‘.‘ 3.2'. . .T.‘,', _'.';‘g\‘, ‘I my. 1“. .‘T‘I‘j‘hflll‘i . n.» v: - I a; u 4‘ ‘..'. n. .I'.._,‘_‘ .. V "'"w \ - ‘mu . ‘ ';:2\Z‘li,&411‘-‘3&‘35:33.3“ COMPUTER ASSISTED INSTRUCTION IN HEALTH FRUFESSIGNS EDUCATION: GUIDELINES FOR UTILIZATION Bissertafion for the Degree of Ph. D. r MICHIGAN STATE UNIVERSITY , . JOHN PAUL CASBERGUE 1974 . ‘ LIBRAR Y Michigan State University “WV. thesis entitled 644:, A COMPUTER ASSISTED INSTRUCTION IN HEALTH PROFESSIONS EDUCATION: GUIDELINES FOR UTILIZATION presented by John Pau; Casbergue ‘2; i"- :1. ' has Uzeen' acgépge'ggwards fulflflment o'f the feqfi mentsfljr Ph.D. (wee in Education (Instructional DeveIopment and Technology) . Ema. Major professor £9 *‘13 ‘24,, Mb? .. (23$? ABSTRACT COMPUTER ASSISTED INSTRUCTION IN HEALTH PROFESSIONS EDUCATION: GUIDELINES FOR UTILIZATION BY John Paul Casbergue The problem investigated in this study was to identify the most critical factors which facilitate or inhibit the development of CAI in health professions educational programs. Once these critical factors were identified, they were used to prepare a set of guidelines for health professions administrators and educators who are responsible for considering or planning for the Utilization of CAI. As a first step, the study developed a methodology which combined a modification of the Nominal Group Process method of problem identification with principles of survey research and questionnaire design. The study was conducted in three phases. The first phase of the study consisted of the identification and prioritization of the critical factors influencing the development of CAI as perceived by CAI-experienced administrators, faculty and technical staff in three John Paul Casbergue nedical education programs that have pioneered the develop- nmnt of CAI in health professions education. These insti- tutions were The University of Illinois Medical Center, Massachusetts General Hospital with Harvard University, and The Ohio State University. Separate problem identifi- cation meetings were held at each institution with the CAI planning and development faculty and staff. The second phase of this study consisted of a mail survey to the 108 deans or directors of the insti- tutional members of the Association of Schools of Allied Health Professions (now the American Society of Allied Health Professions) and the CAI-experienced health pro- fessions personnel from the three medical education institutions. They were asked to rate their perceived degree of cruciality of 28 factors identified in Phase I of the study. In the third phase of the study, the data obtained frOmthe first two phases were utilized to prepare a set 0f Guidelines for the utilization of CAI. These guide- lines were validated with CAI-experienced and inexperienced health professions administrators and faculty members. It was concluded that there are common crucial factors across health professions educational institutions that influence the development of CAI. Among the most Critical factors facilitating the development of CAI Were the need for tOp level administrative support and John Paul Casbergue commitment to the use of CAI; the need for the faculty to be convinced of the learning benefits of CAI; and access to a reliable computer facility or system. Among the most critical factors inhibiting the development of CAI were the high initial investment required for the develop- ment of CAI; the lack of institutional administrative structure to support and develop CAI; and the lack of recognition among the faculty as to how to utilize CAI as an integral part of the curriculum. Further, it was concluded that there is a high rate of agreement (rs = 0.8213) among CAI-experienced and CAI-inexperienced health professions administrators and faculties on facilitating factors. However, there was almost no agreement (rs = 0.0909) between the exper- ienced and inexperienced personnel on inhibiting factors. One of the broad generalizations which seemed warranted from this study is that inexperienced health professions administrators may put the emphasis on the less important factors and not adequately address the factors reported as most critical by the CAI-experienced personnel. The guidelines and over 200 factors identified as influential in the development of CAI by the CAI- experienced group provide numerous considerations for administrators contemplating the utilization of CAI. COMPUTER ASSISTED INSTRUCTION IN HEALTH PROFESSIONS EDUCATION: GUIDELINES FOR UTILIZATION BY John Paul Casbergue A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Instructional Development and Technology 1974 Copyright by JOHN PAUL CASBERGUE 1974 Dedication to My wife, Eugenia, and our three children Paul, Maria and Lisa They provided the encouragement, support, love, patience and understanding that enabled me to complete this study. ii ACKNOWLEDGMENTS I wish to express my sincere appreciation to my Committee Chairman, Paul W. F. Witte, Ed.D., who was a constant source of counsel and encouragement through my entire graduate program and to Norman T. Bell, Ph.D., Co-Chairman and dissertation director who provided con- siderable assistance in the design and implementation of the study. The other members of my committee who provided guidance and willing counsel at many points during my graduate program and this study are Allan J. Abedor, Ph.D., Hilliard Jason, M.D., Ed.D., and Gregory L. Trzebiatowski, Ph.D. To Howard S. Teitelbaum, Ph.D., who was a continuous source of counsel and inspiration during the critical phases of this dissertation, I express my special appreciation. The numerous members of the medical school faculties and the American Society of Allied Health Pro- fessions who participated in the study deserve credit for its success. Harold A. Wooster, Ph.D. of the Lister Hill Biomedical Communications Center CAI Experimental Network; G. Octo Barnett, M.D., Massachusetts General Hospital; iii Gary Drennon, University of Illinois Medical Center, and James V. Griesen, Ph.D., formerly of The Ohio State Uni- versity, generously cooperated in arranging meetings with the CAI planning groups of the medical education insti- tutions. William M. Samuels, Executive Director; Robert Atwell, M.D.; and Aaron L. Andrews, M.P.H. of the American Society of Allied Health Professions provided assistance and support in working with the allied health educational institutions. The faculty, fellows and staff of the Office of Medical Education Research and Development (OMERAD), Michigan State University, were helpful and supportive at all stages of the study. The faculty of OMERAD also provided an educational environment that became a major and valued component of my educational program. Secretarial assistance was ably provided by Janice L. Smith and Julie Swieczkowski. Kowit Pravalpruk of the Office of Research Consultation, College of Edu- cation, Michigan State University, assisted in the sta- tistical analysis used in the study. The study was conducted while I was a Fellow in OMERAD and a Special Fellow of the National Center for Health Service Research and DevelOpment. The educational program and this study were supported, in part, by a National Institutes of Health Fellowship (1F03HSS4, 258-01) from the National Center for Health Services Research and Development. iv TABLE OF CONTENTS Chapter Page I 0 BACKGROUND 0 o o o o a o o o 0 o 1 Goals of the Study . . . . . . . 4 Limitations of the Study . . . . . 5 Definition of Terms . . . . . . . 6 Order of Presentation . . . . . . 8 II. RELATED RESEARCH . . . . . . . . . 10 Studies of Factors Facilitating the Development of CAI in General Education . . . . . . 11 Studies of Factors Inhibiting the Development of CAI in General Education . . . . . . 15 Studies of Applications of CAI and of Factors Influencing the Development of CAI in Health Professions Edu- cation. 0 O I O O O O O C O 18 Generalizations from the Review of the Literature . . . . . . . . 23 Implications of Literature Review for This Study . . . . . . . . 24 III. METHOD OF CONDUCTING THE STUDY . . . . 26 Overview of the Methodology . . . . 26 Phase I . . . . . . . . . . 26 Phase II . . . . . . . . . 27 Phase III 0 O O O O O C O O 27 Phase I o o o o o o o o o . o o 27 Selection of the Phase I Partici- pants for the Study . . . . . 28 The Nominal Group Process . . . 28 The Nominal Group Process as Used in This Study . . . . . . . 29 Comments on the Nominal Group Process . . . . . . . . . 31 Chapter Phase II . . . . . . . . . . . Phase III. 0 o o o o o o 0 O 0 Summary . . . . . . . . . . . IV. RESULTS AND DISCUSSION . . . . . . . Results of Phase I . . . . . . . Results of Phase II . . . . . . . Use of CAI in Allied Health Edu- cation . . . . . . . . . . Results of Phase III . . . . . . . Preparation of Guidelines . . . . DiScussion of Critical Factors. . . . Attitudes. . . . . . . . Economics. . . . . . . . Learning and Instruction. . . Organization and Administration Personnel. . . . Software . . . . . . . . Technology . . . . . . . Summary . . . . . . . . . . . V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS FOR FURTHER RESEARCH . . . . . . . Summary . . . . . . . . . . . Conclusions . . . . . . . . . . Conclusions Regarding Crucial Factors. . . . . . . . . . Conclusions Regarding Differing Per- ceptions of Factors Influencing the Development of CAI . . . . Recommendations for Further Research. . APPENDICES Appendix A. Guidelines for the Utilization of Computer Assisted Instruction in Health Pro- fessions Educational Programs . . . . vi Page 32 35 36 38 38 39 39 43 43 48 48 51 52 54 55 56 57 59 60 60 61 62 '63 65 69 Appendix B. Summary Data Regarding Cruciality of Factors Included in the Mail Survey Instrument . C. Educators. Education Institutions H. REFERENCES vii Mail Survey Instrument and Letters of Transmittal Evaluation Form for Prototype CAI Guide- lines Pre-Study Survey of Interest in CAI Guide- lines Among Allied Health Professions List of Participants From the Three Medical Nominal Group Process Task Statement Form. A Composite Listing of All Factors Identified As Influencing the Development of CAI Page 74 8O 81 82 83 91 103 104 LIST OF TABLES Page University of Illinois Medical Center, Critical Factors in the Development Of CAI O I O O O O O O O O O O 40 Massachusetts General Hospital with Harvard University, Critical Factors in the Development of CAI . . . . . . . . 41 The Ohio State Universitx.Critical Factors in the Development of CAI. . . . . . 42 Responses by ASAHP Group on Anticipated Use and Appropriateness of CAI in Education of Health Professionals . . . . . . 44 Crucial Facilitating Factors Rated in the Study . . . . . . . . . . . . 76 Crucial Inhibiting Factors Rated in the Study . . . . . . . . . . . . 77 Summary Data Regarding Item-By-Item Rating of Cruciality of Facilitating Factors By ME Groups and ASAHP Group. . . . . 78 Summary Data Regarding Item-By-Item Rating of Cruciality of Inhibiting Factors By ME Groups and ASAHP GVoup. . . . . 79 viii LIST OF FIGURES Figure Page 3-1. Format of Cruciality Rating Scale for Factors 0 O O O O 0 O O O O O O 34 ix CHAPTER I BACKGROUND The demands for health care and health manpower are outstripping the ability of educational institutions to meet these demands with traditional educational approaches and methods (Keller, 1965). These demands, coupled with the changing roles of the health professions, and the varied learning styles of students, are creating a growing sense of the need for better educational methods. Medical education is being challenged as never before (Stewart, 1968). Educators are seeking to modify their _approaches to instruction in order to improve the effective- ness of teaching and learning systems. Jason states: Patterns and techniques of instruction which had been hallowed by decades of use are being modified and even jettisoned and the search is on for new instructional modalities which hold the promise of getting more done in less time (1968, p. 37). Thus, the need to educate and to provide con- tinuing education for the large numbers of people in the specialized disciplines required for the delivery of modern health services mandate the development and use of newer instructional techniques (Herskovitz and Skolnick, 1972, p. 85). Health professions educators and administrators should be aware of the capabilities of the computer and the potential of computer assisted instruction (CAI) when seeking new techniques for improving their educational programs. The computer is becoming an increasingly significant and available tool for instruction. Hammond states: There appears to be widespread agreement that com- puters have the capacity to facilitate individualized instruction and that their flexibility permits a variety of instructional strategies. Many believe that the computer has the potential to enhance the productivity of the individual teacher and improve the quality of the learning process (1972, p. 1005). Universities are beginning to develop courses with the computer as an integral part of their instruc- tional systems. "In the United States within a relatively short span of fifteen years, nearly all the universities and more than a third of the four-year colleges provide computing services for research and instruction (Molnar, 1972, p. 7)." In the health professions educational programs, progress toward improving instructional effectiveness through the use of the computer and computer assisted instruction is just beginning. In a recent survey of 561 * health sciences institutions (Brigham, 1973a), over a * Health sciences include the health professions and also dentistry, pharmacology, public health and veterinary medicine. third stated that they were using or planning to use computerized instruction in their curriculum. In most cases, however, this represented a