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Using the Constructivist TridimensionalDesign Model for Online ContinuingEducation for Health Care ClinicalFacultyKay Kyeong-Ju Seo a & Chalee Engelhard aa University of CincinnatiPublished online: 06 Mar 2014.

To cite this article: Kay Kyeong-Ju Seo & Chalee Engelhard (2014) Using the ConstructivistTridimensional Design Model for Online Continuing Education for Health Care Clinical Faculty,American Journal of Distance Education, 28:1, 39-50, DOI: 10.1080/08923647.2014.868754

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The Amer. Jrnl. of Distance Education, 28:39–50, 2014Copyright © Taylor & Francis Group, LLCISSN: 0892-3647 print/1538-9286 onlineDOI: 10.1080/08923647.2014.868754

Using the Constructivist Tridimensional Design Modelfor Online Continuing Education for Health Care

Clinical Faculty

Kay Kyeong-Ju Seo and Chalee EngelhardUniversity of Cincinnati

This article presents a new paradigm for continuing education of Clinical Instructors (CIs): theConstructivist Tridimensional (CTD) model for the design of an online curriculum. Based on prob-lem-based learning, self-regulated learning, and adult learning theory, the CTD model was designedto facilitate interactive, collaborative, and authentic learning. The authors conducted experimentalresearch with twenty-one physical therapy (PT) CIs to explore how the participants perceived theusefulness of the online curriculum structured around the CTD model in improving their knowledgein student mentoring. The CTD-inspired module was effective in that the participants perceived animprovement in the quality of their mentoring skills and they were able to maintain best practices.

Online professional development is still an underexplored method in health care-related facultyeducation. Clinical Instructors (CIs) have found that there are not enough online courses availablefor them (Housel and Gandy 2008; Recker-Hughes et al. 2010).

Cole and Wessel (2008) indicated that students value CIs who not only involve them in patientcare but also model professional behavior. CIs are mentors to physical therapy (PT) students whilethey are in clinic. Furthermore, Kelly (2007) stated that an exemplary CI employs active learningand reflection. The aforementioned studies suggest that the use of these instructional strategiescan dramatically improve the quality of students’ clinical rotations. Unfortunately, not all CIshave the instructional knowledge base to be able to comply with these guidelines (Recker-Hugheset al. 2010).

This brings into question what the best practices are for continuously educating CIs so thatthey are able to reach a high level of quality mentoring. This study was designed to provide adirection in this important quest.

PURPOSE OF THE STUDY

The purpose of this study was twofold. The first purpose was to create an online curriculumfor CIs based on the Constructivist Tridimensional (CTD) model, which the researchers of this

Correspondence should be sent to Kay Kyeong-Ju Seo, School of Education, University of Cincinnati, P.O. Box210022, Cincinnati, OH 45221-0022. E-mail: kay.seo@uc.edu

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study had developed. The second purpose was to assess the effectiveness of the training modulefrom CIs’ perspectives. To this end, the primary research question explored in this study was asfollows: To what extent and in what ways do CIs perceive the usefulness of the CTD-based onlinecurriculum in improving the quality of mentoring of students in the clinic?

Using quantitative data, the researchers tested the hypothesis that the CIs participating in theonline learning module would have higher ratings on mentoring skills in a posttest than in apretest. Based on qualitative themes, the researchers also examined if the CIs would perceive theonline learning module to be useful in improving the quality of student mentoring.

CURRENT TRENDS

A literature review on recent studies in this area revealed two important trends (Cole and Wessel2008; Dieker et al. 2009; Gill 2007; Hadley, Davis, and Kahn 2007; Jedlicka et al. 2002; Robson2009; Weidner and Henning 2005). The first trend focuses on the need to discover instructionalcharacteristics the CI can exhibit to promote the best student learning environment. In order tosupport this trend, it is important to develop resources that promote the characteristics to elicitsuccess of the adult learner. It is also important to explore what co-workers and supervisors can doto provide support in decreasing the initial strain of mentoring a student. The second trend drawsattention to best practices. What should the most effective instructional design look like? What isthe best delivery system? These questions point to the fact that health care professionals requireappropriate resources for continuing education so that instructional training can occur in thesespecific areas. A resource that encourages community and prompt feedback may facilitate theprop needed to promote clinical success for both the CI and the student (Stanton 2001). Therefore,the aforementioned two trends confirm the need for research and development of resources forclinical faculty.

