Developing a Problem Based Learning model for Internet-based teaching in academic oral health education

Developing a Problem Based Learning model

for Internet-based teaching

in academic oral health education

Nikos Mattheos, DDS

UNIVERSITY OF MALMÖ Department of Periodontology Centre for Oral Health Sciences

στη µητέρα, τον πατέρα, την αδελφή µου.

χωρίς την αγάπη τους, τίποτα δε θα είχε νόηµα.

to Rolf,

for teaching me the art of doubting

and the science of searching for the answers.

To Tuuli,

Contents

Introduction

a. Problem Based Learning ………3 b. Problem Based Learning in Distance Learning ………4

c. The Virtual Classroom ………5

Aims ………8

Material and Method

a. literature review ………9 b. Study I ………9 c. Study II ………11 Results a. literature review ………14 b. Study I ………16 c. Study II ………18 Discussion ………20 Conclusions ………23 Acknowledgements ………24 Reference ………25 Attached publications publication I publication II publication III publication IV

ISBN 91 – 631 – 1855 – 6

This Licenciate thesis is based on the following published studies:

I. Mattheos N, Schittek M, Attström R, Lyon HC. Distance learning in academic health education: a literature review.

European Journal of Dental Education 2000: 5: 67 – 76.

[PubMed]

II. Mattheos N, Nattestad A, Schittek M, Attström R. A Virtual Classroom in undergraduate periodontology: A pilot study.

European Journal of Dental Education 2001: 5: 139 – 147.

[PubMed]

III. Mattheos N, Nattestad A, Attström R. “Local CD-ROM in interaction with documents coming over the Internet”.

European Journal of Dental Education 2000: 4: 124-127.

[PubMed]

IV. Mattheos N, Wretlind K, Nattestad A, Attström R. Interaction in virtual versus traditional Problem Based Learning classrooms. A pilot study in education for oral health professionals.

American Journal of Distance Education, Readings in Distance Education No. 8, 2001: 85-97.

Introduction

a. Problem Based Learning.

Problem Based Learning (PBL) was first introduced in health education in McMaster university in Canada as early as 1969 (Barrows, 1996). This educational method has since then attracted an increasing interest among the academic health care community. Several medical and dental schools throughout the world have by now fully or partly adopted PBL for their undergraduate education (Rohlin et al., 1998; Greenwood et al., 1999; Lim et

al., 1999; Smales, 1999; Gwee et al., 2001; Samy, 2001), including some

prestigious institutions of the western world such as Harvard University (Khoo

et al., 1988) . Advocates of PBL claim that professionals trained this way will

develop stronger clinical reasoning, critical thinking and self directed learning skills (Schwartz et al., 1992; Lim et al., 1999; Kwan, 2001; Ozuah, 2001), while the acquired knowledge will be in context with the clinical needs and will be better retained (Norman et al., 2000). In addition PBL would better prepare students to fit in a lifelong learning process. However many educators and administrators question these benefits or argue that the advantages of PBL may be too marginal to justify the resources required in sustaining it (Colliver, 2000). It is also of interest that several variations of PBL have been developed for in-classroom teaching, triggering the ongoing discussion regarding which models are legitimate applications of the initial philosophy and which are oversimplified imitations (Samy, 2001).

In 1990, the Centre for Oral Health Sciences in Malmö introduced a full PBL curriculum (Rohlin et al., 1998). Students are organised into small groups who attend “thematic” modules under the guidance of a tutor-facilitator. Rather than serving as an active resource person, the tutor acts as the guide of the group, propelling and steering the discussion when necessary. Each session is developed around a clinical case, or “problem.” The process of studying and “solving” the problem follows six clearly identified steps (Table 1) that allow the students to reach the learning objectives by building their new knowledge, understanding, and skills into the context of what they already know. The first three steps are characterized by a high level of interaction and brainstorming, ending with the formulation of one or more hypothesis. The last three steps involve the collection, organization, and evaluation of information, a structured presentation of knowledge and opinions and the final testing of the hypothesis. In the undergraduate curriculum, each PBL module usually consists of two three-hour, in-classroom sessions separated by a week’s interval. During the first session, the students work through steps 1-3. After the days of individual

searching (step 4), the students conclude the module in a second session (steps 5 and 6).