small experimental teaching unit (developed by an enthusiastic faculty member) and used in a few courses. Of all the reported computerized teach- ing material developed in medicine, 44% was developed at a single institution and 74% of the total came from only three institutions (Brigham, 1973b, p. 186). The apparent lack of acceptance of CAI as an educational tool in health professions education, in spite of its potential, is usually attributed to several factors. The factors most often cited are the high investment cost of CAI instructional systems, insti- tutional resistance to change and the lack of available CAI course material. These factors, however, are only alluded to in the literature. The literature reveals a lack of empirically based evidence concerning the influence of these and other factors on the development and use of CAI in health professions education. Surely, an awareness of these factors would enable educators and administrators to plan more effectively for, and make educational decisions regarding, the use of CAI as an instructional medium (Anastasio, 1972, p. 1). Such decisions could include (1) the consideration of CAI; (2) the develOpment and implementation of a CAI system; or (3) the utilization of CAI materials and/or systems developed at other insti- tutions. To assess the need for such factors in develop- ing or utilizing CAI in health professions education, this researcher surveyed by questionnaire (Appendix C) the institutional members attending the national meeting of the Association of Schools of Allied Health Professions (ASAHP) in Houston, Texas on November 14, 1972, to deter- ‘ mine whether identification of factors influencing the development of CAI would be helpful to educators and administrators in allied health professions programs. Of the 74 official delegates (usually the dean or director of each school) representing the 96 institutions (ASAHP membership as of November, 1972), 74 (100%) responded in the affirmative to the questionnaire. The researcher therefore felt that this response further indicated there is a need for more research relating to the factors that influence the development and utilization of computers in health professions education. Goals of the Study The goals of this study are: (l) to identify the critical factors which facilitate or inhibit the development and utilization of CAI in health professions education as perceived by current, experienced users of CAI in medical education and (2) to develop a set of guidelines for health professions administrators and faculty to use in planning for the utilization of CAI as an instructional medium. It is suggested by the researcher that guide— lines for planning as well as a better understanding and insight into the crucial factors associated with effec- tive planning and utilization of CAI may provide educators with the confidence needed to consider CAI objectively as an instructional medium. Thus, the guidelines developed in the study should be helpful in facilitating planning and increasing effectiveness in the utilization of CAI in health professions education through better informed administrators and faculty. Such guidelines should also aid in reducing the negative effects of a poorly planned or improperly introduced innovation. Limitations of the Study The study will rely on the CAI-experienced health professions educational personnel (of which there are relatively few) for identification of crucial factors influencing the development of CAI. It will not include CAI users in elementary and secondary schools and the nonmedical areas of higher education. Second, the study will not provide an empirically tested method for decision making. Third, the study will not provide an evaluation of the effectiveness of CAI as an instructional medium, nor information on types of available hardware and software or the specific costs of installing CAI systems. Definition of Terms For the purposes of this study, certain terms common to the subject or methodology are defined as follows: Allied Health Personnel.--The term "allied health personnel" includes those personnel who support and work with physicians, dentists, and nurses in the areas of patient care, public health, health research, and environmental health. Such workers function at pro- fessional, technical, or supportive levels to complement and supplement the activities of other health profes- sionals (Allied Health Education Programs in Senior Colleges, 1971, Washington, D.C., U.S. Government Print- ing Office, 1973). Association of Schools of Allied Health Pro- fessions (ASAHP).--This Association, established in 1967, consists of approximately 120 health professions edu- cational institutions (circa January, 1974). In 1974 it was renamed the American Society for Allied Health Professionals (ASAHP). The prior name will be used throughout this report as the study was instituted and completed prior to the renaming of the organization. Computer Assisted Instruction (CAI).--Computer assisted instruction (CAI) in this study refers specifically to uses of the computer as a medium of instruction. It includes the tutorial, inquiry or dialogue, simulation, and problem-solving modes of instruction. Crucial Factors.--Crucia1 factors include attitudes, conditions or processes which are of varying levels of importance in influencing the development or utilization of CAI in either a facilitating or inhibiting manner . Development.--Development includes the process of considering, planning, designing, utilizing and/or evaluating CAI. Facilitating Factor.--This is a process or condition that positively influences CAI development. General Education Programs.--These are elemen- tary, secondary, or college level programs other than health professions educational programs. Guideline.--An action or function set forth as a guide to utilization of CAI based on the results of this study. Health Professions Educational Programs.--These are college or university based programs which educate physicians, dentists, nurses and allied health personnel. Inhibiting Factor.--This is a process, con- dition, or obstacle that negatively influences CAI development. Perceived Cruciality.--The degree of importance or criticality assigned to a crucial factor. Utilization.--The use of CAI materials that may have been developed, adapted or adopted from internal or external resources. Order of Presentation The literature relevant to the development of CAI and related research studies is reviewed in Chapter II. Included are studies of the development of CAI in general education and the factors influencing this development. The use and acceptance of CAI in health professions edu- cation are also reviewed. In Chapter III, the methodology of the study is described. The methodology involved three phases. Phase One consisted of group meetings at three medical education institutions with CAI-experienced per- sonnel to identify critical factors in the development and utilization of CAI. Phase Two consisted of a mail survey to the three medical institutions and the insti— tutional members of ASAHP to assess the perceived impor- tance of the critical factors identified in Phase One. Phase Three included analysis of data from Phase One and Two and the preparation and validation of guidelines for the utilization of CAI. Chapter IV presents the results and discussion of Phases One, Two and Three. In Chapter V, the study is summarized, the major conclusions are pre- sented and recommendations for further research provided. Guidelines for the utilization of CAI are found in Appendix A. CHAPTER II RELATED RESEARCH This chapter will review studies related to the following three areas: (1) Studies of factors facilitating the development of CAI in general education; (2) Studies of factors inhibiting the development of CAI in general education; (3) Studies of applications of CAI and of factors influencing the development of CAI in health professions education. These areas were chosen to identify research on the factors that have influenced the development of CAI and to provide insight for health professions educators considering CAI as an instructional medium. Also, in order to limit the review of research to current materials in a rapidly changing technology, major reliance is upon materials published since 1968. Materials published earlier were reviewed and are referenced only if of special signifi- cance o 10 11 Studies of Factors Facilitating the Development of CAI in GeneraI Education The literature emphasizes, generally without the benefit of empirical evidence, that teachers and adminis- trators are apprehensive toward CAI (Marolin, 1967; Cullinan, 1968; Testerman, 1973). Tuttle (1970) provides an expansive review of computer-based instruction. Three empirical studies by Christopher, 1969; Robardey, 1971; and Hess and Tenezakis, 1973, that examined the role of attitudes of teachers, school administrators and students as well as other factors that influence the acceptance of CAI as an instructional medium are discussed. Tuttle (1970) conducted an extensive descriptive study of the historical development of computer capabili- ties as an educational medium from 1958 to 1968. Among his conclusions are two that are seen by this researcher as potentially influencing the acceptance of CAI. They are: l. The teacher's role shifts "from purveyor of information and record-keeping to specialist in educational management, diagnostics, prescriptive procedure, etc. [p. 380]." 2. The student's role shifts from passive to active involvement in the educative process, and toward increasing control of teaching-learning activities [p. 381]. Although Tuttle made no prediction of any positive or negative influence, he recommended these areas he studied .further to identify the effects on roles and relationships <>f students in learning. Further, he recommended that 12 studies be made to identify the problems that are encountered when CAI is implemented as a means of pro- viding information to guide administrators in their decision making. Christopher (1969) found from his literature review three obstacles which commonly occur in the use of computers in instruction. They are: 1. the fledgling state of the art of computer assisted instruction; 2. the necessary financial commitment required by the medium and; 3. the resistant attitudes among professional educators toward the use of mechanically controlled instruction (1969, p. 2). He described most programs as being in developmental stages and attributed the lack of progress both to the inadequacy or lack of sufficient compatible and tested software and to the reluctance of educators to commit their resources to CAI systems which may soon be modified. But despite the decrease in the cost of utilizing com- puters, due to improved technology, he felt that incom- patability of hardware and software as well as competition among manufacturers were delaying the willingness for educators to make the investment required by CAI. Christopher also stated that resistant attitudes of educators is more likely due to the magnitude of changes that CAI may cause than to the computer itself; 13 and he referred to the fear, apprehension, and attitudes among educators which prohibit the "intelligent investi- gation" of the capabilities of CAI. As part of the same study, Christopher conducted an empirical investigation to determine if school admin- istrators' attitudes could be affected by "an acceptable computer assisted instruction experience." He found that (1) a structured experience with CAI did cause attitudes to become more favorable toward CAI; (2) the experience caused a decreased apprehension toward CAI among school administrators; and (3) administrators who were knowledgeable of computer applications in education possessed a more favorable attitude toward CAI. Another of the three studies examining factors influencing the development of CAI was conducted by Robardey (1971). He examined the relationships between attitude, knowledge, and other variables regarding CAI among 256 teachers and principals in one Michigan county. After an extensive survey directed at determining atti- tudes toward CAI, he suggested that "exposure to the computer and computerassisted instruction tends to foster a positive attitude toward this mode of instruction [p. 34]." On the basis of survey results, he concluded that there is a positive, statistically significant, relationship between knowledge and attitude in respect to CAI. 14 The third of the three studies included in this section was by Hess and Tenezakis (1973) who sought to examine the long-term effects of CAI on educational institutions and particularly on the role of the teacher and the attitudes of students toward CAI. This was accomplished by comparing attitudes of 189 seventh- to ninth-grade students toward CAI and other sources of information and instruction such as classroom lecture or reading. Hess and Tenezakis reported that in the eyes of both CAI and non—CAI students the computer had a more favorable image than the teacher and textbooks. It appeared that these favorable student attitudes were related to some predicted role changes of teachers and opportunities for more personal and creative instructional contact with students. In summary, there is some evidence to support the position that knowledge of, and a positive experience with CAI will cause administrators, students and teachers to have a more positive attitude toward CAI as an instruc- tional medium. The studies by Christopher and Robardey suggest that educational leaders within an institution who are contemplating the use of CAI should initially plan to acquaint administrators, faculty, and students about CAI through various activities such as internal or external educational workshops