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Web-based instruction and its impact on the learning activity of medical

students: A review

Article  in  Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia · November 2006
DOI: 10.5507/bp.2006.055 · Source: PubMed

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Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2006, 150(2):357–361. 357
© J. Potomkova, V. Mihal, C. Cihalik

WEB-BASED INSTRUCTION AND ITS IMPACT ON THE LEARNING ACTIVITY

OF MEDICAL STUDENTS: A REVIEW

Jarmila Potomkovaa, Vladimir Mihalb, Cestmir Cihalikc

a
Medical Learning Resource Centre, Palacky University Library, 775 03 Olomouc, Czech Republic.
b
Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University, 775 20 Olomouc, Czech Republic
c
Department of Internal Medicine, T. Bata Regional Hospital, 762 75 Zlín, Czech Republic
e-mail: [email protected]

Received: September 20, 2006; November 1, 2006

Key words: Computer-assisted instruction/Medical education/Web-based tutorials/Self-directed learning

Background: The aim of this review was to summarise the experience on implementation of information technol-
ogy to support the teaching and learning process in medicine. Particular attention was paid to web-based tutorials,
their impact on increasing the effectiveness of medical instruction and motivation of students towards self-directed
learning. Most of the studies selected for the purpose of the review comprised evaluation of the web-tutorials in view
of practical implementation, strengths, weaknesses, and main preferences in comparison with traditional lecture-based
education.
Method and results: We searched MEDLINE via PubMed using MeSH term “computer-assisted learning” between
1996 and 2005 and selected for inclusion in this review were studies on the implementation and evaluation of web
based tutorials in medical education. Additional related papers were obtained through cross-referencing. We found
that overall, students prefer Web tutorials to traditional lecture-based classes for accessibility, ease of use, freedom of
navigation, high medical image quality and advantage of repeated practice, that web-based learning has been continu-
ally developing and that it is a very important tool in Evidence Based Medicine.
Conclusions: Web based education is an important tool in medical training. It will require transformation in the
way medicine is taught from instructor based to self directed learning. It is above all seen as a device for information
retrieval and storage.

INTRODUCTION and technology management skills and student outcome

evaluation. Students preferring faculty-directed classroom
Large educational establishments are responsible for learning will also have to consider their roles in the proc-
facilitating the uptake, development and implementation ess of redesigning faculty-directed classroom learning for
of technology in teaching and learning. Development of Web-based instruction4.
new learning environments can promote active participa- As far as the terminology is concerned, Daniel5 sug-
tion through repeated practice, encourage shared experi- gested that a more appropriate term for web-based edu-
ences and enhance student motivation1. The World Wide cation would be web-enhanced education, since the use
Web is now a rich educational resource that promotes of technology augments the learning potential of each
and facilitates student learning and is increasingly being individual course.
used to deliver course content in medical and nursing
programs. It has evolved from computer-assisted instruc-
tion that started approximately 30 years ago2. METHODS OF REVIEW
In 1995, McEnery et al.3 recognised the potential of
utilizing the world wide web as a method for interactive We searched MEDLINE via PubMed using MeSH
medical instruction for geographically dispersed students. term “computer-assisted learning” between 1996 and
In medicine in particular, the integration of Web-based 2005. The studies dealing with implementation and evalu-
instruction into medical curricula is a great challenge both ation of web-based tutorials in medical education were
for faculty and students to use the technology efficiently selected for inclusion in the review. Additional papers
and effectively to support teaching and learning. on general principles of self-directed computer-assisted
Teaching Web-based courses are a new experience instruction were obtained through cross-referencing.
for most university teachers and require adoption of new
concepts of role of faculty. Issues to be considered by
faculty when introducing Web-based instruction include
instructional design, faculty-student interactions, time
358 J. Potomkova, V. Mihal, C. Cihalik

