Context of digital skills in healthcare practice

Research reveals that the more a hospital embraces digital technologies the better off its patients will be (Govindan et al., 2010). The evidence indicates there are likely to be fewer cases of patient harm and fewer complications associated with document management. Unfortunately, only a small percentage of hospitals and doctors’ offices are currently embracing digital technologies, and the majority of healthcare providers lag far behind other more developed healthcare settings in implementing these innovations (Govindan et al., 2010; Wetterneck et al., 2006). However, researchers, legislators and digital technology experts hope this change will come about over the next decade, with some strong investment in infrastructure. Such investments should enable the adoption of healthcare education technologies such as remote access systems, telehealth, electronic health records and patient tracking systems and, most importantly, staff and patient education in these areas (Gill, Gill & Young, 2013; Gyurko & Ullmann, 2012). Due to the rapid advancement of technologies that have enabled the gathering and sharing of information, and real-time communications in healthcare, the healthcare professionals of tomorrow (who are learning today) essentially need to become experts in the use of these technologies. For example, nursing students studying today need to familiarise themselves with digital technologies to ensure their application in the clinical context is safe, effective and user-friendly. The digital skills learnt today will save time in the workplace, streamlining processes and expediting communication (Dudding, 2009). By way of example, though telehealth is more common than it once was, certain technical, social and infrastructural barriers prevent its more common use in nursing. As restrictions around nursing licensure change to accommodate changing practices and technologies, telehealth use by nurse practitioners will only increase. In order to move forward, nursing students need to embrace these communication technologies as part of their professional development.

Telehealth can also play a key role in the ongoing training of nursing students engaging in clinical placement. The technology allows training and technical support for the use of distance learning while nursing students are on clinical placement. Greater support at the bedside for students has never been more possible than now. Mobile applications such as FaceTime or Facebook, and free communication tools like Skype, can now provide students with remote support for their learning needs (Gassert, 2000; Nguyen, Zierler & Nguyen, 2011).

Mobile and online communications: Distance learning strategies

Online learning facilitates students’ abilities to learn at their own convenience and at their own pace (Hamilton & Friesen, 2013; Sawyer & Howard, 2007). Some would argue that the physical separation from fellow learners and teachers may result in a reduction in communication and important social interactions, and the development of an uncertain sense of attachment to a community of learners. Researchers argue that these feelings of detachment may affect a student’s motivation, and could lead to reduced performance, more dissatisfaction and increased attrition (Horn, 2013; Kelland, 2011). Hence those opposed to online learning would suggest that face-to-face interaction can positively influence learners’ motivation, active participation and interest in learning (Thompson & Lynch, 2003). However, these theories fail because they do not consider the options for flexibility that online technologies afford. Online technologies do offer a sound platform for personal interaction, with the capacity to facilitate effective communication (Gyurko & Ullmann, 2012). In addition, face-to-face learning is not an option for many rural and remote learners. For some learners, there is no alternative but to participate online and at a distance (McLeod & Barbara, 2005).

Research that has focused on online communication in education has generally centred around the generation of personal interactions, reading and writing capabilities, or the effects of online learning on communication (Wright, 2013). This research has demonstrated that online communication tends to lead to more balanced contributions than face-to-face engagement, with less dominance by highly opinionated personalities (Gill, Gill & Young, 2013; Hamilton & Friesen, 2013; Warschauer, 2001). Participation in communication is an essential ingredient of learning, and introverted personalities who are less likely to contribute in face-to-face discussions are more likely to participate in, and make valuable contributions to, discussion in an online environment (Yan, 2013). This gives digital communication platforms a distinct advantage when compared with traditional, didactic systems of learning. There is clear evidence that reading and writing skills can improve when students are also asked to engage with online learning materials. Well-validated research indicates that this arises because students take more pride in their work when posting something on an online platform (McAllister & Watkins, 2012; Roper, 2007). The impact of online learning can be measured by the extent to which it improves access to information, and therefore the generation of knowledge. The online delivery of programs and courses allows students to participate, irrespective of their geographical location. A message, activity or piece of content can reach a wide audience in a matter of seconds (Gill, Gill & Young, 2013; McLeod & Barbara, 2005). Often people seek expert opinions, viewpoints and points of clarity on given topics or best practices. Ready access is the key to keeping people engaged, and mobile communication via online media allows this (Collier, Gray & Ahn, 2011).

