Nurse Education Today 35 (2015) 373–382

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Nurse Education Today

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Comparison of meaningful learning characteristics in simulated nursingpractice after traditional versus computer-based simulation method:A qualitative videography study

Paula Poikela a,⁎, Heli Ruokamo b, Marianne Teräs c

a University of Lapland, Faculty of Education, Centre for Media Pedagogy (CMP), P.O. Box 122, FI-96101 Rovaniemi, Finlandb Centre for Media Pedagogy, University of Lapland, Faculty of Education, Centre for Media Pedagogy (CMP), P.O. Box 122, FI-96101 Rovaniemi, Finlandc University of Helsinki, Institute of Behavioural Science, Siltavuorenpenger 5A, FI-00014 Helsinki, Finland

⁎ Corresponding author. Tel.: +358 16 341 341.E-mail address: paula.poikela@ulapland.fi (P. Poikela)

http://dx.doi.org/10.1016/j.nedt.2014.10.0090260-6917/© 2014 Elsevier Ltd. All rights reserved.

s u m m a r y

a r t i c l e i n f o

Article history:

Accepted 10 October 2014

Keywords:VideographyThemes of meaningful learningSimulated nursing practiceSimulation-based learningComputer-based simulationLecture

Background: Nursing educators must ensure that nursing students acquire the necessary competencies; findingthe most purposeful teaching methods and encouraging learning through meaningful learning opportunities isnecessary to meet this goal. We investigated student learning in a simulated nursing practice using videography.Objectives: The purpose of this paper is to examine how two different teaching methods presented students'meaningful learning in a simulated nursing experience.Design: The 6-hour study was divided into three parts: part I, general information; part II, training; and part III,simulated nursing practice. Part II was delivered by two different methods: a computer-based simulation and alecture.Settings: The study was carried out in the simulated nursing practice in two universities of applied sciences, in

Northern Finland.Participants: The participants in parts II and Iwere 40first year nursing students; 12 student volunteers continuedto part III.Methods:Qualitative analysis method was used. The data were collected using video recordings and analyzed byvideography.Results: The students who used a computer-based simulation program were more likely to report meaningfullearning themes than those who were first exposed to lecture method.Conclusion: Educators should be encouraged to use computer-based simulation teaching in conjunction withother teaching methods to ensure that nursing students are able to receive the greatest educational benefits.

© 2014 Elsevier Ltd. All rights reserved.

Introduction

In recent years, healthcare educators have been searching for anddeveloping new teaching methods, including simulation, to find cost-effectiveways to achieve better student outcomes. There is lack of placesto organize practical training in hospitals, and there are not enough staffmembers to supervise students. New teaching methods offer practicaltraining in alternative ways. Studentsmay carry out their practical train-ing as a part of the simulated nursing practice. Simulation has been sug-gested as one alternative and an appropriate teaching strategy (Swansonet al., 2011).

Simulations can be classified as computer-based, screen-based, orhuman-based. In computer-based simulations, the entire learning processcan take place alone or online with other learners. A computer can directscreen-based simulation, with the simulation learning process projected

.

onto a large screen. Finally, human-based simulation includes the useof a mannequin simulator that is directed by a computer (Banks, 2011;Eldabi et al., 1999; Lampotang, 2008).

As McAllister et al. (2013) stated, there is an absence of basic peda-gogical studies in the field of simulation. To fill this gap, this pilot studywas conducted to provide insight into and an understanding of howmeaningful learning characteristics appear during a simulated nursingpractice after an introduction by two different teachingmethods. Simu-lation learning should receive further evaluations using a variety ofresearch methods. This study will give a new pedagogical basis for in-vestigating not only nursing education outcomes, which are extremelyimportant, but also explore how meaningful learning is evidenced andperceived by nursing students using the videography method.

Theoretical Background

Keskitalo et al. (2010) developed a simulation-based learningmodelof facilitating, training, and learning (the FTL model, Fig. 1). The model

Fig. 1. Facilitating, training, and learning (FTL) model.

ISSDmodelFig. 2. The ISSD model.

