Therapists' Experiences with Computer-assisted Instruction in Hand Therapy

Susan Toth-Cohen MS, OTRlL, CHT Thomas Jefferson University Department of Occupational Therapy

Patricia Baxter Petralia, MS, OTRlL, CHT NovaCare, Outpatient Rehabilitation Division

Kathleen Swenson Miller, MS, OTRlL Thomas Jefferson University Department of Occupational Therapy

T he challenging healthcare environment of the 1990s has increased the demand for

hand therapists to demonstrate clinical excellence and cost-effective outcomes. Therapists are ex­pected to have superior knowledge and clinical skills, and education is considered essential for con­tinued growth within the field of hand therapy.l,2 Yet, in many clinical environments, funding for continuing education has decreased. Therapists must increasingly rely on self-study to give them­selves "the competitive edge," given fewer oppor­tunities to attend employer-funded conferences. Methods of continuing education include tradi­tional conferences, teleconferences, study groups, informal self-study using books, formal self-study courses, and computer-assisted instruction (CAI).

Since the 1960s, CAI has been used as a learn­ing tool, and experimental studies of CAI have demonstrated learning outcomes at least equal to those provided by other presentation modes in al­lied health and medical schools.3,4,s Reported ad~ vantages of CAI by allied health educators include capacity for advanced graphics display,6 active learner involvement/ individual control of the rate and sequence of instruction/-9 and provision of im­mediate feedback.7,8

Despite the perceived benefits of CAI, attempts to evaluate learning outcomes in medicine, allied health, and education have not produced clear con­clusions about its effectiveness. Experimental stud­ies, particularly "media comparison" research de­signed to examine the effectiveness of one medium over another, have been criticized because there are

Correspondence and reprint requests to: Susan Toth-Cohen, MS, OTR/L, CHT, Thomas Jefferson University, Department of Oc­cupational Therapy, 130 S. 9th Street, Suite 820, Philadelphia, PA 19107.

ABSTRACT: This pilot study explored therapists' experiences with computer-assisted instruction (CA!) programs as a means of self-study in hand therapy. Qualitative methodology was used to describe the therapists' responses to the CA! programs. Therapists described a number of features that they valued in the CA! programs: the capacity of the CA! to provide multiple sensory input, to gain and hold their attention, to provide feed­back, and to provide personalized instruction, as well as the programs' speed and ease of use. Therapists identified the ma­jor limitation of the CA! programs as the inability to provide expert guidance for complex problem-solving in hand therapy practice. Future study of the value of CA! and other computer technology for self-study and continuing education is needed so that hand therapists can use these media to optimal advan­tage. J HAND THER 10:41-45, 1997.

other intervening variables, such as novelty and in­structional method, that could account for differ­ences in performance on pre- and post-tests.10,1l

These studies have also been criticized for the short duration of most experiments, which fail to take long-term effects such as retention into account.12

Proposed alternatives to media comparison studies in CAI include investigations of learner attributions and beliefs,lO cost-benefit analyses/ and qualitative approaches for assessing the value of CAI to indi­viduallearners.13,14

Although CAI is widely used in allied health and medical school programs;lS,16 the literature does not indicate that therapists in clinical practice are currently using CAI as a means of self-study. No studies of CAI in hand therapy have been reported.

In order to explore the use of CAI as a self-study method, a qualitative pilot study was conducted. Specific purposes of the study were to observe and describe therapists' response to CAI and to obtain preliminary information on therapists' perceptions of the value of CAI as a means of self-study in hand therapy.

METHODS AND MATERIALS

We conducted a descriptive study using qualita­tive methodology. The purpose of qualitative re­search is to describe, understand, or interpret ex­perience from the subject's point of view.17 The qualitative approach was considered most appro­priate for this study because the central purpose of the investigation was to gather information on the therapists' responses to CAI and their views about its use. Additionally, since virtually nothing is known about the topic, an extensive quantitative study using a large sample would be inappropriate. Qualitative rather than quantitative research de­signs are best suited for investigations that are ex­ploratory in nature when little is known about the

January-March 1997 41

topic and when the purpose is to gain an under­standing of the phenomenon by listening to partic­ipants and formulating an image based on their ideas.18 The participants in this study were viewed as the source for understanding their response to CAI instead of relying on the results of an instru­ment, such as an achievement test or survey, to pro­vide the data. Thus, the study focuses on the ther­apists' descriptions and observations about CAI rather than statistical comparisons of test or survey scores. The number of participants reporting a par­ticular observation is included so that the reader can gain a sense of the emphasis of a particular topic; however, these numbers are not intended to provide statistical comparison.

