Innovating Professional Development for Future Health Care Practitioners

• 06/01/01

The United States health care system, at the beginning of a new century, is in a state of transition. What used to be a primarily hospital-based approach to health care patterned after the medical model is now being rapidly transformed into an outpatient approach more closely aligned with the health or preventive medicine model. The medical model, which treats diseases once they are diagnosed, will not be the best way to educate health care practitioners in the coming years, when health care will be focused more on maintaining health and preventing diseases. These changes in the way health care is delivered to the population have a tremendous impact on the professional development of soon-to-be health care practitioners. The education of future health care practitioners must address these fundamental changes in the delivery of health care if they are to meet the needs of the population.

The education of dietitians in this country has paralleled the education of other professionals in the health care arena. The usual minimum qualifications required for an individual to become a registered dietitian are a four-year degree, plus a period of supervised practice. Traditionally the supervised practice component, frequently referred to as an internship, is located in hospitals and other medical institutions. In most internships, less time is devoted to community-based practice opportunities than the time spent in acute care hospitals. Since the health care model of the future is predicted to be one based on prevention and health promotion, dietetic internships today need to provide more, not fewer, community and public health practice opportunities for students.

Another concern related to the education of future health care practitioners is that of meeting the demands for practitioners in the more rural areas of the country. This dilemma is seen across the spectrum of medical education, from physicians to nurses, dietitians, and other professions. Training programs tend to be found in larger cities, where the hospitals and other acute care medical facilities are located. It is often difficult for people who live in more remote areas of the country to move to a metropolitan area to participate in an internship. Consequently, there are future practitioners living in rural areas who could fill the need for health care professionals. The growth of the Internet and the rapid expansion of distance education provide ideal opportunities for training health care professionals.

In 1995, the Department of Nutrition and Dietetics at the University of Delaware (UD) developed its own Dietetic Internship program. Currently, the internship is accredited by the Commission on Approval for Dietetic Education of the American Dietetic Association, and is in its sixth year of operation. The internship is cosponsored by the Delaware Division of Public Health, and serves as a professional development ladder for state public health employees seeking to become registered dietitians (R.D.). The internship, as originally approved, provided practice opportunities throughout the state of Delaware.

The program has recently been granted approval to expand the internship to include a national distance education option, whereby prospective applicants will remain in their home locations while completing the internship’s requirements. The only time that the distance students will come to the University of Delaware is to take part in a two-week orientation program at the beginning of the internship. Administered completely online and using the latest in computer technology, the distance education internship includes video-streamed lectures, video conferencing, chat rooms, and online submissions of written assignments. Distance interns will be responsible for locating their own facilities and preceptors, but will follow the educational curriculum as provided by UD’s Department of Nutrition and Dietetics.

Because the Internet knows no boundaries and affords innovative instructional designs, it is an ideal solution to the perplexing problems involved in educating future practitioners situated in underserved areas of the country. The Internet also delivers high-quality preventative medicine models of professional development.

In a new era of communication where “the most popular method of providing information and distance learning is Web-based teaching” (Porter 1997), we must take steps to ensure the accessibility and effectiveness of online educational resources. For more than a year, the Dietetic Internship has explored the teaching and learning potentials of an Internet-delivered professional development curriculum. Like most educators, we’ve been beckoned by the wealth of online learning tools made widely accessible and, in many cases, free of cost. We’ve been pleased to note that the first chapter of integrating technology into the internship curriculum has been largely successful.

Part In-Class, Part Online Instructional Environment Really Works

Since its beginning, UD’s Dietetic Internship has utilized a variety of educational technologies to both manage and deliver instructional events. Interactive television and streaming video, for example, are used to broadcast weekly seminar classes. Discussion forums, chat rooms, and e-mail have also served the program well, not only for the distribution of resources and assignments, but also for fostering communication between interns and faculty outside the regular class meetings.

Uniting these tools to create teaching and learning experiences demonstrates the level of content richness that can be achieved with sufficient planning. For instance, we’ve paired the immediacy of video streamed presentations with follow-up chat room discussions. Orchestrating out-of-class real-time learning events indeed helps to close the anonymity gap between participants, bringing faculty and interns closer together though synchronous, meaningful dialogues. Online discussion forums, with their ability to thread, or visually map, the evolution of messages, construct greater meaning for long-term, asynchronous idea sharing. The interns, in most cases, have a positive learning experience with the discussion forums, chiefly because we partner many of the discussion topics with online assignments. With each assignment, an intern has the opportunity to pore over related discussions made thick by daily message postings. E-mail is an alternative, but encouraged method of communication.