b. Problem Based Learning in Distance Learning

Despite the spread of PBL in health education in-campus teaching, its adoption by Distance Learning (DL) course designers has not been similar. Only few attempts were made to adopt a PBL model in distance learning (Gianni et al., 1998; Chan et al., 1999; Price, 2000). One might expect distance learners to benefit more from a PBL approach, due to their particular social and professional characteristics (Solomon et al., 1991; Kuthy et al., 1996). We often experience in distance learning courses the occasional introduction of supportive problem-based or case-based modules, either stand alone or implemented in more or less didactic structures (Engel et al., 1992; Phipps et

al., 1999). A common concern of course designers in the past was that the

various distance learning media could not easily facilitate the level of interaction necessary for PBL (Mattheos et al., 2000a). Others, believed that PBL, being designed for small group, in-campus learning is simply not well suited to the distance learning mode of study (Price, 2000). In addition, it is considered difficult to introduce inexperienced students to the PBL methodology over distance (Kamien et al., 1991). However, the recently introduced structures of a virtual classroom are indicated to provide course designers with the necessary interactive tools to effectively accommodate PBL and other collaborative learning methods (Cravener, 1998; Gianni et al., 1998; Fox et al., 1999). The integration of various resources and communication tools under one simple and affordable distance learning environment is something that no previous media could achieve to a satisfactory extend.

Table 1.

Six identified steps that will allow student to reach the learning objectives within the PBL study group. (From Rohlin et al 1998).

1. define the problem 2. generate hypothesis 3. formulate learning goals

4. collect additional information outside the group 5. synthesise newly acquired knowledge

c. The Virtual Classroom

The terms “Virtual Classroom”, “Virtual Learning Environment,” and “Integrated Distributed Learning Environment” (Cravener, 1998) are rather new and not yet clearly defined. A simple but comprehensive way to describe a Virtual Classroom would be as the network-based structures that simulate the learning environment of a physical classroom in terms of interaction and functionality (Mattheos et al., 2000a). With a combination of powerful communication tools, these environments allow real time one to one, one to many or many to many interaction, mainly text based but with the possibility of audiovisual interaction being more and more reliable. The inclusion of multimedia, search engines and databases, hypertext and various synchronous collaborative activities under this framework, constitutes a powerful tool for distance education, that has inspired many to envision the so-called “Virtual Universities” in the near future (Duvauferrier et al., 1998; Seka et al., 1998; Richards, 1999).

The possibility of synchronous audio or audiovisual interaction is not new in DL (Anneroth et al., 1994; Mattheos et al., 2000a). Microwave televisison (Dirksen et al., 1993), audio conference (Marshall et al., 1985; Kuramoto et al., 1997), interactive television and teleconference (Williams, 1985; Gehlauf et al., 1995; Huston, 1997), satellite links (Hinman, 1996) and several other tools have been successfully used to link remote groups of learners with learning resources since many years (Figures 1 & 2).

Figure 1.

Typical settings for audio conference, as used for distance learning purpose within health education. (from Mattheos et al 2000a)

Figure 2

Typical settings for audiovisual teleconference, as used for distance learning purpose within health education. (From Mattheos et al, 2000a)

Yet, none of these media succeeded in accommodating PBL, as they were based on focal groups, expensive studio technology and therefore were unable to achieve interaction up to the level of the individual learner, as PBL would demand (Figure 3).

Figure 3.

The flow of communication in a typical teleconference session. Linking of remote groups is possible, yet the student is not able to interact as an individual within a remotely located group. Although this structure would be ideal for “tele-lecturing”, it could hardly accommodate PBL through distance.

student

The real potential of VC environments is not based on the possibilities offered by the technology, but rather on the fact that all these tools for the first time appear under one integrated and affordable environment. In this way, a Virtual Classroom allows the distant learner to interact and participate in the learning experience as an individual from his own computer at home, while still being part of a group (Figure 4).

Few evaluations of Virtual Classrooms in medical and dental education can be found in current literature. As the concept and the structure of such classrooms are relatively new, evaluation mainly exists in the form of case studies (Lang, 1992; Hiltz, 1995; Gianni et al., 1998; Huges et al., 1998; Cravener, 1999; Fox et al., 1999; Hara et al., 1999; Jones, 1999). Some authors suggest that Virtual Classrooms are likely to support collaborative activities and complicated learning methods such as PBL and Dynamic Knowledge Networks (Gianni et al., 1998), even achieving higher levels of interaction than in the classroom (Cravener, 1999). The variety of means of interaction offered (text based synchronous or asynchronous, co-authoring activities etc), as well as the ability to record and categorise each discussion and intervention during the learning sessions are likely to enhance learning and also provide the faculty with a unique opportunity to study and improve instructional methods (Cravener, 1999). Therefore, introduction of virtual classrooms as a supplement to in-classroom teaching might constitute an added value. Several universities in Europe and the US have already introduced VC support for their in-campus

tutor

students Learning Resources

Figure 4.