and provide experiences With CAI. Hess and Tenezakis' study further demonstrates 15 the need, as suggested by Tuttle, to recognize the implications of technological developments upon indi- viduals and educational institutions. Studies of Factors Inhibiting the Development of CAI in General Education Two empirical studies by Luskin (1970) and Anas- tasio (1972) sought to identify the factors that inhibit or negatively influence the development of CAI. As evidenced in the previous studies, attitudes are a significant factor to consider in planning for CAI. Awareness of obstacles to the introduction of an edu- cational innovation is likewise helpful to educational planners. Luskin (1970) sought to identify and to examine the obstacles to development of CAI particularly as they relate to junior colleges (Luskin included all instructional uses of computers in his definition of CAI). He conducted a series of 127 individual interviews from which he identified 22 obstacles to CAI which he then included in a survey instrument. The survey instru- ment was administered to 75 of the same personnel inter- viewed which included educators with expertise in CAI, junior college administrators, and representatives of hardware/software companies active in CAI. This survey was conducted for two reasons: (1) to classify the 22 factors (obstacles) obtained from the interviews as critical inhibitors, considerable inhibitors, or minor 16 inhibitors and (2) to determine when in the future these obstacles would be resolved. Of the 22 obstacles con- sidered crucial inhibitors to CAI development, seven emerged as critical. They were: (1) availability of individuals with appropriate component skills; (2) sufficient local funds; (3) sufficient funds for research and development; (4) attitude of faculty; (5) lack of incentives to stimulate preparation of educational software; (6) poor documentation of educational software; and (7) the existence of a communication gap between educators and representatives of industry. Ten obstacles were reported as considerable inhibitors: (1) high cost; (2) lack of definition of required skills; (3) lack of definition of appropriate personnel combinations; (4) inability to share developed software; (5) poor distribution mechanisms; (6) the traditional nature of education; (7) inade- quate copyright laws; (8) attitude of administrators; (9) general availability of audio-visual devices; and (10) general availability of appropriate terminal devices. Five obstacles were reported as minor: (1) ability to choose between instructional strate- gies; (2) attitude of the public; (3) lack of suf- ficiently powerful author languages; (4) ability to measure educational effectiveness; and (5) atti- tude of students [p. xiv]. Luskin concluded, "The shortage of individuals with appropriate component skills is the most critical obstacle appearing in the findings of the study [p. xiv]," and that the idea of CAI may eventually win acceptance in education but it may be as late as 1988 in general education (p. xv). A more recent study by Anastasio (1972) was undertaken to identify the obstacles to the widespread use of c outline Anastasi 17 omputers in the instructional process and to strategies for overcoming the difficulties. 0 defined the term CAI to include all aspects of computer use in an instructional context. The study methodol ogy utilized the Delphi technique with 30 par- ticipants from the areas of curriculum development, edu- cational computer duction. from the dimensio 1. emphasiz developi research, educational administration, law, science, and computer hardware and software pro- Anastasio classified the inhibiting factors Delphi questionnaires as having the following us: The lack of "good readily available" CAI materials was cited as the most critical inhibiting factor. The lack of demonstration capability of "high quality use" and economic feasibility of CAI. The failure to recognize that CAI requires an extensive reorganization of course materials and pedagogy in order to be utilized effec- tively [p. 31]. CAI requires a high capital investment even when good cost effectiveness can be achieved in the long run [p. 41]. The use of CAI will require a change in the established patterns of instruction and a restructuring of the traditional role of the teacher [p. 35]. The design of more appropriate hardware and software systems is moderately inhibiting in the development of CAI. In summary, the Luskin and Anastasio studies e the problems inherent in introducing and ng applications of CAI in general education. 18 They provide the most comprehensive, empirically derived lists of obstacles to the development of CAI found in the literature. As such, they are helpful in specifying the factors and expanding the knowledge of and about the critical and less critical factors. Therefore the studies are considered quite useful to educational planners as they consider CAI. Yet, there is no reasonable way for these findings to be generalized to health professions education without further research. In the next section, the literature on research on factors influencing the development of CAI in health professions education will be reviewed. Studies of Applications of CAI and of Factors Ianuencing the Development of_CAI 1n Health Professions Education In 1967, four publications directly relating CAI to health professions education appeared in the literature (Stolurow, 1967; Geertsma, 1967; Fonkalsrud, 1967; Stark- weather, 1967). Stolurow states: The health sciences and professions seemed an excel- lent place to start, not only because of the cost of instruction and the critical personnel shortages, but also because of the problems attendant upon the education and training of the various members of this community of specialists (1970, p. 3). In contrast, Skolnick states: This concept (CAI) has always been and still is full of promise, but the promise has been very slow to be fulfilled. The difficulties have 19 not primarily related to hardware. . . . The problem instead has been one of software, of the instructional materials and the computer program to control the new medium (McTernan, 1972, p. 43). Four references have recently appeared in the literature which provide a more optimistic perspective and further insight into the state of the art of CAI in the education of health professionals. In the first study, Griesen (1971) attributed the growth and positive acceptance of CAI in medical education at The Ohio State University to the fact that faculty were involved in developing concepts about CAI and its use in teaching and learning rather than just being involved in the details of computer coding. The involve- ment of students in education and medicine in the planning stages was another factor that contributed to the favorable response to CAI [p. 54]. Griesen also examined medical student preferences and performance in an independent study mode (in which CAI was a significant medium of instruction) versus tra- ditional group instruction. He reported: 1. Students who elect independent study and enroll in such a curriculum display more positive reactions to their school environment at the completion of their programs than do students who complete a group instruction curriculum [p. 154]. 2. Students who enroll in an independent study curriculum possess certain personality char- acteristics that differ from those choosing a group instruction curriculum [p. 153]. 20 Brigham, in a Guide to Computer Assisted Instruction in the Health Sciences (1973a), provides a listing of specific current applications of CA1 and a comprehensive bibliography of the CAI literature directly related to health sciences education. Brigham lists each of the 362 courses offered in 109 of the 561 schools responding to the survey. It should be noted that many of these institutions offer only one or two courses while some offer a large number. For example, The Ohio State University has 81 CAI courses in the College of Medicine; University of Kansas School of Medicine has 20; and Harvard Medical School has 38. But the number of institutions employing CAI is increasing rather rapidly. Of the 561 institutions reporting, 78 reported they were using CAI as an instructional medium; 116 anticipate using CAI; and 367 do not anticipate using CAI. Further- more, the Lister Hill Biomedical Communications Center CAI Experimental Network (Lister Hill Network) now offers CAI to health professions educational institutions without CAI capability through a national network (Brigham, 1973a). The rapidly increasing number of CAI users and the appearance of several articles regarding CAI in health Professions education indicates CAI is an increasingly idntegral part of many related health professions edu- cational programs (Ingersoll, 1974; Meyer & Beaton, 1974; Brigham & Kamp, 1974) . Furthermore, a perusal of the 21 literature indicates that questions regarding the adoption of CA1 are more of "when" and "how" rather than "if" (Hickey, 1968, p. 7). Another reference is provided by Bitzer and Bitzer (1973) who, in an experimental study in nursing education, utilized CAI to present simulated patients to student nurses and commonly encountered questions or problems. They found that students taught by CAI learned the same materials as well or better than the control group taught by conventional classroom methods and that they learned them in one-third to one-half the time. They also stressed that CAI must be accepted by both students and instructors if it is to be of practical use. This finding is suppor- tive of Robardey's observation in general education that acceptance of CAI is influenced by the way it is intro- duced and by teachers' and students' preconceived atti- tudes Ipp. 6-7]. Bitzer and Bitzer's attitudinal studies revealed that 54% of the nursing students initially had difficulty in concentrating on the lesson because of attention needed to Operate the terminal equipment. How- ever, shifts in attitude were found by students' accep— tance of CAI for learning difficult material as they became familiar with the terminals. Thus, Bitzer and Bitzer stated: By the end of their courses, over 50 percent of students typically rate PLATO (the CAI system) as the "best," "easiest," and "most preferred" 22 medium over lecture, textbook or movie; while from 0 to 15 percent rate PLATO as "worst" or "hardest" to learn from. Instructor evaluation of the material was almost uniformly favorable [p. 201] . Gaston's (1972) study related students' attitudes toward CAI and their achievement in dental school tests and on the Dental National Board Examinations (DNB). He found that students who were favorably disposed toward CAI, as measured on an attitude scale, (1) achieved higher grades in the courses when CAI was used as adjunct material and (2) received higher grades in the first two years of dental school. However, he reported that the favorably disposed students who scored higher during the last two years of dental school had a lower entering grade point average than did other students. Thus, CAI was perceived by the faculty as a helpful learning resource to these students. In summary, the literature on CAI in the health professions is mainly reports of surveys, specific activities or experiences with CAI or the viewPoints of educational leaders. Empirical studies are more recently being reported and initiated. Stolurow and others have described the appropriateness of recognizing and exploiting the potential of CAI to assist in meeting health and educational needs. CAI's feasibility for Jincreasing rates of learning is now being demonstrated. Yet, there is little in the literature to guide health 23 professions administrators or faculty in planning or decision making regarding the development and utilization of CAI as an instructional medium. However, an optimistic projection of CAI's future roles in university-based and continuing education programs for health professionals indicate an exciting opportunity for the future. Generalizations from the Review ofithe Literature The following generalizations have emerged from this review of the literature: 1. Technological developments such as CAI have implications for changes in roles and relation- ships of teachers and students as well as instructional design. 2. The acceptance of CAI by teachers and school administrators is strongly related to their knowledge of how CAI can be utilized in instruction. 3. Educational planners must recognize that there are cognitive and noncognitive variables which impinge on individuals' achievement in and attitude toward independent study modes such as CAI. 4. CAI is a feasible instructional medium to con- sider in health professions education in terms 24 of learning effectiveness, increasing numbers of students that can be served and the limited numbers of faculty and educational programs presently available. 