Nurse Education Today (2006) 26, 680687

Nurse Education Today

intl.elsevierhealth.com/journals/nedt

Online teaching strategies to improve collaboration among nursing students

Laurie Posey *, Christine Pintz
The George Washington University, School of Medicine & Health Sciences, 900 23rd Street, NW, Suite 6163 Washington, DC 20037, United States
Accepted 20 July 2006

KEYWORDS
Online learning; Collaborative learning; Critical thinking; Instructional design

Summary Collaborative problem-solving is an essential competency for nurses and all health professionals. This paper compares the design characteristics and educational benets of three online-teaching strategies that nurse educators can use to build the critical thinking and social skills needed for effective collaboration: computer supported collaborative learning, case-based facilitated discussion, and cognitive exibility hypermedia. These strategies support a critical instructional outcome required for effective collaboration: the ability to examine, assess, and synthesize multiple perspectives to resolve illstructured problems (i.e., problems for which there is no clear-cut solution). Descriptions, examples, and guidelines for implementing each strategy are provided. By integrating these strategies into their online courses, nurse educators can prepare nurses to work effectively with others to solve complex problems in clinical practice and the broader health-care system. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 680687 and Nurse Education in Practice Vol. 6, No. 6, pp. 372379.

Introduction
This paper will compare and contrast three online teaching strategies that educators can use to develop nursing students collaborative problem-solving skills. Computer supported collaborative learning (CSCL) engages small groups of students in joint problem-solving activities. In case-based facilitated discussion (CBFD), the instructor guides
* Corresponding author. Tel.: +1 202 994 9313; fax: +1 202 994 2576. E-mail address: [email protected] (L. Posey).

students critical discussion of a complex clinical case or problem. Cognitive exibility hypermedia (CFH) is an interactive learning environment that enables students to explore multiple cases and learning themes from multiple perspectives. Although each of these strategies offers unique benets, they all support a critical instructional outcome required for effective collaboration: the ability to examine, assess, and synthesize multiple perspectives to resolve ill-structured problems (i.e., problems for which there is no clear-cut solution). By learning to assess ideas and assumptions critically, including ones own, and to develop

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Online teaching strategies to improve collaboration among nursing students holistic solutions based on the broadest available consensus, nursing students can become more effective collaborators and clinicians.

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Collaboration and critical thinking

Nurses encounter many types of problems in clinical practice. Some contain all the necessary data to solve the problem, having clear goals and known solutions. These are referred to as well-dened problems (Charlin and Van der Vleuten, 2004). Other clinical situations are ill-dened and characterized by uncertainty (Fox, 2000). An ill-dened problem may require additional information to understand it fully. The ability to solve problems in the context of uncertainty is the hallmark of professional competence (Johnson, 1988) and the knowledge needed to reason successfully in these contexts is referred to as professional knowledge (Scho n, 1983). Professional knowledge is enhanced by active learning processes, which include collaboration. Knowledge-rich tasks require strong interaction between the structure of knowledge and the processes of reasoning and problem-solving. Bromme and Tillema (1995) maintain that professional knowledge establishes itself by integrating, tuning, and restructuring theoretical knowledge to the demands of practical situations and constraints, and that theoretical knowledge requires transformation before it becomes practical knowledge. Mezirow (2000) denes transformative learning as an experience through which individuals become critically aware of their assumptions and expectations, and transform and expand their existing frame of reference to be more inclusive, reective, open, discriminating, and exible. Through constructive discourse, transformative learners clarify their personal assumptions and come to understand those of others, critically assess the reasons justifying these assumptions, and make decisions based on resulting insights. Thus, critical thinking and collaboration can be viewed as complementary: learners intellect and capacity for self-reection is essential to the collaborative process, and critical thinking is enhanced through collaborative experiences that stimulate learner exploration, critical assessment, and synthesis of alternative perspectives in problem-solving. Ideal critical thinkers are not only logical, but also open- and fair-minded, exible, and self-aware (Facione, 1990).

Background
Nurses must be able to collaborate with other nurses and health professionals to solve emerging problems in a dynamic and increasingly complex health-care system. Concerns about quality problems in health care have spurred a renewed emphasis on collaboration in all health-care disciplines, and nursing educators are being called upon to take a fresh look at the curricula in an effort to better address essential collaborative skills (Greiner and Knebel, 2003).

