Clinical Computer-Assisted Simulation Exercise (CCASE) as a Strategy for Distance Learning in the Philippines
Introduction
Computers are changing the way people learn. Information is made available on demand at the touch of the keyboard anytime and anywhere. I propose the use of a computer-aided software to augment the continuing education program of the Nutritionist-Dietitians' Association of the Philippines (NDAP). Association members pass an examination before they are licensed; they are also annually required to complete 15 continuing education hours.
The Philippines is a country made up of more than 7000 islands. Air travel is used between major islands but between the smaller islands only ferry boats are available. Land transportation between towns or barangays consist, mainly of busses on often times poorly maintained roads. The information superhighway via world wide web presents a most convenient tool allowing access to learners, unlimited by continent, country, island, town or barangay.
The Problem
Early this year, I spent two months in the Philippines to complete my commitment on a Balik (returning) Scientist grant sponsored by the Philippine Department of Science and Technology (DOST) and the United Nations Development Program. In addition to my assignments with the Food and Nutrition Research Institute and at the University of the Philippines (UP), I was also asked to participate as a speaker in the continuing education program of NDAP. Approximately thirty members were in attendance at my session. Before beginning, I asked key questions to determine their level of knowledge on the topic. I was very disappointed at the lack of response. At the end of my presentation, the group, which had dwindled in size at this point, had only two questions. It was my feeling that the members were physically present only to "earn" continuing education hours. There was no way to evaluate what they had learned! The objective of this proposal is to improve the present continuing education program of NDAP.
Six of the top ten causes of death in the Philippines are pneumonia, tuberculosis, gastroenteritis, colitis, bronchitis, and avitaminosis, all related to malnutrition. The traditional rice-vegetable-and-fish diet pattern of Filipinos remains nutritionally inadequate in quantity and quality as confirmed by the results of the 1993 Food Consumption Survey conducted by the Food and Nutrition Research Institute. Competent health care providers such as nutritionists and dietitians can significantly impact the nutritional status of the population. Competency assurance can be demonstrated by an integrated continuing education and assessment program.
A Proposed Solution
The current trend in the United States towards reevaluation of professional competency assessment and assurance, not only in dietetics but also in nursing, physical therapy, pharmacy, medicine and occupational therapy, brings to the forefront the need to explore improved credentialing practices of nutritionists and dietitians in the Philippines. That proposed by the American Dietetic Association is described as "continuous learning that is self-initiated, self-directed and self-evaluated". CCASE is proposed as a strategy for upgrading the certification program of NDAP.
CCASE is an acronym for CLINICAL COMPUTER-ASSISTED SIMULATION EXERCISE. It is an interactive instructional software package that combines a database of case histories, a series of exercises, glossary, references, and multiple choice evaluation questions to assess the learner's knowledge. The original goal of CCASE was supplementation of the nutrition component of the nursing curriculum. It was designed to teach students how to interpret case studies and make clinical decisions.
In CCASE, data is stored in an Oracle database running on a Sun Workstation while networked Macintosh computers running Supercard retrieve data and display the results in easy to read form. Over six years, CCASE has evolved into a user-friendly software package that includes both framework and specialty applications allowing faculty to develop instructional units related not only to nutrition but also to other disciplinary specialties. Authoring tools allow faculty to create or update specialty units and also allow them access to learners' responses and evaluation scores. Continuing evaluation of CCASE has demonstrated favorable learning outcomes. Upgrading of CCASE is continuing and soon a CCASE on the Web is scheduled for pilot testing. It is intended that this upgraded version of CCASE will be available globally on a subscription service. The School of Nursing and Office of Instructional Technology, in a continuing partnership in the University of Michigan (UM), support the project.
Four nutrition units have been completed: Nutrition Assessment, Nutrition Interventions in Non Insulin-Dependent Diabetes Mellitus, Nutrition and Pregnancy: Risk Factors and Interventions and Nutrition Therapy for End Stage Renal Disease. Authoring of units on hypertension and hyperlipidemia is scheduled.
In addition to reasons given above, using the upgraded CCASE on the Web presents other advantages:
- NDAP members will be able to use CCASE on the Web from a computer running MacOS, Windows, or Unix, or any operating system that supports a web browser. CCASE will become a delivery vehicle for distance learning in a variety of learning settings or locations: colleges, universities, professional associations, centers, institutes, commercial organizations, etc.
- NDAP members using CCASE on the Web units will be able to use all Internet features such as medical databases, references, newsgroups, dietetic on-line, and e-mail, allowing members the option of discussing issues with faculty and other members, and participating with colleagues in electronic communities.
