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Health, knowledge, and networked communication.


This paper presents the experiences of a networked community of nurses who have expertise in heart care, and whose aim is to produce knowledge useful for medical practitioners, people with a heart condition and their families. The nurses built knowledge in collaboration, shared their practices from a distance, and produced an instrument for the benefit of the population. A constructivist theoretical approach was applied through a multimethodology integrating ethnographic and discourse analysis techniques. Results suggest that the nurses engaged in a higher order level of conceptual change.


To address a long standing heart disease crisis in the Canadian health, the most frequent cause of death among Canadians, I conducted research in collaboration with the OIIQ-Order of Nurses of Quebec and a number of partners (hospitals and health centres) and the CEFRIO--French Speaking Centre of Informatization of Organisations with the goal of building a networked community of nurses. During a six month period, thirty three nurses from the Quebec, Ontario, and New Brunswick volunteered to discuss online their practices and knowledge about cardiology


The objective of this research was twofold: (1) To engage nurses in active collective reflection in order to address health system problems related to cardiology, and (2) To verify whether a participatory community building strategy enabled by networked argumentation would lead the nurses to build knowledge collaboratively. I use the term networked argumentation to describe the reflective process through which conditional structures (If-Then lead to conclusions in online conversations. According to Grize (1991) all conversational activity should be seen as argumentation. The research was designed using quantitative and qualitative techniques to assess the pertinence and adequacy of conferencing systems and a participatory community building strategy for fostering in-depth thinking and higher order collaborative learning.

Theoretical Framework

When people participate in electronic conferences they have written "conversations", they "argue online". These conversations have neither the formal structure of essay writing nor the informal character of personal conversations. The literature, although scarce, has highlighted that online "conversation" allows participants to reflect more consistently about their ideas because of the editing process that is involved in active reading and writing (Harasim, 1990; Bruer, 1994, Scardamalia, and Bereiter, 1994). Asynchronous text-based online participation can induce partners to engage in collaborative learning and knowledge building. How? I hypothesized that applying the strategy of participatory community building and the Knowledge Forum [1] conferencing system scaffolding tool would both support collaborative in-depth understanding leading to conceptual change and knowledge building.

A constructivist view of conceptual change can be understood in terms of the adaptation process and the role of metacognition. Knowledge acquisition supposes an active process of conceptual assimilation and accommodation leading to adaptation to the social environment (Piaget, 1959). A new adapted path of understanding through recursive comprehension and interpretation is necessarily the result of a conceptual change. Metacognition is an awareness of our own cognitive processes (or a vigilant state in which we are able to understand and transform concepts and ideas). Constructivism points to the difference between succeeding when performing an action and understanding it (Piaget, 1974). A person can succeed in identifying a problem and structuring it through language but to understand it supposes an awareness of its premises and conclusions. Conceptual change, then, is an intentional and reflective problem-solving metacognitive process in which previously held concepts and ideas lead to new--or transformed--ones.

The notion of scaffolding, introduced by Bruner (1975), is related to the support that an adult can provide to a child (Vygotsky's zone of proximal development). For adults "conversing" online, "development" could be understood as the distributed progression of discourse. The distributed and progressive nature of electronic conferencing (Salomon, 1993) allows a threefold scaffolding process: (1) that is achieved by the facilitator through adequate intervention in order to support the progression of the discourse, (2) that is assumed by the participants through motivation and mutual support, and (3) that is played by technological tools allowing all participants to advance the networked argumentation process. Scardamalia (2002) explains that technologies such as Knowledge Forum's scaffolding tool which allows users to insert tags that "label" (or give a title to) a phrase or a part of a message, can support a progressive process of production and improvement of ideas that are important for a networked community.

Research Method

I designed a multimethodology integrating ethnographic techniques (participatory community building and structured observation) and discourse analysis.

Participatory community building

Participatory design is a methodology used in software development that involves the active collaboration of users. I adapted the concept of participatory design for community building in which the scientific director of the OIIQ, the facilitator, and the nurses all participated in the design of the community of nurses.. Documentation of the process was done through ethnographic note-taking. The process of participatory community building had two steps. First, OIIQ, the CEFRIO and I identified the basic needs to launch the community. Knowledge Forum was chosen to support communication in the community, and a nurse with an expertise in heart care was selected for the role of community facilitator. Second, I contributed by actively participating in the design of the community building strategy.

The nurses were recruited by the facilitator. Two face-to-face meetings were organized, one in Montreal and the other in Quebec City to gather together those living in the adjacent regions of these cities. The nurses living in distant parts of Qu6bec, News Brunswick, and Ontario met through telephone conferencing. The face-to-face and telephone meetings had two goals: socializing and training. The nurses discussed what kind of community they would be willing to build, and they were trained on the use of Knowledge Forum.