It can be difficult to stay up to date with the latest information. Even the best-intentioned student can forget how to complete every procedure, or remember all the processes and policies needed to work in a hospital or other healthcare setting. Mobile devices have the potential to revolutionise the way nurses learn and to enable them to remain up to date with the latest information. In 2014, some 70 per cent of Australians owned a smartphone or a tablet device, with nearly one-third of people owning both. The average Australian adult owned four mobile devices (Deepend, 2014). Ownership rates in New Zealand are comparably high: in 2012, 60 per cent of New Zealand adults owned smartphones and 19 per cent owned tablets (News, 2013).

Because mobile devices are easily carried on the person, they serve as portals to online information. Textbooks and articles can readily be accessed, searched and read using mobile devices – particularly tablets (Duffy, 2012). YouTube or Vimeo videos can be viewed showing examples of processes and procedures (Clifton & Mann, 2011). By using mobile devices for learning, educators are leveraging the skills and technologies students already have, making them more likely to be adopted for study and in the workplace.

Emerging learning technologies

Those in favour of mobile and online learning technologies tend to believe that they offer a learner the ability to interact synchronously or asynchronously with their teachers and peers, in real time at any hour of the day, regardless of time zones. This can also mean that the teacher does not always need to be present for learning to occur; rather, students can engage with each other at their own convenience. Although communication with a teacher may be delayed, it can still occur, and an individual’s learning needs can be met (Bozalek et al., 2013; Herrington & Parker, 2013). University academics often make use of online communication and learning strategies, inclusive of discussion forums or real-time virtual classrooms. The virtual classroom can enable group communication and facilitate effective discussion, even allowing for group work in rooms within the virtual classroom before reconvening class discussions (Martin, Parker & Allred Oyarzun, 2013; Taras et al., 2013). Researchers are also working on remote-access systems that enable a high fidelity of learning, such as emulated intravenous pumps. These offer learners basic through to complex learning scenarios that have been shown to be as effective as face-to-face training (Bowtell et al., 2012). In this way, face-to-face practical or clinical sessions can be emulated online.

YouTube, multimedia and open learning resources in the form of short snippets or lectures, simulations, animations and virtual world scenarios provide academics and students with a variety of teaching and learning tools (Gill, Gill & Young, 2013). These can be applied and adapted to learning needs in various ways, ensuring personal learning styles are not neglected. Many of these platforms offer the learner a chance to effectively practise the art of communication prior to engaging in real-world scenarios (Bowtell et al., 2012).

Open online learning resources can help students who have never fully mastered key concepts, or who have perhaps forgotten them (Bowtell et al., 2012), to learn. They provide options for students who have struggled to follow or engage in classroom tutorials (Gill, Gill & Young, 2013). Even textbooks are changing to incorporate video and audio clips, animations and rich graphics. These textbooks are becoming more interactive, allowing both instructors and students to annotate, add or change material – including interactive assessment questions and feedback. These electronic texts are, of course, accessible via smartphones, tablets, e-readers and other mobile devices (Brown, 2012; Rockinson-Szapkiw et al., 2013).

Digital learning as a substitution process

Time is always a limiting factor when it comes to learning opportunities – or, more importantly, exposure to the best learning opportunities. This particularly occurs when students need to acquire certain competencies in a given timeframe (Bowtell et al., 2012; Miranda & Lima, 2013). In a typical nursing program, most students have limited exposure to simulated patient scenarios or real clinical experience. The capacity to learn and test effective communication skills is therefore somewhat limited. It is imperative that trainee health professionals get adequate exposure to high-fidelity communication scenarios involving patient interaction, as well as interaction with other healthcare professionals. This can occur using several frameworks (Peters, 2004) – for example, ISBAR (Introduction, Situation, Background, Assessment and Recommendation) is a well-known tool used to communicate patient issues with colleagues (see Chapter 2 and Chapter 4). It was originally developed in the military to ensure effective communication of key issues from one person to another. By using the tool, a person can better plan their communication, making it clear and precise for the end receiver and thereby reducing the likelihood of misunderstanding (Brindley & Reynolds, 2011). It is particularly effective for ensuring that all key messages are summarised, particularly if a health professional requires some urgent action regarding a patient. Another valuable tool is PACE (Probe, Alert, Challenge and Emergency). This is valuable when a healthcare professional believes a patient may be at a significant risk due to the actions of another healthcare professional. Using graded assertiveness, a healthcare professional can learn to PACE their way through some effective communication in order to prevent patient harm (Brindley & Reynolds, 2011).

