CBI: facilitating students' medication dosage calculation and self-efficacy. (The scholarship of teaching and learning).

Abstract

The present study examined the effects of two modes of instruction (computer-based and print-based) and the presence or absence of graphics on students' drug dosage calculation performance and self-efficacy beliefs with 56 undergraduate nursing students. It was hypothesized that students receiving computer-based and graphics-enhanced instruction would score higher on the post-test and report higher self-efficacy beliefs to solve drug dosage problems than students receiving the print-based mode of instruction. As expected, the groups receiving computer-based instruction scored significantly higher on the drug dosage problems and reported greater self-efficacy beliefs than the groups receiving print-based instruction. Graphics-enhanced instruction also led to higher test scores but not self-efficacy beliefs. Implications of the results are discussed in relation to the role of computers and graphics in learning.

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Knowledge of math among nurses is crucial in calculating drug dosages for medication, yet assessment of student nurses demonstrates that they do not possess the basic math concepts for calculating dosages of medication (Pozehl, 1996; Worrell & Hodson, 1989). Providing quality instruction to aid student nurses on dosage calculation has been a challenging task for nursing educators and has become a priority with schools of nursing (Worrell & Hodson, 1989). Many instructional materials, some of which have been computer-based, have been developed to (a) assist nursing students in mastering math skills (Weaver & Koehler, 1966) and (b) improve their attitudes toward math (Hamby, 1986). Nevertheless, the majority of students continues to be seriously deficient in mathematical calculations (Pozehl, 1996). The scope of this study is to test the effectiveness of a computer-based instructional module with graphics on nursing students' medication dosage calculation problems and self-efficacy beliefs.

The introduction of computer-based instruction has provided educators with new methods of teaching in school classrooms (Robinson, 1998) that have resulted in increases in student learning (Khalili & Shashaani, 1994) and test scores (Weaver, 2000). Specifically, in the nursing field, research studies show that when computers are employed as tutors in drill-and-practice exercises for dosage calculation problems, they promote student mastery of these skills (Worrell & Hodson, 1989; Reynolds & Pontious, 1986). For example, Reynolds and Pontious (1986) conducted a study with 143 nursing students to determine whether computer-assisted modules are positively related to student achievement. These researchers found that this method of instruction enhanced the students' achievement of medication dosage calculation and was cost and time efficient for both students and faculty. Although these computer-based modules were optional, students tended to choose computer drill and practice problems more often than the other supplemental activities available. However, research studies conducted to determine whether computer-based instruction has an effect on students' attitudes toward math have found small or no significant differences between students that used computer-based instruction and students that used worksheets (Hamby, 1986; Kulik, Kulik & Cohen, 1980).

In an effort to maximize the effects of computer-based instruction on student achievement and attitudes toward learning, researchers have explored other factors that may aid the learning process, such as graphics. The term graphics has been defined as "visible things other than printed words that are used in a communication process" (Dwyer, 1994), and may include illustrations, diagrams, photographs, and some computer-generated animations. Although no research has been conducted with nursing students, studies with other samples show that computer-based instruction with graphics leads to higher levels of achievement. For example, Chao, Cennamo & Braunlich (1996) found that learners in a graphics-enhanced lesson delivered on a computer scored higher on a post-test and showed higher levels of retention and retrieval of learned information than learners with instruction that did not include graphics. Graphic organizers are effective because they help learners acquire information by providing organization and serving as retrieval aids (Spaulding & Dwyer, 1999). Additionally, they direct the learner to important concepts; contribute to the reinforcement of existing mental models that aid in information processing and the formation of new mental models (Robinson, 1998).

Further research is needed in the area of nursing to examine the effects of instructional computer-based modules enhanced with graphics on student proficiency in medication dosage calculation as well as the role of computers on student's self-efficacy beliefs rather than attitudes. Self-efficacy, which is one of the most highly regarded perceptual predictors of human motivation, is defined as perceptions about one's capabilities to organize and implement actions necessary to attain a designated level of performance (Bandura, 1997). Findings from correlational and training studies have consistently demonstrated the importance of self-efficacy beliefs in student academic achievement and affect. It has been shown that individuals with high self-efficacy beliefs persist longer in the face of obstacles, exhibit more effort, show high skill acquisition and report low levels of anxiety (Bandura, 1997; Zimmerman & Kitsantas, 1997; 1999). Consequently, examining the role of different modes of instruction may provide useful information about instructional intervention strategies that may enhance nursing students' motivation and subsequently performance in drug soakage calculation.

