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Teaching nursing psychomotor skills in a fundamentals laboratory: a literature review.



Aim. The aim of this article is to determine the most effective methods of teaching psychomotor skills.

Background. Research has pointed to a gap between nursing practice and nursing education. Due to a number of conditions, nursing students are learning basic skills in laboratories, rather than clinical settings. Method. A literature review was conducted to evaluate studies published since 1995 that compared alternative and traditional methods of teaching skills to novice nursing students.

Results. Of the 13 studies found, most assessed computer-related methods. A few examined alternatives, such as the use of standardized patients, high-fidelity manikins, and a mental-imaging technique.

Conclusion. Based on this limited evidence, it appears that teaching methods providing access to online interactive materials were significantly more effective than others. Three studies found that a combination of traditional lecture and demonstration methods plus computer use was more effective than either method alone.

Key Words Psychomotor Skills--Fundamentals--Learning--Nursing Education--Teaching


THE TRADITIONAL NURSING FUNDAMENTALS COURSE INTRODUCES BASIC PSYCHOMOTOR SKILLS FOR PATIENT CARE. Boxer and Kluge (2000) identified those skills beginning registered nurses (RNs) perform most often: universal precautions for infection control, vital sign assessment, intravenous therapy management, medication administration, and patient hygiene. Patient care and safety can be compromised when such basic skills are deficient (Bloomfield, Roberts, & While, 2010). Patients have reported that the proficiency and efficiency with which the practitioner performs skills can produce or reduce patient anxiety (Bjork, 1995).

Reimbursement structures are shifting to "pay-for-performance" systems, which depend on nurses to ensure that hospitals meet certain measures for quality, efficiency, and patient satisfaction (Lutz & Root, 2007). Bjork (1995) found in a literature review that over a 40-year period, patients had the stable perception that good nursing care involves the practical, technical, or manual aspects of physical care.

Yet Benner, Sutphen, Leonard, and Day (2009) reported that there is a significant gap between nursing practice and nursing education. Internationally, students and educators have expressed concerns about this gap and the inadequate skills of new graduates (Bloomfield et al., 2010; Borneuf & Haigh, 2010; Heslop, McIntyre, & Ives, 2001; Lofmark, Smide, & Wikblad, 2006; Spitzer & Perrenoud, 2006). Gerrish (2000) reported that some new graduates had deficits in skills involving medication administration, giving injections, and managing intravenous fluids. There is also debate about the adequacy of the traditional teaching methods of lecture and demonstration used to teach clinical nursing skills (Bloomfield et al., 2010), methods that allow students to learn directly from subject experts (Bloomfield et al., 2010) but that may not meet the diverse needs of students (Jeffries, Rew, & Cramer, 2002).

The teaching of clinical skills has begun to shift from clinical settings to skills laboratories. Benner et al. (2009) point out that hospitals care primarily for physiologically unstable patients, while the less acutely ill are cared for in the home and community. Also, the well-documented nursing shortage and the increasing need for care in our aging society are pressuring United States nursing programs to expand, at the same time that schools are struggling with a faculty shortage (Benner et al.). The use of skills laboratories for teaching basic nursing skills is increasing because of the demands of caring for increasingly acutely ill patients in hospitals, shorter hospital stays, staff shortages, an increased number of students, and an increased ratio of students to faculty, which limits teaching opportunities in many clinical areas (Bloomfield et al., 2010; Miracle, 1999; Tanda & Denham, 2009).

Miracle (1999) reviewed research findings on the teaching of psychomotor nursing skills and identified strategies such as the use of performance checklists, mental imagery, simulation, and multimedia but concluded that there were too few well-designed research studies. Jeffries, Kost, and Sweitzer (2009) also reviewed research on the teaching of psychomotor skills and identified strategies such as lectures, work-based learning approaches, simulation, objective structured clinical examinations, student-centered approaches, and multimedia and computer-based learning. Jeffries et al. concluded that nontraditional approaches to teaching psychomotor skills were equivalent to the more traditional classroom approaches. Ten years after Miracle's review (1999), Jeffries et al. again identified a need for better designs and more comparative research on best practices for the teaching and learning of psychomotor skills.

But the question remains: what are the most effective methods of teaching nursing students to perform psychomotor skills safely, proficiently, and efficiently? The purpose of this article is to review and synthesize comparative research studies examining methods used in a skills laboratory.