Subjects

Participants in this study consisted of seven oc­cupational therapists working in outpatient hand rehabilitation facilities. Therapists' experience ranged from 18 months to 14 years. No participants were certified hand therapists at the time of the study; two therapists have since become certified. Five of the seven participants had little or no com­puter experience prior to the study.

Procedure

The first author traveled to the therapists' clinical setting and observed them during the time they used the CAI programs. Therapists reviewed pro­grams on a portable computer (provided by the re­searchers) at their clinical sites and were given time off from their work schedules to participate in the study. Participants were asked to choose two pro­grams they wished to use from a list of five pro­grams related to hand therapy. The researcher as­sisted the therapists in using the programs only if they asked for help. Because the purpose of the study was to explore how therapists perceived the experience of using the CAI, participants were en­couraged to review the programs as they wished. The researcher did not set predetermined time lim­its or recommend specific procedures for reviewing the material.

The CAI programs available for review con­sisted of the following five Hypercard stacks de­veloped by occupational therapists in academic or clinical settings:

• SplintStack, a case study and problem-solving ex­ercise in splinting of the PIP joint

• Hand Deformities, a description of pathology and hand therapy management of boutonniere and mallet finger injuries

• Computer Comfort, a consumer-oriented program on ergonomics

• Splint Review, a description of basic splinting principles

• Biomechanics, a review of basic biomechanical principles

42 JOURNAL OF HAND THERAPY

Therapists proceeded through the two pro­grams they chose at their own pace and according to their own preferences. Actual time spent using the programs ranged from approximately 20-40 minutes. Therapists were interviewed immediately after using the two programs.

Unstructured interviews represented the major source of information about participants' responses to the CA!. The purpose of this type of interview is to reveal the participant's views rather than to identify or confirm what the researcher expects or considers important.19 Participants were first asked a broad question ("What was that like for you?") to elicit descriptions of the experience; they were then asked more specific questions based on obser­vations and field notes. For example, the researcher questioned therapists about specific behaviors they displayed while using the CAI, such as moving closer or farther from the screen or looking at par­ticular pictures or animation for long periods of time. These questioning strategies helped expand and clarify the researcher's observations and initi­ated discussions that provided a more detailed ac­count of the therapists' experiences.

All interviews were audiotaped and tran­scribed verbatim. The constant comparative method20 described in Guba2I was used to analyze transcripts for common themes. This method al­lowed data to be systematically categorized and subjected to a continual process of reflection and reformulation by the researcher. Themes were sum­marized and mailed to participants, who were in­vited to comment on them in order to confirm that their views were accurately represented. Another researcher independently audited the investigation by reviewing all field notes, preliminary interpre­tations, transcripts, and other materials that made up the study. This is a way of ensuring the trust­worthiness of the study-that is, that the research­er's conclusions are logical based on the data from the participants.

RESULTS

Six primary therues were identified from the interviews as features of the CAI that the partici­pants considered valuable. They are summarized below; see also sample comments from the tran­scripts in Table 1.

Ability to Gain and Hold Attention

Four participants described the capacity to gain and hold their attention as a key aspect of CAI use. Participants discussed three major points within the theme of gaining and holding attention: (1) the CAI programs reviewed in the study have features that promote greater concentration, such as the ca­pacity to provide multiple sensory input and feed­back to the user, as discussed below; (2) the ability to concentrate is critical for using any type of learn­ing tool; (3) both the external environment (Le., a fast-pased clinical setting) and individual learning

TABLE 1. Primary Themes and Sample Comments

Theme Sample Comments

Gains and holds attention It's good because I always have trouble concentrating and paying attention to a lecture. I would probably get more out of this.

It would break up the monotony of reading because, when you're reading, so many other things are distracting you.

If your attention starts to wander, it brings you back. Provices multiple sensory input Visually you're seeing it, you're reading it; then, if you hear something, too, it draws your

attention. I'm a visual person. I learn more through pictures. If I can visually see it in my head, I can

usually come up with the correct terminology. I learn by pictures more than reading. They give me an idea. I usually glance at them first,

before I even do any reading. Quick to use You can easily flip from page to page or you can go from one area to another; whereas in

books, it's difficult to find the exact same spot where you are. If you only wanted to look through a certain part of it, you didn't have to search through the

whole book; it was right there for you. The facts are right there; you don't have to read through paragraphs trying to find the key

information. Easy to use Very ease to use.