The hybrid in-class/online internship model has been successful so far. By analyzing measurable learning outcomes, we have learned that supplementing classroom-based instruction with online communication and learning tools offers local interns extended learning. When our proposal to extend the internship to a national audience was approved, however, our current arsenal of educational technology commanded an overhaul. The piecemeal composite of online teaching and learning instruments was not going to support the needs of a start-to-finish distance education course design. We needed help. Naturally, we teamed up with the university’s educational technology specialists: the Faculty Technology Development Staff. Through our joint efforts we would unlock the potential of our current use of technology to maximize learning outcomes within the internship’s full distance education option. We would also discover innovative uses of multimedia to build upon an existing paper-based core component of the internship: problem-based learning (PBL) case studies.

A Word on PBL Case Studies within the Internship

Concisely, problem-based learning is a method of instruction that helps students hone their professional development skills so as to become more successful in their post-college careers. Barbara Duch, associate director of the Math and Science Educational Resource Center at the University of Delaware, describes PBL as a means of “challenging students to ‘learn to learn’ so that they can achieve the highest potential in their chosen professions” (Duch 1995). In working to solve real-world problems, students are provided public health case studies, each focusing on a different dimension of professional responsibility.

Our vision was to reproduce these case studies in an online environment, but not merely as text-based media. We needed to give them an interactive edge that would engage distance education participants who do not benefit from the face-to-face problem-solving dynamics important to PBL. These case studies are the centerpiece learning affairs that equip interns with the skill sets essential to their success in community-based health promotion practice.

Generating a total online professional development experience meant streamlining our existing collection of educational technologies while integrating the capstone PBL case studies.

Transforming Our Current Program: A Journey into Innovation

Providing the set of learning tools to add value beyond the traditional current learning modes of the internship, the Department of Nutrition and Dietetics called upon UD’s Faculty Technology Development Staff (www.udel.edu/present), a faculty technology development group within IT User Services, and the staff of PRESENT (Practical Resources for Educators Seeking Effective New Technologies), a teaching and learning center within IT User Services. Their educational technology experience has influenced scores of teaching with technology initiatives, with a proven track record of improving learning outcomes. Through a few consultations, we shared our case study vision and they offered an innovative e-learning design strategy.

Delivering a PBL case study across the Internet has been done before at a number of higher education institutions. The Instructional Technology Group helped us recognize that engaging learners with sophisticated instruction, like PBL, required an equally compelling e-learning experience. To do this we were advised to become familiar with two progressive educational technologies: WebCT and Internet video.

About one year ago, the University implemented a course management system called WebCT (www.webct.com). CT stands for course tools: a set of online learning resources integrated into one system. WebCT was the perfect choice for the online delivery platform because it combines over 40 teaching and learning tools that seamlessly integrate with our instructional design. Additionally, WebCT offers complete administrative control over student enrollment, while allowing us to make quick and easy changes to any aspect of the course.

We attended the required training for WebCT and worked closely with the Faculty Technology Development Staff to carefully choose the appropriate tools for each component of the distance education version of the internship. As with most selection processes, we started with a broad list of WebCT tools and functions and then scaled back some to exact student learning outcomes.

With guidance from the Development Staff, we decided that WebCT’s content module — a dynamic table of contents — would be the delivery vehicle for day-by-day topics. We developed a template using Netscape Composer (a Web page authoring application, available free at www.netscape.com) and inserted the appropriate agendas and resources into their respective templates. Then we uploaded the files to WebCT and deployed them through the content module so students can efficiently access daily topics. In addition, we used WebCT’s internal hyperlinks to add a menu bar that lets students jump to a discussion forum, chat room, or e-mail to share ideas about what they encountered in the content module. We feel that at the core of professional development exists human interaction. In an e-learning environment, giving every student a point of access to communication tools every step of the way is essential.

Throughout the content module, we provide strategic textual prompts for interns to access any of the three selected communication tools: discussion forums, chat rooms, or e-mail. Research suggests that students are predisposed not to use online communication tools as a primary means of exchanging complex ideas. There are many reasons for this; the most obvious is the amount of time and labor it takes to type versus to speak a series of thoughts. Students are also used to immediate feedback when an idea is shared with a group. When using a discussion forum or e-mail, the turnaround time is not instantaneous. Therefore, student commitment to these tools often flares early with enthusiasm, but soon wanes with frustration. Reid (1994) suggests that “the physical and psychological distance between students and instructors” in a distance education classroom “means that a new communication regime must be created if they are to communicate effectively with one another.” One solution to this problem is to design communication “events” over the course of online instruction.