The flow of communication in a Virtual Classroom. As the whole learning experience is accessed through the student’s computer, the learner is able to interact with other students, tutors and learning resources as an individual and 100% through distance. Formation of Virtual groups is possible as well

teaching (Centre for Academic Dentistry (ACTA), 2000; University of Leeds, 2000).

As Virtual Classrooms attract an increasing attention of academia and industry, they are expected by many researchers to play a significant role in health education in the future. Therefore, the adaptation of an existing PBL model into these media would be of significant application. Such a model would allow students to benefit from the flexibility of distance learning via the Internet, while preserving the learning philosophy, function, and effectiveness of in-classroom PBL.

• Review the current evidence and experience in the fields of Distance Learning, Internet-based learning and Virtual Classrooms in health education, especially in relation to the Problem Based Learning approach.

• Develop and describe a functional network based PBL model, based on the existing experience and evidence and simple technology, adjusted to the needs of dental students and professionals in oral health.

• Identify strengths and weaknesses, as well as factors of importance in the development and implementation of such a model in undergraduate and post graduate health education and initially investigate its acceptance and effectiveness.

Aims

Material and method.

a. literature review

A literature review was conducted aiming in summarising the present experience, the current state of the art and the future trends and tendencies that can be identified in the field of distance learning in health education. The review was focused on undergraduate and postgraduate education of medical and dental professionals. Current literature and resources were examined, mostly focusing on publications made during the 1990’s, as technology has dramatically changed the potential of DL during this period. Eighty-five publications from 1985 to 1999 were reviewed. Thirty of them, which clearly described a methodology or a specific course design, were selected for further categorisation. These studies were classified according to year of publication, media employed, target audience, type of evaluation (if existing) and reported results. In addition, an effort was made to categorise distance-learning applications, according to the kind of interaction they could facilitate. Finally an analysis of the factors of importance was attempted, identifying factors related to learning methodology, student and staff acceptance, assessment methods, and reported effectiveness of DL. The technological aspects, relevant to DL in health education were reviewed in a separate article (Mattheos et al., 2000a).

b. Study I

The first study was a PBL Virtual Classroom in basic periodontology that was attended by 28 students from 13 European countries. The course was fully Internet based and the learning method chosen for the study was PBL (Rohlin et al 1998). Only 4 out of the 28 students were attending a faculty with PBL curriculum. The PBL philosophy was initially presented to the students during an introductory workshop held in Barcelona in October 1998. This workshop also included a brief introduction in distance learning, as well as detailed presentation of the design, the structure and the aims of the Virtual Classroom. Students were voluntarily organised in 4 groups of seven. Four PBL tutors from the academic staff of the department of Periodontology were allocated to the different groups. In order to follow the six learning steps of the PBL model used in this course, each group was provided with three means of communication: asynchronous web boards (password protected), synchronous on-line communication and e-mail lists. Each group was instructed to employ all communication methods, but they could decide independently on when and how often each of them should be used. Duration of each thematic

session and the pace of discussion was decided individually by each group. Upon completion of each session, the secretary of the group presented the

progress of the discussion and the final conclusions in a summarising document. A web site was built to serve as communication centre and gateway to the virtual classroom (Fig. 5).

Fig. 5. The home page of the

Virtual Classroom

The learning material of the course consisted of a large number of videos with sound, as well as series of high quality images. The problem of transmission of the learning material, in particular the video clips, through slow modem connections, was dealt with by means of simple HTML technology and a specially designed CD-ROM. The CD-ROM could not be used as an independent learning tool and students could not access the material in a structured way without interaction over the Internet. In this way, the CD-ROM with the learning material was not a ”digital textbook”, but rather an extension of the network, a part of the interaction, able to assist the learning process in any direction decided at any stage (Mattheos et al., 2000b).

In addition, the use of the CD-ROM allowed the group tutor to use the videos during on-line (synchronous) discussions with the students, without any delay due to downloading times (Fig 6). Formative evaluation of different learning aspects was carried out at different stages throughout the course, and a summative evaluation took place during June 1999, using on-line questionnaires and a final synchronous meeting. The questionnaires included both multiple choice and free text questions, as well as topics for personal commentary. One line assessment meeting was carried out in each group, while the final on-line meeting was an open agenda discussion among the tutors, the technical team and the group chairpersons.

