An Approach to International Internet Based Delivery of Nurse Education Author David Gillham B. Sc., B. N., M. N. St

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An Approach to International Internet Based Delivery of Nurse Education

David Gillham B.Sc., B.N., M.N.St.

Lecturer in Nursing University of South Australia


The development of the Internet is changing the nature and quality of university education at an astonishing rate. Worldwide changes in electronic communication and commerce are now set to challenge the established role of existing universities. Universities are increasingly participating in a commercially competitive global market involving students from many different countries. In order to accommodate the technological and cultural diversity of the target audiences, universities will increasingly need to provide flexible teaching delivery and develop sensitivity to cultural differences. This paper will explore international online delivery introducing issues of culture, language, information supply, flexible delivery and response to students learning needs. Experience gained from a ground breaking international online nursing course will be discussed in relation to global online education. The paper will help to identify some of the issues that require urgent consideration, focusing particularly on nurse education.


Developments towards global education collaboration are starting to accelerate. Universitas 21, The Artic University, and other international university networks have recently been publicly announced. These ventures involve large numbers of universities linking with the aim of producing common course content of high quality, generally to be delivered online. Universitas 21, for example, is described by Sadlak (1998) as a group of similar profile universities from Australia, Canada, New Zealand, Singapore, the United Kingdom and United States. Such collaboration has the potential to facilitate the efficient pooling of resources and, as a consequence, increase the quality of online teaching resources. However, this may create a situation where only the strongest and biggest players in Internet based education will survive and grow. In particular, universities and university collaborations with widely established reputations and strong marketing strategies may come to dominate the global online education marketplace.
This paper will discuss developments in global online education introducing issues related to quality, culture, international delivery and commercialisation. The paper will describe the successful implementation of an offshore online nursing course, the Online Bachelor of Nursing International (OBNI). This example will be used to provide a specific context for the examination of global online delivery issues.
Australian universities are being increasingly encouraged to generate income and become less reliant on centralised Government funding. Disciplines such as medicine have generated substantial income from overseas fee paying students, while nursing schools have attracted only small numbers of students from overseas. Recent technological change and, in particular, advances in Internet software have created new opportunities for universities to provide international education in nursing. It is now possible, for example, to live in remote areas of Australia and undertake a degree from a UK based university. Nursing students throughout the world can now study overseas based online courses in their own country without having to pay costly travel and living expenses and without leaving family and employment. The first OBNI course delivered in Malaysia by the University of South Australia involved students who were experienced, skilled, senior nurses with the financial resources, personal circumstances and motivation to study nursing courses. As a consequence, the impact of the OBNI course was likely to reach well beyond the student group as senior nurses incorporated knowledge gained from the OBNI into Malaysian nursing practice.

Online Health Information and Nurse Education

Changes in information technology are having a dramatic impact on education. Only ten years ago university students were just beginning to widely use personal computers for word processing. Since this time email, word processing and the Internet have transformed university education and activities. In particular, computer software that is widely available, user friendly and practical has had the greatest impact. In the health care professions supply of information via the Internet has become simple, efficient and widely accessible. Brown (1999) discusses the impact of technological advances upon nursing, claiming there has been an explosion of knowledge, emphasising that nurses now access research information directly. This is in contrast with traditional nursing practice where most of the relevant nursing practice information was passed on by word of mouth from experienced nurses or medical doctors.