There are strategic prompts or cues within the content module materials, directing students to share their understanding of a specific discussion topic and respond to at least two postings on that topic. Each communication “event” is given a direction and purpose, instead of interns merely posting something at random or only when there’s confusion. In effect, this technique sustains the interns’ commitments to the discussion tool over the entire course and actively engages constructive peer-to-peer feedback. Kemery (2000) supports highly structured asynchronous communication events such as this to activate what he calls “the behavioral skills necessary for effective online contribution.”

Although we’ve had marked success in the past, the Development Staff recommended that an accountability framework exist for the communication tools. Ensuring that everyone participates in a meaningful way, an informal assessment was developed based on how the interns will communicate online. Using WebCT’s discussion archiving feature in conjunction with the student management system allowed us to design a holistic scoring rubric that communicates how well each student is participating in the discussion forums. The rating scale range is Outstanding, Very Good, Average, Below Average and Poor. Next to each performance level is a standardized description of what it means to be Outstanding or Below Average, etc.

Because the interns begin their online professional development at locations all across the nation, we recognized that building student-to-student and student-to-teacher relationships online might help to establish more enthusiasm when the time comes for them to meet face-to-face. In order to promote a synchronous communication “interplay between teachers and learners, in environments that have the special characteristic of being separate from one another” (Moore and Kearsley 1996), we initiated a chat room with scheduled meeting times for students based on their time zones. For example, the east coast time to chat might be on a Wednesday evening at 8:00 PM. We will record, archive, and analyze these real-time conversations and use them to generate more online discussion topics and get a general picture of our audience.

Guest speakers have always been a symbol of the working professional. We plan to schedule guest speakers within the chat rooms. Students will read an article or publication produced by the guest speaker and then will be able to participate in a Q & A chat session at an agreed upon time. We can use the chat archive to generate even more questions within WebCT’s discussion forums or e-mail.

Sending e-mail between course members was a concern in the past because of multiple Internet service providers among students. All too often addresses would change without notice or important messages would be lost among the normal pile of personal and spam mail in the instructors’ or students’ inboxes. Integrating WebCT’s e-mail tool established a dedicated messaging system available only to those enrolled in the course. We have made it the only acceptable way to send course-related e-mail between students and instructors. Consequently, the only e-mails in a WebCT inbox are messages directly related to the internship.

Preparing interns for the Registered Dietitian (RD) exam was another challenge. Heretofore, practice exams were administered in a classroom setting during the portion of the internship at the university. To extend practice opportunities beyond the physical boundaries of the classroom and to the distance education group, we’ve reproduced the same practice exams using WebCT’s self-test generator. This is an important improvement over the old method for two reasons. One, it gives learners access to the exam 24 hours a day, encouraging greater contact with this critical assessment. Two, the WebCT self-test has instructor feedback functions that are not possible in an in-class environment. As interns answer each question online, we’ve associated precisely targeted feedback depending on which answer was chosen, right or wrong. This type of guidance could only occur ex post facto in a traditional classroom, usually after the exam was corrected. WebCT automatically scores the practice test and provides exact advice to the students with every item. This type of targeted instructor commentary based on the learner’s decisions is a large component of the interactive multimedia case studies delivered though WebCT.

The Department of Nutrition and Dietetics has historically relied on problem-based learning (PBL) case studies to drive professional development in the area of public health. As a particularly “experience based” industry, the responsibility of a registered dietitian is to bridge theoretical understandings to practical applications in a public health environment. It was the job of the Faculty Technology Development Staff at UD to figure out a way to maximize the authentic learning experiences of PBL in an online setting. In other words, how do we bring the sophisticated dynamics of working with clients in public health to an Internet-based learning module?

After conducting a needs analysis, the Technology Development Staff submitted an e-learning instructional design that would become a revolution in the way we deliver professional development case studies to our interns. By integrating HTML with original video footage delivered via Apple’s QuickTime video technology (available free at www.apple.com), they developed sustainable interactive multimedia versions of the traditional paper-based case studies.

The basic timeline of the client consultation case studies occurs in a straightforward manner. First the case is presented in narrative format, exposing the background of the client. The intern uses a variety of learning resources: charts, forms, records, tables, articles, and Web sites related to the client’s situation. Once these media have been considered, the students answer several open-ended “learning issues” questions. Answering these questions activates the sought-after creative and critical professional behaviors among the developing R.Ds. The answers are then submitted using WebCT’s assignment submission utility, graded by the instructor, and discussed at greater length in both online and classroom settings. Once the assignment is submitted, WebCT automatically makes available (releases) the “interview” portion of the case study.