The facilitator and I designed the conferences together. The most important ones were "At the heart of our exchanges", designed for discussing which heart problems were most appealing and relevant for the nurses' professional lives, and "Heart health kit", in which the nurses collaboratively authored a booklet to be distributed among the ill and their families. The facilitator also built a web site to host documentation on cardiology and other information important for the community. The Knowledge Forum labels tool was used to enable a structured argumentation process. This tool allows the user to "label" a part of or a whole message. I proposed scaffolds that required participants to be aware of the "arguments" they were constructing, in line with established views in argumentation theory. I discussed the scaffolds and the meaning to be attributed to them with the OIIQ's scientific director and facilitator. The scaffolds, later presented and validated by the participating nurses, were:

(1) Claim--introduction of a contextual situation to express concerns and difficulties about the practice, affirming something;

(2) Data: introduction of facts, statistics, scientific data, research results or other information that could have an influence on the practice and would support a claim;

(3) Envisaged solutions: engaging in a process of hypotheses formulation that could support or not a claim depending on the data;

(4) Questioning: formulation of interrogations;

(5) Opinions: expressing ideas about information found in a previous message as a way of introducing a new turn of argumentation.

My goal as researcher was to enable the nurses to anticipate, prior to writing, what their arguments would be, and apply the scaffolds intentionally (meta-cognitively) without affecting spontaneity. The use of the scaffolds would guide the interpretation of the messages. For example, a message with a clear presentation of a claim would solicit a different reaction than a message proposing a hypothesis (envisaged solution). This strategy would assist the nurses to become metacognitively aware of the knowledge building process. My role during the six months was to read the messages and to consult with the facilitator on intervention strategies that she might use to advance dialogue and motivate the community. The nurses were aware of my role, and agreed with my participation as the facilitator's "coach".

Discourse analysis

I developed a constructivist method of discourse analysis in which the progression of logical forms is seen as a way to identify conceptual change and collaborative knowledge building. The unit of analysis is a judgment (sentence) structured upon a technological unit (message) (Campos, 2004). Judgments are schemes that express physical or symbolic actions through discourse. Piaget explains that action schemes are the products of assimilation and accommodation processes in which previous acquired procedures are applied to new situations. This process, as explained above, leads to change (learning) in which new or old objects are incorporated to known schemes (1959). Understanding discursive conceptual change allows the verification of collaborative learning and knowledge building. The judgments were coded according to the above-mentioned scaffold categories: (1) Claim, (2) Data, and (3) Hypothesising: "Envisaged solutions" and "Questioning" [2].

Results and Discussion

Quantitative analysis

The database contained 545 messages. I studied two conferences, one in which problems related to heart care practices were identified ("At the Heart of our exchanges", with 122 messages), and the second in which the nurses worked together to prepare deliverables to address the previously identified problems ("Heart health kit", with 141 messages). In the first conference, the nurses explored the difficulties of engaging patients in the prevention of heart failure, and proposed ways to encourage them to share the responsibility for their treatment with the medical personnel and their families (a sort of structured brainstorming). In the second conference, the nurses prepared a teaching instrument to be given to the patients to help them to control symptoms and signs of heart failure and, therefore, to enable auto-surveillance. There is continuity between the first and the second conferences.

Quantitative data show that the nurses applied scaffolds in 73.8% of the messages of the first conference, and 67.4% of the second. If messages with scaffolds are isolated from those without scaffolds, 92% of the first conference sentences and 70.8% of the second could be found within scaffolds. These numbers show consistent scaffold use, suggesting that the nurses intentionally structured their thoughts in a meta-cognitive way. Other numbers are eloquent with regards to this hypothesis. In the first conference, the occurrence of all types of scaffolds is reasonably balanced. It must be noted, though, that the pair "questioning / envisaged solutions" is responsible for 51.3% of all occurrences, indicating a high level of inquiry and hypothetical reasoning. In the second conference, this trend changes significantly because the scaffold "data" is responsible alone for 39.5%. Reflective thinking suggested by the use of the scaffolds "questioning / envisaged solutions", though, is still high (32.9%). The differences can be explained by the nature of each conference: In the first the nurses were brainstorming while in the second they were gathering information (data) to build the kit.

Qualitative analysis

Here are examples of scaffold use (conference "At the heart of our exchanges"):

a) Message written by the facilitator

Claim--The problem concerning the patient decision to take charge of his/her health is related to the non modification of behaviours that are health damaging. It seems to be important, following what you have proposed, that the patient becomes responsible for his/her own health.

Envisaged solutions--The solutions envisaged here refer to the importance of considering the needs of each patient and that of following his/her level of adaptation to the illness in order to enable the nurses to guide him/her in the process of taking charge of his/her health.

Questioning--What are the nursing strategies that should be specifically designed to follow to patients in their process of taking charge of their health in order to help them to change behaviours damaging to their health? What are the models of behaviour change that could guide our discussion?

b) Message written by a participating nurse

Claim--With psychiatric patients there are contracts made to enable them to take charge of their health and made them responsible for the follow up. We have one contract concerning aid, another one concerning what has to be done to act effectively ... Because they engage in the process of taking charge, most contracts are respected.