Method Journals were browsed to enable the searcher to assemble a suitable set of search terms. The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Libraries were searched using various key words, but because the pertinent articles used various synonyms for many of the terms that were not categorized under the key words, the results were far from comprehensive. Examples of key terms used initially were teaching method, nursing education, nursing skills, fundamental, fundamentals, psychomotor, basic skill, basic nursing skills, clinical skill, and clinical skills, all with a date of 1990 or later. Whittemore and Knafl (2005) stated that computerized databases are efficient but have limitations: inconsistent search terms and indexing problems may restrict the yield to only about half of eligible studies. Six pertinent articles were located in this initial effort.

Database-assigned key words in CINAHL as well as in Medline varied widely among the pertinent articles located, limiting the value of using assigned keywords in the search process. By comparing commonly used words in the full text of the pertinent articles, including synonyms, a Boolean full-text query was prepared. This query was further limited by requiring the word learning or teaching in the title, a common feature of all six pertinent articles initially located. A comparison search for the most recent year was made in which learning or teaching appeared in the text and not in the title, in which the number of responses was much larger, but with no additional pertinent articles being located.

An advanced literature search was conducted using the CINAHL Plus with full-text database limited to English-language peer-reviewed research articles from January 1995 to July 2010. CINAHL's advanced Boolean query was used as follows: TI (teaching or learning) and TX (fundamental or fundamentals or psychomotor or basic skill or basic skills or clinical skill or clinical skills) and TX (nurse or nurses or nursing). "TI" limits the terms to those in the articles' titles, and "TX" encompasses the full text in the articles. Eleven articles (including the six identified earlier) were selected from the 396 responses based upon the following additional inclusion criteria for this review: a) a psychomotor skill was the focus of the teaching; b) novice nursing students were taught in a skills laboratory; and c) the teaching method was compared with a traditional teaching method and outcome measures were defined. Manual search of the references cited in the articles found in the computer searching yielded two more research articles that met the criteria for this review. The total number of articles selected was 13. (See Table on following pages.)

Results The 13 studies, published between 1998 and 2010, took place in skills laboratories in schools of nursing in six countries, including six in the United States (Beeson & Kring, 1999; Grady et al., 2008; Jeffries, 2001; Jeffries et al., 2002; Powell, Canterbury, & McCoy, 1998; Salyers, 2007); two in Australia (Bauer, Geront, & Huynh, 2001; Bauer & Huynh, 1998); two in the United Kingdom (Bloomfield et al., 2010; Wright, Hogard, Ellis, Smith, & Kelly, 2008); and one each in Ireland (Kelly, Lyng, McGrath, & Cannon, 2009), Korea (Yoo & Yoo, 2003), and Taiwan (Lu, Lin, & Li, 2009).

SAMPLES Participants in the 13 studies were novice nursing students studying psychomotor skills in nursing laboratories. Only four studies reported complete demographic data (Bloomfield et al., 2010; Jeffries, 2001; Jeffries et al., 2002; Lu et al., 2009). Two reported gender only (Grady et al., 2008; Wright et al., 2008). One reported the demographics from the previous year as representative of the present sample (Salyers, 2007). All studies used convenience samples from a single institution. Samples ranged in size from 10 (Kelly et al., 2009) to 147 (Lu et al., 2009). Four had a sample size of less than 40 (Bauer & Huynh, 1998; Grady et al., 2008; Kelly et al., 2009; Salyers, 2007). Eight studies reported attrition rates.

RESEARCH DESIGN Four studies did not use randomization (Grady et al., 2008; Jeffries et al., 2002; Yoo & Yoo, 2003; Salyers, 2007). Six used a pretest-posttest design (Beeson & Kring, 1999; Bloomfield et al., 2010; Jeffries, 2001; Jeffries et al., 2002; Lu et al., 2009; Wright et al., 2008). The other seven used posttest only. All compared two methods of teaching psychomotor skills, except for two studies that compared three methods (Bauer & Huynh, 1998; Bauer et al., 2001). Only three studies reported a power calculation (Bloomfield et al., 2010; Jeffries, 2001; Kelly et al., 2009).