Learning to collaborate
True collaboration goes beyond cooperative activity. In the context of complex problem-solving, collaboration depends on cognitive diversity the synthesis of understandings and viewpoints to achieve a solution beyond the capability of an individual (Gardner, 2005). Collaboration requires interdependence a reliance on one another in solving problem or achieving mutual goals (Heinemann and Zeiss, 2002). Becoming explicitly conscious of ones own goals and values and developing an appreciation for the value of cognitive diversity are essential to the development of shared understanding and the collaborative problem-solving process (Gardner, 2005). Senge (1994) describes two phases of collaboration: dialogue, which requires group members to suspend their individual assumptions and engage in a free and creative exploration of the issues, and discussion, which involves reaching a consensus and formulating group decisions. The essential competencies that support this process are selfreection, the ability to examine ones thinking and its inuence on behavior and inquiry, the ability to ask questions and consider multiple points of view in the face of complex issues and divergent perspectives (Senge, 1994). From this perspective, collaboration can be viewed as a group process that depends on the contributions of each participant. Moreover, education designed to improve collaborative skills in health care should focus on the knowledge, skills, and values of all individuals who contribute to a groups collaborative process and problem-solving performance. Educational activities should promote the individual competencies that will prepare students to participate effectively in future collaborative processes.

Critical thinking & collaborative discourse in online learning

With more and more health-care education being delivered via the Internet, nurse educators need strategies for developing critical thinking and col-

682 laborative problem-solving skills online. Webbased learning provides a rich environment for engaging learners in critical discourse. In fact, online learning offers some signicant advantages over traditional, classroom-based courses. Students have time to look more objectively at collaborative dialogue and think more carefully about their participation in it. Some evidence suggests that the social aspects of collaboration may be better supported through asynchronous communication than they are face to face because roles are equalized and written exchange leads to more thoughtful, careful communication (Uribe et al., 2003; Wegerif, 1998). In contrast to faceto-face collaborative experiences, time and distance away from a decision-making situation may enable learners to think more critically about a problem, to more fully consider their own and others perspectives in their decision-making, and to reect on their role in the collaborative process (Garrison, 2003). Garrison (2003) observes that online education nurtures independent thinkers in an interdependent collaborative community of inquiry (p. 47). Garrison et al. (2001) also describe the overlapping relationship between cognitive presence, social presence, and teaching presence in online learning. Their research suggests that deep, meaningful online instruction includes an appropriate mix of social, cognitive, and teacher-facilitated experiences. This is consistent with a generally accepted premise that three types of interaction contribute to learning in an online course: learner-teacher interaction, learner-learner interaction, and learner-content interaction (Moore, 1989). Anderson (2003) maintains that sufcient levels of any one form of interaction can result in deep and meaningful learning and that integrating more than one mode of interaction, albeit less efcient, is likely to enhance learner satisfaction with online learning. Indeed, there are numerous studies linking each type of interaction to online learning effectiveness (Perry and Edwards, 2005; Swan, 2003).

L. Posey, C. Pintz

Computer-supported collaborative learning

Koschmann (2002) denes CSCL as a eld of study centrally concerned with meaning and the practices of meaning making through joint activity, and the ways in which these practices are mediated through designed artifacts. Online learning activities based on CSCL engage small groups of students in a joint problem-solving experience. The processes and outcomes of CSCL are supported by the online environment, but the thinking, learning, and problem-solving processes are controlled entirely by the students. A unique benet of this strategy is participation in an authentic collaborative process. Students experience real-world group dynamics in the context of shared problem-solving. Small group discussions are most likely to realistically represent the collaborative process that students will encounter on the job. An example of a CSCL learning activity is presented in Fig. 1. In this activity, learners work in groups to explore and analyze a sector of the health-care system, identify a signicant problem, collectively formulate a solution, and develop a presentation advocating their position. Computer-based supports include online guidelines for the activity, links to sources of relevant information on the Internet, and a structured group discussion forum. Guidelines for designing and implementing successful collaborative learning activities include (adapted from Egerton et al., 2003):  Promote positive interdependence by challenging students with complex problems that are likely to rely on the expertise and participation of all team members.  Require individual accountability by clearly establishing expectations for individual student contributions.  Establish a system and guidelines for peer feedback.  Model and facilitate the use of collaborative skills such as trust building, communication and conict management.  Make team members responsible for setting group goals, periodically assessing what they are doing well as a team and identifying changes that will help them function more effectively in the future.