374 P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

was built on the process of teaching, studying, and learning (TSL)(Kansanen et al., 2000), the characteristics of meaningful learning(Ausubel, 1968; Hakkarainen, 2007; Ruokamo and Pohjolainen, 2000),and the process of learning through simulation (Joyce et al., 2002).Based on theoretical examination and empirical research, the following14 characteristics of meaningful learning were selected for the focus inthismodel: experiential, experimental, emotional, socio-constructive, col-laborative, active, responsible, reflective, critical, competence-based, con-textual, goal-oriented, self-directive, and individual (Fig. 1). Dreifuerst(2012) has studied that using meaningful learning (DML) in debriefing,clarify students' support students' learning and development teachingpractice.

In an earlier paper, we presented a computer-based simulationprogram analysis based on the FTL model. We developed an extensionof the FTL, namely, the introduction, the simulation, scenario, and de-briefing (ISSD)model (Poikela et al., 2013; Fig. 2). The ISSDmodel followsthe same phases as the FTL model. In our previous paper (Poikela et al.,2014), we validated this model by examining first-year nursing students'statements to identify which meaningful learning characteristics ap-peared in the model and to what degree: not at all, weakly, or strongly.In our earlier studies (Poikela et al., 2013, 2014), students' descriptionspointed to experimental and contextual as the most important charac-teristics of learning for their level of nursing education. Individual andcompetence-based characteristics are missing from the model becausefirst-year students do not have enough basic knowledge of nursingpractices.

Many comparative studies of different teaching methods havebeen conducted. These studies have compared traditional teaching andsimulation-based teaching,methods used in classroom teaching, blendedlearning methods, and comparisons between low-, moderate-, and highsimulation. Moreover, there aremany studies of web-based versus tradi-tional teachingmethods (Arnold et al., 2013; Campbell et al., 2008; Reimeet al., 2008; Swanson et al., 2011; Tosterud et al., 2013). Previous researchwas primarily been carried out using quantitative methods; significantdifferences between teaching methods have not been found. However,

it has been reported that nursing students are more confident and satis-fied after simulation-based teaching. In addition, studies have comparedcomputer-based, web-based, and online learning to face-to-face, tradi-tional, and classroom approaches (Campbell et al., 2008; Golchai et al.,2012; Siegel, 2005). Most of the results show that combining e-learningtechnology with traditional teaching and blended learning enhances,for example, students' motivation and efficiency.

Knowledge constructed through experience and experimental learn-ing is still the base of nursing education (Kolb, 1964). Experimentallearning can be defined as the foundation for further developing teach-ing and learning strategies. Very simply, Kolb's learning cycle involves

Initial information on the VIRVE network, the TETRA

simulation-based learning

The students’ learning zone

Traditional teaching

Computer-based simulation

Four TETRA phones

circulating in the

classroom

The student’s learning zone

Group 1(n=23)

Group 2(n=17)

PART I

General information

(1 hour)

PART II

TETRA phone training

(2 hour)

Break (1 hour)

PART III

Simulated nursing

practice (2 hour)

Lecture Computer-basedsimulation

Fig. 3. The research design.

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feeling from the concrete experiences of the nursing practice, watchingwith reflective observation what is happening, thinking to build newknowledge and skills, and doing through rehearsal and practice. Poikela(2012) developed Kolb's experiential learning cycle further and adaptedthe ideas of Nonaka and Konno (1998) about the zones and spaces oflearning. Learning spaces represent concrete spatial environments andzones of learning are expressing situations where the learning takesplace. Simulation-based learning always connects to the spaces and thezones of learning, reflection for action (before action), reflection in action(during action), and reflection on action (after action) comprise the rolesof reflection and action in learning (Poikela, 2012).

In this research, we addressed the following question: To whatextent do meaningful learning characteristics appear in a simulationnursing practice presented after lecture or computer-based simulation?

Fig. 4. The description of the si

To answer this question, we chose communication for the topic ofthe simulated nursing experience. The renewed emphasis on patientsafety in nursing practice has highlighted the challenges in routine dailyhealthcare communication processes and has raised awareness of theimportance of reaching colleagues quickly. Finnish legislation requiresthe medical sector to use the State Security Networks Ltd., Homepages(2014), which is known in Finland as the VIRVE network (VIRVE is anabbreviation of the Finnish words ViranomaisVerkko). This network usesa special phone called a terrestrial trunked radio (TETRA) (TerrestrialTrunked Radio, 2014) for healthcare communication. The use of theTETRA phone enables experts to reach one another quickly in emergen-cies, even if the network is interrupted and normal phones fail (Poikelaet al., 2013). Therefore, the use of TETRAwas the subject of the instructionand simulation experience.

mulated nursing practice.