TEACHING METHODS COMPARED Ten studies compared traditional teaching methods with either computer-based teaching or a combination of computer-based and traditional teaching. Seven of the 10 compared only traditional teaching with computer-based teaching; one compared traditional teaching with a combination of traditional teaching and computer-base teaching (Lu et al., 2009); and two made comparisons among traditional, computer-based, and the combination of the two (Bauer & Huynh, 1998; Bauer et al., 2001). Only two of the 10 computer-based approaches were web-based so that the students could access the programs at any time from any computer (Lu et al., 2009; Salyers, 2007). The remaining eight used videos, CD-ROMs, or dedicated computer locations (Bauer & Huynh, 1998; Bauer et al., 2001; Beeson & Kring, 1999; Bloomfield et al., 2010, Jeffries, 2001; Jeffries et al., 2002; Kelly et al., 2009; Powell et al., 1998), with Jeffries et al. using dedicated computer locations on only some modules.

Two studies used simulation: one compared a standardized-patient method to the traditional lecture (Yoo & Yoo, 2003); the other compared a high-fidelity physical model to a low-fidelity physical model (Grady et al., 2010). Wright et al. (2008) used a mental-imaging technique as an adjunct to the traditional lecture and compared it to traditional lecture.

OUTCOME MEASURES All 13 studies considered skill performance as an outcome measure and employed a checklist of critical skills. All studies used assessors to score student demonstrations. One also assessed the students' perceptions of their performance (Grady et al., 2008).

Seven studies used multiple-choice knowledge tests (Beeson & Kring, 1999; Bloomfield et al., 2010; Jeffries, 2001; Jeffries et al., 2002; Kelly et al., 2009; Lu et al., 2009; Salyers, 2007). Satisfaction levels were measured on a Likert scale in four studies (Jeffries; Jeffries et al., Kelly et al.; Salyers).

All but three of the studies (Bauer & Huynh, 1998; Kelly et al., 2009; Wright et al., 2008) addressed reliability and validity of findings. In three studies, assessors had been blinded to group (Grady et al., 2008; Lu et al., 2009; Powell et al., 1998). A majority of the studies measured outcomes either immediately or within a week of instruction. In three, however, outcomes were measured at the end of the semester (Salyers, 2007), at four weeks (Grady et al., 2008), and at six weeks (Kelly et al., 2009). Only one study (Bloomfield et al., 2010) measured outcomes more than once, testing for retention of knowledge and performance skills at two weeks and eight weeks of instruction.

PSYCHOMOTOR SKILLS TAUGHT The most frequently taught skills were blood pressure measurement (three studies), followed by Foley catheter insertion, intramuscular injection, and sterile dress ing change (two studies each). Appearing only once in the 13 studies were mouth care, back care, position change, glycerin enema, nasopharyngeal suction, nelaton catheterization, nasogastric tube insertion, oral medication administration, use of peak flow meters and incentive spirometers, pulse oximetry, and handwashing.

COMPUTER-BASED TEACHING METHODS None of the eight computer-based studies that were not web-based found a significantly better effect on the performance of the psychomotor skill over the traditional teaching method when initially measured (Bauer & Huynh, 1998; Bauer et al., 2001; Beeson & Kring, 1999; Bloomfield et al., 2010; Jeffries, 2001; Jeffries et al., 2002; Kelly et al., 2009; Powell et al. 1998). Bloomfield et al., however, in a follow-up measure at eight weeks, did find a statistically significant difference on skill performance in favor of the computer-based teaching method. Two studies (Bauer & Huynh; Bauer et al.) found a combination of non-web-based computer teaching and traditional teaching to be better than either alone for blood pressure measurement skill. Lu et al. (2009) found the combination of a web-based course management tool in addition to the traditional classroom lecture and demonstration method to have a significantly better effect on intramuscular injection skill performance than the traditional method alone.

COMPUTER-BASED TEACHING METHODS AND KNOWLEDGE GAIN Seven computer-based studies measured knowledge as an outcome. Three found the computer groups to have significantly greater knowledge gains than groups taught by the traditional teaching method. Of these three, one used a computer-based teaching method alone for oral medication administration (Jeffries et al., 2001); another added a computer web-based lecture to live demonstrations for nasopharyngeal suction, catheter insertion, and wet-to-dry dressing changes (Salyers, 2007); and a third used a combination of a web-based course management tool in addition to traditional classroom methods for intramuscular injection skill (Lu et al., 2009). Another three found equivalent results for knowledge gain (Bloomfield et al., 2010; Jeffries, 2002; Kelly et al., 2009). An older study, Beeson and Kring (1999), found that the combination of a traditional lecture with a video presentation did significantly better on knowledge gain than a computer-based (interactive video) teaching method alone for blood pressure measurement.