Online teaching strategies to support collaborative problem-solving

Three collaborative strategies that promote reective, critical thinking and engage students in interdependent problem-solving are computer-supported collaborative learning, case-based facilitated discussion, and cognitive exibility hypermedia. Table 1 describes how the strategies differ and how each approach offers unique educational benets.

Case-based facilitated discussion

Case-based facilitated discussion refers to instructor-guided online discussions that center on a prob-

Online teaching strategies to improve collaboration among nursing students

Table 1 A comparison of strategies for improving collaboration and critical thinking in online courses Cognitive exibility hypermedia What is the strategy? Learner-directed exploration of multiple cases and content themes from multiple perspectives Instructional problems, cases, perspectives, and content themes are predened by the instructor/ designer The learning process is selfdirected and reective The collaborative process is simulated Instructional supports are integrated into the interactive learning environment The learner may adapt his/ her learning process based upon new discoveries The student determines the instructional outcomes by choosing which content to view and in what sequence to view it Computer supported collaborative learning Case-based facilitated discussion

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Who designs the instructional setting/context?

Instructor facilitated, Small-group decisionmaking in the context of ill- asynchronous discussion in the context of ill-structured structured problems problems Instructional problems are Instructional problems are dened by the instructor/ dened by the instructor/ designer designer

What is the learning process? What is the collaborative process? How are instructional supports provided?

The learning process is shared The collaborative process is natural Instructional supports are provided up-front and/or integrated into the learning environment The group may adapt their learning process based upon the ideas/discoveries of group members Students determine the instructional process and outcomes independently through a natural group process

The learning process is shared The collaborative process is natural, but guided The instructor provides instructional support at appropriate times based on learner needs and progress The instructor can adapt the learning process based upon ideas/discoveries of individuals or the group The instructor guides the instructional process and moves students toward a desired outcome

Who adapts the learning process?

Who determines the instructional outcomes?

lem or case study. Asynchronous discussion forums in which instructors facilitate the exchange of ideas among learners are an essential element of any online course. By anchoring discussions in one or more clinical problem-solving situations, educators can use asynchronous discussions to develop students collaborative problem-solving skills. An example of an asynchronous online discussion illustrating how an instructor can promote collaborative problem-solving and critical thinking is presented in Fig. 2. A unique benet of CBFD is instructor guidance. By moderating online discussions, educators can guide learners through complexities, overcome obstacles, and facilitate the group process. CBFD enables the instructor to guide knowledge-building and instructional outcomes by adapting to student needs, building on student ideas and discoveries, and redirecting dialogue as needed. The instructor can adjust their level of presence in discussions to meet instructional needs. By participating in the dialogue, learners advance their understanding through the constructive and creative effort involved in both contributing to the dialogue as well

as listening responsively and critically to the contributions of others (Wells, 2004). Guidelines for designing and implementing successful CBFD experiences include:  Develop discussion or cases that focus on realworld situations or problems.  Use the Socratic method to teach by asking rather than telling. By carefully constructing discussion threads to promote dialogic inquiry, questions can help expose errors in reasoning and spur critical thinking.  Facilitate an evolving discussion by maintaining the role of guide rather than expert. Rather than providing answers, ask questions to guide learners toward discovering them.  Identify teachable moments to optimize student insights.  Encourage students to question one another to keep dialogue moving forward.  Honor and encourage the integration of multiple perspectives into the discussion by building on the conceptual, cultural, and experiential contributions of different students.

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L. Posey, C. Pintz

Figure 1 In this example of computer-supported collaborative learning (CSCL), students work in groups to explore and analyze a sector of the health-care system, identify a signicant problem, collectively formulate a solution, and develop a presentation advocating for their position.

 Provide ample time for, and explicitly prompt, information gathering and critical reection outside the discussion to enable students to participate in a more meaningful fashion.  Provide a rubric or metric to help guide students toward meaningful participation in online discussions.

Cognitive exibility hypermedia

CFH environments enable individual learners to explore freely interrelated cases, themes, and perspectives to more fully comprehend the intricacies and variations that characterize complex content and problems (Spiro et al., 1988).

Online teaching strategies to improve collaboration among nursing students

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Figure 2 In this example of case-based facilitated discussion (CBFD), the instructor asks questions to prompt deeper critical thought and additional discussion about a clinical situation.