In the health professions online information supply is beginning to transform health and nursing practice as increasing emphasis is directed towards the need for research to underpin practice. There is, to this end, a widely regarded trend towards information that is concise, digestible and immediate to remedy need. Evidence Based Practice sheets are an example of this trend. As Internet authoring software has become more user friendly, at the same time there has been an exponential increase in the development of high quality health related Internet sites. International collaborations such as Cochrane now provide websites giving simple access to systematic research reviews, thereby facilitating rapid access to some of the best available research evidence worldwide. Furthermore, this research information is of a multi-disciplinary nature thereby providing nurses with access to information previously only easily accessible to the medical profession. As Brown (1999, p9) claims, Internet technology may “serve as a catalyst in bringing positive changes in the practice and the profession of nursing in collaboration with other health disciplines.”
While the Internet may open up numerous possibilities for multi-disciplinary education in the health science areas, there are already many reported examples citing effective use of computers in nurse education. Lowry and Johnson (1999) highlight the benefits of computer assisted instruction in health care education for both patient education and staff development. Hayden (1996) suggests a high level of acceptance of computer assisted instruction amongst both physicians and nurses working in emergency care areas. Specifically, Hayden reports strong demand for real-time consultations indicating nurses and physicians perceive computers as enhancing professional development. Real-time consultation can enable health professionals with access to the Internet to pose clinical questions able to be answered immediately and conveyed via the Internet.
However, the more common asynchronous computer mediated communication may be almost as effective. Cobb and Baird (1999) highlight the potential for continuing education courses to use the Internet to provide nurses with quick, up-to-date information while Wyatt et al (1999) advocate efficient and creative Internet based resource use for health professional education.
Although there is widespread support for the perceived benefits of Internet based education, many authors express reservations in relation to the lack of evaluation data collected on Internet based education and the absence of consideration of education theory in Internet course development. Ryan and Carlton (1999, p272) state that higher education is moving with deliberate speed to an electronic classroom while highlighting the lack of research on use of the World Wide Web (web) for nurse education. Similarly, Mallow and Gilje (1999) discuss the increased use of technology in the delivery of health science courses in the absence of any guiding philosophy of education or pedagogy. As we will see in the next sections, this has significant, complex implications for culturally appropriate nurse education.
If influential nurses in developing countries undertake Internet based nursing courses, there is great potential to change health care delivery worldwide and establish strong global nursing communities. However, despite the advances in Internet based education, barriers to successful offshore online teaching delivery are numerous. Furthermore, there is limited evaluation data on online nurse education and even less information on international cross-cultural nurse education using this relatively new means of teaching delivery.

An Example of International Internet Based Delivery of Nurse Education in Asia

This paper provides a specific example of a Bachelor degree conversion course developed in Australia and delivered in Malaysia using primarily online delivery. This one-year full time equivalent course allowed hospital trained, experienced nurses to increase their qualifications to degree level. The OBNI course development was not specifically guided by an established education philosophy. However, the course was underpinned using an evidence based framework. Evidence based practice (EBP) is often described using four steps: formulating research questions from practice; locating information; critically analysing information; and applying the information to practice. This framework was ideal for an Internet based course as it provided an effective mechanism for the location and critical evaluation of Internet based health information. In this way students were able to gain maximum benefit from advances in Internet health information supply such as the development of the Cochrane database. Students developed skills in using online research information thereby providing them with the means of continually updating their nursing practice according to the best research evidence available worldwide. This approach was particularly well suited to Malaysian students who strongly valued the application of scientific research to practice. Furthermore the EBP framework was even more applicable because students entering the courses already had substantial clinical experience. Consequently, the development of vocational skills needed for initial employment was not as crucial as for typical undergraduate courses, thus allowing far greater focus on the development of life-long learning skills. In addition, students’ strong clinical grounding allowed them to formulate practice based questions and interpret research information in relation to the context of local practice.
Early planning of the online course considered the following factors:

  • the vocational needs of students.

  • the learning characteristics of the target student group

  • the expected type of student interaction

  • the nature of the subject content

  • the availability of web based information resources

  • the staffing resources required

  • the hardware and software requirements

The course consisted of four subjects: a clinical specialty for which most students gained credit due to previous studies; leadership and management; nursing knowledge and research; and nursing practice, reflection, analysis and innovation. All subjects were carefully structured so that the application of Internet resources to practice played a major component in subject content and assessment while at the same time remaining theoretically and practically relevant to the needs of practising nurses. This means practical and educational precision in the way subjects were designed and delivered.

Given the wealth of Internet based resources, it was possible to construct information rich content and provide students with the opportunity to develop skills in the effective use of this information. In this way students were able to acquire the necessary skills and information resources to allow learning to continue well after the completion of the course. Thus, rather than accumulate the ability to recall static course content, students were provided with skills to continually access information to update practice, building upon their already strong experience-grounded knowledge base. Importantly, the unique characteristics of local practice as well as the knowledge and experience of students were recognised by lecturing staff.

Given the diversity of Malaysian religion, culture and government, appropriate approaches to teaching needed to be both flexible and sensitive. In fact, the student group itself contained a variety of different ethnic, language and cultural groups. In addition, subjects needed to be modified to adapt to the local technological environment.

The following table outlines some strategies implemented by the University of South Australia for offshore online nursing course delivery.