MANIKIN FIDELITY, STANDARDIZED PATIENT, AND MENTAL IMAGING Significantly better results were seen with a high-fidelity manikin than with a low-fidelity manikin on performance of nasogastric tube insertion and Foley catheterization (Grady et al,, 2008). Yoo and Yoo (2003) found that the group using a standardized patient did significantly better on the performance of mouth care, back care, position change, in-and-out catheterization, and glycerin enema skills than the traditional lecture and demonstration group. The mental-imagery group did significantly better on the blood pressure skill performance than the traditional teaching method group, but there was no significant difference for sterile dressing changes (Wright et al., 2008).

EFFECT OF COMPUTER-BASED TEACHING METHOD ON SATISFACTION Jeffries (2001) found the interactive, multimedia CD-ROM teaching method conferred higher student satisfaction. Jeffries et al. (2002), however, found that the traditionally taught group was significantly more satisfied than the group using a self-study module with CD-ROM. Salyers (2007) likewise found that the traditionally taught group was significantly more satisfied with the course. Kelly et al. (2009) surveyed all the students in the class (not just those who participated in the study) as to their attitude about using online video as a teaching method and found female and more mature students more positive about the method.

Discussion Ideally, deciding how to teach clinical skills to novice nursing students in skills laboratories is based, at least in part, on evidence--and the stronger the evidence the better. Several of the studies reviewed were reasonably well designed, including Lu et al. (2009), Bloomfield et al. (2010), and Jeffries (2001). But they were few in number, and all had limitations, many of them major.

For example, several had small sample sizes--only three reported power or sample size calculation--and some samples were not randomized. All studies used a sample from a single institution. Most used a posttest-only design. Inconsistent measures, unequal instructional times, different intervals between instruction and testing, and only one or a limited number of psychomotor skills being tested limited the generalizability of findings. Most lacked a theoretical framework, and the studies often had uncontrolled variations between groups. None of the studies analyzed the relative costs of alternatives from either the student's or the institution's perspective. Some studies had instrument reliability and validity issues. Overall, the quality of the evidence is weak; thus, more rigorous research is necessary.

Unsurprisingly, because computer-assisted learning (CAL) is gaining in popularity (Bloomfield, While, & Roberts 2008), most alternative teaching methods identified were computer-based. Jeffries (2001) noted the shift from teacher-centered to student-centered instruction resulted in approaches such as interactive multimedia CD-ROMs. CAL allows the student to practice psychomotor skills safely and to view repeated demonstrations of a procedure (Bauer et al., 2001).

Based on this limited evidence, teaching using web-enhanced course materials (Lu et al., 2009; Salyers, 2007) may be significantly more effective than teaching without them. For example, Salyers found significantly better cognitive gain, but not performance gain, with web-based materials than with traditional teaching methods. Salyers noted that his "experimental group experienced many problems with the technology," such as trouble downloading PowerPoint documents (p. 9). Lu et al. did not report such problems and found significantly better cognitive and performance gains with web-based teaching.

Many students now have powerful computers and high Internet speeds and are more skilled with computers than their predecessors; they can access materials at any time and from almost any place. Instructors also have more powerful computers and servers, greater Internet capacity, and more experienced programmers to help in writing programs. The costs of computers and Internet access have gone down.

The cost of implementing technologic teaching methods is as important a factor as effectiveness, yet none of the studies considered cost. Additional research addressing cost along with effectiveness would be valuable.

In three studies (Bauer & Huynh 1998; Bauer et al., 2001; Lu et al., 2009), the combination of traditional lecture and demonstration plus computer use was more effective than either alone. Further, Salyers (2007) showed that adding a web-enhanced lecture to a traditional demonstration significantly improved cognitive results. It appears that to optimize novice students' learning of nursing fundamentals, various teaching approaches should be used together.