CFH is a method of teaching advanced levels of problem-solving in ill-structured knowledge domains (Spiro et al., 1992). The key characteristics of a CFH learning environment are the representation of multiple perspectives; application and adaptation of conceptual knowledge to rich cases and examples; emphasis on domain complexity and the interrelated and web-like nature of knowledge; and the encouragement of active knowledge construction (Jacobson and Spiro, 1993; Ludwig, 2000). A unique benet of scenario-based decisionmaking is control over the collaborative learning experience. CFH activities can be designed to provide students with an opportunity to consider multiple perspectives in the context of multiple clinical situations, creating a simulated collaborative discourse experience. Character scripts can simulate divergent perspectives in order to challenge students to confront and resolve conict in the context of carefully planned scenarios. An example of this approach is presented in Fig. 3. In this activity, learners can choose among three ethical decision-making situations, select online characters representing multiple health-care disciplines to hear their perspectives related to each case, and explore an interactive model to learn about the ethical decision-making process. Guidelines for designing and implementing successful CFH learning activities include (adapted from Egerton et al., 2003):  Promote cognitive exibility and the transfer of knowledge and skills by providing opportunities for learners to explore concepts from multiple perspectives.  Emphasize knowledge construction, rather than transmission of information, by anchoring learning activities to a complex and authentic task or challenge.

 Trigger more advanced thought by presenting multiple stakeholder viewpoints and additional problems that include some but not all elements of previously encountered problems and perspectives.  Support the learner in developing ownership of an overall problem or task, and provide an opportunity for reection on both content and learning process.  Be available as a resource or direct learners to resources to support learning, decreasing the level of support over time.

Putting it all together

What is the right way to develop collaborative skills online? The best answer to this question may be all of the above. Online collaborative learning activities that challenge small groups of students with complex decision-making scenarios may be the most appropriate way to prepare students for collaborative clinical practice. Additionally, reective questions can prompt learners to think about their role in collaborative processes and simulated collaborative experiences can place learners in difcult or complex situations that may or may not arise naturally in the course of collaborative learning activities. Depending on the complexity of the problem or the desired learning objectives, educators may choose to moderate small group collaborative activities. For example, planned case-based exercises related to professional and ethical concerns, similar to those used in the CFH example, have been effectively used to prompt critical discourse among students from multiple disciplines (Ryan, 2001). Implementation of these strategies may be challenging, however. Students do not always do their

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Figure 3 In this example of cognitive exibility hypermedia (CFH), learners can choose among three ethical decisionmaking situations, select online characters representing multiple health-care disciplines to hear their perspectives related to each case, and explore an interactive model to learn about the ethical decision-making process.

share, may clash with one another intellectually, or fail to cooperate with their colleagues. This can lead to resentment among team members and disdain for collaborative learning. Engaging in critical discourse is difcult and transformative learning can be uncomfortable. Students, especially those who are grade- or product-oriented, may not appreciate the educational value of the collaborative learning experience. Instructors can overcome these obstacles by:  Providing guidelines and ground rules to guide the collaborative process.  Providing multiple communication channels among learners and instructor(s).  Allowing time for students to plan and coordinate logistics.  Maintaining an appropriate facilitation presence such that students feel supported but not dominated.  Grouping students by interest (and time zones).  Emphasizing consequences for nonparticipation.  Using peer evaluations.  Explaining and emphasizing the value of the collaborative process as it relates to students professional aspirations.

Conclusion
Developing learners critical thinking and collaborative problem-solving abilities throughout their education is an important component of the multidimensional curricular reform needed to advance the nations agenda to improve the quality of healthcare. A multidimensional problem requires a multidimensional solution. To prepare nurses with the knowledge, skills and attitudes they will need to participate as effective members of a health-care team, education must go beyond the dissemination of knowledge and provide opportunities for students to practice collaboration in the context of real-world problems. Deep, meaningful learning is a complex process. The concept of blending cognitive and social learning experiences in a way that engages students actively and reectively has signicant implications for online instruction targeting higher-level skills, and is particularly applicable to the development of collaborative problem-solving abilities. The rapid growth of online education in health professions education presents an important opportunity to integrate inquiry-based, collaborative problemsolving experiences within the context of other curricular topics. By supporting active, authentic,

Online teaching strategies to improve collaboration among nursing students collaborative learning that emphasizes both multiple perspectives and individual reection, nurse educators have the potential to signicantly improve students collaborative problem-solving skills.

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