Table 1:

Target audience characteristic


  • High value given to education and strong respect for University staff

  • Students were respected as very experienced health professionals

  • Students were provided with good life long learning opportunities

  • Large numbers of students as followers of the Islamic faith

  • Lecturing staff acknowledged they had little or no understanding of Muslim religion

  • Attempts were made to eliminate materials likely to be extremely offensive

  • Time allocated for prayers in teaching programs

  • Student representatives were asked to notify lecturers of any social and cultural needs related to religion. (this did occur)

  • Willingness to pay for education

  • Students with modest financial backing

  • Every attempt was made to deliver good value for money

  • Links were made with local low interest student loan schemes to help pay for course fees

  • Textbook use and other costs were minimised through collective bargaining with suppliers

  • Qualifications from Western universities are given high status

  • Ensure the course offered is of the highest possible quality to match the perceived status

  • English skills are variable

  • Extensive resources were provided to support students with English language use

  • Students are generally very conscientious and competitive

  • Caution was used with expectations placed on students. (If demanded by lecturers, some students would work 16 hours per day at the expense of their family life and personal health)

  • Clear precise written feedback provided by markers minimising unnecessary jargon

  • Many varied and unique practice environments particularly in rural areas

  • Respect was shown for students’ local knowledge and informed networks. (For example, practice based examples from Malaysian practice were used as the basis for online database searching activities)

  • Caution was emphasised in the application of research to practice (For example, students were taught to identify problems with the application of American research to Malaysian health care)

  • The common goal of the health professions, of positive patient outcomes, was emphasised

  • Limited computer use and computer literacy amongst students

  • Hands-on instructions in basic Internet and email use provided

  • At least one week intensive face to face teaching with each subject was provided

  • Printed backup instructions for all students were provided

  • Students formed small study groups and used these to enhance efficacy of online communication

  • Slow access to web site resources because of slow Internet connections

  • Use of institutional computing facilities with good connections whenever possible

  • Email was used rather than online discussion where necessary

  • Computer access equity amongst course participants

  • Online participation was not directly linked to assessment as this could not be accessed by all students

  • Indirect assessment links were made between assessment and online participation to provide incentive for using online resources

While the strategies above go some way to accommodate the local needs of students, a further important consideration is the precise manner in which the technology is used. Online delivery can place an additional barrier (the technology) between lecturer and student. It is very important for lecturers to respond promptly to students and to invite further feedback from them as required.

The World Wide Web (web) can certainly provide students with information resources not otherwise available to them and allow very powerful international communication via email. This is enormously valuable to students who may have an isolated professional environment. However, unless students can use the Internet to access information relevant to assessment, they may not fully value this information. For example, a nurse working in rural Malaysia may encounter the Cochrane and Infectious Diseases databases for the first time in an online course. While this information may be immensely valuable for their practice, the student may not access these databases in sufficient depth until they are linked to assignment content requiring students to explain the critical analysis and application of this database information to their practice. However, given access difficulties for some more isolated students, alternative strategies needed to be in place so students without adequate Internet access could complete their assessment.
Preliminary evaluation suggests the course described has been very well received by students as indicated by the anecdotal data to follow. However, the success may be largely attributed to the flexibility of delivery. At this stage, preliminary recommendations in relation to the type of nursing course and student groups likely to be suited to flexible online delivery include:

  • Students should have strong clinical practice skills and knowledge base

  • Students are able to work independently using an adult learning model

  • Students can develop skills in dealing with large quantities of information

  • The target student group has good Internet access and adequate computer literacy

  • Substantial subject content is available through the web and is most efficiently accessed via websites

  • Teaching staff are enthusiastic about, and skilled in, online delivery

  • Strong technical support is readily and consistently available for students and staff

Global Nurse Education Implications

From the perspective of Australian universities, the marketplace for online nursing courses in Asia is considerable. Asian countries place particularly high status upon Western qualifications and likewise value Internet use. As a country with a relatively small population, a highly developed education system, strong computer technology, close proximity to Asia and distance education experience, Australia is extremely well placed to provide such education. In order to produce online nurse education courses of world class quality, a transformation in thinking to a global perspective is needed. While it is obvious that once resources are placed on the Internet, they become available world-wide, yet current university structures are geared towards Internet delivery being used for local students. If courses are successfully offered globally, substantial income can be generated for universities while students are charged relatively low prices.

