Using a Telehealth Program to Provide a
Teaching learning Experience for College Students

Janice Putnam
Department of Nursing
Central Missouri State University
Warrensburg, Missouri, USA

Amy Kiger
University Health Center
Central Missouri State University.

Allison Norwood
Department of Nursing
Central Missouri State University.

Kim Steiglitz
Department of Nursing Putnam
University of Missouri, Saint Louis, Missouri

Peggy Ward-Smith
Department of Nursing
University of Missouri, Saint Louis, Missouri

Abstract

This study explored the use of nursing students (N = 65) as tele-health counselors for smoking cessation. The nursing students
were instructed to use therapeutic communication and behavior change theory to interact online with the subjects (N = 24). The
course was monitored by the clinical instructor, and discussed in a clinical post-conference setting. Results: The nursing student evaluations were mixed. The students liked: "communicating therapeutically", learning about Blackboard, developing technology skills, the wellness setting, and "helping people stop smoking". Several students were uncomfortable talking to someone who they did not know. The students generally reported that the technology was effective for learning.

Introduction

In response to differing accessibility needs for smoking cessation programs for college students (Central Missouri State University's State of Tobacco Usage Report, 2003), a peer delivered, telehealth smoking cessation program was implemented. Junior level baccalaureate nursing majors applied the principles of therapeutic communication and client education using telehealth in the educational delivery platform BlackboardTM. These individuals fully developed and implemented this innovative smoking cessation course. The purpose of this project was to provide education directly to those unable to attend a face-to-face program. The results indicate that the telehealth intervention was as successful as face-to-face support for smoking cessation. The focus of this article is on the teaching and learning experiences of the nursing majors and clinical instructor participating in this project.

Prevalence
The Centers for Disease Control (CDC) (2003) estimate a yearly loss of 5.6 million years of life, over 440,000 deaths each year, $75 billion in direct medical costs, and 6.4 million children that will die prematurely because of tobacco use. The surveillance data specific to Missouri reveals an adult prevalence of smoking of 27%, the third highest in the nation (CDC, 1998). Of adults aged 18-24 years, 40.8% of males and 30.8% of females reported smoking. According to the Missouri Partnership on Smoking or Health, Missouri ranked last nationally for funding tobacco prevention programs, and the economic cost to Missouri residents is $3.841 billion annually (CDC, 1997). Despite the high prevalence of tobacco abuse, there have been no formal smoking cessation programs available at this university prior to fall semester 2003.

Smoking Cessation Programs
The American Lung Association (ALA) has developed a "gold standard" smoking cessation program titled the "Freedom from Smoking Program". This program is a multiple component intervention that adapts combinations of individual counseling, education, pharmacotherapy, and peer support. Program efficacy for the traditional "Freedom from Smoking Program" has been reported to be 27% sustained abstinence at 3 months, and 19% abstinence at 1 year (Lando, McGovern et al. 1990).

The "Freedom from Smoking Program" is delivered face-to-face by certified counselors. This program had two limitations restricting its implementation at the university. The classroom delivery format was not accessible to the rural population of smokers who reside off campus. The second limitation surrounded scheduling difficulties, which resulted in little flexibility in group meeting times.

Technology and smoking cessation
There is an exponential increase in the use of and research documenting the implications of technology as an alternative delivery format in changing health behaviors. High-level technology delivery formats for health behavior change interventions include the use of interactive technology, CD-ROMs, and accessing the Internet or "Web".

These high-level technology delivery approaches were identified in health promotion literature. Studies include smoking cessation programs (ONeill, Gillispie et al. 2000), preventing alcohol and smoking use (Gerbert, Berg-Smith et al. 2003), smokeless tobacco cessation programs (Fisher, Severson et al. 2001), self-help programs for students with eating disorders (Parham 2001), and cancer education and prevention (Agre, Dougherty et al. 2002; Thomas, Stamler et al. 2002).