Overall, the findings in the literature can be summarized into three preliminary concepts. First,the research maintains that learning modules for CIs enhance learning specifically if they are tai-lor made to the situation (Dieker et al. 2009; Gill 2007; Hadley, Davis, and Khan 2007; Robson2009). Second, students’ behaviors in the clinic improve by using Professional Behaviors (Coleand Wessel 2008; Davis 2008; Foord-May and May 2007; Hayes et al. 1999; Hull and Saxon2009; May et al. 1995; Morren, Gordon, and Sawyer 2008). Finally, there is an increasinginterest in the use of video-based online learning modules to deliver strong continuing educa-tion programs for clinical faculty (Dieker et al. 2009; Hadley, Davis, and Khan 2007). Thesethree concepts serve to support the need for the current study and lay the foundation of thisresearch.

CONCEPTUAL FRAMEWORK OF THE CTD MODEL

Identifying a suitable instructional design model is an important task in distance education. Theresearchers of this study developed the CTD model consisting of problem-based learning (PBL),self-regulated learning (SRL), and adult learning theory (ALT), with constructivism as the coreof the framework.

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CONSTRUCTIVIST TRIDIMENSIONAL DESIGN MODEL 41

Constructivism and Online Learning

Hull and Saxon’s (2009) research emphasizes the use of constructivism in the online learningenvironment to elicit positive learning outcomes in professional development. Constructivismis an umbrella term that identifies knowledge as constructed when learners interact with theirenvironment (Cheaney and Ingebritsen 2005). Well-known constructivists—namely, Vygotsky,Bruner, Dewey, and Jonassen—affirm constructed knowledge should have a strong associationwith group interaction (Huang 2002). In the field of PT, one pathway in which knowledge pro-duction frequently occurs is when therapists collaborate to resolve patient issues. This is alsotrue with networking between students and CIs. Because this type of collegial activity occursregularly, providing a learning environment that follows this behavior pattern is important.

Problem-Based Learning (PBL)

PBL is an instructional approach based on constructivism. Essentially, PBL uses authentic sit-uations to solve an issue so that active learning can take place. According to Cheaney andIngebritsen (2005), PBL activates a student’s prior knowledge and promotes student-centeredlearning through a real-world problem. Anderson and Tredway (2009) found that as studentsimmerse themselves into a case, they tend to transition into the role of stakeholder that enablesthe learner both control of and responsibility for the learning process. This is exactly the paththat PT students need to take in order to be successful in the clinic. Likewise, through utilizationof PBL in the clinic, CIs become facilitators who promote not only learning but also reflectionand application of new knowledge. This increases their motivation and development of enhancedthinking skills.

Self-Regulated Learning (SRL)

With this painted picture of immersion and motivation, a link between PBL and SRL appears.SRL is defined as a learning process that focuses on the learner’s ability to self-direct his/herlearning, involving the student’s level of motivation, cognitive processing, and thinking strategies(Shen, Lee, and Tsai 2008). Tsai and Shen (2009) stated that coupling PBL with SRL couldpromote better learning outcomes. As West (2011) indicated, learner autonomy is a key elementin distance education. Shen, Lee, and Tsai (2008) further indicated that PBL could encourage self-directed learning evidenced by students having choices in answering case questions and havingcontrol over the direction each case takes. In addition, a close link between high self-regulationand solid performance in computer-based instruction supports the use of SRL in forming theCTD model. Thus, with authentic cases, motivated students, and online learning, PBL and SRLtogether present a positive correlation.

Adult Learning Theory (ALT)

Peters (2000) clarifies that truly enhanced knowledge takes into consideration prior knowledgeand promotes students taking ownership of their learning experience. This is congruent withALT. Although many educational theories utilize children as the ideal population for the basisfor their philosophy, ALT differentiates itself on the premise of addressing adults as unique

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learning entities. ALT’s characteristics involve self-directed learning, lifelong and experientiallearning, learner motivation, readiness to learn, social and critical thinking skills, and high auton-omy (Knowles 1990). Knowles indicates that adult learners bring to educational environments aset of expectations, goals, and experiences that are distinct from younger learners. Their differentexpectations, goals, and experiences become significant when looking at online environments.Due to what adult learners bring to the learning environment, they will not appreciate a learn-ing experience that is not based on authentic conditions or their capability to be self-directed.Therefore, ALT can inform continuing education programs that target mature professionals.