Several studies looked at other approaches. One found that standardized patients were more effective than traditional lecture demonstration. Another found that high-fidelity manikins were more effective than low-fidelity manikins. Yet another showed that a mental imaging technique used as an adjunct to the traditional lecture demonstration was more effective in teaching blood pressure measurement. As each of these approaches had only a single study with significant weakness in design, further, more rigorous research is appropriate.


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Susan McNett, PhD, RN, is clinical assistant professor, Indiana University School of Nursing, Indianapolis. For more information, contact her at
Table. Alternative and Traditional Teaching of Nursing Psychomotor
Skills: Studies Reviewed (N = 13), 1998-2010 Powell et al., 1998
This US study compared a self-directed videotape with traditional
faculty-assisted teaching of medication administration involving
different routes (injection, oral, topical).

Design: Randomized, posttest only.

Sample: Junior nursing students (n = 98) enrolled in the first
clinical course of a baccalaureate nursing program during the fall
and spring semesters.

Outcome Measures: Observed skill-performance test with 17 items
covering the behaviors necessary to administer medication.

Results: No significant difference between the groups.

Bauer & Huynh, 1998 This Australian study compared a
self-instructional CD-ROM with a traditional lecture/demonstration
method, as well as a combination of both, for teaching blood
pressure measurement.

Design: Randomized pilot study, posttest only.

Sample: First-year university nursing students (n = 27).

Outcome Measures: Observed skill performance test using a 16-step
checklist (collapsed into 6 categories).

Results: The CD-ROM group adhered to the procedural steps better
than the traditional lecture/demonstration group. The group
receiving both methods performed best.

Beeson & Kring, 1999 This US study compared interactive video and
traditional lecture/linear video for teaching blood pressure

Design: Randomized pretest-posttest.

Sample: Sophomores (n = 104) enrolled in a nursing assessment

Outcome Measures: A 14-item multiple-choice test measured knowledge
about blood pressure and an observed skill-performance test using a
20-item checklist measured performance.

Results: Both groups showed significant gains in knowledge, but the
lecture/linear video group scored significantly higher than the
interactive group on the knowledge test. There was no significant
difference in performance of blood pressure measurement.

Bauer et al., 2001 This Australian study compared a
self-instructional CD-ROM with traditional lecture/demonstration
and both together for teaching blood pressure measurement.

Design: Randomized posttest only.

Sample: First-year university nursing students (n = 67).

Outcome Measures: Observed skill performance test using a checklist
based on the 16 steps of the procedure.

Results: The 16 steps of measuring blood pressure were adhered to
better by the combination group than by either the
lecture/demonstration-only or CDROM-only group. The CD-ROM-only
group demonstrated the skill poorly.

Jeffries, 2001 This US study compared an interactive, multimedia
CD-ROM with a traditional lecture for teaching oral medication

Design: Randomized pretest-posttest.

Sample: Juniors (n = 42) beginning a fundamentals nursing course in
a large midwestern university.

Outcome Measures: Forty-item knowledge test based on course
objectives and learning dimensions; pretest and posttest questions
were the same but were presented in a different order. An observed
skill performance test used a checklist from the students'
textbook. A student satisfaction questionnaire was also used.
Response scale ranged from +2 to -1.

Results: The interactive, multimedia CD-ROM teaching method group
did significantly better on the posttest knowledge score. No
significant difference between the two groups in their ability to
demonstrate the skill correctly. The interactive, multimedia CD-ROM
teaching method group demonstrated higher student satisfaction.

Jeffries et al., 2002 This US study compared interactive,
student-centered, self-study modules (using CD-ROMs when available)
and a traditional lecture/demonstration format for teaching sterile
dressing change.

Design: Pretest-posttest.

Sample: University students enrolled in a nursing fundamentals
class (n = 120): 70 were sophomores in a student-centered
fundamentals course and 50
were juniors in a traditional lecture/demonstration fundamentals

Outcome Measures: Twenty-item instructor-developed knowledge test
that covered surgical asepsis. Observed skill performance of a
sterile dressing change; student satisfaction questionnaire
assessed teaching method, self-efficacy in learning, and attitudes
of self-reliance in learning.

Results: There were no significant differences between the two
groups' pretest and posttest cognitive gains. The groups were also
similar in their ability to demonstrate the psychomotor skill
correctly in the skills laboratory. The student-centered group was
significantly more satisfied with the teaching method used.