Teaching Learning for Nursing Students

Nursing informatics has been defined as the integration of nursing and computer science to expand the knowledge of nursing and to provide support for nursing practices (Simpson, 1998). One aspect of nursing influenced by computer technology includes telenursing / telehealth as a method of patient education. The use of teleheath has been documented as an effective intervention for weight loss management (James, Folen et al. 2001). The need for computer skills in nursing is well documented (Elfrink, 2000, Hannah, 1988, Hovenga et al, 1996, Lowry & Johnson, 1999, McGonigle & Eggers, 1991, Travis & Brennan, 1998). McNeil and colleagues (2003) explored the skill preparation and computer technology of nursing students, faculty and clinicians. Telehealth was identified as one intervention available that may improve the quality and cost effectiveness of patient care.

The use of telehealth has been documented in fields of medicine, social work and school-based care (Young & Ireson, 2003; McCarty & Clancy, 2004). There is a paucity of telehealth and computer technology education in the curricula of many nursing programs (Kenny, 2002). This documents the need for research related to optimal teaching and learning strategies using telehealth in nursing programs.

Incorporating a telehealth intervention in nursing education encourages students to explore the benefits and risks of using computers in health care. The educational goal of this project was to allow the student to integrate knowledge of the adult teaching / learning process into clinical practice. The objectives were to discuss the benefits and purpose of client teaching, articulate factors that facilitate and factors that are barriers to learning, to discuss how principles of learning affect nursing care, to discuss learning in relation to age, environment, mental capability, education, readiness, timing, desire or interest, and previous knowledge, to include sociocultural diversity into the learning experience, and to apply the nursing process. Therefore, delivering the Freedom from Smoking program using the Blackboard format included telehealth support from nursing students in the form of small online group discussions in an instructor supervised environment. A review of the literature revealed no articles evaluating the use of the Blackboard format to deliver a smoking cessation program.

Technology and the College Student
Many of today's college students are members of the newest generation, the Millennial Generation. This population is a group of individuals who insists upon the use of computer technology and who find computers a non-threatening source of information and entertainment (Howe & Strauss, 2003; Eng & Gustafson, 1999). Many colleges provide online education using the Blackboard format. This allows students to become accustomed to, as well as expect, online learning.

Blackboard Incorporated (Blackboard, 2003) has developed an extremely successful course management system designed to enhance teaching and learning. Over 2,000 higher educational institutions in the United States are currently using this system (Blackboard, 2003). The features of Blackboard include flexible content management, assessment management, an online grade book, communication tools (including a virtual classroom), chat rooms and discussion boards. The communication features provides synchronous or asynchronous communication. Small group discussions or private messaging is also available. The discussion boards and virtual classroom features encourage peer engagement. Blackboard provides a password secured course management system that integrates and protects the participant's identity.

Macromedia Breeze (Macromedia, 2005) is computer software that integrates Power Point with Macromedia Flash to provide more effective educational communication. By adding streaming audio to Power Point presentations, Breeze enhances distance teaching and learning. Requirements for Breeze include Windows, a web browser, Macromedia Flash Player, and Microsoft Power Point software. A microphone with noise suppression and speakers on the desktop are the hardware required. An advantage to this software system is the increased online download speed of files that are converted to Breeze. This is important for students using modem connections. The process to convert a Power Point presentation to a Breeze presentation involves recording the audio, uploading the presentation to Macromedia, and then publishing the presentation where it is converted into an online format including streaming audio.

A Needs Assessment
In 2002, a needs assessment using the Core Alcohol and Drug Survey (n = 521) revealed the daily use of tobacco increased as students progressed towards graduation (Central Missouri State University's State of Tobacco Usage Report, 2003). Smoking prevalence was reported by 48% of the males, and by 26% of the females. These data support the need to develop smoking cessation programs specifically for this population.

Specific Aim

The aim of this project was to provide a teaching / learning opportunity for undergraduate nursing majors to use telehealth. Under the supervision of a clinical instructor, these students applied the principles of therapeutic communication and adult education to assist smokers in the quitting process.

Specifically, this feasibility study provided an opportunity to develop and implement an online smoking cessation intervention. The outcome of this project provided data on student perspectives of telehealth as a teaching learning tool.

Research Design and Methods

Setting
This smoking cessation program was implemented at a Midwest state university with 1,581 graduate and 8,340 undergraduate students. Nearly 7,000 students have used interactive television and online learning courses at this university since 1998.

Sample
The traditional classroom format of the ALA intervention was converted and modified into the Blackboard format in three consecutive semesters. This was completed with the support of a junior-level baccalaureate nursing majors (N= 65). Enrollment in the course for the purpose of quitting smoking was available free of charge to any student currently enrolled at the university.