The present study attempted to systematically investigate the effects of computer-based instruction and graphics on students' achievement and self-efficacy. To our knowledge this is the first study to examine the role of computer-based instruction and graphics on students' self-efficacy beliefs. It was hypothesized that computer-based instruction would enhance students' drug calculation proficiency and self-efficacy beliefs more than the print-based instruction. It was also expected that computer-based instruction with graphics would lead to the highest level of drug calculation achievement and self-efficacy perceptions among nursing students.

Method

Participants

The sample of this study consisted of 56 undergraduate nursing students from a large public southeastern university. The age of these subjects was approximately 23 years old, with 50 (89.3%) females and 6 (10.7%) males. The participants were 44 (79%) Caucasian, 3 (19%) Hispanic, 7 (13%) African American, 1(1.8%) Asian and 1(1.8%) did not specify. Of those who reported their GPA and Mathematics SAT scores, the means were 3.4 and 538 respectively.

Measures

Pre-test of prior Knowledge. Prior medication dosage calculation was measured with a 10-item, print-based, multiple-choice instrument that was administered before instruction began. This pretest examined the students' knowledge of drug dosage calculation using proportion. An example includes "Which is greater, 60 grains or 1 dram?"

Achievement Skill (Post-Test). A 10-item, multiple-choice instrument was developed to measure the learner's knowledge of measurement conversion using proportion in medication dosage calculation. Achievement on the post-test was scored on a 0 to 10-point range. Specifically, these 10 test items covered one area of the nursing competency test: units of weight measurement in the apothecary (grains, drams, ounces) and metric (grams, milligrams) systems and conversions between systems using proportions. Based on pilot testing and consultation with two expert nursing math instructors, it was determined that the ten test items selected were adequate in evaluating the students' math knowledge in this narrow area represented in the nursing math competency test.

Self-Efficacy Scale. This scale was developed based on the guidelines outlined by Bandura and Schunk (1981). Self-efficacy involved participants' perceived capability to solve each of the 10 dosage problems. All identical 10 items were introduced with the phrase "How sure are you that you will be able to solve this problem correctly?" on a scale ranging from 1 (not sure at all) to 10(very sure). Each student's score was composed of the average self-efficacy rating for the 10 items. The interitem reliability of this scale was .91.

Task Materials

Four versions of instruction (computer-based/with graphics; computer-based/text-only; print-based/text with graphics; or print-based/text-only) were developed. All four instructional modules consisted of step-by-step instructions on how to convert proportions using weight measurement units in the metric (milligrams and grams) and apothecary (grains, drams, and ounces) systems of measurement. The content of these materials was developed based on Hegstad and Hayek (1994) recommendations for math instruction. An expert nurse instructor also validated the content. Graphics included pictures, illustrations and diagrams. They were integrated in the text based on the works of Robinson (1998) and Rieber (2000). All instructional modules with and without graphics were pilot tested with first-year nursing students.

Design and Procedure

The volunteer participants signed an informed consent form at the beginning of the first class of the semester. The 56 volunteer participants were randomly assigned to the four versions of instruction: computer-based/with graphics; computer-based/ text-only; print-based/text with graphics; and print-based/ text-only. One of the researchers administered the data questionnaire, pre-test assessment, instructional module, self-efficacy scale, and post-test to the participants. Specifically, all participants were instructed to proceed through the instructional module (computer-based or print-based), on their own without referring to previous pages of the module. In addition, they were instructed to sequentially look at each post-test problem, provide a self-efficacy judgment about the problem, and then attempt to solve it. Once completed, the experimenter collected each packet. The experimenter recorded the times that the participants began and ended the computer and printed versions of instruction.