Table 1The length of the video recordings.

Group 1 Group 2

Part II actionFor action 27 min 27 s 5 minIn action 16 min 2 s 4 min 12 sOn action Photos Photos

Part III actionFor action 16 min 37 s 20 min 8 sIn action 24 min 3 s 52 min 8 sOn action 39 min 36 s 46 min 52 s

Table 3The themes of meaningful learning appearance.

Group 1 Group II

The themes ofmeaningful learning

Part II Part III Part II Part III

Concretesimulationexperience

Concretesimulationexperience

Concretesimulationexperience

Concretesimulationexperience

Reflection For In On For In On For In On For In OnConcrete x x x xPersonal x x x x x x x x xSocial x x x xLiable x x x x xContent-based x x xMetacognitive x

376 P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

Methods

The current study adopts the methods of videography inquiry. Thismethod is one form of qualitative research, and its main use is in field-work; it is valuable in nursing research because it involves the researcheras part of the environment and content (Lambert et al., 2011;Morse andField, 2002; Robinson, 2013; Roper and Shapira, 2000). The videographymethod is useful for developing anunderstanding of somethingnew, dif-ferent, or unknown (Cruz andHigginbottom, 2013). In this study, a videorecordwas used to explore the effects of two different teachingmethodsin a simulated nursing practice. Data were analyzed using videographybecause this type of analysis allows for a deeper understanding of learn-ing, human interaction, and human behavior. Video, as an epistemolog-ical tool, can sometimes be a better tool than words (Goldman, 2009;Barron, 2009).

The Teaching Experiment and the Participants in the Study

This quasi-experimental study was organized in spring 2013 in twouniversities of applied sciences in northern Finland. All nursing studentswere aware of ongoing study and they gave signed assent to it. Therewere a total of 40 first year nursing students enrolled in this study.The student groups were not equal, because university intake numbersare different and some students were absent. The participants weredivided into two groups by university: group 1 (n = 23) and group 2(n = 17). Their prior nursing education included basic nursing skillsand theory, including Levels 2 and 3 first aid skills (Senior First Aid).Level 2 covers all aspects of training for “Providing Basic EmergencyLife Support,” and Level 3 includes learning to use an automated ex-ternal defibrillator, but not for resuscitation medication (AmericanRed Cross, 2014). The students also had eight weeks of basic practicaltraining at health centers (Poikela et al., 2013). No pre-testedwas carriedout because the nursing curriculum is based on national competences.The researchers trusted that both groups had reached the previouscompetences.

Table 2Combining data and theory.

Themes of meaningful learning Description

1. Experimental= Concrete

Practice nursing skills, try many times, establiscommunicate effectively, know the environme

2. Emotional, individual= Personal

Facial expression, gestures, confusion, happinemobilizing resources

3. Socio constructive, collaborative= Social

Find a solution together, discuss, use cognitiveleadership

4. Active, self-directed, responsible= Liable

Eager to learn even though others students are

5. Competence-based, goal-oriented,contextual, experiential= Content-based

Goal-oriented action combined with previousskills, able to integrate all available informatiothe workload

6. Critical, reflective= Metacognitive

Be able to critically examine one's own actionsone's own thinking, common skills and knowlattention wisely, anticipate and plan

The experiment day lasted 6 h, which included a 1-hour lunch break(Fig. 3).

Group 1 was taught to use the TETRA phone through lecture. Thedecision as to which university group was to receive the lecture andwhich the computer-based simulation learning was based on practicalconsideration; the computer-based simulation program was alreadydownloaded by the staff of the other city hospital. The teacher wasrecruited because she was a paramedic nurse and had used a TETRAphone for years; she taught what she had learned through her experi-ence. The researchers named this type of teaching, where the teachergives knowledge top down, “lecture”. Group 2 was trained to use thephone via a computer-based simulation program. The computer-basedsimulation training was self-directed (Fig. 3).

Six volunteer students from each of the two groups continued on topart III, the simulated nursing practice. The scenario of the simulatednursing practice was based on students' knowledge and skills; itfollowed the FTL model (Fig. 1). The main goal of the simulated nursingpracticewas to learn and use the TETRA phones for communicating andsharing information.

Fig. 4 describes the students' roles and the aims and content of thesimulated nursing practice.

Students were divided into pairs in part III, resulting in three groupsfrom each of the teaching method conditions. They reflected learningfor, in, and on the action in learning zone.