Provides feedback It's right in front of you, so it's easier to sit down and review. Advantages It reinforced what I was learning. If I didn't understand something, I'm sure it's going to show

up on the quiz, if I didn't get that question right. Then, maybe I should review the screen that pertains to that question.

Disadvantages Someone with experience would be more beneficial over a computer who's never worked with

people. Provides personalized instruction Depending on what level you are as a student or as a therapist ... you can learn information

from what's on the screen. You can get as much or as little information as you want.

attributes (ability to focus) are important factors that influence a therapist's ability to concentrate on a learning tool in order to gain maximum benefit.

Multiple Sensory Input

Five participants mentioned multiple sensory input-which included seeing, hearing, moving the mouse, and touching the keyboard -as a val­ued feature of the CAI programs they reviewed. Multiple sensory input was viewed both as an aid to concentration and as a way to present informa­tion to facilitate learning. In particular, five partic­ipants cited the importance of visual input. They noted that the graphic displays captured their in­terest, helped them to visualize key structures, and. aided their comprehension of the text.

Speed of Access

Five participants mentioned that it was impor­tant for them to quickly find the information they needed. Speed of access was a logical consideration for determining feasibility of use if therapists wanted to use the programs at their clinical sites during working hours, given the busy, fast-paced clinical settings in which they worked. Five partic­ipants compared the CAI with a book, reporting that the CAI program was quicker to use. Four par­ticipants also reported that information was easier to find with the CAI program. In this, they ap­peared to be referring to basic structural differences between books and CA!. Specifically, CAI is char­acterized by a "sparse" writing style/2 whereas ref­erence textbooks are known for their detailed de-

scriptions. Textbooks present information in a linear sequence, but CAI programs typically have menus and buttons that allow the user to choose the order of presentation and move rapidly from one section to another. (All the CAI programs used in the study were structured in this way.)

Ease of Use

Five participants specifically mentioned ease of use as an important feature. Ease of use may have been a focus for therapists in this particular group because the majority had very'little computer ex­perience. For four participants, it was only the first or second time they had used a computer. Of these, three expressed the view that the programs were easier to use than they tl)ought they would be.

The categories of ease of use and speed of ac­cess appeared to be related and were often reported together. Therapists wanted to spend as little time and energy as possible to get the information they needed for patient care. As one participant ob­served, "I don't want to spend the time to figure out how to use the computer. I want it to be right up there, easy to do .... I want the information."

Capacity for Feedback-"Computer as a Tutor"

Four participants emphasized the capacity of the CAI program for providing feedback as a key feature. The primary advantage of the feedback, which was provided chiefly through quizzes, was its use as a self-assessment tool. Participants re­ported that feedback reinforced correct answers

January-March 1997 43

and identified areas in which they needed review. Feedback from the programs also served as an in­centive to thoroughly review the content. This was seen as important because, during self-study, the therapist might not take the extra time and effort to quiz herself or himself or to review to make sure that she or he understood the material.

Despite the advantages of feedback provided by the CAI, participants also identified significant limitations. In particular, they expressed the view that the feedback they received would not be suf­ficient to help them treat complex clinical problems. While the CAI was useful in providing an overview or basic information-for example, when present­ing protocols for specific diagnoses-therapists emphasized the importance of conferring with an experienced clinician when dealing with unusual or difficult clinical situations: "It's not so concrete .... It's not what you see in the book; it's not what you see here. When it gets to the complicated parts, that's when you need another person. That's when I don't think the computer can help you."

Capacity for Personalized Instruction

Closely related to the "computer as tutor" was the CAI programs' c<;lpacity to adapt to individual learning needs. Participants noted two means of adaptability: (1) being able to use the programs at home or at work, whichever they preferred (if they had access to a computer); and (2) the ability to choose which information they wished to review and review it at their own pace using menus and submenus within the programs. The flexibility of choosing the portions of the program they wanted to see was also considered a way to adapt to ther­apists' different levels of experience. For example, a therapist with little experience in treating a pa­tient with a particular diagnosis could use the same program as an experienced therapist but might ex­amine the information in more detail.