Combining PBL, SRL, and ALT

To show how constructivism lends itself to continuing education, Peters (2000) emphasizes thatutilizing the constructivist framework in education of health care professionals aids in the tran-sition from inexperienced to experienced practitioners. PBL and SRL working together mayproduce elevated levels of student learning outcomes (Shen, Lee, and Tsai 2008). In addition,ALT aligns with PBL and SRL with the core being constructivism. This was realized in the CTDmodel characterized to be interactive, collaborative, authentic, and learner centered as illustratedin Figure 1.

ONLINE MODULE DESIGN

The module that the researchers developed for this study focused on educating CIs in fourareas related to creating rich educational environments for students, including (1) establishingthe groundwork for clinical experiences, (2) identifying interventions to prevent adverse situa-tions, (3) implementing enhanced listening skills, and (4) increasing awareness of ProfessionalBehaviors.

Module Structure

The module was composed of a series of alternating linked video vignettes and text-based instruc-tional slides. The module began with an introduction, learning objectives, and a pretest. Next, themodule launched into a short video vignette to set the stage for the educational experience. The

PBL

ALTSRL

Constructivism

FIGURE 1 The CTD Model (color figure available online).

PBL = Problem-Based Learning. ALT = Adult Learning Theory. SRL =Self-Regulated Learning. CTD = Constructivist Tridimensional Design.

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CONSTRUCTIVIST TRIDIMENSIONAL DESIGN MODEL 43

content following the vignette stressed for the CI to be proactive with the student by providinga thorough orientation. The subsequent vignettes initiated a sequence of discussions between aCI and a Center Coordinator of Clinical Education about a student who failed to incorporatethe CIs’ feedback. Professional Behaviors were introduced next, along with information on howto complete a remediation plan. The adoption of active listening strategies added to the skillsto help the CI coach the student on how to get back on track. The learner can clearly see on-screen how the CI can achieve a positive outcome when confronting a student about unacceptablebehavior.

Another opportunity for the learner to embrace the online experience was through decisionpoint slides, which allowed the learner to interact with the module by clicking on a hyperlink andchoosing which decisions she/he would make if she/he were the CI in the scenario. If the learnerchose the less-desired option, then the learner was eventually redirected to the more appropriatepath only after the consequences of her/his decision were disclosed. The decision points enabledthe learner to engage in the module by providing the opportunity to explore new possibilities ofhow to deal with these types of situations without having to suffer real-life entanglements. Afterexposing the learner to the complete series of video vignettes and instructional slides, the moduleended with a positive resolution.

Application of the CTD Model

As evident in the module structure, constructivism played a strong role in the design of this learn-ing module. For instance, a hyperlink within the module led to a wiki where the learner providedpeer feedback to specific inquiries about the module and clinical experiences. This specific taskcreated a social constructivist element. Also, the module centered on PBL. This was evident earlyin the module when the learner was initially presented with a problem that eventually required thelearner to draw on past experiences, learn new content, and explore self-reflection. For example,the student in the video vignette was asked by the CI to research articles for an unfamiliar patientdiagnosis, but instead the student was observed texting and looking through a magazine. The stu-dent’s behaviors presented the problem that the learner had to resolve over the next hour. SRLguided the design to where facilitation of learner motivation occurred. The learner was providedchoices when answering module questions and control of what direction the case would unfold.ALT also played a part throughout the learning experience. An authentic case was presentedwhere the learner could make decisions based on his/her experience along with new content.As described earlier, PBL, SRL, and ALT forged a partnership in the module design.

METHODS

Data Collection

Participants. The participants of this study consisted of twenty-one PT CIs mentoring doc-toral students enrolled in a public research university in the midwestern United States during thestudents’ nine-week clinical rotation. On average, the participants had nine years of experienceas a CI and thirteen years of experience as a licensed physical therapist. There were seventeenfemales and four males, which is consistent with the gender breakdown for the PT profession.

