowledge but limited understanding of educational theory, we felt it was beneficial to link the activities to established theories. Each activity is therefore presented within the grounding context of a particular theory of learning. As an Open Education Resources or OER, the e-textbook is available for free at http://www.aupress.ca/index.php/books/120234. It is available online, on Smartphones or in print (for a small printing charge).
Conclusion
In this chapter I illustrated a selection of approaches that faculty and tutors in the Faculty of Health Disciplines at Athabasca University, Canadaâs Open University have successfully implemented with online undergraduate and graduate students. The approaches are grounded in a view that post basic health professions students are passionate about upgrading their education and are actively engaged in their own efforts to learn. They are supported by literature exploring the construct of autonomy support.
This discussion is followed by a presentation of a range of strategies instructors can use as they begin to recognize and support studentsâ own efforts to learn. I explained how instructors can demonstrate instructional immediacy in online classes. The chapter concluded with a suggestion that podcasts, group work and virtual gathering spaces can be used to establish the kinds of peer connections that also affirm learnersâ own efforts. For those who are interested in reading about additional approaches that AU instructors use, a free e-textbook is available.
In closing, although understanding and supporting studentsâ efforts to learn may not always be straightforward, the ongoing process of continually encouraging students to share the ways they are engaging with course material and the actions they are taking to integrate the new knowledge is critically important. This is both a challenge and an opportunity for online educators in health professions programs.
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