Fig. 6. The tutor replies to the student’s request with a html document

placed on the server. The document contains a link to the relevant images and films on the student’s local cd drive. The student just have to click on these links to rapidly retrieve the illustration material and long downloading times over the Internet are avoided.

c. Study II

The second study was built around a PBL continuous education course for health professionals, which dealt with oral health care for the elderly. A web page served as a “gateway” to the tools and learning resources (Fig.7).

Fig 7. The course home page

Once again, the PBL method of the course was based on the Malmö model (Rohlin et al., 1998). However, in this pilot study in-classroom interaction was combined with -and not replaced by- virtual interaction. This allowed testing and evaluation of the various kinds of interaction involved. Therefore, only the first three steps of the PBL module took place in the classroom, while steps 4 and 5 were supported by

asynchronous interaction and step 6 by synchronous interaction on the Internet. Eight people registered for the course, and they were organized into two groups of four. All eight participants were professionals in the field of health care and had no previous experience with either distance learning or PBL.

The participants’ mean age was 39 years. Each group was assigned one PBL tutor from the academic staff of the faculty. Both tutors were professionals in oral health care and were experienced in guiding PBL in-classroom sessions. Although the tutors had attended seminars on computer-assisted learning and distance learning, they had no previous experience with Internet-based teaching. Three kinds of interaction were employed during the course: Virtual synchronous (chat), Virtual asynchronous (WebBoard) (Fig 8), and In-classroom interaction.

• Virtual Synchronous and Asynchronous interaction

The virtual environment was facilitated by means of the WebBoard’s software package, which includes tools for synchronous and asynchronous text-based interaction. All synchronous discussions were recorded by the server. Each meaningful unit of communication by a person was considered as one “input.” These inputs vary from simple responses, such as “yes” or “no,” to complicated sentences contributed by a person. Measurements such as the total number of inputs, inputs per minute, and inputs per person were carried out.

• In-Classroom Interaction

The in-classroom sessions were assessed by an independent observer. In-classroom interaction measurements were performed during five randomly selected periods of five minutes, in one three-hour PBL session. Only verbal interaction was recorded, with each input being one meaningful verbal sequence. Facial expressions, body movements, emotional signs, and other nonverbal communications, were not registered. The purpose of this registration

Figure 8.

Screenshot from the asynchronous communication tool of Webboards. Overview of submitted messages and ongoing discussion is available in the left frame, while individual postings and new messages are viewed in the right frame.

was to measure the quantity of in-classroom verbal interaction as compared to the data collected by the synchronous online discussions.

• Attitude and Competence

The overall attitude of the participants towards distance learning and virtual environments was assessed by means of a final open discussion and two questionnaires. An open discussion with an independent observer took place after completion of the course, whereby participants were invited to comment on various aspects of the learning experience. The participants’ competence with computers was measured on a percentage scale, based on replies to twenty-six questions representing tasks of increasing complexity.

Results

a. literauture review

Results from thirty of the studies reviewed since 1985, were classified according to certain methodological features (Table 2). Two main categories of distance learning applications were identified in the literature regarding dental and medical education: the undergraduate applications and those that aim at a postgraduate level (Table 3).

Table3. Categories of distance learning applications in academic health education. 1. In- Curriculum Distance Learning Undergraduate Distance Learning

2. Extracurricular Distance Learning

1. Structured Advanced Education (MSc., Diploma

etc.)

2. Specialist education

Credited

Postgraduate Distance Learning

3. Continuing education

Non credited

The evolution of technology has predominated the learning methodologies of distance learning to the extent that a similar evolution can be observed in distance learning courses. The possibility and quality of interaction with resource persons and other students, appears to be the determining factor for the methodology applied in distance learning courses. Therefore, it was possible to identify three distinct generations of distance learning applications from a methodological point of view (Table 4). Each of these was characterised by certain technological and methodological features and could be appropriate for different educational needs.

It was concluded that accreditation, team-work and personal contact, are stressed by most authors, as important factors for increasing motivation and minimising drop out rates. It was also indicated that interactive applications and especially the virtual learning environments tend to employ more complicated learning methodology, with encouraging results. However it was apparent that applications in distance learning lack the support of a solid theoretical framework and there is a relative paucity of original research work in this field. Out of the thirty finally selected studies, only 5 were based on a clear research protocol including control groups. The majority of studies in this field use selected sample and typically base their results on post-course questionnaires, they have therefore limited control over novelty effects and other confounding factors.