A very strong argument can be constructed advocating the development of high quality course content through cooperation between institutions. Already various institutions specialise in particular areas and approaches to health care. For example, some hospitals specialise in cardiac surgery while other specialise in paediatrics. A simple extension of this situation is for universities to link with health care institutions, and each other, and importantly share information through web databases. Cooperation rather than competition between universities can be both mutually beneficial and commercially strategic.
Websites such as Cochrane, Medline, and CINAHL already provide substantial contributions to global online nurse education. Clearly, these databases have contributed a great deal to improved standards of health care in developed nations and a more systematic approach to the application of research to practice has been developed. According to students studying the OBNI, Cochrane, Medline, and CINAHL are also important in Malaysia. While it is extremely difficult to quantify the impact of high quality information supply for nurses, it can be surmised that databases of this type will continue to contribute to the professionalisation of nursing worldwide. The true benefits of this global information supply can be recognised to some extent with Internet based nurse education. This is apparent when nurses travelling to remote Asian rural areas are accessing and critically analysing information from high quality health care databases. International communication via the Internet can be extremely beneficial for nurses in remote areas who would otherwise have limited opportunities for professional communication.
However, a major limitation of current global Internet based health information supply is the inevitable lack of information specifically relating to the health care of developing nations. Kirkpatrick et al (1998, p15) describe the use of electronic technology to integrate cultural diversity and global awareness concepts into a nursing curriculum. However, much more is needed, such as the development of databases like Cochrane but specifically dealing with developing nation health issues.
Relatively little is known about the information needs of the targeted health professional students in developing countries. While access, bandwidth, language and even electricity supply are important issues, identifying the specific information and learning needs of health professionals in developing nations is an important and urgent research priority.

Globalisation Theories and Global Education

In providing an approach to culturally sensitive issues in online nurse education, it is useful to link the importance of electronic communication to the conceptual aspects of globalisation. Globalisation theories carry significant, complex implications for international online nurse education. Two major and contrasting effects of globalisation likely to impact upon international online education have been described as Americanisation and Fundamentalism.
Featherstone (1995) describes Americanisation as a global culture based on the economic and political culture of the United States. Robertson (1992) describes North American television as highlighting the presentation of global issues according to American interests without explicitly identifying American interests. Likewise Ritzer (1993) cited in Featherstone (1995, p8) uses the term “McDonaldisation” to describe

“the process by which the principles of a fast-food restaurant are coming to dominate more and more sectors of American society and the rest of the world.”

Ritzer explains that such principles impact on education, leading to a mass bureaucratisation and progressive standardisation.
The export of Western education to developing nations can to some extent be conceptualised as “McDonaldisation” in that it is driving the commercial interests of universities, ultimately for the benefit of Western countries. One certainly hopes that in this process education and health care standards in developing nations will improve. Clearly there is a very strong case for further investigation of the impact of the Internet based education on local health care in developing nations.
In contrast, and perhaps as a reaction to Americanisation, is a return to Fundamentalism described by Giddens (1996, p215) as a reaction to modernity, as a way of purifying tradition. Importantly, Giddens draws attention to the use of global electronic communication to promote Fundamentalism and, ultimately, the way people are educated. The influence of Fundamentalism in many developing nations is substantial and often far stronger than Americanisation. As a consequence, predicting the cultural impact of Western education is extremely complex.
International online nurse education needs to be sensitive to local political and religious preferences. Many countries interested in international online courses may be primarily Muslim, with their respective populations becoming increasingly fundamental in their beliefs. While the reaction to globalisation is complex and will vary according to location, it is very likely there will be at least some negative response to Americanisation. There is the potential for online nurse education to be perceived as part of the process of Americanisation simply because delivery occurs via the Internet.

Potentials and Pitfalls of Global Education

Clearly, international nurse education raises numerous very complex issues. In an ideal environment these issues would each be debated and investigated prior to course implementation. However, it is likely universities will move at maximum speed to capture this commercial market. Global nurse education has enormous potential benefits depending on how this is implemented. Newson (1998) concludes that globalisation of education provides universities with the opportunity to strengthen their role in relation to intellectual pursuit, dissemination of knowledge as a public resource and promotion of democratic life and values. However, as Newson points out, instead of universities being an influential agent in change, they have been ravaged by restructuring, reorientation and reconfiguring.
Table 2 provides an overview of some of the more important issues in relation to global education. Each of the issues identified in table 2 is complex and multifaceted. Consequently, while the table does identify positive and negative implications for online global education, it must be recognised that whether the individual item is positive or negative may depend on the individual perspective of the reader. This means that a balance between the needs of local communities and global trends will need to be found: a local-global nexus between global information technology culture and local lives. For example, there is little doubt that powerful major television networks would view the potential loss of advertising revenue as devastating, yet this is classified as a positive factor in the table.
Table 2:

