oulu 2018 d 1455 university of oulu p.o. box 8000 fi-90014...

UNIVERSITY OF OULU P .O. Box 8000 F I -90014 UNIVERSITY OF OULU FINLAND

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University Lecturer Tuomo Glumoff

University Lecturer Santeri Palviainen

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ISBN 978-952-62-1828-1 (Paperback)ISBN 978-952-62-1829-8 (PDF)ISSN 0355-3221 (Print)ISSN 1796-2234 (Online)

U N I V E R S I TAT I S O U L U E N S I S

MEDICA

ACTAD

D 1455

AC

TAM

ari Virtanen

OULU 2018

D 1455

Mari Virtanen

THE DEVELOPMENT OF UBIQUITOUS 360° LEARNING ENVIRONMENT AND ITS EFFECTS ON STUDENTS´ SATISFACTION AND HISTOTECHNOLOGICAL KNOWLEDGE

UNIVERSITY OF OULU GRADUATE SCHOOL;UNIVERSITY OF OULU, FACULTY OF MEDICINE;RESEARCH UNIT OF NURSING SCIENCE AND HEALTH MANAGEMENT

ACTA UNIVERS ITAT I S OULUENS I SD M e d i c a 1 4 5 5

MARI VIRTANEN


Academic dissertation to be presented with the assent ofthe Doctoral Training Committee of Health andBiosciences of the University of Oulu for public defence inAuditorium P117 (Aapistie 5B), on 4 May 2018, at 12noon

UNIVERSITY OF OULU, OULU 2018

Copyright © 2018Acta Univ. Oul. D 1455, 2018

Supervised byProfessor Maria Kääriäinen,Professor Elina HaavistoDoctor Eeva Liikanen

Reviewed byDocent Sini ElorantaDocent Vesa Taatila

ISBN 978-952-62-1828-1 (Paperback)ISBN 978-952-62-1829-8 (PDF)

ISSN 0355-3221 (Printed)ISSN 1796-2234 (Online)

Cover DesignRaimo Ahonen

JUVENES PRINTTAMPERE 2018

OpponentProfessor Hannele Turunen

Virtanen, Mari, The development of ubiquitous 360° learning environment and itseffects on students´ satisfaction and histotechnological knowledge. University of Oulu Graduate School; University of Oulu, Faculty of Medicine; Research Unit ofNursing Science and Health ManagementActa Univ. Oul. D 1455, 2018University of Oulu, P.O. Box 8000, FI-90014 University of Oulu, Finland

Abstract

The digitalization of the society, the changing structures of education and the tightening resourceshave hastened the development of open learning environments. The aim of this study was todevelop a ubiquitous 360° learning environment (360° ULE) on histotechnology (HT) educationand evaluate its effects on student satisfaction and on HT knowledge in the biomedical laboratoryscience degree. In addition, the purpose was to provide systematic and transparent information onthe development process. The study proceeded in two phases, i.e. development and evaluation.

In the development phase, the criteria for ubiquitous learning environments (ULE) and the usein higher education were defined by a scoping review. Based on the review the first version ofULE was produced in the histotechnology (HT) context. The ULE was piloted in a study wherean experimental group (n = 29) studied via ULE and a control group (n = 28) via a conventionalweb-based learning environment (WLE). The data was collected at the end of the term by anelectronic questionnaire, and it was analyzed statistically. In the evaluation phase, the effects onthe student's HT knowledge of (n = 115) and on satisfaction (n = 112) were evaluated in a quasi-experimental study. The data was electronically collected in the beginning and at the end of theterm and analyzed statistically.

The results from scoping review showed that the ULEs were not widely used in highereducation. The criteria for ULEs were defined as flexibility, context-awareness, personalizationand interactivity. These criteria were emphasized in the production of the ULE, evaluated in bothphases. Based on the pilot study the flexibility, context-awareness and personalized operationswere perceived as positive, whereas interactivity was seen as needing further development. In thefinal study, the students were very satisfied with the used ULE with significant improvements intheir HT knowledge.

Based on the results the development process of 360° ULE was stated as effective and valid.The process was described systematically and transparently. Further development, optimization,and evaluation was recommended when implementing the 360° ULE as a part of HT curricula inthe biomedical laboratory science degree.