Author Year Method Kind Subject Evaluation Results - conclusions 1 Williams 1985 interactive television UG Medicine not present increased acceptance 2 Marschall et al 1985 telephone conference UG Medicine not present increased acceptance

3 Hibbard et al 1986 telephone conference Ex Medicine questionnaire increased acceptance 4 Kamien et al 1991 audiovisual material, study

groups UG General Medicine questionnaire increased acceptance 5 Patterson et al 1991 printed material CEP Fissure carries questionnaire changes in diagnostic

procedures of users 6 Holborow et al 1991 Telephone conference, site visits,

audiovisual material

HD Dentistry not present increasing number of students,

high completion rate 7 Lyon et al 1992 Interactive software UG Medical controlled group study Similar test scores in both

groups

Computer group needed 43% less time 8 Lang WP 1992 Computer conference UG Dentistry questionnaire,

recording of interaction

positive acceptance, problematic evaluation, students developed information access and retrieval skills. 9 Marschall et al 1993 Printed material,

telephone conference

ST Medical Photography not present not present 10 Dockning S. 1993 Printed material CEP Nurse education not present not present

11 Dirksen et al 1993 Microwave television UG Nurse education questionnaire similar achievements and attitude between distance and in classroom students, complex and expensive technology

12 Ndeki et al 1995 printed material, site visits

CEP Medicine Questionnaire, pre-post test

enthusiastic acceptance, increased motivation 13 Hayes et al 1996 Web based patient CEP Medical user comments enthusiastic acceptance 14 Macfarlane et al 1996 Hypertext CEP Epidemiology not present not present

15 Hinmman AR 1996 Satellite transmission CEP Epidemiology not present increased cost - effectiveness 16 Van Puten 1996 Web based UG Prosthodontics not present Internet environment

suitable for examinations 17 Tannenbaum et al 1996 not present UG Dental hygiene not present not present

18 Gould et al 1997 Asynchronous conference CEP Dentistry controlled group study low participation from most users

study undergoing evaluation

19 Cochrane et al 1997 workbooks, teamwork Ex Medicine not present better pass rate of course users

increased acceptance 20 Kudryk et al 1997 Two way video CEP Dentistry cost-effectiveness

study in 38 of 40 cases, diagnosis was possible at distance

21 Bailey J. 1997 Two way Int. Video UG Paediatric dentistry not present increased faculty students acceptance

22 Kuramoto et al 1997 Audiographics teleconference CEP Nurse education questionnaire positive acceptance technical difficulties 23 Lewis et al 1998 Two way video CEP Family Medicine controlled group study Similar achievements in

both groups, decreasing acceptance and

low level of interaction in distance group

24 Smith et al 1998 Two way video HD General Dentistry questionnaire Increased acceptance, High completion rate, Improvement in skills of users

25 Gianni 1998 Virtual Classroom UG Medicine Recording of interaction

High level of interaction, Theoretical background development

26 Agius et al 1998 Web based UG Occupational Medicine, Env. health

questionnaire

group reports gains in technological expertise, achievement of learning objectives

27 Rogers et al 1998 Computer based UG Surgical skills controlled group study Similar achievement of learning content, lower proficiency level in the computer instructed group 28 Hobbs et al 1998 in classroom,

computer network, satellite network

UG Emergency medicine controlled group study Similar achievements in distance and control groups.

29 Dugas et al 1999 Web based CEP Medicine not present not present

Table 4.

Main characteristics of distance learning applications as according to the level of interaction provided. (Mattheos et al 2000a)

b. Study I

Twenty-three students completed the first pilot study course in May 1999 (82.1% completion rate) and 15 (53.5%) fully participated in the course assessment process that followed. All drop-outs occurred during the first six weeks of the course. The majority of students (53%) considered the ability to effectively handle information technology for purpose of their education as the most important benefit from the course. A smaller percentage (21%) considered the encounter with the PBL as the major profit from their participation (Table 5).

1st generation 2nd generation 3rd generation Correspondence

Courses

Interactive Courses Virtual Classrooms Interaction - No interaction - Evaluation Questionnaires - Audio (early) - Audiovisual (late) - Audiovisual - Syncronous- asyncronous text discussions

- Sharing of working files and resources

- On line libraries

Technical demands

- less demanding - Both server and client demanding

- Mostly server demanding

Technology mail ,workbooks,

tapes, slides, Videos Radio, TV broadcast CD-ROM

Web applications

-Teleconference -Two way video -Microwave TV -Fibre optics, satellite

- Internet - Multimedia - HTML

Methods - Self teaching - Didactic courses

- Study groups - Problem Based Learning - Dynamic Knowledge Networks Mostly applicable to - Individual professionals - Professionals or undergraduates - larger groups - Professionals or undergraduates - Individuals or groups

Table 5. Student’s response in the question “What was the most important thing you learned

during the Virtual Classroom?”