RESULTS lated formats with a special interest in the value of various

types of questions facilitating final exams.
From Lecture-Based to Computer-Assisted Teaching Similarly, Kemp, Morrison, and Ross8 stressed the
and Learning need for instructors who are also the designers of tuto-
Yolton and deCalesta6 foresaw a revolution in educa- rials to propose student-directed instruction taking stu-
tion that would involve a shift from the traditional lecture dent characteristics and learning styles into account. It
style of information presentation toward a more active was decided that the instruction should be seen through
style of learning. Many educators now believe that stu- the perspective of the learner rather than the content.
dents must actively participate in the learning process Compared to traditional lecture-based teaching, instruc-
so that information be truly understood, retained and tional strategies need to change not only what is taught,
transformed into knowledge. This revolution has led to but how it is learned9.
an increased understanding that the mass of knowledge
in most professions is too large to be absorbed. These Effectiveness of Web-Based Instruction in Medicine
concepts have triggered innovative, computer-based edu- Even if a large numer of studies have described com-
cational techniques. parable outcomes from Web-based and traditional class-
Based on their 30 years of experience with computer- room instruction, there are few such studies for medical
aided pharmacology instruction, Kerecsen and Pazdernik2 curricula.
developed a computer-assisted teaching system compris- Gallagher et al.10 examined the effectiveness of alter-
ing both computer-assisted instruction (CAI) and com- native methods of course delivery by comparing student
puter-managed instruction (CMI). This system evolved profiles and instructional outcomes from a dental hygiene
from microprocessors to the current World Wide Web gerontology course offered both on the Web and in a tra-
system. It was first used in the early 1970s to teach phar- ditional classroom setting. Questionnaires were sent to
macology to second year medical students. CAI consists both groups of students completing the course. The data
of educational programs and the majority of them are collected included familiarity with Web-based instruction,
self-instructional requiring fill-in-the-blank or response extent of prior computer training, and student evaluations
to simple multiple-choice questions. Initially, they were of course effectiveness. A comparison of student charac-
written by faculty members, later many of the programs teristics participating in the two course formats revealed
were elaborated by medical students in cooperation with statistically significant differences in instructional out-
faculty members who were experts in particular fields. comes. Student retention of course material six months
In their experimental study Foust, Tannery and after completion of the course was greater in the Web-
Detlefsen7 focused on Web-based tutorial implementation based format. Students selecting a Web-based course for-
for the delivery of health sciences libary user education mat demonstrated greater motivation and learning success
that is one of the numerous responsibilities of reference based on final course grades, completion of assignments,
medical librarians. The experimental study was undertak- and knowledge retention over time. Age, previous experi-
en to determine if a trial web-based tutorial could be used ence with online courses, and selection of teaching mode
as an effective alternative to the traditional library lecture. may have been confounding factors however.
The authors emphasized the significance of evaluating Yolton and deCalesta6 examined a variety of Web-
web-based tutorials as a method of learning, indicating based educational methodologies in optometry classes,
that they could serve as an alternative to the more tradi- ranging from shifting classes totally to the Web, to using
tional lecture delivery. This finding is extremely important the Web for pre-class preparation. Initial student accept-
to those who plan library training programs and informa- ance of Web-based courses was good, but an undesirable
tion management education. It may be concluded that the trend emerged as a tendency for students to print out Web-
web-based tutorials can do at least as well as a traditional presented material rather than reading from the computer
classroom style lecture, and consequently the delivery of screen. Other concerns with shifting material from lecture
web-based instruction can become a substitution form of to the Web include peer and administrator acceptance of
user education. this teaching style and issues associated with valuation of
Perlman, Weston, and Gisel1 reported the importance professors who no longer give stand-up lectures.
of web-based learning environments offering interactive, Green at al.11 emphasized the role of web tutorials pro-
authentic, self-directed learning opportunities in occupa- duced by health sciences libraries to provide a service in
tional therapy educational programs. They have claimed new electronic resources to users outside the library and
that Web-based technology represents a new instructional around the world. Online tutorials are a valuable means of
mehod to support cognitive learning, including the analy- providing instruction on how to access and use important
sis, synthesis and evaluation of knowledge. The form of resources. The authors described among others how the
a case-based tutorial gives opportunitites to practice and work could be evaluated.
receive feedback. These authors also describe the theoreti- Another evaluation study12 focused on student satisfac-
cal foundations of tutorial development, implementation tion with a mixed learning method for teaching radiologic
and evaluation. They give a practical outline of tutorial anatomy that integrated web-based instruction with small
constructs in terms of setting, user-friendly menu, interac- group and didactic teaching. The mixed learning model
tion with the hyper-textual environment and content-re- comprised a brief didactic introduction followed by web-
Web-based instruction and its impact on the learning activity of medical students: a review 359

