Teaching and Learning in Nursing (2011) 6, 22–26

www.jtln.org

Multifarious instructional design: a design grounded inevidence-based practice

Kenya Harris MA, RNC*

Bronx Community College, Nursing and Allied Health Sciences, Bronx, NY 10453, USA

* Corresponding author.E-mail address: kenya.harris@bcc.cu

1557-3087/$ – see front matter © 2011doi:10.1016/j.teln.2010.07.002

Abstract The National League for Nursing developed core competencies for nurse educators. Thesecompetencies require nurse educators to develop evidence-based teaching practice, utilize technology,and manage individual students' learning styles (www.NLN.org).In an effort to decrease attrition and increase student retention in a beginning medical–surgical course, amultifarious instructional design was implemented. This design was developed based on evidence-basedteaching and learning styles to address the diverse student learning styles encountered in an associatedegree nursing program. Multifarious instructional design incorporated technology to enhance thelearning in the classroom. This design improved student retention by 30%.© 2011 Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing.

KEYWORDS:Evidence-based;Nurse educator;Technology;Learning styles;Instructional design

1. Introduction

The need for change in the nursing education curriculumhas been well documented. Educators have been encouragedto move away from the traditional lecture-style formatpresentation to new methodologies that include activeparticipant learning, such as digital technology. This newpedagogical approach was introduced in an associatedegree RN program (Billings & Halstead, 2009; Halsteadet al., 2005).

In an effort to decrease attrition and improve learningoutcomes in a beginning medical–surgical course, amultifarious instructional design was designed. In the past,this course was primarily taught by using the traditionallecture presentation along with the occasional use ofPowerPoints and group presentations. Huxham (2005) hasdemonstrated that traditional lectures do not stimulatethoughts or change attitudes, nor does it fulfill the variablelearning styles. According to Fleming (1992), this method of

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teaching only appeals to the auditory and read/write learner.Students learn based on one or more of the preferences oflearning, which are Visual, Auditory, Read/write, andKinesthetic (VARK). One-dimensional teaching styles leadto student and instructor frustration, likely resulting in a30%–40% students failure rate, and high attrition ratesamong the nursing students in a community college.Traditional teaching strategies seemed to prove ineffectivein lowering the attrition rate. Revisions were made in thismedical–surgical course based on the assumption thatstudents learn in different ways. Students were not giventhe VARK questionnaire or any other learning style survey.

A revised pedagogical approach improved the educationaloutcomes in this medical–surgical course. Digital technol-ogy was combined with traditional teaching strategies toexpand classroom walls and extend class time.

2. Multifarious instructional design

In nursing education, there is a large amount of contentto be disseminated in a short period. Each content area

National Organization for Associate Degree Nursing.

Table 1 Visual, Auditory, Read/write, and Kinesthetic

Learning styles Technology

Visual PowerPoint, video podcast, screen castingAuditory PodcastKinesthetic Electric response units (clickers), VoiceThreadRead/Write Online discussion boards, blogs, Wikis, PowerPoints

23Multifarious instructional design

is evaluated for its retention, whether on course examina-tions or on the National Council Licensure Examination.A poor understanding of content can have a rippling effecton the success of a student. An educator's responsibilityis to present the content effectively to address the varietyof learners.

According to Webster's Dictionary (2009), multifariousmeans to have many elements and to be diverse. Teachingrefers to the direct and deliberate actions intended to inducelearning; therefore, a multifarious teaching approachincludes the use of a variety of teaching strategies todeliver the content. Arthur (2007) and Nilson (2003) agreethat students learn best when a variety of instructionalmethods are used.

Technology must be implemented into the course toachieve this. Combining technology with traditionalteaching strategies will allow for more class time, whichin turn will allow more teaching of content while improvingstudents' preparedness. Content can be taught usingdifferent strategies, such as video casting, VoiceThreads,reading assignments, and simulation. Each teaching strat-egy will appeal to a different type of learner. This articlediscusses a multifarious instructional design that usesseveral teaching strategies in combination with technologyto enhance critical thinking and application of knowledgewhile managing different learning styles.

3. Advantages of integrating technology intothe course

Some educators shy away from the use of technology, notrealizing that they have been using a basic form of technologyfor many years. In the past, educators would roll overheadprojectors, portable cassette players, and TV/VHS carts intothe classroom for audio and video presentations. Using moresophisticated technology in a course can help instructorsmanage different learning styles that they often encounter inthe classroom.

• According to Dockstacker (2000), some of theimportant reasons to integrate technology into theclassroom include the following: Students are motivat-ed by technology, thus increasing academic engage-ment time.

• In the information age, there is an intrinsic need tolearn technology.

• Students learn where to find information in aninformation rich world.

• While working more in-depth with the content, studentsare able tomove beyond knowledge and comprehensionto application and analysis of information.

• Students develop computer literacy by applyingvarious computer skills as part of the learning process.

• Correctly designed, more depth into the content-areacurriculum is possible.