Results

The data for each dependent measure were analyzed using a 2 (mode of instruction, computer versus print-based) x 2 (presence or absence of graphics) ANCOVA using the pretest as a covariate. For the measure of drug calculation skill, there was a significant main effect for mode of instruction F (1,51) = 3.98, p = .05, and a significant main effect for graphics F (1,51) = 5.05, p = .05. Students who received computer-based instruction (M=8.29) surpassed those that received print-based instruction on the post-test scores (M = 7.43). Students who were exposed to graphics-enhanced instruction (M = 8.32) performed better on the post-test than students who were exposed to instruction without graphics (M = 7.39).

The measure of self-efficacy yielded similar results. An ANCOVA revealed that students that received computer-based instruction (M=8.64) reported significantly higher self-efficacy than those who received print-based instruction (M = 7.70), F (1,51)= 4.76, p = .05. Students that received graphics-enhanced instruction (M = 8.41) also tended to report higher self-efficacy beliefs than students who received instruction without graphics (M = 7.93), but this finding did not reach significance. Table 1 presents the means and standard deviations for all conditions and measures. See issue's website <http://rapidintellect.com/AEQweb/spri02.htm> Students' completion time was also recorded. Although time was not a dependent variable of the present study, it is worth mentioning that participants in the print-based condition of instruction completed the materials in approximately one hour, whereas the participants in the computer-based version of instruction completed the materials in approximately one-half of an hour.

Discussion

The task of adequately preparing nursing students to become proficient in drug dosage calculations presents a problem for nursing educators, who are searching for better ways to instruct the students and students, who often view medication dosage calculation as a frustrating task. In the present study, it was shown that computer-based instruction enhances student medication dosage calculation more than print-based instructional modules. These results replicate the findings of Reynolds and Pontious (1986) who showed that computer-assisted instruction assists nursing students to attain mastery of medication dosage calculations. Interestingly, learners receiving print-based instruction required more time to complete the lesson and post-test and scored lower on the post-test than those receiving the computer-based instruction. This may imply that computer-based instructional modules speed up processing of information or sustain the students' attention longer than print-based modules for instruction (Rieber, 2000; Robinson, 1998).

Additionally, students who were instructed with graphics scored higher on the post-test than students who did not received graphics-enhanced instruction. Research studies show that computer-based instruction supplemented with graphic instruction facilitates the recall of information, particularly of new rules and concepts, as well as structural relationships mentioned in the text (Chao, Cennamo & Bruanclich, 1996). Students in the present study who received graphics-enhanced instruction may have used the graphics to clarify the interpretation of the printed text or to code information for storage in memory (Rieber, 2000). Regarding self-efficacy, it was shown that computer-based instruction significantly enhanced students' beliefs about their capability to solve these math problems. This is a significant finding because research in other areas has shown that self-efficacy is a powerful predictor of one's achievement and future engagement in a task (Bandura, 1997; Zimmerman & Kitsantas, 1999). Because self-efficacy is inversely correlated with math anxiety, a very common problem among nursing students (Pozehl, 1996) that leads to more errors in medication dosage calculations, enhancement of self-efficacy may reduce the students' math anxiety and increase skill proficiency. However, graphics-enhanced instruction did not reveal a significant effect on students' self-efficacy. Numerical differences in the means indicate that students tended to feel more self-efficacious in the instructional condition supplemented with graphics.

In closing, the results of this study have important implications for nursing educators who are trying to address the challenge of improving nursing students' math calculation skills (Worrell & Hodson, 1989). Based on the findings of this study, computer-based instructional modules may be more effective in teaching math concepts to nursing students than traditional methods of instruction. This study revealed an increase both in the students' scores and their motivational beliefs, as measured by self-efficacy. Limitations of the present study include the small sample size and the fact that no information was collected about the students' familiarity or expertise with computers. Future studies should replicate these results using larger sample sizes and perhaps more interactive computer instructional modules with various multimedia aspects (e.g., interaction and sound). Future research should also examine whether gender differences exist. With only six males in this study, it was not possible to determine if there was a gender effect. In addition, instructional modules in other content areas of the nursing mathematical competency test should be developed and tested.

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Harriette A. LaVarre, Florida State University Anastasia Kitsantas, George Mason University, VA

Harriete LaVarre is a graduate student in the Department of Educational Research. Anastasia is an assistant professor in the Program of Educational Psychology at the Graduate School of Education, George Mason University.