Keywords: 360° technology, biomedical laboratory scientist, histotechnology,ubiquitous learning environment

Virtanen, Mari, Ubiikin 360° oppimisympäristön kehittäminen ja sen vaikutuksetopiskelijoiden tyytyväisyyteen ja histoteknologian osaamiseen. Oulun yliopiston tutkijakoulu; Oulun yliopisto, Lääketieteellinen tiedekunta; Hoitotieteen jaterveyshallintotieteen tutkimusyksikköActa Univ. Oul. D 1455, 2018Oulun yliopisto, PL 8000, 90014 Oulun yliopisto

Tiivistelmä

Yhteiskunnan digitalisoituessa, koulutuksen rakenteiden muuttuessa ja resurssien tiukentuessaavointen oppimisympäristöjen kehittäminen korkeakouluopetuksen tarpeisiin on välttämätöntä.Tämän tutkimuksen tarkoituksena oli kehittää ubiikki oppimisympäristö (ULE) histoteknologi-an opetukseen ja arvioida sen vaikutuksia bioanalyytikko-opiskelijoiden tyytyväisyyteen ja tie-toon histoteknologiasta. Tavoitteena oli tuottaa uutta tietoa, jota voidaan hyödyntää kehitettäes-sä tulevaisuuden oppimisympäristöjä ja arvioitaessa 360o -tekniikan laajempaa hyödyntämistäkoulutuksen eri osa-alueilla.

Tutkimus eteni kahdessa vaiheessa: oppimisympäristön kehittäminen ja sen vaikuttavuudenarviointi. Ensimmäisessä vaiheessa määritettiin ULE:n kriteerit kartoittavan kirjallisuuskatsauk-sen menetelmällä ja kuvattiin niiden käyttöä korkeakouluopetuksessa. Tämän perusteella kehi-tettiin ULE:n ensimmäinen versio, histoteknologian (HT) opetukseen, jota käytettiin pilottitutki-muksessa. Koeryhmä (n= 29) opiskeli ULE:ssa ja vertailuryhmä (n=28) perinteisessä verkko-oppimisympäristössä (WLE). Aineisto kerättiin sähköisellä kyselyllä opetuksen jälkeen ja analy-soitiin tilastollisesti. Tutkimuksen toisessa vaiheessa arvioitiin ULE:n vaikuttavuutta opiskelijoi-den tietoon histoteknologiasta (n=115) sekä tyytyväisyyttä (n=112) oppimisympäristön käyttöön.Aineistot kerättiin kvasikokeellisella asetelmalla bioanalyytikko-opiskelijoilta ennen ja jälkeenopetuksen. Aineistot analysoitiin tilastollisesti.

Kartoittava katsaus osoitti ULE:n vähäisen käytön korkeakouluopetuksessa. Tärkeimmiksikriteereiksi osoittautuivat joustavuus, tilannesidonnaisuus, personoidut toiminnot ja interaktiivi-suus. Näitä ominaisuuksia painotettiin kehitystyössä ja arvioitiin molemmissa vaiheissa. Pilotti-tutkimuksen tulosten perusteella joustavuus, tilannesidonnaisuus ja personoidut toiminnot näh-tiin positiivisina, kehitettävää interaktiivisuudessa, jonka perusteella ULE:a optimoitiin varsi-naista tutkimusta varten. Tulosten mukaan opiskelijat olivat erittäin tyytyväisiä ULE:n käyttöönja heidän osaamisensa vahvistui merkittävästi.

Tulosten perusteella kehitysprosessi todettiin tehokkaaksi ja luotettavaksi. Prosessi kuvattiinjärjestelmällisesti ja läpinäkyvästi. Tulosten perusteella suositellaan kehittämistyön ja optimoin-nin jatkamista, jonka jälkeen ULE voidaan liittää osaksi bioanalytiikan HT opintoja ja opetus-suunnitelmaa.

Asiasanat: 360° technology, bioanalyytikko, histoteknologia, ubiikki oppimisympäristö

To You who love me most

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Kiitokset

Tämä työ on ajatustasolla saanut alkunsa jo vuosia sitten. Kiinnostus tutkimuksen tekemiseen on ollut läsnä koko opiskelu- ja työurani ajan. Samoin läsnä on ollut jatkuva halu elämänmittaiseen oppimiseen ja kehittymiseen. Tämä työ oli luonteva jatke, päätökseksi en uskalla sitä edelleenkään sanoa. Päätös tämän työn aloittami-sesta oli helppo, se vain odotti aikaansa, paikkaansa ja oikeaa, ajankohtaista ja mu-kaansatempaavaa aihetta, joka sitten vanhan uskomuksen mukaisesti, löytyi sieltä, mistä osasi vähiten etsiä. Tässä tapauksessa luontevasti yhdistyivät kiinnostus his-topatologiaan, histoteknologiaan ja opetuksen pedagogiseen kehittämiseen digitaa-listen menetelmien avulla.