Yoo &Yoo, 2003 This Korean study compared a standardized patient, a
traditional lecture/demonstration format, and practice on
laboratory manikins in the teaching of mouth care, back care,
position change, nelaton catheterization, and glycerin enema.

Design: Nonequivalent, posttest only.

Sample: Sophomores in a fundamentals nursing course (n = 76).

Outcome Measures: Observed performance of mouth care, back care,
position change, nelaton catheterization, and glycerin enema. Five
standardized operational manuals were developed, one for each
skill, based on the textbooks. This manual included the critical
behaviors to be demonstrated by students and was used as a

Results: The standardized-patient group did significantly better on
the performance of the skills.

Salyers, 2007 This US study compared a web-enhanced lecture plus a
three-hour lab session with a three-hour traditional lecture and
demonstration for teaching nasopharyngeal suction, catheter
insertion, and wet-to-dry dressing change.

Design: Posttest only.

Sample: Students (n = 36) enrolled in a beginning nursing skills
laboratory course.

Outcome Measures: Sixty-item multiple-choice cognitive final exam.
Observed skill performance test using a checklist of predetermined
critical elements. Satisfaction survey that consisted of one item,
overall satisfaction with the course, using a 5-point Likert scale.

Result: The web-enhanced/demonstration group performed
significantly better on the comprehensive cognitive final exam. The
traditional lecture/ demonstration group was moderately more
satisfied with the course.

Wright et al., 2008 AUK study compared mental imagery training
along with traditional teaching and a traditional teaching method
for teaching blood pressure measurement and sterile dressing

Design: Randomized, pretest-posttest pilot study.

Sample: Preregistration nursing students at one university (n =

Outcome Measures: Objective structured clinical examinations;
students performed one of the two skills on a simulated patient and
were awarded points for performing each element of the skill.

Result: The imagery group scored statistically significantly higher
on the blood pressure measurement but not on sterile dressing

Grady et al., 2008 This US study compared high-fidelity and
low-fidelity simulators in teaching nasogastric tube insertion and
Foley catheter insertion.

Design: Posttest only.

Sample: First-year nursing students (n = 39).

Outcome Measures: Observed skill performance test using a checklist
of predetermined critical elements; 21-item checklist for
nasogastric tube and 15-item checklist for urinary catheter

Results: There was significantly higher performance with
high-fidelity than with low-fidelity manikin training.

Lu et al., 2009 This Taiwanese study compared a web-based course
management tool combined with traditional classroom instruction and
traditional classroom instruction for teaching intramuscular

Design: Randomized (by cluster, not individual student),
pretest-posttest, two-group study.

Sample: Second-year nursing students in a class studying a
fundamental nursing subject (n = 147).

Outcome Measures: Nine-item knowledge assessment scale and a
76-step performance scale on intramuscular injection.

Results: The web-based group had statistically significantly higher
knowledge gain and skill performance.

Kelly et al., 2009 An Irish study compared online videos with
traditional lecture/demonstration for teaching peak flow, incentive
spirometry, and pulse oximetry.

Design: Randomized, posttest only.

Sample: First-year nursing students in a skills-based module (n =

Outcome Measures: Objective Structured Clinical Examination using
standardized assessment tools developed by the project team;
15-item multiple choice knowledge quiz. Attitude questionnaire,
which consisted of 16 Likert-scale statements eliciting whether
students strongly agreed, agreed, disagreed, or strongly disagreed.

Results: There was no significant difference between the two groups
on knowledge or performance.

Bloomfield et al., 2010 A British study compared computer-assisted
learning with traditional lecture/demonstration for teaching

Design: Randomized, pretest-posttest.

Sample: First-year nursing students (n = 231 at baseline, 164 at 2
weeks, and 86 at 8 weeks).

Outcome Measures: Twenty-item multiple-choice test measured
knowledge; an Objective Structured Clinical Examination measured
performance. A 17-item skill-performance checklist was used.

Results: There were no significant differences between the groups'
knowledge scores. Skill performance scores were similar in both
groups at 2-week follow-up, but at 8-week follow-up there were
significant differences in favor of the computer-assisted learning
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Date:Sep 1, 2012
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