Table 1 shows types of technology that can be used basedon different learning styles (retrieved March 2009 fromwww.Vark-Learning.com). Learning styles was adaptedfrom www.Vark-Learning.com.

4. The reconstruction of the Course

A beginning medical–surgical course was reconstructedto address the diverse learning styles of the studentpopulation. This course was offered in the second semesterof a four-semester associate degree nursing program at acommunity college. The content areas in the medical–surgical course included respiratory disorders, cardiovascu-lar disorders, cardiac disorders, orthopedics, and gastroin-testinal disorders. The purposes of the reconstruction were toimprove student retention, decrease attrition, and improvethe application of knowledge in the clinical setting.Traditional teaching strategies were revised with digitaltechnology. The teaching strategies were altered, changed,and implemented over the course of the three semesters.

5. Lecturing

Heritage Dictionary (2009) defines lecture as anexposition of a given subject delivered before an audienceor a class. There are benefits to using lecture as a teachingstrategy, such as time efficiency for covering complexmaterial and provision of background information notavailable to students. It also allows for clarification ofcomplex, confusing, and/or conflicting concepts. Nilson(2003) believes that this is a passive teaching strategy, asmost students neither absorb nor retain the informationsimply by reading or hearing it. Arthur (2007) stated thatsome disadvantages to lecturing are that it decreasesstudent's participation in the learning environment, andonly approximately 10%–20% is retained. Huxham (2005)suggests a limited amount of time should be placed onlecturing, and more interactive and reflective teaching styleshould be employed.

6. Video casting

Video casting is the delivery of audio and video contenton demand. Video casts are an excellent way to produce

24 K. Harris

video or PowerPoint lectures. There are hundreds ofcommercial and free softwares available that can be usedfor creating video casts. Examples of free software includeWindows Movie Maker, iMovie (Apple), and WindowsMedia Encoder. Examples of commercial software areAdobe Premier Elements, Corel Video Studio, and Nero(Ahead Software). Hardware needed to create video castinclude webcam, video camera, and a microphone.

It is often difficult to engage students in active learningactivities because they have not completed the readingassignments or the material has not been covered (Nilson,2003). Converting lectures into video cast offers theadvantages of maximizing lecture-style teaching whilegiving the lecture portability. The video cast can be viewedbefore class, allowing the instructor to use class time formore active learning strategies, such as role-play, educa-tional games, or simulation. The video cast must complywith the best practice for a lecture-style teaching modality,such as 15- to 20-minute intervals, illustrate abstractconcepts, and adding pictures and diagrams. To make thevideo suitable for both the auditory and visual learner, thevideo must contain graphics, such as pictures, diagrams,and charts. PowerPoints that contain only words or moviesof a person lecturing are not suitable for visual learners(Fleming, 1992).

PowerPoints that were made for certain content areataught in this medical–surgical course were converted intovideo casts. Each video cast was no longer than 15 minutes.The videos illustrated abstract concepts and displayedpictures and diagrams. These videos were placed onBlackboard 1 week prior to class for viewing.

Evaluation of this method indicated that students andfaculty thought video casting was impersonal and did notprovide opportunity for questions and answers about thelecture. To resolve the students' issues, they were instructedto write questions down and bring them to class or posttheir questions online on Blackboard in a forum called“muddiest point.” The students' questions were answeredduring the first 5 minutes of class, whereas those questionsplaced online were answered online. Answering thequestions online allowed for an instructor to provide amore in-depth answer to the questions because there wereno time restrictions.

7. VoiceThread

VoiceThread is a Web-based tool that allows the userto upload videos, images, documents, and presentationsand have a discussion about them. Participants can addcomments by using one or more of the following methods:telephone, webcam, microphone, text, or upload ofa document. It even allows participants to draw on the screen.

Kinesthetic learners prefer to learn through real-lifeexperience or simulation. VoiceThread appeals to the

kinesthetic learner because it can be connected to realityand allows for application of theory. The experience iswhat stimulates the learning for the kinesthetic learner.

Integrating VoiceThread into this course providedstudents the opportunity to engage in client teaching. Italso stimulated critical thinking by allowing students toproblem solve and discuss different types of legal and ethi-cal issues. In one example, students were asked to reviewand discuss a clip about a nurse caring for a patient withan indwelling Foley catheter, who was also a child moles-ter. The nurse removed the Foley catheter without deflat-ing the cuff. The nurse's action has serious ramification notonly medically but also legally and ethically. The studentswere not given any instruction as to what aspects theyshould discuss. This allowed for different opinions andideas to be shared. It also allowed the instructor to eva-luate the students' thought processes and to evaluate thestudent's ability to carry over content that had been taughtin previous semesters.

Another way VoiceThread was integrated into this coursewas by recording a client who had a knowledge deficit abouther medications (prednisone, calcium, and vitamin D),discussing her medical regimen. The client was experiencingadverse effects from prednisone, such as moon face, weightgain, and mood swings. The client also had a dressing on herright arm. The students were asked to review the clip and usethe nursing process to help the client.