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Research design. The CIs consenting to participate were randomly assigned to either atreatment group or a control group through the Excel random assignment function. The treatmentgroup was asked to take a pretest and then the online learning module, which was availablethroughout the nine-week rotation for them to refer to as often as they deemed necessary. After therotation, they participated in a posttest. This delayed posttest enabled the researchers to observeif the CIs had employed the strategies learned from the module and to assess the existence of anylong-term impact of the treatment. The pre- and posttests primarily served to assess the amount oflearning that took place in four areas: (1) establishing groundwork, (2) working through studentissues, (3) active listening with conflict resolution, and (4) using Professional Behaviors as aresult of participation in the learning module. Two online focus group interviews followed theposttest for the treatment group. The focus group interviews facilitated a social constructivist-empowered networking environment where the CIs engaged in synchronous peer interaction toprovide feedback and assessment of the effectiveness of the module. Finally, a member check wasperformed to ensure the concepts generated from the focus group reflected the actual findings. Thecontrol group took the pretest to help the researchers establish a baseline and obtain the footingto assess whether the treatment group was representative of the sample.

Data Analysis

Mixed-methods approach. The researchers used both quantitative and qualitative methodsto answer the research question for this study. The pre- and posttests in a Likert scale generatedquantitative data and underwent analysis with a Wilcoxin Signed Ranks test. Factors that dictatedthe use of this specific test were twofold. One, the Likert scale represented a nonparametric designwith the use of a pre- and posttest. Second, the samples used were dependent samples. Two focusgroup interviews and a member check were conducted to collect qualitative data on the partic-ipants’ feedback and assessment of the effectiveness of the module. The qualitative data wereanalyzed using a series of coding steps including open, axial, and selective coding, suggestedby Grounded Theory (Strauss and Corbin 1998). Open coding requires a constant comparisonof codes to ensure no duplication occurs. Axial coding serves to put the codes into categoriesor themes and then links the themes together to create a relational statement. The final step isselective coding, requiring the development of a theoretical scheme that eventually evolves intoa core category. Through these steps, themes became apparent.

Selection bias. The researchers examined the presence of selection bias for the participantsusing two sets of calculations. First, a close examination of the sample as it related to the popula-tion of CIs used annually for the program enabled the researchers to discuss the potential gener-alization of the findings to the population. This required the use of descriptive statistics. Second,a comparison of the control group with the treatment group provided the footing to assess if thetreatment group was representative of the sample. The analysis required a Mann–Whitney U.

Trustworthiness and dependability. The researchers used a built-in audit trail to ensurethe trustworthiness and dependability of the study. This trail included the researchers’ notes andlogs to confirm that each step planned in the methodology was obeyed (Lincoln and Guba 1985).Additionally, the fact that the participants in the online focus groups directly typed their responsesto the researchers’ guided questions contributed to the integrity of the study. This approach elim-inated potential errors in transcription. After the focus group, a member check was performed to

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ensure the concepts generated from the focus group reflected the actual findings (Mertler 2006).Finally, the researchers used an external coder who served to provide another layer of reliabil-ity for the study. The external coder allowed the researchers to triangulate the data results, thusstrengthening the veracity of this study.

FINDINGS

Group Selection

In order to define the role of selection bias in the study, the researchers made a comparisonfirst between the sample and the population and then between the control group and the treat-ment group. Due to the size of the population, the annual database statistics were included asthey represent CIs used throughout the academic year. Table 1 provides descriptive statistics tocompare the CIs from the sample, population, and annual database. The information from thistable demonstrates that the groups were indeed similar to each other, thus minimizing selectionbias.

Next, the researchers compared the pretest results from the control and treatment groups toassess if the treatment group was representative of the sample. The researchers used the Mann–Whitney U test to analyze the Likert scale scores from the four content areas. The results ofrunning this test ranged from 46.50 to 55.50. A score of 30 or less would have equated to a pvalue equal to or below the .05 level. This would have indicated a significant difference betweenthe two groups. Therefore, there is quantitative evidence to support that the two groups weresimilar, thus minimizing selection bias.