In real-world training environments, there is often minimal exposure to the types of situations in which nurse or other health professional students can develop and make use of such communication tools. However, digital learning environments such as virtual clinical settings can provide a platform for repetitive exposure to conflict scenarios or challenging situations that require effective communication. This enables a student to better develop communication competence and confidence. As another example, simulated nursing labs offer an effective means for students to practise communication with patients regarding everyday procedures such as wound management and medication administration (Bowtell et al., 2012).

The driving societal forces for online learning

Online teaching platforms are fast becoming more popular, with their use expanding well beyond the university sector and into the business and healthcare domains. Study within university climates that include remote training and instruction, and video web conferencing (Peters, 2004), can only become more popular. Together with the popularity of online learning, websites and innovative learning technologies are also being developed by academics to cater for the conversion to learning via distance modes. One of the major driving forces has been the changing expectations for academic learning in online learning environments. Applications with specific operations and purposes are also being created to cater for the increasing online demand and presence of students (Shen et al., 2013). These are being designed to aid learning, ensuring there is equivalence with traditional face-to-face models, while also matching the everyday social expectations of online social media (Macdonald, 2004).

The sudden escalation in and popularity of social media applications have made it possible to create an environment that offers variety and flexibility. This means that modern students need to remain current and open to rapid change in learning systems. A variety of communication applications, such as practice labs, student self-checks, teacher lesson plans, social forums, virtual classrooms such as Blackboard Collaborate, chat and other forums enable effective communication with teaching staff. The modern student wants to balance family, work and study; the development and further refinement of innovative online systems and supporting applications is now making this desire a reality (Cui, Lockee & Meng, 2013).

Without the rapid evolution of these applications, online delivery might not have received the widespread endorsement it currently enjoys. Online applications offer a conducive environment for students and their teachers, as well as trainees and instructors. Such applications help with the creation and management of flexible lesson planning, access to and management of digital library resources, readily available and cyclical student feedback with online surveys, electronic assignment submission and online examination (Cui, Lockee & Meng, 2013). Access to internationally relevant content is now both a key feature and a driving demand from students. The internet has opened up the ability to rapidly acquire information and synthesise it into something meaningful (Keengwe, Adjei-Boateng & Diteeyont, 2013; Shen et al., 2013).

Digital literacies and learning inequalities

In online learning environments, students need to be able to identify, locate, evaluate and effectively use information for their own professional learning and personal improvement. This means they must be able to navigate a plethora of new and rapidly evolving technologies. We tend to think younger generations are like sponges, and generally adapt very quickly to new systems and applications. However, it is wrong to assume that every individual has the competency and capacity for such an adaptation. High school curricula still invest little energy into this new way of learning, and many school leavers are still not digitally literate (Beach et al., 2009; Cui, Lockee & Meng, 2013). Therefore, the university sector must formulate orientations that familiarise new students with the online environment (Roper, 2007).

The internet provides access to a staggering variety of information from online academic journals to practitioner blogs, YouTube videos, Facebook groups and websites of all descriptions. The problem is not a lack of information but rather determining which of these sources are reliable and credible. In the healthcare setting, using incorrect or out-of-date information can have significant consequences. The ability to search for, locate, evaluate and use the information needed is known as information literacy (Eisenberg, 2008). It is not enough to be able to use a computer or mobile device. The modern practitioner needs to be able to apply those computing skills to address real-world situations and challenges, and to be able to locate the information that will help to solve those problems.

A number of attempts have been made to better define ‘digital literacies’ and their relationship to acquiring knowledge and skills. Other educational goals inclusive of traditional learning modes, such as computer training, library access and use, and clinical reasoning skills, relate to information literacy. The necessary digital literacies are evolving over time, and are essential tools to ensure social and academic well-being in a complex and rapidly evolving society (Macdonald, 2004).