The learning potential of multimedia was also compared to articles and textbooks, using a scale from 1 (inadequate) to 5 (excellent). The majority of students rated multimedia as an excellent learning tool (mean score 4.6), while textbooks were rated by most students as “very good” (3.6) and articles as “good” (3.0) (Table 6).

Students rated their competence with computers prior to the course on a scale from 1 (almost unfamiliar) to 5 (almost expert). The majority of students rated themselves between 2 and 3, with a mean of 2.78. This self-assessment was later shown inconsistent with the students’ actual ability to handle the technology used.

The PBL method as practiced in the network environment, was accepted positively by most students. All students reported feeling confident

15 6 2 5 0 5 10 15 20 25 Computer Literacy PBL Other no evaluation 28 students 0 0 0 1 3 0 6 8 5 6 4 10 2 0 3 6 9 12 15

Inadequate poor good very good excellent

Multimedia Textbook Articles

Table 6. Students respond in the question “How would you rate Multimedia

with the PBL before the course begun. However, during the first case tutors realised that many students had an incorrect comprehension of the learning method. In particular, students originating from strongly didactic environments tended to understand PBL as a quiz or a competition, rather than a slow stepwise learning process. This fact caused a temporary pause in the course, as the tutors had to focus on comprehension of the learning method before moving on to the actual case discussions. An on-line meeting was arranged, where the tutor and some already experienced PBL students carried out a “demonstration” session.

Team spirit was included by most students among the strengths of the course. The elements facilitating team spirit were reported to be team decision making, team problem solving as well as independence and private Internet areas for the teams.

c. Study II

All eight participants completed the course. From both the questionnaires and the open discussion during the second pilot study, it was evident that participants appreciated the PBL approach, considering this to be one of the main strengths of the course. PBL was reported to be “dynamic” and “engaging.” However, they all agreed that PBL is more demanding in terms of time and effort than traditional teaching methods.

The participants appeared reserved towards the online synchronous communication. Five of the eight participants replied that they were not satisfied with the online meetings, mentioning that it was difficult to lead a proper discussion. In particular, they felt the online discussions were more “superficial” than the in-classroom ones. However, six of the eight particpants considered the online discussions to be valuable for maintaining the contact among the group members and facilitating teamwork during the intervals between in-classroom meetings. In addition, only two thought the online discussions could be effectively replaced by normal e-mails. Six out of eight also believed that there was no need for more face-to-face contact. The asynchronous interactions were judged as “valuable,” but participants still reported they would rather submit their comments during the in-classroom or online meetings. This fact probably explains the lower than expected use of the asynchronous board for content related purposes.

The questionnaires revealed a slight increase in the attitude that Internet-based distance learning is more effective and stimulating after completion of the course. Also the mean score in the computer competence test was increased from 34 % to 45 % after completion of the course.

The postings on the asynchronous web board were categorised in four groups according to their content. The major finding was that students would not use the asynchronous board for communication relevant to the actual course content as much as it was anticipated. Out of 165 postings throughout the course, 36 (22 %) were related to the content, 32 (20 %) to technology, 48 (29 %) were miscellaneous and 49 (29 %) were uploads of the students essays. During the evaluation it was apparent that students would rather hold their questions or comments for the in-classroom meetings or chats, rather than posting on the web board.

When comparing the virtual synchronous with the in-classroom verbal interaction, two differences were apparent:

• The speed of discussion in the classroom session is much higher, with an average of 13.4 inputs per minute, compared to the 2.1 inputs, which was the highest rate observed during the online discussions.

• The involvement of the tutor in the discussion is much less in the classroom, with a mean of 4.8 inputs per session (SD 2.1), amounting to 7% of the total interaction. During the virtual interaction the tutor involvement was around 40 %, as the tutors had to continuously steer the discussion.

Discussion

There is an apparent lack of a conceptual theoretical framework to support distance learning applications. Cases reported so far seem to focus rather on the effectiveness of a certain technology than on the design and evidence of effectiveness of a learning method. Encouraging and sometimes enthusiastic results are widely presented in case studies. However, the few carefully controlled studies seem to suggest a more cautious approach, although they tend to agree that students educated through DL courses present similar achievements with their in-classroom controls. Further research is needed to investigate all the variables involved and identify the factors that contribute or jeopardise the success of a DL course. The weaknesses and strengths of the traditional teaching methods in comparison to the appropriate DL alternatives have to be further investigated (Phipps et al., 1999).