Data Collection

During part II, four TETRA phoneswere circulated in each group (theuniversities only have four phones, and it was administratively difficultto get more). The students were trained on the use of the TETRA phone,and data were collected through questionnaires and video recordings;after part III, interviews of each pair of students took place and wererecorded by video. Moreover, three researchers took field notes of their

Experiential learning Concrete simulation experience

h role clarity,nt

Doing, watching Reflection in action (during)

ss, joy, Feelings

aids, designate Thinking, watching,doing

passive Doing, thinking

knowledge andn, distribute

Thinking Reflection

For/in/on action(before/during/after action)

and reflect onedge, allocate

Thinking Reflective observation in/on action(during/after action)

Time A snapshot from the video Description Concrete

simulation

experience

The themes of

meaningful

learning

Lecture

60 min

In this photo, only the teacher is speaking.

She is sharing what she had learned. The

teaching was very traditional.

The students sat quietly in classroom and did

not ask questions.

Practicing

45 min

The students were divided into groups and

focused on how to use the TETRA phone Reflection in

action

Personal,

Liable

Practicing

without

teacher

15 min

Only one student had the TETRA phone in

her/his hand at a time.

For most of the practice, only one student

spoke at a time. Some of the others made

comments and the rest of the students were

quiet.

Reflection on

action

Concrete,

Personal

Fig. 5. Group 1: Learning to use the TETRA phone.

377P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

observations. Our previous two papers (Poikela et al., 2013, 2014) pre-sented the results of the analysis of the interviews and observations bythe researchers. One of these researchers is thefirst author of the presentpaper, which allows for a videography analysis of the recordings becauseshewas present during all parts of the study. In this studywe used videorecording data. We use the term videography rather than video analysisbecause it includes exploiting the observer's knowledge from nursingteaching. The observer was involved in the process and, therefore, un-derstands the meanings of the actions (Knoblauch and Tuma, 2011). Inthis study we used video recording data.

The video recordingswere 4 h, 2min, and1 s long; Table 1 shows thebreakdown of time by group. The time allotted to parts II and III are alsopresented.

Data Analysis

The analysis started with the first author of this paper watchingvideo recordings; the videos were reviewed very carefully through theWindows Live Movie Maker (version 15.4.3555.308, 2010 MicrosoftCorporation, Redmond, WA, USA) three times. The second researcherdid the same analysis, and then we compared the results. Videographyanalysis requires that the researcher is involved in the processes andknow the content of the students' knowledge and the study environ-ment. After review, the themes of meaningful learning, evidenced bythe students during the training in the use of the phone and the simulat-ed nursing practice, were identified (Table 2). Themes of meaningfullearning were classified into the following six groups: 1) concrete,2) personal, 3) social, 4) liable, 5) content-based, and 6) metacognitive.The categories were based on the students' work and conversationvisible in video recordings. We combined the data with the learning

theories, experiential learning, and concrete simulation experience, andfound a connection between the themes of meaningful learning andexperimental learning cycles: feeling, watching, thinking, and doing(Kolb, 1964). As mentioned previously, concrete simulation experiencesare divided into reflection for, in, and on action (Poikela, 2012). Thesethree categories combine the themes of meaningful learning and experi-ential learning (Table 2).

The videography of learning to use the TETRA phone was based onthe ISSD model in group 2 and lecture in group 1. Simulated nursingpractice was carried out based on the FTL model. Table 3 shows howthe themes of meaningful learning appeared on the video analyses.

Results

Figs. 5 and 6 describe students' learning to use the TETRA phone viatwo different teaching methods.

Group 1 participated in a teacher led lecture. The students sat veryquietly; there were no comments, discussion, or questions. The teacherwas the only onewho spoke, and she gave her opinion regarding the useof the TETRA phone. She showed power point slides based on her ownexperiences. In this phase (reflection for action), none of themeaningfullearning themes could be found. It was difficult to determine whetherreflection for action was taking place because the students were soquiet. They were divided into four groups because there were fourTETRA phones available. For reflection in action, one student fromeach group held the TETRA phone. Personal and liable themes couldbe seen because one student at a time practiced on the phone. Onlysome of the students said something or pointed to certain keys. In thegroups, the TETRA phone was circulated a bit from student to student,but some did not seem eager to try it. Finally, reflection on action

Phase Snapshot of the video Description Concrete

simulation

experience

The themes of meaningful

learning

Introduction

The computer-based simulation program

included all of the FTL model phases. In

the facilitating phase, the students

familiarize themselves with the simulation

environment and devises. They could also

determine and set individual goals

The students asked questions as they arose.