Intervention
The ALA lecture materials were converted into seven weekly online modules during a full day computer workshop by nursing students who served as Teaching Assistants. These students, in groups of 3-4 individuals, developed content for each module. Homework, assigned the week before, provided each student with the course content. This content familiarized the student with the ALA program. These students were instructed to consider attraction, comprehension, acceptability, involvement and persuasion for each module developed (Rice, 1991). These modules were designed in a standardized template which included learning objectives, fact sheets, and Power Point files. Within each module a discussion board was developed that posted questions and scenarios to engage the smokers in peer support. The nursing majors designed these discussion boards to address the objectives for the module.

Consultants were available to assist with the development of the course. Assistance for technical issues was available from a representative from Information Services. These nursing majors had no previous experience creating a course, or using the teaching learning options available in Blackboard. The University's Health Promotion Coordinator reviewed all course material and recommended modifications, providing expert validity. The clinical instructor also reviewed these materials for clarity, spelling, and editing before enrolling smokers.

After piloting the program (n=4 smokers), recommendations were made. These recommendations included reformatting the Power Point presentations into Breeze presentation files. This added audio to the lecture material and condense the file size for improved transmission. Word processed files provided the viewer with options in accessing materials. The weekly discussion boards were condensed to encourage continuity of conversations. After incorporating these changes, the program was again piloted (N=11 smokers).
Recommendations from this group resulted in two additional modifications, which addressed smokers' attrition. First, the nursing majors reduced the number of weekly session to four by doubling the number of lectures available each week. Second, two chat sessions were added on the quit day and the following day to provide peer support. The program was piloted once more (N= 25 smokers), with daily monitoring of the discussion board assigned to individual nursing majors.

Procedure
After completing the course construction, these nursing majors used the principles of therapeutic communication and knowledge of behavior change to interact online. Each group was responsible for the weekly module they developed. The assignment included introducing themselves using the discussion board, and responding to all entries within 24 - 48 hours. The course was monitored daily by the clinical instructor. The clinical instructor assigned clinical grades based on the course syllabi. Teaching opportunities for each nursing major resulted from interactions and included HIPPA confidentiality guidelines.

An evaluation was developed, to be completed by the nursing majors at the end of the semester. This evaluation consisted of an open ended questionnaire assessing the perspective of the nursing major's role in this project. These data were secured in a locked cabinet by the clinical instructor. There were no attempts to match the surveys with specific students.

Results

This project outlines the steps for program development and evaluation. The results of this project identified feasibility indicators related to the description of program development and design (information material), participation rates as indicated by the number of "hits" (accessibility), and barriers and facilitators of the program implementation from the perspective of the nursing major.

Description of the Program
Implementing the modifications described in the Intervention Section resulted in a smoking cessation telehealth program. This program consists of four weekly educational units and weekly telehealth interactions using the discussion board which provides therapeutic assistance for smoking cessation.

Accessibility
The statistics from the first pilot revealed 1,310 program hits. The statistics generated by the second pilot were lost due to a technological problem. These statistics were irretrievable from back up files. This problem remained through the student teaching portion of the third pilot, but was resolved prior to smoker participation. The third program pilot resulted in 815 program hits.

The frequency of program hits was, in descending order, discussion boards, announcements, contents area and communication. The most popular time of the day for the students to access the course was at 10:00 - 12:00 pm. The most active days of the week were Monday and Tuesday. Interestingly, there were no hits on Sunday.

Results of Nursing Majors Evaluations
Positive comments from nursing majors included: "creating the power points in class", "communicating therapeutically", "trying something new and mentoring someone", the "required time online" that they otherwise would not do, interacting, "being teachers", "the chance to help other", learning how to post on Blackboard, developing their technology skills, the wellness setting as a whole, and "helping people stop smoking". This was consistent with the second pilot, where data identified that the new technology "…is up and coming with younger people and is vital to our learning", the availability to work from home, the week by week learning that built upon their experiences, and that so many people were giving their input into this program. A comment, from the third pilot, indicated that the fact that everyone on campus has internet access shows "no discrimination or bias".