This exercise allowed the instructor to identify whichstudents were able to apply the principles of patient teachinginto practice. The instructor had an opportunity to evaluatethe student's assessment skills, the student's ability toidentify the side effects of prednisone, and the student'sknowledge about medications.

These educational experiences were discussed in class.

8. Reading assignment

Most classes have a required textbook, and students areassigned reading assignments. Reading assignments appealto the students who prefer the read/write method of learning.When a class is composed of a mixture of learners, itbecomes difficult to integrate active learning strategies whenonly a small portion of the students actually read the assignedreading. It becomes more challenging if the students whohave read the material do not understand it. The questionthen becomes, how does an instructor address readingissues? Wotring, Alpers, and Brown, (2009) suggest givingquestions that provoke critical thinking about the readingsand also giving point values as incentives when readingassignments are done.

According to Bean (2001), students should be taught howto read difficult text in the textbook to stop the vicious cycleof educators' willingness to explain difficult texts becausethey believe students are poor readers. This action on theeducator's part then helps the student develop a mindset that

25Multifarious instructional design

he or she does not have to read because the instructor willexplain the text in lecture. Bean believes that this actiondeprives the students of time needed to practice andovercome the challenges that are required to become agood reader. Based on Bean's analysis of the readingdeficits of students today, the following strategies wereimplemented in this medical–surgical course. Studentswere required to have a dictionary and a thesaurus. Theywere instructed to read the text several times if the text wasdifficult. Several topic areas were not discussed in class norwere lectures provided. One week prior to class, studentswere given a case study based on the reading assignmentsand questions.

A total of seven case studies were given. Students wererequired to submit the case studies online before class time.Most of the students completed all seven case studies, andthose students who did not complete the case studies wereactive participants in the simulation, role-play, or game inclass for that day. This gave those students anotheropportunity to learn the material.

Feedback from the students revealed the case studieshelped students to understand the content. The case studiesprepared students for class, which allowed them to engage inthe active learning exercise.

9. Active learning strategies

Engaging students is a challenge when they are unpreparedfor the lesson. To implement active learning activities into thecourse, there are many assignments given to improve theirknowledge base prior to class time, such as reading assign-ments, lectures, case studies, and questions. The teachingmodalities that were used during class time were simulation,games, concept maps, and role-play. Simulation and role-playwere used most of the time because it is the most effective wayto address the kinesthetic learner needs.

Students agreed that the class was exciting andthat simulation helped them connect the theory toclinical. Simulation made the abstract concept clear forthe students.

Fig. 1 Traditional ve

10. Discussion

The implementation of a multifarious design in abeginning medical–surgical course was a slow process.Faculty researched all teaching modalities that were used inthe course. First, the teaching modality was evaluated forbest teaching practices and the type of learner to whom itappealed. Each modality was modified to the meet standardsfor best teaching practice for the individual teaching strategy.For example, PowerPoints were edited to meet the bestteaching practice using this method of presentation. It wasalso edited to appeal to different learning styles.

The second step of implementation was to determine howtechnology was going to be implemented into the course.Faculty attended various conferences related to technology inthe classroom. These conferences educated the faculty aboutthree types of technology used in the classroom: VoiceTh-read, video cast, and simulation. The third step was the actualplacement of the content into the different teaching tools andfinally presenting it to the student body.

Each semester, as the phases of the new pedagogy werebeing implemented, there were small increments of improve-ment to the attrition rate. The overall improvement was notachieved until a complete multifarious design was implemen-ted in a beginning medical–surgical course. The pass rateimproved by 30% (see Fig. 1). Each semester, a class wascreated with students of similar backgrounds and similaracademic grades. Variables such as students repeating thecourse, grading criteria, and tutoring were taken intoconsideration. There were an equal amount of studentsrepeating the course each semester, and grading criteriawere not altered between the semesters. The examinationswere constructed in the same manner. The only variable thatwas not accounted for was tutoring services. Some studentsattended tutoring, but the exact number could not bedetermined over the course of the four semesters.

11. Conclusion

In order for instructors and students to benefit fromthe advantages of the multifarious design or technology

rsus multifarious.

26 K. Harris

in the classroom, the instructor must be willing to learnnew technology and teaching strategies. Faculty musthave the full support of the administration. The support ofthe administration plays an important part in the successof a new pedagogy being integrated into a curriculum.The administration has to support the instructor byproviding faculty development and sometimes incentivesfor instructors who want to teach using a new pedagogy.Faculty must be willing to allow students outcomes todictate their teaching methodology. Research has shownthat students learn differently from one another, soeducators must reach out to them using a variety ofteaching modalities.

Acknowledgments

Special thanks goes to Albert Robinson for teaching methe Technology and providing resources to incorporate thetechnology in a classroom setting. Thank you to HelenPapas-Kavalis, Deborah Morris and Lorrain Emeghbo forgiving me support, encouragement, and above all reading

and editing the article. Last but not least, thank you to BCCFaculty who allowed me to flourish as a novice educator.

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