The teacher was mostly quiet.

Reflection for

action

Concrete,

Personal,

Liable

Simulation

briefing,

scenario

Training was organized by the problem

cases.

Students collaborated with others and also

worked alone.

Reflection in

action

Concrete, personal,

Social, liable,

Content-based

Debriefing All the students took part in reflection and

critically reflected on their own and others’ actions. Reflection on

action

Personal

Fig. 6. Group 2: Learning to use the TETRA phone.

378 P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

showed that only some students had held the TETRA phone, and onlyone student could analyze the learning experience. Reflection on actionwasdrawn formonly one student's personalmonologue. They could notintegrate the new knowledge with previous studies because they werenot involved in building a neworientation to their knowledge and skills.

Group 2 learned the use of the TETRA phone through a computer-based simulation program. The ISSDmodel supported students' personallearning. The program follows simulation learning phases and it clarifiedstudents' independent learning. In reflection for action, students wereable to engage with the simulation environment and the phones andconcrete, personal, and liable themeswere present. They could conceptu-alize themain functions of the TETRAphone; this involved constant, deepthinking. “A student x said, we used this function in the computer-basedsimulation program so and now we can do same in real simulated prac-tice.”The scenarioswere built around simple problemcases. The students

had to reflect on their action, and they were able to use their previousknowledge. Concrete, personal, social, liable, and content-based themesof meaningful learning can be seen in reflection on action.

Using the TETRA Phone in the Simulated Nursing Practice

Figs. 7 and 8 show how the TETRA phones were used in the simulat-ed nursing practice. Both groups (the students who trained the use theTETRA phone through computer-based simulation program and thestudents who got a lecture about using the TETRA phone) were in theirown group in simulated nursing practice part III (see Fig. 3).

The students in the group 1 were confused about how to use thephone in practice. In the facilitating phase of the simulated nursingpractice, part III, they argued over who would take the TETRA phone.They had not acquired the sense of learning and availability of new

Phase The snapshot of the video Description Concrete

simulation

experience

The themes of

meaningful

learning

Facilitating The goals for the students

in the simulation process

were to get information and

familiarize themselves with

their roles, as well as the

simulation environment

and devices.

It was difficult to get six

volunteer students to

continue their participation

in part III.

They wondered whether

they would be able to use

the TETRA phone. They

were unsure how they

could operate the phone.

Reflection for action

Personal

Training The students were nervous

and one asked help from

the others. However, the

students were not

collaborative and the other

students did not respond to

this request.

Reflection in

action

Personal,

Liable

Learning The students were

frustrated. The main goal

was to learn how to use the

TETRA phone, there were

many of critical statements

(e.g., “We only heard how to use the phone”). Most of the students did not

practice the use of the

Reflection on

action

Personal

phone in part II.

Fig. 7. Group 1: part III: simulated nursing practice.

379P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

knowledge in part II. During the training, when they encountered prob-lems in using the phone, they did not support each other; students triedto solve the problemby themselves. The same studentswhowere activein part II took part in the simulated nursing practice and used the phone.In the learning phase, some of the students described their feelingsof uncertainty about what to do and where to get more information.Other students agreed with this opinion. They felt that hearing about

the phone, but not using it, made it difficult to use in the simulatednursing practice.

Group 2 participated in the computer-based simulation; this wasevident in their actions during the simulated nursing experience. Theywere excited and eager to try what they had learned about using theTETRA phone. In the facilitating phase, there were no problems regard-ing whowould take the phone. All the students were very eager to take

Phase Snapshot of the video Description Concrete

simulation

experience

The themes of

learning

Facilitating The goals for the students in the

simulation process were to get

information and familiarize

themselves with their roles, as well as

the simulation environment and

devices.

They were very eager to try the

TETRA phone in practice. It was not

difficult to get students to volunteer

for the simulated nursing practice.

Reflection for

action

Social,

Liable,

Content-based

Training All the students took part into

discussion how to use the TETRA

phone. They were very

collaborative.

Reflection in

actionConcrete,

Personal,

Social

Learning The students were eager to share their

experiences in the training phase.

They talked about how they could

improve their use of the TETRA

phone through practice. Reflection on

action

Social,

Content-based,

Metacognitive

Fig. 8. Group 2: part III: simulated nursing practice.