5. There is a limited amount of empirical evidence defining the factors inhibiting the development of CAI in general education but no empirically based studies were found that sought to identify factors that facilitate the development of CAI. Implications of Literature Review for This Study This dissertation is directed at identifying critical factors which influence development of CA1 and preparation of guidelines for the utilization of CAI in health professions education. The review of literature was most helpful in defining the approach of this study. Studies by Christopher (1969) and Robardey (1971) revealed that there were positive relationships between the knowledge of and experience with CAI, and the atti-. tudes of school administrators and teachers. These studies were helpful in raising questions as to the effects of factors other than attitude toward CAI and its adoption as an instructional medium. Tuttle (1970) recognized the need to identify Etroblems in CAI planning as an aid to later planning and decision-making. Luskin (1970) and Anastasio 11972) 25 sought to identify inhibiting factors in general education but neither sought to identify those factors that are crucial in influencing CAI development in a positive or facilitating fashion. The lack of any such studies in health professions education led the researcher to seek to identify both facilitating and inhibiting factors that are crucial in the development of CAI in health professions education. Tuttle stressed the need to identify problems so that administrators might be more effective by having such information and this assisted the researcher in defining the need for guidelines for the utilization of CAI as a part of this study. Because the published literature on the factors affecting the development of CAI was too limited, par- ticularly in health professions education, a new method- ology was formulated to prepare guidelines for the utili- zation of CAI. CHAPTER III METHOD OF CONDUCTING THE STUDY A methodology was utilized in which critical factors influencing the development of CAI were identified by CAI-experienced personnel in three medical education (ME) programs. The cruciality of these factors was then determined by both CAI-experienced and nonexperienced health professions personnel. The results and analyses of the above data were then used in preparation of a set of guidelines to aid educators in the development and utilization of CAI in health professions educational programs. Overview of the Methodology Phase I The first phase of the study consisted of the identification and prioritization of the critical factors influencing the development of CAI as perceived by CAI- experienced administrators, faculty and technical staff in three medical education programs through the use of the nominal group process. 26 27 Phase II The second phase of the study consisted of a mail survey to determine the perceived cruciality of the factors obtained in the Phase I among allied health pro- fessions educators and a rating of these factors by the ME groups. The extent of application of CAI in allied health professions educational programs was also surveyed. Phase III The third phase of the study was directed at pre- paring a set of guidelines for the utilization of CAI. The guidelines were derived from data gathered in Phases I and II, the analyses of these data, a discussion of the crucial factors identified and knowledge from related research studies that were discussed in Chapter II. Phase I Phase I consisted of a series of nominal group process meetings (Delbecq, 1971, & Van de Ven, 1972) with the members of the CAI development groups of each of the three medical education institutions providing ongoing programs to the Lister Hill CAI Experimental Network. These institutions are the University of Illinois Medical Center, The Ohio State University and Massachusetts General Hospital in Boston. These three institutions have the longest record of experience among the health professions institutions in CAI 28 development. They developed the majority of CAI programs in use by the 55 health professions institutions that were using the Lister Hill Network in 1973 when this study began. Selection of the Phase I Par- ticipants for the Study The researcher, with the aid of Dr. Harold Wooster, Director of the Lister Hill CAI Experimental Network, contacted the directors of the CA1 program at each of the three medical institutions which provide CAI programs to the Network. The goals of the study were described and the institution's participation in the study was requested. The director of each program was asked to select no more than eight members of the CAI program development group to participate in the nominal group process meeting. (Appendix D lists the personnel from the medical education institutions who participated in the study.) The Nominal Group Process The nominal group process produces a prioritized listing of critical factors as ranked by the group members. Delbecq and Van de Ven have described the process as "problem" oriented. This study sought to identify fac- tors, i.e. important variables that influence CAI in a positive or negative sense, not "problems." However, 29 personal communication with Delbecq confirmed this inter- pretation of the process as within his meaning of "problem." This method was chosen as an exploratory research tool to obtain objective and subjective responses that would be more difficult to obtain, particularly in a prioritized fashion, from interviews or questionnaires. The Nominal Group Process as Used in This Study Participants were presented with a Task Statement Form and were asked to "List the subjective and objective factors you have experienced, perceived or anticipate as an administrator or faculty member in planning for the use of CAI in health professions education." (The form used is found in Appendix E.) The process was first conducted for identifying facilitating factors and after a coffee break a second session was conducted for identi- fying inhibiting factors at each of the three institutions. Following each session, the participants' listings were consolidated for discussion. Then each participant selected and ranked the ten problems which he or she per- ceived as most important. (The highest ranked factor of ten factors is given ten points; the second highest, nine points, etc.) The factors were then ranked by total number of points assigned. The results were discussed and then each participant reconsidered his or her rank- ings and completed a second ranking. The final ranks in 30 this process are determined by the total points received by the ranked factors. In the final ranking step, the participants also distribute 100 points among the ten ranked factors to rate his or her perception of each factor's importance. The distribution of 100 points among the ten factors is a modification of the process described by Delbecq and Van de Ven. They suggest having partici- pants assign 100 points to the highest ranked problem and values between zero and 100 to the other nine ranked problems. This appeared to the researcher as an oppor- tunity to "load" the importance that a factor might have even though the total rank points determine the final priority (a discussion of this issue is in the next section). After all sessions were held in the three medical education institutions, the lists of factors were com- pared and a combination of the five highest ranked facilitating factors and the five highest ranked inhibiting factors from each institution were combined into respective lists (duplications were removed). Limiting the lists to the five highest ranked critical facilitating factors and the five highest ranked inhibit- ing factors by each institution was done to limit the total number of variables to be rated on the mail survey 31 instrument in Phase II. A composite listing of all factors is presented in Appendix F. Comments on the Nominal Group Process It is noted by the researcher that the ranking in. the nominal group process is a step designed to provide a prioritized list and also to provide a method of deter- mining results so that the group's areas of agreement can be indicated in a short period of time. A card sorting system and the rank-point assignment technique allows the participants to rank and also rate the items in a short period of time. The researcher communicated with Dr. Andre L. Delbecq (March, 1973), the developer of the nominal group process, concerning the use of ranking as the final order of priority. In subsequent correspondence, Dr. Delbecq stated: There is a great deal of debate in management science concerning the value of rank ordering versus ratings and their reliability. It's my feeling that unless one is dealing with refined areas of technical judgment that rankings are more insightful. I am not enough of a decision scientist to defend this position, but Professor Edwin Bartee has developed a long mathematical defense of the value of rankings as opposed to ratings where the issues are still exploratory (Delbecq, 1974). In regard to the researcher's concerns about the weighting (rating) step, Delbecq stated further: Your (the researcher's) comment concerning the possibility of individuals "loading" on one or more factors with ratings is perfectly correct. 32 The technique (of total rank points only) that you used is quite appropriate and your comments repre- sent one of the weaknesses of that type of rating scale (Delbecq, 1974). Furthermore, the researcher (after conducting this process with numerous groups who were not a part of this study) has noted that participants carefully delib- erate over the first and second ranking steps. But when weighting points are assigned after the second ranking, they are done very quickly and with much less deliberation. This suggests further that the ranking step might be more reflective of the perceived importance of factors ranked. With Delbecq's comments and personal experience with the process, the researcher considers total rank points as the best evidence available for determining ranks for the final priority listing. Phase II In Phase II, a questionnaire developed by the researcher was mailed to the three medical education institutions (ME Groups) and to the deans and directors of the 108 institutions of the Association of Schools of Allied Health Professions (ASAHP Group). In the design of the questionnaire, the choice of whether to use a rating scale versus a ranking scale was made after con- sultation with Dr. Andrew Porter, Director of Office of Research Consultation, Michigan State University (April, 1973). The decision was based on the difficulty a person 33 encounters on ranking a large number of variables on a survey instrument (28 factors in this study) versus the relative ease for a respondent to rate each factor on a five-point scale.* A rank could then be determined based on the mean ratings of the respondents of each factor. The consultant further stated that this procedure would be more likely to obtain a more reliable reflection of the rater's true perception of the cruciality on each factor. In addition, the consultant suggested a rating procedure, as a by-product, would increase the probability that the survey instrument itself would even be completed. The questionnaire was designed to: (1) Obtain a cruciality rating of each factor by the CAI experienced ME groups and by the administrators and educators in the ASAHP group; (2) Obtain data on the extent of utilization of CAI in allied health professions educational programs. The questionnaire (Appendix G) consisted of two lists of randomly sequenced factors: one containing the factors facilitating development of CAI; the other con- taining the factors inhibiting development of CAI. A scale for rating perceived cruciality was provided. The *This is a contrast to the nominal group process where group members in using a card sort method rank items rather easily. Further, Delbecq reports that the dynamics of the group process also motivate the individual to carefully assign his rankings. 34 format of the rating scale on the questionnaire is shown in Figure 3-1. Respondents checked the perceived degree of cruciality for each factor. DEGREE OF CRUCIALITY Not a Factor Minor Considerable Critical I Cannot Rate Fig. 3-l.--Format of Cruciality Rating Scale for Factors. The ordinal values assigned were 4.0 for "Critical," 3.0 for "Considerable," 2.0 for "Minor," and 1.0 for "Not a Factor." "I Cannot Rate" was recorded as a "0" for frequency count only. The researcher utilized this category to provide a means for the rater to identify when he or she was inadequately informed on the item being rated and could choose not to rate the item. This had two purposes: (1) to identify the number of raters with this perceived lack of knowledge, and (2) to remove this rating when, during data analysis, the mean response would be calculated (the computer program adjusts the N accordingly) so that mean ratings would not be skewed by 35 a "0" rating. The mean ratings and frequency distribution of ratings for each factor are summarized in Tables B—3 and B-4 of Appendix B. Phase III In Phase III the results of Phases I and II in which critical factors were identified were analyzed. A rank order of cruciality was established by a listing of descending mean ratings for each list. In addition, although no hypotheses had been stated in the study on the degree of agreement in per- ceptions of CAI-experienced and nonexperienced health professions personnel, a Spearman rank order correlation coefficient was calculated using the derived ranks of the ME group and the ASAHP group to determine whether or not there was a tendency for the ME and ASAHP groups to respond in the same way to the critical facilitating and inhibiting factors. Utilizing the list of critical factors and analyses, the researcher grouped these factors into seven categories. This categorization and development of the discussion section of the study assisted the researcher in focusing the critical factors into a manageable number to prepare guidelines. A set of planning guidelines for the utilization of CAI in health professions education was then developed. The initial guidelines were presented to ten health 36 professions educators and administrators and after their suggestions as to semantic changes were incorporated and content validity confirmed, a later version was formally tested in November, 1973, with 15 members of ASAHP representing programs presently using or anticipating the use of CAI. They were evaluated against two criteria: 1. Is the language used in the guidelines under- standable and acceptable to health professions administrators and faculty members? 