The pilot studies have demonstrated that PBL is a possible and beneficial approach for network-based teaching. In both studies students were very positive towards the PBL as they experienced it over the network, including the method among the strengths of the courses. PBL was characterised as “dynamic” and “engaging”, although students in both cases had no previous experience of the method. Also it appears that the method was successful in creating the necessary “team spirit” and promoting the group work among remote learners. Within the limitations of the current study, it can be concluded that a PBL approach could enhance network-based teaching and should be attempted for collaborative learning among distance learners. However, it was obvious that certain factors should be taken into consideration prior to such an attempt, as they could jeopardise the success of any Virtual PBL course.

It appears that the introduction of inexperienced students in the PBL method is a rather demanding and slow process that probably requires practicing of several sessions, apart from any theoretical knowledge or demonstrations. Trying to familiarise students with PBL over the Internet, might be a complicated, time-consuming and frustrating experience, which could significantly slow down the course progress and discourage students. Within this context, it would be reasonable to require some previous experience with PBL from students who are going to participate in fully network-based courses with this method. Otherwise, some form of introductory workshop should be arranged.

Even if Internet–based PBL is functional, one question arising is whether this model would be comparable to the in-classroom PBL group work. During the fully Internet-based study, several problems of technical nature or related to the comprehension of the PBL method required a lot of time and effort to be solved over distance. It was mainly thanks to the students’ self-motivation and interest that the course was concluded, despite the initial

frustrations. Even so, the groups managed to go through just one PBL case in a total course period of almost four months. Although direct comparisons are not possible, the second course, combining regular in-classroom meetings and having a much more strict structure appeared to be more effective. As the students were gradually introduced to PBL in the classroom, the adaptation of the method was smooth and apparently without problems. The same is true for troubleshooting the technology related problems. As directed by the initial schedule, the groups went through 5 PBL cases in a period of 4 months and concluded the course. Time is an important parameter in network based education, as it is often remarked that virtual students would probably require more time to reach the same achievements than their in-classroom fellow students.

The competence of the students and the staff with computers is another significant factor. Participation in a Virtual Classroom requires a certain level of competence with computers and the use of Internet. Course designers and researchers in this field tend to take this competence for granted when recruiting students for virtual courses. Unfortunately, it is very often observed that students cannot handle the technology (Gouveia-Oliveira et al., 1994; Day

et al., 1995; Lang, 1995; Plasschaert et al., 1995; Ray et al., 1999) or they tend

to overestimate their own competence (Jones, 1992; Grigg et al., 1999). Unless this is identified prior to the course, it can be the source of significant trouble and frustration, both for students and staff. Self-assessment through scales failed to present the course designers with students’ actual level of competence during the first pilot study, despite reported successful use in previous studies (Jones et al., 1991; Fedman, 1992). In the second study, a more detailed questionnaire with tasks of increasing difficulty was used, which apparently had a better value in detecting students’ needs regarding computer competence. Some supplementary computer instruction based on the results of the questionnaire, probably saved a lot of technology related frustration. In the future, a questionnaire with detailed questions of increasing difficulty should be developed, which could objectively reflect the students’ competence and needs within Information Technology.

Strict planning and scheduling appears to be another significant factor with Internet-based learning. It was obvious during the first pilot study that students found it difficult to organise the group work themselves. The structure of the course was somehow “loose” in order to allow flexibility and self-decision within the groups, regarding the communication tools and the time scheduling. However this finally turned out to be a handicap for effective teamwork, as the students experienced a lot of difficulties when trying to decide a path and a timetable suitable for all. As students originated from 13 different universities with different programmes and needs, it was practically impossible to get every member of the group to agree on a certain timetable. Had a strict

timetable been agreed upon before admission to the course, group work would have been much easier.

The synchronous interaction facility was approached in quite a different way by the students in the two different pilot studies. In the first study the students were positive towards chatting. On the other hand, the students of the second study appear more reserved and sceptical towards the potential of the synchronous communication tool. Two reasons seem to account:

Firstly, the two groups had different levels of competence and experience with the media. In the first study, volunteer undergraduate students had been privately using chat long before the course started, therefore they were accustomed not only to the technology and the skills required, but also to the culture of Internet text communication, including shorthand techniques, “emoticons” (Walther et al., 2001) and more. The second group however, consisting of professionals had no previous experience of this communication medium and also probably had unrealistic expectations from it.

Secondly, the inclusion or not of personal contact might have played an important role. After the beginning of the first course, students could only interact through Internet, while in the second course regular in-classroom sessions were carried out. It is often observed that students who are offered interaction possibilities both in-classroom and over the Internet, tend to underestimate the potential of Internet interaction, in comparison to those who can only interact through the Internet (Vrasidas et al., 1999). This might be applicable in this case as well and could possibly be interpreted as a prioritisation of the in-classroom interaction over the Internet based one, when the option exists for both. However, in both studies Internet real time discussions appeared to play a significant role in maintaining teamwork and improving participation.