based structured learning modules including self-study presentation technologies to learn anatomy in panoramic
cases prior to the lab instruction, follow-up cases, and images. Students completed on-line and conventional quiz-
twice-weekly optional review sessions. Students and lab zes covering WP’and ST materials, as well as a voluntary
instructors were assessed on content and design. All the survey. A total of 71 per cent of students preferred WP
radiology labs were rated “very useful” or “useful”. for accessibility, ease of use, freedom of navigation, and
Buckley and Toto13 made an attempt to discover how image quality (p < .01).
students learned in an online learning environment as well According to Thiele, Allen and Stucky19 web-based in-
as to investigate how online communication patterns dif- struction requires transformation from traditional teach-
fered from those in a face-to-face class. In their evaluation ing strategies to directed independent learning. Much
study the authors used students participating in a graduate attention must be given to the creation of effective inter-
program in instructional technology. Various activities active learning experiences that support student-to-student
and assignments were used to procure data on student and student-to-faculty interactions. Evaluation must be
attitudes toward an online learning environment. Over a done of how content is learned, the effects of the use of
period of 3 semesters, student data were collected using computers on learning, and perceived barriers to learning.
qualitative and quantitative methods, including observa- Students’ responses to Web-based education should also
tion, surveys, tests, in-class discussions, and e-mail com- be considered. The authors analyzed the responses of 58
munication analysis. The results of the study confirmed undergraduate and 13 graduate students to their initial
the importance of regular assessment of tutorial quality. experiences with Web-based instruction (WBI). While
Johnson, Xing and Yang14 accentuated the main fea- the educational levels of the students and the courses in
tures of hypertutorials, such as presentation, learner con- which the transition to WBI took place differed for the
trol, practice, feedback, and elaborative learning resources two groups, their computer expertise did not, and similar
based on the results of a randomized controlled trial. They responses to Web-based learning were noted. Differences
showed that the source of hypertutorial superiority in in the types of courses and the expertise of the two facul-
student evaluations of health informatics instruction lay ties with regard to WBI also contributed to the production
in their hypertutorial features. Randomized comparisons of some dissimilar responses.
between the two versions containing the same text and Koch and Gobell20 evaluated the effectiveness of an
graphics differed in the presence or absence of 4 tutorial online tutorial for research design and statistics in psy-
features: elaborative learning resources, practice, feed- chology. Initial research suggested that students using the
back, and amount of learner control. Students gave high tutorial were more accurate in their decisions. Students
evaluations to both Web-based methodologies, but consist- were also more confident in the decisions and found them
ently rated the hypertutorial lessons as superior. easier to make when using the tutorial. The practice with
In the same year, Erickson et al.15 published the re- the tutorial improved problem-solving ability in subse-
sults of a randomized controlled trial to compare pharmacy quent design and statistics scenarios.
students’ acquired knowledge and technical skills after
a traditional lecture versus a Web-based tutorial. There Implictions for Practice: Strengths and Weaknesses
was no significant difference in the baseline knowledge Although the use of technology in teaching and learn-
test scores between the groups. The pharmacy students ing is becoming more prevalent, we have to take into con-
confirmed that the Web-based tutorial was as effective sideration strengths and weaknesses. It may become a
as the standard lecture format. The authors stressed the beneficial investment if the strategy is supported and well
necessity of further testing to assess the longitudinal effect balanced with all other instructional components, matches
of the program. the learning outcomes, supports self-directed learning and
Meyer16 summarized the promising results of an evalua- enables practice and feedback. As a result, learners will be
tion study focused on the quality of his software developed able to acquire new knowledge, manipulate and change it
as a tutorial to support nursing education and training through interactivity and enrich it through feedback1.
dispensation. Student feedback was useful and suggestions In an extensive study Kerecsen and Pazdernik2 discov-
made by the participants who completed the question- ered that students preferred more linear paradigm (text
naire were used to improve and modify the product. – question – response – test – question –response – text)
Boyle and Wambach17 verified a conceptual model in a pharmacology web tutorial. With the more branching
for graduate nursing Web-based instruction in which format the student might select the wrong answer to get
learner-centered pedagogic philosophies and interaction more information. Students found the „Drill and Practice“
techniques were combined to produce active learning at programs the most time-efficient way of mastering exam
each phase of the Web-based courses. The focus was on material. The success of computer-assisted programs was
asynchronous techniques as the dominant form of com- found to depend on their content rather than sophisti-
munication. cated programs or technology. Computers are also very
In a modified cross-over design Ludlow and Platin18 valuable as search engines for obtaining the most impor-
compared self-guided slide/tape (ST) and web page (WP) tant information in a specific field. Evidence based medi-
instruction in normal radiographic anatomy using objec- cine (EBM) has become very important in the training of
tive test performance and subjective preference of first individuals in clinical rotations and residency programs.
year dental students. The two groups of students switched Therefore, it is important that in the first 2 years of un-
360 J. Potomkova, V. Mihal, C. Cihalik