The interview is designed to reflect the social dynamics an R.D. would encounter in a professional client consultation. To achieve this, the Faculty Technology Development Staff and the Department of Nutrition and Dietetics partnered once again to explore how point-of-view video could engage the learner.

Of the several proposed designs, we agreed that an interview system comprised of text-based decisions, client responses to each decision, and text-based critical commentary would be the best approach. To accurately script this, faculty and staff of Nutrition and Dietetics had to reflect on their own experiences and consult with working professionals to capture the essence of how the client described in each case would react to the treatment decisions. In a word, it was agreed that the client must be “emotional.” In turn, scripts were written for each case study client echoing the typical reaction this type of person would have to the respective health promotion treatment decisions. Critical commentary or feedback immediately accompanies every client response — so students can gain further insight into why the client reacted as he or she did. Whichever treatment decision is selected at each point during the interview determines which set of decisions will be released next. Whether the intern makes a good choice or poor choice, the interview continues to move forward. There are no absolutely “right” or “wrong” answers, only degrees of appropriateness. At its conclusion, an interview summary is generated in narrative format assessing the details of the entire consultation. If an optimal sequence of decisions is not met, a link appears prompting the intern to begin the interview again.

Bringing this vision to reality was surprisingly achievable in a 16-week project timeline. Once all the resources, scripts, and professional feedback were in place, it was a matter of purposing them for the Web. A standardized HTML template displays all the media. By hiring local actors to play the roles, complete with props, we spearheaded the video component. Stage lighting, a digital video camera, and audio system gave the video a professional look. The footage was edited with Apple’s Final Cut Pro (available at www.apple.com) and compressed for the Web in QuickTime format. Then the QuickTime videos were embedded into the appropriate Web pages and set to play automatically once the page loaded. All videos can be replayed as often as necessary. The decisions, video responses, and commentaries were diagrammed in a decision tree, each page marked with a unique numeric name. Finally all the Web pages were linked together, uploaded to WebCT, and made accessible to the interns alongside all the other WebCT course media.

With Innovation Comes Better Application

The professional development goal is twofold. The first goal is to train the public health interns to appreciate the diversity among client behaviors and backgrounds in community-based practices focused on health promotion. The second is to model the intricacies of providing the appropriate client consultation: a challenge that, until now, was often remiss in exclusively classroom-based learning.

With the power of the Web, both local and distance education interns can spend significantly more time studying these cases, analyzing the consequences of real-life decisions, and can extract the experiential subtleties of professional development. Moreover, these case studies accompany a successful suite of communication and assessment tools, making the online learning experience centralized and well connected.

We are still striving to produce dietetic practitioners who are skilled in the uses of the latest technology applications, and who can use technology to enhance their lifelong professional development. By integrating the Internet throughout the internship curriculum, we’re providing interns with professional development opportunities that develop their skills today, allowing them to serve in the health care environment of tomorrow.

Charlene Hamilton, Ph.D., R.D., is an associate professor and dietetic internship director for the Department of Nutrition & Dietetics at the University of Delaware. She’s currently involved in developing Web-based courses and exploring creative uses of Internet discussion forums in large lecture classes. Charlene is also committed to the development of interactive Internet experiences in educational settings.

Ann Rucinski, M.A., R.D. is the dietetic internship supervisor at the University of Delaware. Ann has extensive experience as a community nutritionist, particularly in the area of health promotion.

Justin Schakelman is a staff member of the Faculty Technology Development Group, a division of IT User Services at the University of Delaware. Justin is currently pursuing a doctorate in educational technology at the same university.

References

Duch, Barbara. 1995. “The Power of Problem-Based Learning.” About Teaching. University of Delaware. Online: http://www.udel.edu/pbl/cte/jan95-edit.html.

Kemery, Edward R. 2000. “Developing Online Collaboration.” Web-Based Learning and Teaching Technologies: Opportunities and Challenges, Anil Aggarwal (Ed.). London: Idea Group Publishing (IGP).

Moore, M.G., & Kearsley, G. 1996. Distance Education: A System View. New York: Wadsworth.

Porter, Lynnette, R. 1997. Creating Virtual Classroom Distance Learning with the Internet. New York: John Wiley & Sons, Inc.

Reid, E.M. 1994. “Cultural Formations in Text-based Virtual Realities.” M.A. Thesis, University of Melbourne. Online: http://www.ee.mu.oz.au/papers/emr/cult-form.html.

This article originally appeared in the 06/01/2001 issue of THE Journal.