Another important finding was related to the comparison of in-classroom discussions, with those over the Internet. After measuring the “inputs” it was found that a discussion in the classroom is seven times faster than the Internet based synchronous one. Although this interaction difference is only quantitative, it is likely to seriously affect the quality and depth of the discussion as well (Reid et al., 1996). At the basis of these findings, as explained in the second study, it was concluded that Internet discussions are likely to be “filtered” in comparison to the in-classroom ones. The difference in the speed between network text-based and in-classroom verbal interaction is indicative of how the media restricts the flow of communication within the group, forcing the student to reflect, structure and prioritise his/her responses in the discussion. In this sense, computer mediated interaction might be beneficial when the methodology emphasises in promoting students’ ability to reflect, prioritise and better structure his/her communication. On the contrary, when a “brainstorming” is needed, where students are expected to contribute fast and spontaneous thoughts, an in-classroom session might be more effective.

Within the limitations of these studies, it would be possible to conclude that a fully Internet-based PBL is possible and might be beneficial in comparison to didactic approaches in Internet-based teaching, if properly organised. However, such a model might constitute a compromise over the quality standards of in-classroom PBL, at least with the currently available knowledge and technology. A hybrid model, which will combine in-classroom sessions with interaction over the Internet, appears to be the safest and most beneficial approach right now.

In the future, the learning effectiveness of these models and Internet based-learning in general, has to be further evaluated on a research basis. In particular the student gains in terms of knowledge, skills and learning attitude have to be tested in comparison to the conventional in-classroom teaching methods.

Conclusions

• Internet-based PBL is possible, well accepted by students and should be attempted for introducing active and collaborative learning to distance learning courses.

• Personal contact of some form appears to be a significant factor for the success of network-based courses and should therefore not be excluded. • In the design of fully network-based PBL courses, three factors appear of

major importance: Students’ experience with the methodology, students’ competence with the technology and prior agreement to a specific time frame and schedule.

• Synchronous text-based interaction over the Internet is a very important tool for maintaining group work, but also presents certain limitations in comparison to in-classroom discussions.

• With the currently available Internet technology and knowledge, a fully network based PBL would probably constitute a compromise to the quality standards of the in-classroom model. A hybrid approach appears to be safer and more beneficial.

• Further research is needed to assess the learning effectiveness of such models and evaluate the student gains in terms of knowledge, skills and learning attitudes in comparison to in-classroom teaching.

Acknowledgements

• the State Scholarship Foundation, (IKY) Athens, Greece.

• the Council for Higher Education, Stockholm, The National Agency for Higher Education, Sweden.

• The Swedish Agency for Distance Education (Distum), Härnosänd, Sweden. • The Faculty of Odontology, Malmö University, Sweden

I would also like to express my gratitude to all those who have helped me in so many different ways throughout this study:

My main supervisor, Professor Rolf Attstrom. His guidance throughout these years has indeed shaped my way of thinking, while his enthusiasm has been a driving force and an endless source of inspiration.

Assoc. Professor Anders Nattestad, whose constructive comments and ideas have greatly contributed to all aspects of my work.

Professor Klaus Lang, Professor Rudger Persson, Professor Hal Lyon, Associate Professor Göran Petersson and Director Eva Falk-Nilsson, for generously sharing their expertise and providing me with a valuable insight in matters of periodontology, health informatics, education and pedagogics.

Assoc. Professor Katarina Wretlind, co-author of the 4th study, for the great cooperation, her kind support and assistance throughout my research.

My friend and colleague Dr. Martin Schittek, for the endless brainstorming discussions, the comments, the ideas, the laughs and last but not least for his warm and open-hearted support and friendship since the first day we met.

My friend and colleague Dr. Jörgen Jönsson, for his patience and valuable help with all the technology-related issues.

Professor Diarmuid Shanley and the DentEd and DentEd evolves networks of experts, for their valuable contribution and their continuous feedback to our research activities.

My friends and colleagues Dr. Christoph Ramseyer and Dr. Lorenza Canegallo, for sharing with me their ideas and enthusiasm in our common efforts.

Anita Toräng, for her valuable and mostly open-hearted help throughout my whole staying in Sweden.

Finally, I’m deeply grateful to the all the staff and associates of the Dental School and especially the department of Periodontology. Their interest and warmth made me feel like home even from the first day.

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