degraduate medical education students are trained to be of collaborattive implementation of learning. In contrast,
able to use computers to develop problem-solving skills some students report difficulty when navigating through
as well as to search for the most appropriate informa- the hyperlinks and when sending results electronically
tion for using EBM principles. The biggest challenge is to instructors. It is inevitable to monitor the function of
the constant requirement to update wrt both content and all hyperlinks and to provide regular assistance toward
changing technologies. troubleshooting. This requires consistent reviewing of the
Mbarika et al.21 confirmed that learners had a stronger accessibility and interface design of the tutorial in col-
sense of efficacy and perceived skill development when labortion with the technology experts
using multimedia versus paper-based tasks. These at- As confirmed by Foust, Tannery and Detlefsen7, tutori-
tributes are due to the learning-driven constructs within als enable active learning, reduced student memorization,
the technology which can be described as challenging, and increased use of computers as information storage
interesting, reflective, and interactive while learning with and retrieval devices, which could change fundamentally
others. The multimedia approach is successful in provid- the way in which future doctors, patients, and computers
ing situated learning in the classroom, in teaching difficult interact in clinical settings.
concepts, and in transferring theory into practice. It is not An undesirable trend was observed by Yolton and
the multimedia itself, but the learning opportunities and deCalesta6 who recorded the tendency for students to
instructional strategies that the medium affords. print out Web-presented material rather than reading from
Hung and Wong22 observed that technology could sup- the computer screen.
plement classroom and lab instruction and mirror the
content taught in these situations. It has the advantage
of allowing repeated practice. The learner continually CONCLUSIONS
engages in a process of active learning.
Similarly, Duchastel23 emphasized the importance of Most of the studies analyzed for the purpose of this
building learner confidence through successful comple- review point out strengths rather than weaknesses of web-
tion of a learning task. If the learners feel challenged, based instruction used in medical education as an inno-
they may gain interest and motivation which leads to vative tool for increasing effectiveness of both teaching
repeated practice and further conceptual and skill devel- and learning
opment. Nevertheless, it would not be wise to exagger- It may be concluded that computer-assisted instruc-
ate the significance of information technology, because tion since its beginnings more than 30 years ago has been
students actually do not learn from technologies, but undergoing dynamic development towards Web-based
with technologies24. Extensive observations1 have shown education. In medicine, web tutorials represent an effec-
that self-instruction by students can produce feedback to tive educational tool supporting self-directed learning.
the instructors and this can impact further development. Students prefer Web tutorials to traditional lecture-based
Feedback can also be gathered from asynchronous and classes for their accessibility, ease of use, freedom of navi-
synchronous on-line discussions between students and gation, high medical image quality and an advantage of
students and instructors. All these responses reveal the repeated practice.
strengths and weaknesses of the tutorial and enable the All of these aspects lead to increased motivation to
instructors to reflect, review and revise. The authors1 col- acquire comprehensive medical knowledge and master
lected valuable data to help identify positive trends in the clinical skills necessary for practising evidence based med-
instruction, and flaws and deficiencies which could be icine. It should be taken into consideration that tutorial
corrected immediately as well as to determine the initial design and maintenance remains dependent on the exper-
impact on student learning. Long-term results led to the tise of programmers and instructional design consultants.
conclusion that learning could be definitely improved as This diminishes spontaneity for revision and corrections
a result of the added practice, feedback, and repetition. that may delay effective implementation.
This had been expected in particular due to the increased Last but not least, it also requires funding to pay for
opportunity to practice and receive feedback. These re- such service. From the methodological point of view,
sults clearly demonstrate that the technology is a powerful Web-based instruction requires transformation from
instructional tool for opportunity to practice and receive traditional teaching strategies to directed independent
feedback. This represents an important contribution to learning. Ragular evaluation must be carried out of how
increasing practical application of skills as well as cogni- content is learned, the effects of the use of computers on
tive learning. The tutorials also offer immediate feedback learning, and perceived barriers to learning.
to the student through comparison of answers leading to
increased motivation to learn. It is important to main-
tain a counterbalance between the methods and the level ACKNOWLEDGEMENTS
and domains of learning and evaluation. Students may be
more familiar with technology from year to year; students This paper is related to the developmental programme
grow with it. It may be useful to gather information on of Palacky University Faculty of Medicine and Dentistry
how many students implement the tutorial alone or in (Olomouc, Czech Republic), supported by the Ministry
groups of two and three, and to investigate the influence of Education, Youth and Physical Culture of the Czech
 Web-based instruction and its impact on the learning activity of medical students: a review 361

Republic. The web-tutorial under construction is available 12. Shaffer K, Small JE. Blended learning in medical education: use of
at http//noe.upol.cz. an integrated approach with web-based small group modules and
didactic instruction for teaching radiologic anatomy. Acad Radiol.
2004; 11(9):1059–70.
13. Buckley J, Toto R. Assessment techniques for web-based instruc-
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