Governments and educational institutions around the world need to challenge traditional methods of learning and embrace the flexibility and diversity that online systems and applications offer. In modern-day learning, there is a need to move away from the traditional learning of effective communication. Communicating online requires the development of quite specific skills, which might include knowing how to use videoconferencing, teleconferencing, opening and listening to Mp3 and Mp4 files, or something as simple as sending an email. It is imperative that a student entering the academic world learns and understands the etiquette of communicating via these tools (Duffy, 2012; Macdonald, 2004).

Media literacy

Very few healthcare students are exposed to online media as a tool for learning. This is surprising, given the potential to assist in the development of learners’ critical thinking and creative abilities. The benefits of using online media in learning are that the information has no fixed location, no clear philosophy and no conclusive receivers. Online media are dependent on the erratic nature of news broadcasters and enable communication about what is currently topical and important to the learner. Often, very good case studies can come at timely points in the learning cycle to reinforce key messages. By using and interpreting the media, students are able to analyse, evaluate and generate messages in a vast array of media, genres and configurations. Students who are media literate stay informed about current and relevant events that affect their profession. This reveals current trends and issues within the healthcare sector, and can help generate timely reactions and solutions to minimise public outrage (Lukinbeal, 2014; Sur, Ünal & I.s¸eri, 2014).

Media literacy is the ability to decode, evaluate, analyse and produce both print and electronic media (Aufderheide, 1992). Someone who is media literate should feel comfortable with all forms of media, from newspapers to social media, television and even internet search engines. Media can be a form of entertainment and a way of accessing culture – either our own or that of others. Media literacy is also critically important for learning. With so much media available in our society, the student needs to be able to critically analyse that form of media, gauging its quality and accuracy. This becomes very important when assessing the value of a medical aid or treatment that is being advertised (Koltay, 2011). Media literacy includes knowledge of when discretion with media is required – for example, to maintain patient privacy.

Multiliteracies

Multiliteracies is a recent label that is used to reflect the ways in which people communicate with new technologies. Mobile phones and social media have created a shift in the way the English language is used, meaning a new ‘literacy’ must now be embraced. As an example, people now use emoticons to describe how they are feeling or use abbreviated terms that enable timely replies. In healthcare, these new forms of communication need to be incorporated into learning. Ubiquitous connectivity makes the world seem smaller, cultures have become intertwined and a mix of languages is giving rise to variations in the English language (Rowland et al., 2014; Tan & Guo, 2014).

These variations, combined with the rapid evolution in technology and multimedia, have caused a sudden shift in communication. Today, text messaging via phones is not the only way to communicate. Text messages provide a way to interact with sounds and images, movies, posters, different websites and television programs. To survive and thrive, an individual needs to be familiar with these differing modes of communication, and know what it means to live in a multimedia world (Aufderheide, 1992; Sur, Ünal & I.s¸eri, 2014).

Critical digital literacy

Critical digital literacy is necessary in order for all students to learn effectively in online environments. Students require the technological skills and confidence that enable effective access to, and navigation and use of, online information. With the evolution of digital learning platforms, curriculum design has now become more complex, meaning multiple tools can be used to engage students in their own learning (Avila & Pandya, 2013). In nursing, teachers like to communicate with storytelling or situated practice. The benefit to the nursing student is that they can learn from realistic case studies, receiving high-fidelity learning experiences prior to engaging in the real world. This communicates the realities of healthcare, and enables the development of required clinical reasoning skills prior to students taking on real-life problems. Online engagement allows a student to repeatedly receive instruction, and this can build confidence in handling difficult or complex scenarios or tasks. Healthcare students need to build their perception skills – their ability to recognise non-verbal cues or hidden elements in the communication process. The concept of emotional intelligence is paramount, and online case studies or even patient communities can enable the development of better critical thinking processes, enhance perceptual skills and help students to discover their own emotional intelligence in perceiving when colleagues or patients need assistance. The development of critical digital literacies has the capacity to help transform practice. It can enable students to make connections with key concepts before entering the real world – something that can offer students safer and more confident practice (Avila & Pandya, 2013; Greene, Yu & Copeland, 2014).

critical digital literacy:

digital literacies with a focus on critical thinking skills

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