380 P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

part in simulated nursing practice because they wanted to test theirskills and knowledge of the use of the TETRA phone. Reflection in actionwas very lively. All students agreed that therewas an anticipatory atmo-sphere and it was nice to try the skills in practice.

Discussion

This study showed that the students who learned to use the TETRAphone through a computer-based simulation were much more willingto use the phones simulated nursing practice. They could reflect for, in,and on action. Many of the themes of meaningful learning were visiblein the simulated nursing practice; metacognitive and content-basedthemes appeared on action very strongly, and the social theme appearedless strongly. The concrete theme was present in all reflections of action(Beyer, 2012). Itwasmore difficult to highlight the themes ofmeaningful

learning in group 1, because they were so uncertain about using theTETRA phone in the simulated nursing practice. The personal themewas strong, and many students mentioned being frustrated. Frustrationis an emotion that may inhibit learning. Some other themes of mean-ingful learning could be seen, including more personal in action andmetacognitive on action, but very faintly. The pivotal result is that thestudents of the group 2 were more ready to use the TETRA phone.They were curious and found it fun to learn it in action. Enjoyment cre-ates a good learning atmosphere and builds the foundation for gainingdeeper knowledge and skills, for example, using the TETRA phone.The computer-based simulation learning before the simulated nursingpractice improved the students' outcomes (Curtin et al., 2011).

We have described how the themes of meaningful learning appearedfor, in, and on action. Students' deeper learning could be supported byuse of the debriefing for meaningful learning (DML) method and the six

381P. Poikela et al. / Nurse Education Today 35 (2015) 373–382

consistent components: a) engage, b) explore, c) explain, d) elaborate,e) evaluate, and f) extend. The DML process focused students' learningmore toward patient-care reflection on action (Dreifuerst, 2012). TheDML should be used more often to help students focus on patient-carelearning during reflection on action (Dreifuerst, 2012).

Videography represents an effective approach to assist nursingstudents in making decisions and monitoring their thinking in action.Even in their reflections on action the participants, in this study nursingstudents who took part in part III, had time to embellish what they said;in the other words, they could find words to explain their thinking andlearning. Videography has been used in nursing research, but it is notusual in simulation area. However, video record as a research methodcan also be very usefulwhenwe are interested in knowingwhat happensduring the learning process. The limitations of this pilot study were thatthe video recordings were not of sufficient length and not recordedsystematically. For this reason, the data were unbalanced between thegroups. Another limitation of the studywas the short duration of exper-iment and small number of participants. Therefore, these results cannotbe generalized. If the nursing students from the traditional group hadhad more TETRA phones, the results could have been different.

The nursing students knew beforehand that they were participants inthe study. Some students were absent on the research day. The nursingstudents self-determined participation. The rest of the students signedthe assent papers and informed the researchers that they forgot the re-searchers after a while. Bearing ethical considerations in mind, it shouldbe noted that the researchers took video clips from their ownperspective.

Conclusion

This pilot study showed that computer-based simulation has a read-iness meeting learning goals. Nursing students were able to transferknowledge and skills gained through computer-based simulation insimulated nursing practice. The students became aware the computer-based simulation learning effectiveness, and they were able to continueto improve their nursing skills and enhance knowledge in comingwork-ing life. The incoming generation of nursing students, who are futurenursing employee, need innovative learning solution. All innovatorsand developers of learning have to move a step forward from whathas gone before. All tools that support learning need to involve inquiry,particularly those based on information and communication technology.

Author Contributions

Paula Poikela contributed to the study design, data analysis andmanuscript preparation. Heli Ruokamo contirubuted to data analysisand manuscript preparation and Marianne Teräs to manuscriptpreparation.

Funding Sources and Roles

Tekes (The Finnish Funding Agency for Technology and Innovations),the EDRF (European Regional Development Fund) (Grant number70023/12), and a number of public and private financiers have providedthe financing for this research as part of the MediPro project. The au-thors also would like to thank the Doctoral Program for Multidisciplin-ary Research on Learning Environments for the training and support. Thisstudy was part of the research activities of the CICERO Learning Network,Finland, www.cicero.fi.

Acknowledgments

The authors wish to acknowledge Elsevier for the assistance inlanguage and proofing, and Tuulikki Keskitalo and Essi Kuure for theircontributions to the study design and collection of data.

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