Factors likely to influence global online education developments

Potential Positive Outcomes

Associated Problems and

Potential Negative Implications

Collaborative university networks

  • Improved quality as resources for developing online courses are used efficiently

  • Universities are able to further develop specialty areas in education

  • Cost–effective combined offshore marketing can be developed

  • Ability to compete with other university collaborations

  • Information technology incompatibility between institutions

  • Excessive administration workload to deal with the bureaucracy of multiple institutions

  • Loss of individuality as specialty courses become less economically viable

  • Increased bureaucracy and technological barriers separate students from lecturers

  • Technological convergence (television and the Internet)

  • Decreased control of advertising revenue by major television networks

  • Increased commercialisation of the Internet leading to greater commercial education opportunities

  • Extensive opportunities for diverse entertainment and education in an interactive online environment

  • Increased commercial media involvement in online education

  • Entertainment begins to dominate education and starts to dictate delivery style and content


(Sponsorship of global online education projects by mult-national corporations)

  • More funding made available for education institutions from non- government sources

  • Market pressure focuses education on the vocational preparation of graduates

  • Courses are designed solely to meet the needs of large employers at the expense of achieving broader educational goals

  • Traditional aspects of university education such as debate of political issues, philosophical discussion, critical and innovative thinking take a secondary role to commercial interests

  • Quality control for education and training overshadowed by commercial interests

Impact of globalisation

  • Increased information supply to large numbers of people via the Internet

  • Americanisation of education

  • Reaction against Americanisation prevents uptake of online courses

  • The online education is linked strongly with e-commerce, thus becoming a mechanism to extract money from developing nations

Impact on diversity, equity and culture

  • Universities maintain their individuality as they become part of collaborative networks

  • Improved financial viability allows universities to support non-commercial courses

  • Cultural identity is recognised and valued by universities

  • Traditional university values relating to equity and diversity are recognised and developed further

  • Education becomes standardised as global accreditation and standardisation of courses develops

  • Courses that are not viable commercially are cancelled

  • A single Americanised culture is portrayed in the majority of education materials

  • Traditional university values disappear in the absence of face to face contact and due to the pressure of commercialisation

Impact on autonomy

  • Universities have a stronger autonomous voice as they become financially independent from governments

  • Universities promote the moral and ethical values of their sponsoring multinational corporations


An internationally competitive global online education environment is developing with changes starting to occur at an exponential rate. However, there has been relatively little consideration, debate or research into the issues arising. Research is needed into student learning using online delivery, cross-cultural education and international education. At this early stage those implementing education programs will need to react intuitively to new situations and, above all, remain highly flexible. Local characteristics such as the speed of Internet access and individual student characteristics such as computer literacy are crucial issues. However, the relative success of the online offshore nurse education program described in this paper points to an enormous potential for international online delivery. Online delivery is in its very early stages. As Internet facilities, access and students’ computer skills increase worldwide, this potential will further develop. The impact for students in developing nations will be far-reaching. Internet access can remove many of the communication and education barriers restricting the advancement of health professions. However, it is crucial that we remain aware of the potential misuse of technology. Improved global health information supply is relatively simple provided there is co-operation to produce the best possible education outcomes. Global online nurse education can be exploited commercially. It is the responsibility of university educators to see that this occurs in a manner beneficial for students and the ultimate recipients of health care. The Cochrane Collaboration has shown the way forward by maintaining patient welfare as the highest priority. The development of a commercial global online education environment is likely to revolutionise education and life generally for all those with access to the Internet. The issues raised in this paper require urgent attention and discussion because the way in which global online education is developed will determine whether or not the outcomes are beneficial for all concerned.

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Robertson, R. (1992) Globalization: Social Theory and Global Culture. London, Sage.
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Sadlak, J. (1998) ‘Globalization and concurrent cheallenges for Higher Education’. in The globalization of Higher Education (ed) P. Scott. Open University Press, Buckingham[England], Ch. 8.
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