- NDAP faculty members will be able, with adequate technical support and documentation, to author, edit or upgrade course units from any computer any where, as long as it has a web browser and an Internet connection. In addition to units presently available and under development here, NDAP and UP faculty members can author units pertinent to health problems in the Philippines, such as interventions in chronic and severe malnutrition, and specifically those related to deficiencies in calories and protein, iron, iodine and vitamin A.
Protocol for Collaboration
Collaboration between UP, UM and NDAP had to be established in order to implement the distance learning partnership. Brief descriptions of these institutions are given below.
The UP system is the premier institution of higher education in the Philippines. It is a multicampus university with six autonomous units on 11 campuses and a 1,000 bed teaching hospital. The UP Open University (UPOU) was created in 1996 following efforts by the administration to democratize access to the university. UPOU's mission is to provide wider access to quality higher education by offering distance education beyond the physical boundaries of the conventional system. It provides support services to bridge the physical separation of teacher and student, the latter assuming autonomy of the learning process. It has established 13 learning centers on UP campuses and seven other cooperating state colleges and universities strategically located throughout the country. A diploma (or certificate) and two master's program are presently offered; many more, including a doctoral program and the NDAP continuing education program are planned for 1997. The UPOU homepage can be accessed at http://www.upou.org/.
Since the 1960's, UM has been one of the leaders in information technology in the United States. CCASE, likewise, was at the cutting edge of technology when adapted to distributed computing in 1990 and once more when CCASE on the Web is launched into cyberspace as planned for next year. The NDAP-UPOU project will serve as a global pilot test site for CCASE on the Web.
NDAP was organized 40 years ago, and presently has approximately 5000 members. Five years later the Dietetics Law was passed, requiring an examination to practice and the accumulation of 15 continuing education hours per year to maintain the license to practice. The continuing education program of the association is planned by a committee that schedules the date and location of the annual educational events. In addition to the annual convention, the association regularly holds update sessions, seminars, workshops and symposia on varied topics to meet the needs of the members. The proposed CCASE on the Web will be an additional venue for continuing education of nutritionists and dietitians. NDAP's committee chair for continuing education is Maria Patrocinio E. de Guzman.
Periodic and recent contacts with the two Philippines institutions facilitated the establishment of the partnership. Being a UP alumnus and also a charter member and former president of NDAP has been a great help in this effort. The information infrastructure in the Philippines was spearheaded by the DOST. Most major cities have established Internet connection within the confines of higher education. I met DOST Secretary William Padolina during a Balik-Scientist conference this year. Upon inquiry by electronic mail, he referred me to his wife, Dr. Maria Cristina Padolina, who serves as Chancellor of UPOU. She is apprised of this proposal and is definitely interested in the partnership, having already identified a potential author from the UP faculty. Ms. de Guzman is a mutual personal friend and professional colleague.
Several matters still require clarification before the partnership agreement becomes official. First, a choice between a mirror or independent site has been suggested and needs be explored with UM. Second, the choice on where the learner's responses to the exercises and evaluation questions will be routed will depend on the answer to the first question. It can be made available to UPOU/NDAP through the UM subscription service. Or a combined high tech/low tech method is also possible. Responses, particularly to the evaluation questions, can be recorded using pen and paper and submitted at the learning center immediately upon completion. These arrangements are possible and flexible but written procedures are needed. Third, the subscription service fee will need to be determined. Fourth, CCASE on the Web and all but the recently completed unit on renal nutrition is copyrighted by the UM; renal nutrition is copyrighted to the authors. If hard copies are made of parts of the units, permission is needed to prevent violation of the copyright law. Policies on copyright and royalties will also need to be clarified. Fifth, procedures are also needed to recruit Philippine authors who will write and maintain upgrade of their units. Sixth, a procedure and schedule is needed for the continuing and periodic evaluation of the distance learning partnership. Finally, while interest in the project has been received from the three collaborating units, a memorandum of agreement will need to be developed and signed. It should include clarification of these issues, assignment of responsibilities and establishment of deadlines for each of the three collaborating institutions.
Conclusion
As we approach the third millennium, it is exciting to share CCASE on the Web with a developing country, across the Pacific Ocean to eleven or more different sites in the Philippines, enabling members of the dietetic profession access to information at the touch of the keyboard. It is a feat that I, as charter member and past president of NDAP and alumnus of UP, would have not dreamed of accomplishing. But distance learning is here and three members of these three institutions are eager to move forward via cyberspace. We invite other institutions to consider subscribing to CCASE on the Web for credit courses and staff training as well as a strategy for continuing education.
Units are now available on the following topics:
- Nutrition Assessment
- Pregnancy
- Cardiovascular Health
- Health Issues in Sports Nutrition
- Non-Insulin Dependent Diabetes
- End Stage Renal Disease
- Essential Hypertension
- Obesity
- Aging
For more information contact ninfa@umich.edu