2. Are the guidelines perceived as useful by administrators and faculty members? The validation form is included in Appendix H. A final evaluation of the guidelines was made during a presentation in February, 1974, at the National Library of Medicine. Attending were 25 persons including the Director of the Library, the Director and staff of the Lister Hill CAI Experimental Network, representatives from the Association of American Medical Colleges and ASAHP, and users and potential users of CAI in health professions education. Summary The first phase of this study consisted of critical factor identification sessions at three medical education institutions experienced in CAI. The nominal group process was utilized in this phase. A survey instrument 37 was developed utilizing the results of Phase I and field tested with allied health and medical education faculty and administrators. The second phase consisted of a mail survey to determine the perceived cruciality of the factors identified in the first phase in the CAI-experienced group and the allied health professions educational programs and to determine the extent of application and experience in CAI in allied health programs. The instru- ment was mailed to the ME Group and to the deans and directors of the 108 institutions which were insti- tutional members of the ASAHP. The third phase included an analysis and dis- cussion of the data obtained in the previous phases and the preparation and validation of a set of guidelines for the development of CAI in health professions. CHAPTER IV RESULTS AND DISCUSSION The facilitating and inhibiting factors influenc- ing the development and utilization of CAI which were identified at the three medical education institutions and those factors rated for perceived cruciality are presented and discussed. The use, and anticipated use, of CAI in allied health education is also summarized. The chapter concludes with a comparison of the findings of this study with the findings of other related studies. Results of Phase I The Phase I nominal group process identified the most critical factors (those facilitating and those inhibiting) influencing the development and utilization of CAI in medical education at the three institutions providing CAI programs to the Lister Hill Network. Over 200 factors were generated by the three groups. A composite list of all factors listed in the nominal group meetings are included in Appendix F. The lists of the ten highest priority facilitating factors and ten 38 39 highest priority inhibiting factors from each group are presented in Tables 4-1 through 4-3. It is interesting to note that there are some high priority factors that are listed by all three ME institutions and several that are listed by only one ME institution. For example, "high costs of CAI" appears as a critical inhibiting factor among all three ME insti- tutions but "Funding for CAI based on task analysis" is mentioned by only one ME institution. This suggests to the researcher that there may be factors that can be generalized across institutions but that some may be institution-specific. This is an area of inquiry sug- gested for further research. Results of Phase II Thirteen questionnaires were received from the three medical education (ME) participants (the same number that participated in the nominal group meetings). One hundred and eight questionnaires were sent to the ASAHP member schools: 103 were returned (a response rate of 95%) of which 90 (83%) were usable and included in the ASAHP group. Thirteen ASAHP questionnaires were incomplete, consequently they were not included. Use of CAI in Allied Health Educatibn A total of four ASAHP institutions reported use of CAI for more than one year. These institutions used Tab 40 la 4-1 University of Illinois Medical Center, Critical Factors in the Development of CAI N = 3 Facilitating Factors Inhibiting Factors Rank Rank Rank Points‘ Factor Rank Points Factor 1 20 Top administrative l 26 Administrative structure support restricted promotion ' of CAI 2.5 19 Top level health pro- 2 23 No on-going faculty- fessions administrator CAI staff organi- is liaison between CAI zation exists staff and faculty 2.5 19 Operational computer 3 16 CAI programs do not facility available relate to existing curricula of users 4 17 Funding for ca: based 4 13 High costs with little on task analysis documented results 5 15 Joint faculty and CAI 5 ll Incompatability of CAI staff production and material with edu- evaluation of software cational goals 6 13 CAI is an integral part 6.5 10 Lack of understanding of the curriculum of CA1 by faculty and students 7.5 10 Easy student access to 6.5 10 Central computer terminals facility is not a part of total educational program 7.5 10 Direction of CAI defined 8 9 High operational costs by the curricula 9 6 Continuous production 9 7 Competition between CAI and evaluation of CA1 groups to promote own materials brand of programs 10 5 Establishment of written 10 7 Cost for development of priorities and objec— software in terms of tives time and resources * cf. Chapter II, final ranking points determine final rank per Published procedures. 41 Table 4-2 Massachusetts General Hospital with Harvard University Critical Factors in the Development of CAI N - 4 Facilitating Factors Inhibiting Factors Rank Rank Rank Points Factor Rank Points Factor 1 40 Adequate funds for per- 1 39 High initial investment sonnel, hardware and software 2 31 Validated documented 2 30 Lack of institutional CAI programs available framework 3.5 29 Competent faculty and 3 26 Lack of perceived need technical staff by faculty available 3.5 29 Availability of CAI 4 25 Inadequate evaluation network mechanism for cost benefit and cost analysis 5 1? Commitment to CAI as 5 15 Transmission problems an educational tool 6 16 Reliable CAI network 6 14 Lack of money to develop with guaranteed access content to users 7 10 Availability of support 7 13 Lack of validation of personnel CAI program 8 9 CAI terminals in insti- 8 10 Nontransferability of tutions are highly CAI programs accessible to users 9 8 Appropriate educational 9 8 Lack of faculty commit- orientation to faculty ment to schedule stu- and others dents for CAI 10 7 Trial use of CAI system 10 7 Lack of clearly defined before institutional commitment objectives for CAI programs 42 Table 4-3 The Ohio State University,Critical Factors in the Development of CAI N - 6 Facilitating Factors Inhibiting Factors Rank Rank Rank Points Factor Rank Points Factor 1 40 Top level administrative 1 48 High investment costs support 2.5 32 Adequate budget for 2 34 Time investment for implementation and planning and develop- develOpment ment period 2.5 32 Qualified director of 3 33 Lack of administrative CAI support 4 23 Stable and reliable 4 32 Faculty do not perceive computer facility proper use of CAI available 5 21 Independent study 5 31 Lack of adequate soft- curriculum in were progress 6 l9 Qualified technical 6 25 Cost benefits unknown staff available 7 13 Students' interest and 7 24 Unknown effectiveness of support of use of CAI CAI instruction 8 12 Abundance of course- 8 21 Inadequate computer ware compatability 9 11 Time saving for 9 18 Requires large support faculty staff 10 10 Authoring recognized as 10 15 Lack of recognition and a publishing endeavor reward system for faculty 43 CAI as part of their educational program. One institution used CAI only for experimental purposes. Prior to rating the factors, the ASAHP group was asked two questions regarding the anticipated use and appropriateness of CAI for health professions education. The questions and responses are in Table 4-4. Results of Phase III Preparation of Guidelines The guidelines presented in Appendix A were pre- pared after an analysis of the cruciality ratings by the ME and ASAHP groups of the facilitating and inhibiting factors included in the mail survey instrument. The mean ratings for each item were converted to a rank- ordered listing and the data for each group and other data from the questionnaire are summarized in Appendix B. In reviewing these data while preparing guidelines, a considerable variation was noted in the rankings of indi- vidual inhibiting factors of the ME group and of the ASAHP groups. For example, in Table B-2 in Appendix B, the medical education group lists "Cost benefits are unknown" as the least crucial of the 12 inhibiting factors rated and the ASAHP group rates this as the third most crucial factor. Another comparison reveals time medical education group's second most crucial factor 153 the "Lack of institutional framework for development 44 we we we we mmm won ommucmoumm noncommmm H o H v mm mm mo mosmoqmum mmmmmmmm mmmmmmwm mm Nmmmmmwm omnmmmwo scoumwmwosH owume moumd hamcouum Aomuzv numbed: HMGOflusufiumsH mmHw ust on» as Hammond Hmcoflusooom Moo» no name Homemade as me Hem means on HHH3 Someone HMdOflumosom encammomoum season moo» peso senescence so» on .H i LII mascowmmomoum enamom mo cowumooom ca Hmu mo mmocouswumoummm one on: oousmflofiusd so moouo mmdmd mo noncommom vlv UHQMB 45 of CAI" and the ASAHP group rates it as the least crucial inhibiting factor of those rated. These observed differences led to analyzing the items using the Spearman rank order correlation coefficient (Seigel, 1956, p. 204). The following correlations between the ME group and the ASAHP group were found: 0.8213 Facilitating Factors rS Inhibiting Factors r 0.0909 8 These two statistics indicate that both groups tend to rate the facilitating factors in the same way since the correlation is large and positive. Whereas, there is relatively little agreement on the inhibiting factors which have a correlation which is close to zero.* In the development of guidelines, it becomes important not only to address those factors which are prioritized differently between the groups but also to emphasize those factors which are ranked the same between the groups. The reason for this is not to lose sight of important or highly crucial factors for CAI develop- ment merely because they do not differ between the two groups. For example, in Table B-2 in Appendix B, both groups rated "High initial investment for people, time and hardware" as the most crucial inhibiting factor in the study. This underscores the important nature of this * 0.0909 is not statistically different from zero. 46 factor. Therefore, not to include it or comment on it in the discussion would be a serious error since any list of recommendations for the development of CAI guidelines must include this factor. Also, it is important to note that prioritizing within each group can lead to a misinterpretation of the data. It should be stressed that all the factors in the facilitating column and inhibiting column (Tables B-1 and B-2, Appendix B) are crucial by virtue of how these fac- tors were originally determined (see Chapter II). There- fore, the reader should interpret each factor as neces- sary in the guidelines and further research can indicate which subset of these factors, if any, can serve as a sufficient core for adopting CAI. A final point of discussion refers back to the high correlation of perceptions of facilitating factors and the low correlation on inhibiting factors. It could be suggested that since the inexperienced ASAHP group perceived the facilitating factors in the same way as the experienced ME groups, that guidelines for naive health professions educators need only address the inhibiting factors, where reported perceptions differ. Thus, why bother the administrator with something he already "knows"? It must be noted that the crucial factors were identified by the CAI-experienced ME groups and then the factors were presented in an instrument 47 to the inexperienced group for a review and rating. The naive raters thus had the opportunity to consider a factor presented to them; they were not asked to derive the factors and then rate them. Thus, one cannot say with certainty that the high correlation on facilitating factors means that the inexperienced group would perceive or even generate these same facilitating factors if they were not suggested to them. Indeed, the low correlation on the inhibiting factors suggests the inexperienced administrators may put the emphasis on the wrong factors and not deal with the more critical factors as specified by the experienced people. This point supports, in the researcher's view, the need for guidelines incorporating both facilitating and inhibiting factors. This was further supported during the guideline validation pro- cess. The inexperienced health professions educators who reviewed the prototype guidelines included such comments as: "Yes, very helpful"; (the guidelines) raise questions we should attend to and identify the necessary support and "Yes, particularly (useful) in communicating these CAI considerations to other faculty and administrators." The guidelines themselves are presented in Appendix A. 48 In the next section, a discussion of categorized factors is presented for the facilitating factors and inhibiting factors on which the guidelines are based. * Discussion of Critical Factors A discussion of the factors influencing CAI is included in this section and will be discussed in logical categories. There will be overlap on statements of interrelated factors where appropriate. The seven cate- gories are (l) Attitudes (includes recognition and reward); (2) Economics; (3) Learning and Instruction; (4) Organi- zation and Administration; (5) Personnel; (6) Software; (7) Technology. Attitudes Factors identified in this category include the need for faculty and student commitment to CAI and a system of recognition and reward for motivating faculty to undertake the necessary development effort in order to utilize CAI more effectively. Over 94% of the raters stated that faculty commitment to CAI was among the most crucial factors in the development of CAI. Such commit- ment is a critical element in (l) the objective consider- ation of CAI as an instructional medium, (3) the appro- priate use of the medium, and (3) the determining factors * The data from which these analyses are made are summarized in Appendix B. 49 in student acceptance of CAI as an effective learning medium. For, as described in the literature by Tuttle (1970), CAI will not only change the faculty member's way of teaching; it will affect his familiar way of relating to students, his relationship with peers, and his work setting. Therefore, plans to consider and diffuse an innovation such as CAI should give careful consideration to the factors of faculty commitment and how this might be accomplished. Further, the ME groups said during their dis- cussions that this aspect of attitude and commitment to diffusion of the innovation, CAI, if desired as an instructional medium, is one that can be considered and dealt with at the earliest stages. It does not require the capital investment, the most critical inhibitor reported, for hardware or technical staff. But it does require a planned approach to involve faculty, likely selected on the basis of openness, status, and leadership (as change agents or opinion leaders) in considering or planning for CAI. Considering the early state of the art of CAI in health profession education and the presently limited amount of software, the edu- cational preparation of administrators and faculty may be the most promising opportunity to bring about objec- tive consideration of CAI or other technologically based instructional media. 