Quantitative Results

The hypothesis for this study was that the CIs participating in the online learning module wouldhave higher ratings on the appropriate mentoring skills in the posttest than in the pretest. In orderto test this hypothesis, the researchers compared the responses of the pretest with the posttest

TABLE 1Comparison of Groups

Sample Population Annual CI database

Size 21 24 117Years as a physical therapist 13.26 14.69 12.39Years as a Clinical Instructor 9.45 10.73 9.28Academic degree BS = 23.8% BS = 29.2% BS = 27.4%

MPT = 38.1% MPT = 33.3% MPT = 46.2%DPT = 38.1% DPT = 37.5% DPT = 25.6%

Credentialed Clinical Instructor Yes = 57.1% Yes = 54.2% Yes = 47%No = 42.9% No = 45.8% No = 53%

Note: BS = baccalaureate. MPT = Master of Physical Therapy (PT). DPT = Doctor of PT. CI = Clinical Instructor.

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TABLE 2Comparing Pretest to Posttest

Areas covered MeansMinimum

scoreMaximum

scoreWilcoxin Signed

Ranks test

Area 1—Establish groundwork Pretest 3.307 2 4 .046Posttest 3.667 3 4

Area 2—Work through student issue Pretest 2.539 1 4 .058Posttest 3.083 2 4

Area 3—Active listening with conflict resolution Pretest 3.308 2 4 .180Posttest 3.358 2 4

Area 4—Use Professional Behaviors Pretest 2.615 1 3 .068Posttest 3.168 2 4

using a Wilcoxin Signed Ranks test. Table 2 illustrates the scores of the pretest and the posttestwith the associated Wilcoxin Signed Ranks test. The results show that not only did the means con-sistently increase from the pretest to the posttest but so did the ranges. Keeping in mind a targetof .05 level of significance, the “successful groundwork for orientation” prompt achieved signif-icance (.046). The next closest prompts to being significant were “handling significant issues”(.058) and “working with a Professional Behaviors plan” (.068), slightly missing significanceby .008 and .018, respectively. The only stagnant range was the “active listening with conflictresolution” prompt (.180).

The two prompts that barely missed statistical significance were likely due to the fact that CIsare encouraged to contact the university as an early warning system when the student’s undesir-able behavior was severe enough to warrant a Professional Behaviors plan. Therefore, a minimalincrease in guidance was not surprising. Thus, the fact that the mean scores were trending upwardwith this sample size indicates the possibility of significance with a larger sample size.

The posttest contained another significant piece for answering the quantitative aspect of theresearch question. The researchers asked the treatment group what level of effectiveness theyperceived when mentoring their students in the clinic as a result of taking the online module.The choices were “no change in level of effectiveness,” “minimally more effective,” “moderatelymore effective,” and “extremely more effective.” Eight CIs chose “moderately more effective,”which equated to 66.7%. Three chose “extremely more effective” and one chose “minimally moreeffective.” None of the CIs selected “no change in level of effectiveness.” Therefore, the resultssupport the hypothesis for this study.

QUALITATIVE RESULTS

With respect to the qualitative aspect of the research question, the associated theme statement forthis study was that the CIs would perceive the online learning module to be useful in improvingthe quality of student mentoring. An analysis of the qualitative data from the focus group inter-views and the member check led the researchers to further determine whether the CIs had indeedlearned from the module and they were more capable of working with challenging students thanprior to taking the module.

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Two focus group interviews took place utilizing Adobe Connect. Nine of the participants fullyparticipated in the focus groups. The first question asked them how many times they had returnedto the module during the nine-week rotation. Four of the nine went back and two of the four wentback twice. One of the nine stated she would have gone back but failed to remember she had thatoption.

The second question of the focus group directly asked if the module was effective in teachingbest practices for CIs. The responses consistently stated the module was effective. However, theparticipants identified different parts of the module that they felt were more useful than others.For instance:

Nice resources, good framework for communication. (Male CI: 8)

It gave me some ground rules to use with a student, which was helpful. (Female CI: 5)

I do think the module was effective for handling issues that may come up during a clinical rotation.It will definitely be something I remember to refer to in the future if any problems come up. I like theidea of having a plan of action. (Female CI: 15)

The third question asked the participants if the module was effective in improving the qualityof mentoring of doctoral students. Most of the responses were similar to these:

Yes, I felt better able to meet with the student and address issues with a more structured format. I didfind that I didn’t use the formal action plan because we had multiple issues, but it provided a niceframework to build from. (Female CI: 25)