Envisaged solutions--A contract with cardiac patients is a solution to be considered.

What can be achieved by the use of argumentation scaffolds? In the examples presented above, it is possible to verify that a process of conceptual change was taking place (adapting a scheme to a new situation). The facilitator structures the message presenting a "claim" (the need that patients take charge of their health), "envisaged solutions" (a reference to previous suggestions already made), and "questioning" the participants to propose solutions to the problem. One of the nurses, under the scaffold "claim" asserts that with psychiatric patients, contracts are being used. The envisaged solution (hypothesis) is that this procedure could be applied to patients with heart problems. Conceptual change can be identified here because the hypothetical aspect of networked argumentation enabled the nurse to jump to another path of understanding by proposing a solution for the problem [3]. In addition, one can assume that collaborative learning occurred because this passage also led to the knowledge building process that resulted in the production of the "Heart health kit".

In the conference "At the heart of our exchanges" the nurses explored the problems of teaching, educating, and helping the patients to take charge of their health. It was a brainstorming process in which they explored dozens of issues related to this subject in the search of the most appropriate deliverable to the ill. I consider that the nurses were, in this conference, in a reflective mode. This interpretation is in line with quantitative data demonstrating high level use of questioning and hypotheses formulation. It was in this conference that the nurses, democratically, decided to build together a heart health kit, co-authored in the next conference. The writing of the instrument, developed in the next conference ("Heart health kit"), led the nurses to be in what I call a production mode. This interpretation is also in line with quantitative data which show a frequent use of the data scaffold. Although the facilitator was in charge of the community, and encouraged participation, it is important to state that her behaviour was democratic and that her leadership was explicitly accepted by the voluntary participants.

The use of the argumentation scaffolds suggests, at least, that: (1) they were intentionally used to organize the content of the contributions (judgments), and (2) most judgments were meta-cognitive because it would be very unlikely for the nurses to structure practical knowledge having a scientific foundation while being naive and/or unaware of what they were doing.


Although no definite proof could be presented that the scaffolding strategy (participatory community building and use of the scaffolding tool) triggered conceptual change, the positive results achieved are related to the design applied. One could argue that discussion would have been profound in the absence of scaffolds, and that only experimental methodologies enable proof of a possible active role of scaffolds in triggering conceptual change, collaborative learning, and knowledge building. However, such a design would be inapplicable in real life contexts such as the one presented here. Experimental methodologies would, certainly, impeach spontaneity and, arguably, freeze interactions. In this community, the nurses used at least one of the scaffolds in most of the messages (88% in the first and 92% in the second conference). It is plausible, then, to believe that the whole strategy used to apply this tool had a significant role in the collaborative knowledge-building process of the networked community of nurses; they made claims, presented data to support them, questioned, hypothesized, and proposed a concrete solution to the problems discussed.


[1] Knowledge Forum is a conferencing system designed to support knowledge-building processes. It was chosen, among other reasons, because it has a "scaffolding" tool that allows users to insert "label" in the message text. By "labeling" the text, users can categorize their thoughts.

[2] The scaffold "Opinions" could have the sense of claim, data or hypothesizing. The intercoder reliability (two independent blind coders) is 92.41%.

[3] The database has more consistent examples of conceptual change. Because they are long, I present a simple case.


Bruer, J.T. Schools for thought: A science of learning in the classroom. Cambridge, MA: MIT Press, 1994.

Bruner, J. S. "The ontogenesis of speech acts." Journal of Child Language, Vol. 2, 1-20 (1975).

Campos, M. N. "A constructivist method for the analysis of networked cognitive communication, and the assessment of collaborative learning and knowledge building," Journal of Asynchronous Learning Networks, Vol. 8, No. 2, 1-29 (2004).

Harasim, L. Online Education: Perspectives on a New Environment. New York: Praeger, 1990.

Grize, J.-B. Logique et langage. Paris: Ophrys, 1991.

Piaget, J. Reussir et Comprendre. Paris: Presses universitaires de France, 1974.

Piaget, J. "Apprentissage et connaissance." In Pierre Greco, and Jean Piaget, Eds. Apprentissage et connaissance, 21-67. Paris: Presses Universitaires de France (1959).

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Scardamalia, M. "Collective responsibility for the advancement of knowledge." In B. Smith, Ed. Liberal Education in a Knowledge Society, 67-98. Chicago: Open Court (2002).

Scardamalia, M., and Bereiter, C. "Computer support for knowledge-building communities." The Journal of the Learning Sciences, Vol. 3, No. 3, 265-283 (1994).

Milton Campos, PsyD., is Professor of Networked Communication and Cognition.
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Author:Campos, Milton
Publication:Academic Exchange Quarterly
Date:Sep 22, 2004
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