50 The aspects of recognition and reward were reported as important factors in maintaining a positive attitude and commitment toward CAI. Recognition within the institution as well as monetary and professional recognition were referred to in written comments on the survey instrument and verbal comments during the ME group meetings. Financial incentives were reported as desirable but faculty release time for development was also reported as important. But there is presently little institutional recognition of the knowledge and time commitment for CAI materials development. Recognition of CAI development efforts by a faculty member's peers and external professional groups was also found to be crucial in the ME institutions as was the need to con- sider the authoring of CAI materials as a publishing endeavor-~an historical source of evidence of academic achievement. In summary, the commitment of faculty and students to value and support CAI is considered a critical element in its develOpment. This study indicated that passive acceptance of CAI will not lead to effective utilization of CAI as an integral part of the instructional systems even with financial support. In addition, there must be systems for recognition and reward of development efforts. Financial support and reward systems are needed, but 51 internal and external professional recognition of faculty authoring and development of CAI will increase the likeli- hood of continued faculty commitment to CAI. Economics The primary concern of both experienced and potential users of CAI was the high initial investment costs. As referenced earlier, cost effectiveness was not as critical an issue as seen by the ME group but was still important because the investment costs are a sig- nificant barrier, particularly when coupled with other activities competing for funds. But, this study revealed that experienced CAI users in medical education did not rate the inadequacies of measures of cost effectiveness and unknown cost benefits as critical as did the ASAHP group. Verbal comments by the ME users during the nominal group process meetings indicated that increased motivation and effectiveness, and increased learning rates of stu- dents were factors that had to be considered in establish- ing cost effectiveness. This perspective of cost-effec- tiveness and learning-effectiveness is particularly relevant to health professions educational programs because as described in Chapter I, increasing demands for health manpower, an increasing number of students, and a limited number of faculty and educational programs are emphasizing the need for improved effectiveness in existing teaching and learning systems. When weighing 52 the relative advantages of CAI, the health professions administrator must recognize the economic as well as social-organizational implications. However, due to rapid changes in technology and computer-related costs, he or she should not disregard CAI as an instructional medium because of present costs or concerns of cost effectiveness. Again, the researcher found that "Cost benefits are unknown" was the least inhibiting factor of those rated by the ME groups. But systematic analyses of the cost and learning effectiveness of present instruc- tional methods, projections of the impact of CAI and other innovations on the educational program, and related development activities should still be a part of any effort to develop or utilize CAI on a widescale basis. Learning and Instruction The lack of integration of CAI into the health professions educational programs and the lack of under- standing of the alternative forms of CAI were reported (by over 65% of the raters) as crucial factors that are directly related to the faculty's understanding of and commitment to CAI as a medium of instruction. These and related factors indicate the need for faculty education and understanding of CAI as an instructional medium rather than merely a technological innovation and this would include an understanding of the need for an 53 instructional system to be redesigned and restructured if CAI is to be used effectively. There must also be a movement from teaching-oriented pedagogy to learning- oriented approaches. In this respect, the acceptance of individualized instruction as a learning mode was rated by over 80% of both groups as a critical or considerable factor in the development of CAI. There was also agreement among the groups that CAI would be most effective as an integral part of curricula (70% rated critical or considerable). How- ever, verbal and written comments also support the use of CAI for remedial learning and as an optional resource for students if integration into the curriculum was not yet feasible. The somewhat limited number and types of CAI courses available make this a feasible alternative. In summary, faculty knowledge of the instructional alternatives provided by CAI and an understanding of how to integrate CAI with other instructional modalities remain as crucial factors in the development of CAI. These factors and faculty attitudes toward CAI, which affect student acceptance of CAI, again demonstrate the need for educational planners to provide educational opportunities and demonstration as means for interested faculty to learn about and "try-out" CAI as an instruc- tional medium before undertaking a long-range development effort. 54 Organization and Administration In the perception of over 91% of the ME and ASAHP groups, the development and implementation of CAI on more than an experimental basis will require top-level adminis- trative support and commitment to CAI in order to provide the necessary support and organizational structure. Other crucial factors were the establishment of a central office to lead, coordinate, and facilitate the development of CAI materials and the establishment of an organizational mechanism whereby faculty and CAI technical staff can work together in the development of these materials. Discussion in the ME groups suggested that this need for faculty and CAI technical staff to work together is apparently more important as CAI is being planned and implemented. Once faculty and staff understand their responsibilities, there is a decreased need for joint efforts in developing CAI programs. But continuing joint efforts were suggested for long-range planning, review of new developments, and formative and summative evaluation. Also, joint efforts were seen as helpful in keeping CAI available primarily for instructional purposes rather than solely for research and/or admin- istrative purposes. In summary, top-level administrative support of and commitment to CAI is necessary for its development and implementation. Cost factors and developments in 55 CAI technology will influence administrative decision- making; but once there is a decision to develop and implement CAI, support must be provided for educational programs for faculty, for leadership, for instructional and technical staff, and for computer-system capabilities. Personnel Three personnel factors emerged as crucial for the development of CAI in the ME nominal group process meetings: (1) a highly qualified director of CAI must be available; (2) a top—level health professions educator should be available to serve as liaison between CAI staff and faculty; and (3) faculty knowledgeable in computers and health care and an experienced CAI technical staff must be available. There was agreement that the recruitment of a competent staff is an important element for effective diffusion of CAI. The ME groups reported most success in developing and utilizing CAI materials when the faculty did not have to become experts in the technical aspects of CAI as well as being content experts. And even in those schools where CAI is made available through a network, the availability of a technically competent 56 person(s) to assist faculty and students in using hard- ware or software was reported in discussions as highly desirable in overcoming the frustration that can occur with errors in input (or output), unanticipated dis- connections, or systems failures. Software The availability of a large number of appropriately documented and validated CAI programs had a derived rank of three as a facilitating factor by the ME groups, but the factors more representative of the current state of development were the inhibiting factors. These are: (1) There is a lack of adequate software; (2) Available CAI programs do not relate to the curricula of most health professions educational programs. The lack of adequate software had a derived rank of seven as an inhibiting factor by the ME group and second by the ASAHP group. It cannot be stated with any high degree of certainty, but this may be a dissemination problem as well as an actual lack of courses. The literature revealed that there are approximately 85 courses available through the Lister Hill Network. The discussions indicated that though these may be primarily for physician education, many of the programs are in the basic sciences, i.e. histology, gross 57 anatomy, physiological chemistry and physiology. At least part of these are potentially adaptable for health professions educational programs such as dietetics, nursing, occupational or physical therapy, or other programs. Moreover, the multitude of programs present a variety of instructional strategies available through CAI. This capability would be most helpful for demon- stration or experimental applications by potential users of CAI. The factors related to software reflect the adolescent age of CAI. The past difficulties attributed to weakness and/or complexity of programming languages are less important due to strengthening of programming capability and the use of CAI personnel to carry out the technical programming of a CAI course designed by faculty. However, the lack of programs per se will remain a problem until there is an expanded number of faculty or other content specialists involved in program design and development for the varied needs of the health professions educational programs. Technology The availability of a reliable computer, on- premises or by network, has a rank of first and second most critical facilitating factor by the ME and ASAHP groups respectively. The existence of a national CAI 58 network was perceived as slightly less crucial. The only inhibiting factor in this category was "Trans- mission problems cause frustration and loss of interest." Access to a CAI system is, of course, a requisite for the Operational and instructional use of CAI. The development or establishing a computer system, if not available through a network, or within an institution, can be a time-consuming and often discouraging activity. The developing technology is reducing the difficulties, but the establishment of any computer system is still a cause of concern for potential users. Experienced CAI users stressed the need for ”tolerance" and ”patience," and one law often referred to in this respect was "Things take longer than they do." The primary inhibiting factor of frustration due to system failure or transmission problems is a serious one that cannot be negated simply by alluding to the early state of the art. However, experienced users emphasized that faculty and students could accept occasional problems and delays if there were an adequate orientation to this aspect of CAI and user understanding of what kinds of problems occur and why. It is for this reason that failure of the CAI or support systems during demonstrations to potential users is a major concern to those trying to introduce CAI. 59 Summary Each phase of the study and associated findings were presented as they related to the identification of critical factors which facilitate or inhibit the develop- ment and utilization of CAI. The factors were discussed in terms of (l) atti- tudes, (2) economics, (3) learning and instruction, (4) organization and administration, (5) personnel, (6) software, and (7) technology. The guidelines that were developed from these factors, the discussion of these factors