Having been challenged by this past student, I found myself stretching in new areas to be a differentand better CI. The module definitely helped me. (Female CI: 13)

Two other questions from the focus groups also led to answering the research question. Onequestion asked the participants if they felt more capable of working with challenging students thanprior to taking the module. The responses again were consistently positive. The other questionreferred to what would help a CI display best practices ongoing in their practice. Responsesincluded the following:

Having the module available to be able to reference whenever a question or concern pops up. (FemaleCI: 11)

By establishing student and CI objectives & goals day one of the clinical. Then put this information inwriting and have regular meetings to review those objectives/goals to make sure things are on track.(Female CI: 24)

The next step was to perform the member check to confirm that the themes were consistentwith the participants’ intentions. The three randomly selected CIs consisted of one novice instruc-tor and two seasoned instructors. All of the three participants agreed that the online module wasuseful in improving the quality of mentoring of doctoral students and that it made them morecapable of dealing with challenging students. The disagreement occurred with the intended targetpopulation for the module. Female CI: 10, a seasoned instructor, stated that the module was moreapplicable to novices as she had indicated earlier in the focus groups. Female CI: 15, a noviceinstructor, also agreed that novices would benefit tremendously from taking the module but sug-gested that because she was not a seasoned instructor yet, she did not feel she could judge it

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accurately. Female CI: 24, a seasoned instructor, disagreed with Female CI: 10’s perception. Shefelt that a novice might not understand the gravity of a situation, whereas a seasoned instructorwould see more value in implementing the module-taught strategies right away. She stated themodule would be useful for a range of experience levels.

Overall, the member check confirmed the themes generated from the data analysis of the focusgroups and added clarity to the potential audience for the module. Therefore, the findings fromthis mixed-methods approach supported both the hypothesis and the thematic statement.

RELIABILITY

To enhance the reliability of the study, the researchers used an external coder to process the focusgroups data and calculated both interrater and intrarater reliability through the use of Cohen’skappa statistic. This allowed the researchers to triangulate the data results. Thompson et al. (2003)found that using the multirater kappa statistic helped measure the level of agreement of codingthat may not have occurred by chance. Cohen’s kappa formula that was used for this study wasas follows:

K = p − pe

1 − pe

In the formula, (p) stands for the proportion of units that were in agreement and (pe) stands for theproportion of units that would be expected to agree by chance (Bland 2008). Table 3 displays thekappa statistics for both the interrater and intrarater reliability testing for this study. This showsthat the coding for the study was strongly reliable.

LIMITATIONS OF THE STUDY

Although this study yielded meaningful results, it had some limitations. First, due to the smallsample size used in this study, the results were unable to be generalized to the greater population.A larger sample size would have brought greater credibility to the study. Second, this study used apretest–posttest design mainly based on the data from the treatment group while using the controlgroup to obtain the footing to assess if the treatment group was representative of the sample. Thisresearch design enhanced the credibility of the main data source, but a complete pretest–posttestcontrol group design would have been more powerful. Additionally, the number of the items oneach of the tests was small, potentially making the score reliability of the tests low. Increasing

TABLE 3Interrater and Intrarater Results

Data instrument Interrater kappa Level of agreement Intrarater kappa Level of agreement

Focus group 1.00 Almost perfect 1.00 Almost perfect

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not only the number of test items but also the number of participants would have aligned with theSpearman–Brown prophecy (Brown 1910; Spearman 1910) and further validated the findings.

CONCLUSION

The researchers found that the participants did indeed learn from the module and were able toput the module-taught strategies into practice. The researchers also found that the online mod-ule evoked motivation, critical thinking, self-directed learning, and self-reflection and that theparticipants perceived an improvement in the quality of student mentoring.

Future research can add students’ perspectives by examining how students actually assess theperformance of their mentors who have completed the CTD-inspired online module. It would alsobe interesting to explore whether this model can be applied to other disciplines. This could addan interdisciplinary dimension to the model and also bring greater power to the generalizabilityof this research.

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Dieker, L. A., H. B. Lane, D. H. Allsopp, C. O’Brien, T. W. Butler, M. Kyger, M., L. Lovin, and N. S. Fenty. 2009.Evaluating video models of evidence-based instructional practices to enhance teacher learning. Teacher Educationand Special Education 32 (2): 180–196.

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