DISCUSSION

All participants in this study responded posi­tively to use of CAI for self-study of topics related to hand therapy. Features this group of therapists considered particularly important were the capac­ity of the CAI to gain and hold their attention, the speed and ease of use of the CAI programs, mul­tiple sensory input (particularly graphic display), the feedback provided by the CAI, and the adapt­ability of the CAI to different users and settings.

Several features of CAI reported as valuable in this study have been emphasized as key aspects of instructional design in CAI. The importance of gaining the user's attention/3 the use of CAI to as­sist visualization/ and provision of feedback7

,8 were confirmed with this group of therapists. Adapta­bility of the CAI for home or clinic use was another feature these individuals reported as valuable. This may be especially important because so many peo­ple are now purchasing their own personal com-

44 JOURNAL OF HAND THERAPY

puters; about 30% of American households now own a personal computer.24 Use of CAI at home could be important for therapists re-entering clini­cal practice or for those preparing to take the Hand Therapy Certification examination.

Perhaps the most interesting finding was the major limitation that therapists perceived: the in­ability of the CAI to provide expert guidance for complex problem-solving in hand therapy practice. Their comments seem to express the conviction that, when it comes to the art of hand therapy, the computer is an inadequate tool. Part of this un­doubtedly stems from the complexity of hand ther­apy intervention with patients who have under­gone a variety of surgical procedures or medical management, have a highly varied clinical presen­tation, and who experience and adapt very differ­ently to their injury or disease. An emphasis on the art of hand therapy has been central to the profes­sion since its beginnings and continues to feature prominently in current discussions of the field?5,26

At another level, perception of the computer as limited in its ability to fully address key aspects of hand therapy practice also appears to reflect a be­lief that computer programs (at least in their pres­ent stage of development) cannot substitute for a human mentor. This is congruent with a strong em­phasis on mentorship in hand therapy, which has been described both in the sense of individuals re­ceiving help and guidance from those with more experience and in the sense of mentorship that hand therapy leaders provide to the field.

CONCLUSION

This pilot study using qualitative methods ex­plored the experiences of seven therapists who were interviewed after using CAI on topics related to hand therapy. The purpose of the study was to identify features that therapists values as well as the limitations they perceived in using selected CAI programs. The study fills a gap in the hand therapy literature and may help to inform future investi­gations of self-study materials for hand therapists. We also hope that this study will inform and gen­erate interest in developing additional CAI for use in hand therapy.

Future study of this topic is needed, since CAI development is likely to increase as more therapists become exposed to computers in their clinkal set­tings and attain computer competence. Recent de­velopments in computer technology (e.g., voice-rec­ognition systems, 3-D graphics) and expanded use will undoubtedly lead to the development of more computer learning tools. For example, hand ther­apy educational courses accessed through the In­ternet, with instructors interacting directly with course participants, could soon become a reality. This process should be guided by research on the value of CAI, not solely by advances in technology. As Hannafin and Phillips27 point out: liThe need is to identify not only the capabilities of technol­ogy but the capacity of individuals to profit from those capabilities. It is clearly insufficient that some-

thing can be done, of greater importance from an in­structional perspective are should it be done, when should it be done, and under what circum­stances ... . "

The present study explored the experiences of a small group of therapists using CAI on topics re­lated to hand therapy. While the results cannot be generalized to all CAI or to all hand therapists, this work can serve as a framework for further explo­ration of the use of CAI in hand therapy. For ex­ample, future studies might investigate the value of computer learning tools to therapists at various lev­els of experience in hand therapy and the appro­priateness of particular computer tools for individ­uals at different levels of computer literacy. Additional studies could examine the use of CAI in different learning environments and the value of CAI to therapists at different points in their careers. Both quantitative and qualitative methodologies could be used according to the specific research question and the area to be investigated. In some instances, both approaches could be used in the same investigation in order to complement the strengths and weaknesses of each.28 As computer technology expands, so should our knowledge of how best to apply its powerful potential to our field.

Acknowledgments

The authors thank Ann Marie Frankel, Kelly Cordasco, Ellen McCann, Thomas Sacchetti, Nicole Sanchez, Julia Scolnick, and Karen Fluk Waldman for participating in this study. We also thank Joan Jenks, PhD, RN, and Kevin Lyons, PhD, for their valuable guidance on qualitative research design and method­ology.

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