and past research studies, are presented in Appendix A. CHAPTER V SUMMARY, CONCLUSIONS AND RECOMMENDATIONS FOR FURTHER RESEARCH This chapter will summarize the purpose and methodology of the study, present the conclusions, and make recommendations for further research. Summary This study had two goals (1) to identify the critical factors which facilitate or inhibit the develop- ment of CAI in health professions educational programs and (2) to develop guidelines for health professions administrators and faculty to use in planning for the utilization of CAI. The health professions educational program populations included in the study were (1) the three medical education (ME) institutions providing CAI programs nationally through the Lister Hill Biomedical Communications Center CAI Experimental Network and (2) the 108 institutions in the Association of Schools of Allied Health Professions (ASAHP). The CAI-experienced education groups provided, through the nominal group process, a prioritized list 60 61 of the crucial factors influencing the development and implementation of CAI. Utilizing this list of crucial factors, a questionnaire was developed to (1) identify the current state of adoption of CAI in allied health educational programs and to (2) determine the perceptions of the cruciality of factors influencing adoption of CAI of the three CAI-experienced medical education programs and ASAHP institutions. The ASAHP group reported that they (71% of those responding) expect to be utilizing CAI as an integral part of their educational program within five years, and 94% agreed that CAI is an appro- priate instructional strategy to consider in the edu- cation of health professionals. Conclusions There are two sets of conclusions in this study. The first relates to the critical factors which facilitate or inhibit the development or utilization of CAI in health professions education-~the first goal of this study. These conclusions were useful in deriving the guidelines for the utilization of CAI in health pro- fessions education--the second goal of the study. The guidelines are presented in Appendix A. The second set of conclusions is drawn from the identification and examination of critical factors influencing the development of CAI. These conclusions 62 provide insight into the differing perceptions of crucial factors depending on (1) the level of CAI experience of the health professions educator and (2) the perceptions of those from areas other than health professions edu- cation. Conclusions Regarding Crucial Factors 1. THE HIGH FINANCIAL INVESTMENT REQUIRED FOR THE DEVELOPMENT OF CAI IS A PRIMARY INHIBITING FACTOR TO THOSE CONSIDERING THE USE OF CAI. These costs and the lack of evidence of documented cost- effectiveness are seen by some allied health professions educators as so prohibitive that they will not consider CAI. A RELIABLE COMPUTER SYSTEM MUST BE AVAILABLE OR ACCESSIBLE FOR THE CONSIDERATION OR DEVELOPMENT OF CAI. Further, there is a need for continued development of relevant CAI software that meet the needs of the multitude of health professions curricula. THERE MUST BE AN INSTITUTIONAL COMMITMENT TO THE DEVELOPMENT AND UTILIZATION OF CAI. In addition, an institutional framework or organizational structure that supports such utilization must be established. This includes recruitment and/or 63 development of a competent team of faculty and technical staff that can plan, coordinate and assist in evaluating any development or utili- zation efforts. These are critical organizational factors for any health professions educational programs contemplating the utilization of CAI. 4. THERE MUST BE EDUCATIONAL PROGRAMS FOR FACULTY, ADMINISTRATORS AND TECHNICAL PERSONNEL. Edu- cational planners must recognize the need for faculty and administrators' awareness, knowledge and interest in CAI, prior to introducing an innovation such as CAI. 5. FACULTY MUST UNDERSTAND HOW TO INTEGRATE CAI WITH OTHER INSTRUCTIONAL MODALITIES. Furthermore, . they should be aware of the various instructional strategies available through CAI. Faculty exper- ience with learner-oriented pedagogy was found to be a facilitating factor in the acceptance of CAI as a part of health professions curricula. Conclusions Regarding Differing Per- ceptions of’Factors Influencing _Efie Development of CAI 1. There is only partial overlap in both the highest priority facilitating and inhibiting factors cited by the three medical education institutions 64 with CAI experience. This leads the researcher to conclude that there are some institution- specific factors influencing the development of CAI. CAI-experienced and inexperienced health pro- fessions educators tend to agree on perceptions of crucial facilitating factors and fail to agree on several crucial inhibiting factors. The most critical inhibiting factors identified in this study are different, in part, than those reported by Anastasio and Luskin. The "lack of institutional framework for development of CAI" (rank of second most critical factor by the CAI- experienced education groups) and lack of reference to the need for "top-level administra- tive support" and commitment to CAI as an instruc- tional medium are two examples. The CAI exper- ienced medical educators view these as highly critical yet these factors are only alluded to indirectly by Luskin and not reported by those who participated in the Anastasio study. Thus, there are particular factors that are perceived differently in health professions educational institutions than those reported in studies of inhibiting factors in general education. 65 Recommendations for Further Research This study has identified a number of areas which are appropriate to consider for further research. In the view of this researcher, studies in the following five areas would expand present understanding of the processes involved in: the decisions to adopt or reject CAI; the planning, development and/or utilization of CAI; and the factors influencing the development of CAI. 1. The finding that there was high agreement among CAI-experienced users and CAI-nonexperienced health professions educators on facilitating factors and a low level of agreement on inhibiting factors suggests a fruitful area of research. Further study could test the hypothesis that CAI-exper- ienced and nonexperienced health professions personnel perceive critical factors in the same way. This study provides some evidence in this respect but the hypothesis warrants testing under controlled conditions. Similar hypotheses could be tested regarding present users of the Lister Hill Network to ascertain why some health pro- fessions educational institutions are finding high acceptance and utilization of CAI and other institutions low or lack of acceptance of the same CAI programs. 66 This study utilized the three medical education institutions who were among the most experienced in the use of CAI in health professions education as of 1973. The study developed a methodology which combined a modification of the nominal group process with principles of survey research and questionnaire design. This methodology was found to be useful in collecting data on critical factors influencing the development of CAI. This methodology could be used with other health pro- fessions educational institutions (or other types of educational systems) who are presently gaining experience in develoPing or utilizing CAI as a part of their instructional systems. Such an effort would expand the generalizability of the factors and/or reflect the changes that will occur in planning and decision making; software and hardware and other technological developments; in educational programs for faculty and adminis- trators; and other such developments. Further research should be conducted to determine if some factors or guidelines may be institution- specific. The lists of factors for the three CAI- experienced medical education institutions have some overlap and some unique factors. Questions can be raised as to if and why they are idiosyn- cratic to an institution. 67 The need for education of faculty and adminis- trators to prepare them for CAI development and utilization was reflected in the literature and identified as crucial in this study. Alternative instructional systems need to be defined, designed and evaluated for the varying levels and needs of administrators and faculty. Such instructional systems should be designed based on researched needs, learning preferences, and performance data rather than the present method of collecting a group of experts from various educational programs and areas of industry together to lecture to interested administrators or faculty. Computer programming has often been a focus of such work- shops in the past. Yet this study showed that most progress was attained when faculty were not involved in the tedious details of computer pro- gramming or coding of data. Research and participation in development of instructional systems is, in the researcher's opinion, a responsibility and opportunity for those involved in instructional development. A need exists to survey the instructional goals and problems of the medical and allied health professions educational programs to identify where and how CAI might be utilized as an 68 alternative instructional medium. Particular consideration should be given to the use of simulation and problem-solving experiences that might be alternatives to present clinically based experiences which are expensive in terms of time, availability, patient comfort, and financial costs. However, it is questionable whether such a survey can include those institutions with little or no knowledge of CAI. APPENDICES APPENDIX A GUIDELINES FOR THE UTILIZATION OF COMPUTER ASSISTED INSTRUCTION IN HEALTH PRO- FESSIONS EDUCATIONAL PROGRAMS J\ APPENDIX A GUIDELINES FOR THE UTILIZATION OF COMPUTER ASSISTED INSTRUCTION IN HEALTH PRO- FESSIONS EDUCATIONAL PROGRAMS This paper presents a set of guidelines for administrators in health professions educational programs who are considering the use of Computer Assisted Instruction (CAI). The guidelines were developed from a study that identified the factors that were crucial to the development of CAI in medical education at the University of Illinois Medical Center, Massachusetts General Hospital and The Ohio State University. These institutions are pioneers in the development and use of CAI and they have identified the factors that facilitate or inhibit the growth and development of CAI as an instructional medium. These factors have been developed into a set of guidelines for educational planning. The guidelines can be looked upon as actions necessary for the utilization of CAI. The items listed under each guideline are spe- cific factors or considerations that elaborate on the action(s) stated in the guideline. These guidelines should be helpful in assisting the educational administrator in posing the question: Is this institution ready to commit its resources to the development or utilization of CAI? GUIDELINES GUIDELINE I. THE HIGH INITIAL INVESTMENT COSTS OF CAI MUST BE WEIGHED AGAINST THE POTENTIAL GAINS IN LEARNING EFFECTIVENESS, RATE OF LEARNING, AND OVERALL COST EFFECTIVENESS OF THE TOTAL CURRICULUM. A. Studies have reported increased learning effectiveness and reductions of time for learning via CAI, when compared to traditional methods of instruction. B. The costs of development of health professions instructional materials can be reduced through shared network systems. C. Instructional programs (software) can be developed for mul- tiple purpose use with advance planning--thereby reducing overall development costs. D. When high initial investment costs are amortized over large numbers of students and/or long periods of time, the cost per unit of instruction compares favorably with other modes of instruction in health professions curricula. 69 70 The availability of the Lister Hill Center CAI Experimental Network provides an opportunity for many health professions educational programs to utilize CAI without significant investment. (HHDELINE II. RELIABLE COMPUTER FACILITIES AND SERVICES MUST BE A. MADE AVAILABLE. Access to reliable institutional facilities or access to computer facilities by telephone network (where several institutions share CAI materials) is a requisite. The crucial factor is the reliability of the system. Frequent breakdowns, delays or limited access are frustrating to users. There must be a recognition by faculty and students that CAI is in its technological adolescence and that there will be occasional system delays or failures. Recognition and acceptance of the state of the art will facilitate satis- faction in spite of occasional interruptions. The availability of computer networks is altering require- ments for hardware, software and staff. The Lister Hill Center CAI Experimental Network provides an established base of CAI materials and opportunities for further development to many health professions educational programs. GUIDELINE III. THE INSTITUTION MUST MAKE A COMMITMENT TO THE A. DEVELOPMENT AND UTILIZATION OF CAI. Top-level administrative support and commitment to CAI as an instructional medium are required for continued develop- ment, utilization and effective evaluation. Such support and commitment must be clearly communicated to other administrators and faculty. Support by the institution must include facilities, space, and staff as well as recognition and reward systems for faculty. Further, support must be provided for faculty to attend educational workshops or programs and to purchase appropriate reference materials. Access to resource per- sonnel is also an effective means of demonstrating insti- tutional commitment to CAI development. There must be an institutionalized system of professional reward and recognition of faculty involved in CAI develOp- ment. Release time for faculty members has proven to be an effective means of indicating the importance of CAI to the institution. 