Negative comments were not prevalent, but highlight the nursing majors being uncomfortable with therapeutic communication. "It was the most difficult task for me". Other comments were related to the perceived lack of knowledge about smoking. "I didn't know if I knew enough about smoking at first to mentor someone. I soon realized however that I was basically there for support". A few were uncomfortable "telling them what to do." i.e. advice, not support. Two suggested having more than one workshop day would have contributed to their knowledge base. Being a non smoker was reported to be a perceived disadvantage to the nursing student. Some worried that the technology would not function and that they "would miss vital client interaction." The attrition rates of smokers were also of concern.

The results of this project conclude that the telehealth intervention was effective. Although not in the scope of this article, the results of this telehealth intervention mirror the success of face to face programs as reported by Lando and colleagues (1990). There was concern for the client's ability to use the technology during the first pilot because of the long download time requirement. The audio component of the lectures added in the second pilot was well received. However, the attempt to communicate using the Blackboard software did not work well in the rural community where many use dial up modems. One student said "…different than anything I had ever dealt with before…I thought it was a great opportunity."

The nursing majors stated that they developed clinical expertise using telehealth skills. Positive comments included: "I'm learning everyday, and enjoy the convenience." "I really enjoy telehealth. I think it is a good way to reach a mass of people." "It is a learning tool." "I am learning so much more than I thought I would." "It is something to help the community in a convenient, confidential way". Grading, according to the evaluation criteria in the syllabi reflect satisfactory attainment of educational goals. Student grades correlated closely to grades obtained through traditional teaching / learning approaches.

Recommendations
The Macromedia Breeze audio component provided a sense of diversity to the lectures by multiple students recorded the material. Further program development is needed to address the inability of nursing majors and smokers to access Blackboard's lightweight chat with a dial up modem. Macromedia Breeze Live has been suggested by the instructional technology consultant to enhance the speed of interaction during live chats.

Discussion
Smoking cessation will continue to be an area requiring nursing attention. There are no superlative interventions. As long as the tobacco industry is allowed to market to new smokers, and new waves of social smokers transcend into addicted smokers, there will be a need for research on how to teach evidence based interventions, such as telehealth.

The nursing majors were successful in the development and implementation of this innovative smoking cessation course. As a novice nurse, it is a challenge to use therapeutic communication. The access to a greater number of smokers would give nursing majors more interaction time to promote teaching and learning. Additional recruitment and retention of smokers is one way to make this happen.

These data revealed challenges with technology and access specific to rural populations. The increased availability of online college programs that emphasize flexibility and ease of access may increase the response or decrease barriers associated with traditional smoking cessation programs. An online smoking cessation program might provide a forum for remote healthcare providers to reach their clients.

Limitations to this project include the small sample size of the pilot program, the lack of diversity among nursing majors, the smoking cessation program only being available at the university. The possibility that the nursing majors would know the smokers may have altered the intervention. Reporting bias and decreased generalizability may be present due to the self-report format of data collection, however self-report is a feasible approach in this type of study (Polit & Beck, 2004).

Future studies should include measures of effectiveness of telehealth in smoking cessation. A review of studies in the adolescent population demonstrates that peers are at least equally effective as their adult counterparts (Mellanby, Rees et al. 2000). Peer influence has been difficult to utilize because of geographical separation or lack of access to transportation (Hunt, Fagan et al. 2003). Studies on the influence of peers and the impact that increased accessibility using telehealth provides are indicated.

One should also consider other populations for telehealth smoking cessation interventions. School aged children and adolescents were targeted in the past by the tobacco industry in the psychologically based marketing and advertising campaigns featuring Joe Camel and other promotional campaigns. Age appropriate teaching learning materials and interactions should be applied to primary as well as secondary and tertiary health promotion and disease prevention activities.

As the prevalence of smoking among college students remains high, the need for educational programs and the delivery of these programs, specifically developed for this population, is a healthcare challenge. These individuals prefer to use a computer-based internet format to obtain healthcare education. Allowing nursing majors to develop these programs provides peer-based interventions. The purpose of this project was to allow junior nursing majors with the opportunity to apply theoretical knowledge in the development of a healthcare intervention. Thus, this teaching / learning project concluded with a healthcare educational program, aimed at smoking cessation, which was appropriate for the young adult college student. In addition, these nursing majors were provided with the knowledge necessary to provide telehealth. This skill will impact future patients receiving their care.

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