71 GUIDELINE IV. THE FACULTY MUST MAKE A COMMITMENT TO USE OF CAI. A. There must be at least part of the faculty who value and are committed to the use of CAI as an instructional medium. This may initially be one or two faculty innovators or Opinion leaders who can demonstrate to others the utility and potential for CAI in health professions education. Faculty members who are part of the on-going instructional program must be actively involved in the planning and development of CAI. CAI has been successfully developed and integrated into curricula where the faculty were given educational orien- tation to individualized learning and CAI. Educational workshops and other educational support must be provided and/or supported by the institution. CAI can be more readily integrated into curricula which already utilize individualized instructional modes. There are specific examples where computer-based simulations and problem-solving exercises have also proven excellent for group instruction. In this context, CAI can respond to the needs of an individual even though in a group setting. The availability of a CAI demonstration unit is a crucial element in developing awareness and interest in CAI. Faculty members and administrators need opportunities to test the capabilities of CAI and its relative advantage over other instructional media for various instructional problems. Student acceptance of CAI is dependent on acceptance and valuing by the faculty. CAI materials which have been identified as major components of a course are perceived as more valuable by students than any "optional course materials." GUIDELINE V. THE UTILIZATION OF CAI IS FACILITATED BY DEVELOPMENT OF COLLABORATIVE EFFORTS BETWEEN FACULTY AND CAI TECHNICAL STAFF. Traditionally, faculty work as individuals in the develop- ment of instructional materials. In developing CAI pro- grams, however, few faculty possess the technical knowledge and skills required for computerization. The production of CAI materials is best accomplished when technical staff participate in the design and development of programs--a collaborative relationship. The faculty prescribes the context, sets the objectives, and designs the instructional strategy; the technical staff works with the faculty member in these activities and then takes over the technical aspects of preparing and testing the CAI programs. 72 Rational growth and objective evaluation are facilitated by (l) a central office or committee composed of faculty knowledgeable of computers in education, and (2) a technical staff knowledgeable in CAI to guide and coordinate develop- ment. Educational institutions developing CAI should consider utilizing internal resources such as faculty or staff from the areas of educational psychology, evaluation, instruc- tional development and computer science. Long-term team development relationships are necessary in addition to the occasional support and guidance provided by external con- sultants. GUIDELINE VI. CAI MUST BE MADE AN INTEGRAL PART OF THE HEALTH A. PROFESSIONS CURRICULUM. CAI is more than the use of computer-based materials to augment conventional instruction. CAI is best utilized when integrated into the total curriculum. This will require an analysis of the alternative modes of instruction for established objectives and if CAI is appropriate, it is most effective if integrated with other instructional activities. To assure proper use of CAI, the faculty must recognize the alternative modes of instruction provided by CAI. These are: tutorial, drill and practice, problem solving and simulation. Utilization of CAI is best when designed to meet the instructional objectives for a given course or curriculum. However, for demonstration purposes and experimental use, CAI materials developed for other courses may be utilized. GUIDELINE VII. EDUCATIONAL WORKSHOPS, PROGRAMS AND PROCESSES MUST BE PROVIDED TO PREPARE FACULTY, STUDENTS AND STAFF FOR CHANGE DUE TO THE UTILIZATION OF CAI. Educational planners must recognize that the develOpment of CAI will affect roles, relationships and settings of teachers and students. When various modes of individualized instruction and inde- pendent learning are provided, the primary contact between teachers and students may be shifted to an individual or small group basis to resolve problems or discuss materials rather than in a lecture environment oriented toward pre- sentation of content. The implications of such shifts in roles and relationships should be well considered in light of the knowledge of the roles of attitudes and the histori- cal resistance to change. 73 The change in roles, relationships and settings has impli- cations for organizational structure as well as physical design of teaching and learning facilities to accommodate such changes. APPENDIX B SUMMARY DATA REGARDING CRUCIALITY 0F FACTORS INCLUDED IN THE MAIL SURVEY INSTRUMENT APPENDIX 8 SUMMARY DATA REGARDING CRUCIALITY OF FACTORS INCLUDED IN THE MAIL SURVEY INSTRUMENT Tables B-l and B-2 provide the mean ratings and ranks of the ME and ASAHP groups for the sixteen facilitating factors (Table B-l) and the twelve inhibiting factors (Table B-2) included in the mail survey instrument. A Spearman rank order correlation coefficient was determined from the ranks on each table. These correlations were: Facilitating Factors r 0.82l3 5 0.0909 Inhibiting Factors rS Tables B-3 and B-4 present the summary data of the ME and ASAHP groups from the mail survey instrument. These data include: (1) the mean ratings, (2) the standard deviations and (3) frequency distribution of the cruciality ratings on an item-by-item basis. In addition, a statistical item-by-item comparison of the mean ratings by each group was performed utilizing the Kruskal Wallis method (Kerlinger, l973, pp. 287-289). It was determined that there was no statistical difference between the mean ratings on 24 of the 28 factors included in the survey instrument. These differences are noted on tables B-3 and B-4. These tables are included as a finding of the study for the benefit of the reader. In addition, a comparison was made between the ratings of the four ASAHP institutions reporting more than one year of experience with CAI and those with no experience. There was no statistically significant difference between the mean ratings of the four members of the ASAHP group and the other ASAHP members so these data are included in the ASAHP group in all analyses. 74 Factors on which there were statistically significant differences between the cruciality mean ratings of the ME groups and the ASAHP group. FACILITATING FACTORS ME Group Factor Mean Rating Faculty Commitment to CAI 3.3l Individualized learning is an acceptable learning mode 2.85 Faculty perceive CAI as means of saving time 2.33 INHIBITING FACTOR Lack of institutional framework for development of CA1 3.31 *Significant difference at .05 level ASAHP Group Mean Rating Kruskal-Wallis Score 3.63 3.23 2.89 2.67 3.963* 4.481* 5.238* 4.289* 76 TABLE B-I CRUCIAL FACILITATING FACTORS RATED IN THE STUDY ME GROUP ASAHP GROUP FACILITATING FACTORS RANK CRUCIALITY RANK CRUCIALITY MEAN MEAN RATING* RATING Reliable Computer Facility Available l 3.92 2 3.67 Adequate Funds Available 2 3.85 l 3.79 Availability of large number of appropriate CAI programs 3 3.62 6 3.45 Top level administrative support 4 3.54 5 3.54 Establishment of central office to lead, coordinate and develop CAI materials 5 3.46 8 3.24 Faculty Conmitment to CAI 6 3.31 3 3.63 CAI is an integral part of curriculum 7 3.25 13 2.92 Faculty and CAI staff work together in planning and development‘of materials 8 3.23 4 3.57 Highly qualified director of CA1 9 3.08 7 3.36 available Funding for CAI based on task analysis 10.5 2.92 10 3.14 Students committed to and support CAI 10.5 2.92 12 2.94 Individualized learning is an accepted learning mode 13 2.85 9 3.23 Competent faculty and technical staff available 13 2.85 11 3.10 Existence of a national CAI network in health professions education 13 2.85 16 2.82 Top level health professions educator is liaison between CAI, staff and faculty 15 2.77 15 2.85 Faculty perceive CAI as means of saving time ' 16 2.33 14 2.89 *Cruciality Rating Scale Values: Critical 4 Not a factor 1 Considerable 3 I Cannot Rate 0 Minor 2 77 TABLE B-Z CRUCIAL INHIBITING FACTORS RATED IN THE STUDY ME GROUP ASAHP GROUP INHIBITING FACTORS RANK CRUCIALITY RANK CRUCIALITY MEAN MEAN RATING RATING High initial investment for people, time and hardware 1 3.54 l 3.63 Lack of institutional framework for development of CAI 2 3.31 12 2.67 Faculty do not recognize how to utilize CAI as an integral part of curriculum 3 3.23 4 3.02 Lack of perceived need for CAI by faculty 4.5 3.15 6 2.92 No on-going faculty and staff organization exists 4.5 3.15 9 2.82 There is a lack of top level administrative support 6.5 3.08 7.5 2.85 Lack of adequate software 6.5 3.08 2 3.12 Transmission problems cause frustration and loss of interest 8 3.00 11 2.72 Available CAI program do not relate to curricula of multitude of health professions education programs 9.5 2.92 7.5 2.85 Inadequate evaluation mechanisms for cost benefit and cost effectiveness analyses 9.5 2.92 5 2.99 Faculty do not recognize alternative fbrms of CAI (tutorial, problem solving, simulation, etc.) 11 2.83 10 2.78 Cost benefits are unknown 12 2.77 3 3.05 \. 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Fm.m N mme.o mm om F o o Fm. mo.m N m o o o Nm. em.m F e m N F o e m N F o meoom mFFFaz :onaneumFo coFuaF>mo cam: :oFbanFeumFa eoFuaF>mo cam: mematx Nocoaamee ueuecmum NuFFmFuaeu Nocwscoea uemecmum quFaFuzgu +eouumm Quote azm mmOFuNF4muthF wanmmco no HuaOHumNHcmwuov .muouomm o>uuoohbo mcoHuoao Ho mwaHHoom Hmaomuomv .muouomw o>wuuonpsm .coaunusoo maOHmmououn nuance ca Haouuon .uoudowuueNo o>mc so» muouumm o>auoofibo van o>wuoohosm ocu mafia Emom HZMZMHIndependent study versus group instruction in medical education: A study of non-cognitive factors relating to curricular preferences and academic achievement. Unpublished doctoral disser- tation, The Ohio State University, 1971. Hammond, A. L. Computer-assisted instruction: Many efforts, mixed results. Science, June 2, 1972, 176. Herskovitz, A., & Skolnick, M. Instructional technology. In Educating personnel for the allied health pro- fessiOns, E. J. METernan alR..O. Hawkins,T3r. St. Louis: C. V. Mosby Co., 1972. Hess, R. D., & Tenezakis, M. D. The computer as a socializing agent: Some socioaffective outcomes of CAI. AV Communication Review, Fall, 1973, 21 (3). Hickey, A. A survey of the literature. (3rd ed.) Newburysport, Mass.: Entelek, Inc., October, 1968. Ingersoll, R. W. The computer in the health services center. Journal of Medical Education, March, 1974, 42 (3), 298-299. Jason, H. Computers in undergraduate medical education. Proceedings of the conference on the use Of com- puters in medical education. University Of Oklahoma Medical Center, Oklahoma City, Okla. April 3, 4, 5, 1968. Keller, M. D. In Proceedings of the first conference on computer applicatiOns in nutrition and £003 ser- vice management. Edited by JohngP. Casbergue, The OhioTSEate University, July, 1965. 106 Kerlinger, F. N. Foundations of behavioral research. New York: Holt, Rinehart and WinsEOn, 1973. Luskin, B. J. An identification and examination of obstacles to the development of computer assisted instruction. Unpublished doctoral dissertation, University of California, 1970. Marolin, J. B., & Misch, M. R. (Eds.) Education in the 70's. Final report of Educational policy project, George Washington University, U.S. Department of Health, Education, and Welfare, Washington, D.C., Autumn, 1967. Meyer, J. H. F., & Beaton, G. R. An evaluation of com- puter-assisted teaching in physiology. Journal of Medical Education, March, 1974, 42_(3), 295-297. Molnar, A. R. Computer innovations in education. Washing- ton, D.C.: National Science Foundation, January, 1972. (Mimeographed.) Robardey, C. P. A study of selected Michigan elementary and secondary teachers' and principals' attitude toward computer assisted instruction. Unpublished doctoral dissertation, Michigan State University, 1971. Seigel, 8. Non parametric statistics for the behavioral sciences. New York: McGraw Hill Book Co., 1956. Skolnick, M., & Jolly, H. P. Electronic data processing. In E. J. McTernan & R. O. Hawkins (Eds.), Educating personnel for the allied health professions & services. St. Louis: C. V. Mosby Co., 1972. Starkweather, J. A., Kamp, M., & Monto, A. Psychiatric interview simulation by computer. Methods of Information in Medicine, January, 1967, E, I523. Stewart, W. H. Statement of the Surgeon General. Pro- ceedings of the conference on the use Of computers in medical educatiOn in OklEHOma. April, l968: Stolurow, L. M., Peterson, T. I., & Cunningham, A. C. Computer assisted instruction in the healthpro- fessions. Newburyport, Mass.: ENTELEK Inc., Stolurow, L. M. Computer-assisted instruction (CAI), Technical report No. 2. Cambridge, Mass.: Harvard Computing Center, 1967. 107 Testerman, J. D., & Jackson, J. A comprehensive annotated bibliography on computer-assisted instruction. Computer Reviews, October, Novem- ber, 1973, 483-553. Tuttle, J. G. The historical development of computer capabilities which permitted the use of the computer as an educational medium in the United States from 1958 to 1968, with implications of trends. Unpublished doctoral dissertation, New York University, 1970. Van de Ven, A. H., & Delbecq, A. The nominal group as a research instrument for exploratory health studies. American Journal of Public Health, March, 1972. 3 03082 7129 WWINJIMMWlllNilflWflfiifllflllNW