Suurimmat kiitokset osoitan ohjaajilleni, professori Maria Kääriäiselle, joka innostui tutkimusaiheestani heti, vaikka se on edelleenkin innovatiivinen ja suurelle kansalle vaikeaselkoinen. Professori Elina Haavistolle, joka on väsymättömästi, jämäkästi ja rakentavan kriittisesti ohjannut minua kohti lopputulosta. Olen mo-nesti todennut, että jokainen väitöskirjatyöntekijä tarvitsee tuekseen ihmisen, joka suhtautuu tutkimuksen tekemiseen 100% intohimoilla. Se olet sinä, Elina. Ylio-pettaja Eeva Liikaselle, jonka kanssa olemme voineet samalle kehittää histotekno-logian substanssia ammattikorkeakouluopiskelijan näkökulmasta. Valtavan iso kii-tos, että olette, välillä yliaktiivisuuttanikin, jaksaneet. Arvostan työtänne ja osaa-mistanne äärettömän paljon. Kiitos teille, että olette koko ajan nähneet vähän pi-demmälle!

Kiitos esitarkastajille, dosentti Vesa Taatila ja dosentti Sini Eloranta, kriittisistä kommenteistanne. Te teitte työstäni entistä paremman. Nyt olen korjannut kaikki pienetkin virheet. Kiitos seurantaryhmän jäsenille, Helvi Kyngäkselle, Satu Elolle ja Leena Rekolalle, opintojeni systemaattisen etenemisen seuraamisesta. Jokake-väinen tapaamisemme on liikuttanut prosessiani yhtä varmasti kuin muutkin ke-vään etenemisen varmat merkit.

Kiitos, Päivi Helanto ja Jukka, jokavuotisesta epävirallisen seurantaryhmän ta-paamisesta Suomenlinnan kallioilla. Teidän kanssanne sain innostua pedagogiikan kehittämisestä ja tutkimisesta niin, että tämä tie vei lopulta näin pitkälle. Kiitos lämpimästä ystävyydestänne, joka on mahdollistanut monenlaisten asioiden jaka-misen aiheen tiimoilta ja monesti myös sen vierestä. Ilman teitä tämä työ olisi pelkästään patologinen :).

Kiitos koko Oulun yliopiston hoitotieteen ja terveyshallintotieteen tutkimusyk-sikön väelle, joukkoonne on ollut tosi helppo tulla. Teillä kaikilla on ollut merkittävä rooli tämän työn etenemisessä! Kiitos Kristina vertaistuesta, jota mat-kan aikana olen saanut. Positiiviset sanasi ovat lämmittäneet, innostuksesi on ollut tarttuvaa, lisäksi olet loistavaa matkaseuraa.

Kiitos kaikille teille, jotka olette omalla työllänne ja esimerkillänne osoittaneet, että tämä on mahdollista! Olen saanut siitä paljon voimaa. Tästä eteenpäin arvostan

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jokaista väitöskirjaa äärettömän paljon, koska tiedän sen vaatineen uskomattoman paljon.

Kiitos Metropolia ammattikorkeakoulun kollegoille ja taustajoukoille, jotka olette olleet pyyteettömästi tukenani. Olette olleet aidosti kiinnostuneita tekemi-sistäni, ilahtuneet saavutuksistani, tukeneet arjen työssä ja sen onnistumisessa. Teitä on tosi paljon. Teille kaikille ISO kiitos. Kiitos digimentoriverkostolle ja sen innokkaille tekijöille, joiden kanssa olen näissä ympyröissä kuin kotonani. Iso kii-tos teille, Elina Haavisto, Päivit Haho, Haapasalmi ja Haarala, jotka olette tutki-mus-ja kehittämistyöni Metropoliassa mahdollistaneet. Kiitos Hannele, että otit ai-kanaan töihin :).

Valtavan iso kiitos työn rahoittajille, Suomen Histotekniikan yhdistys ry, Sai-raanhoitajien Koulutussäätiö, Laboratoriolääketieteen edistämissäätiö LABES ja Oulun yliopiston tukisäätiö. Ilman taloudellista tukeanne tämä työ ei olisi mahdol-listunut tai ainakaan se ei olisi valmistunut näin nopeasti. Kiitos myös teille, jotka saatte minut aika ajoin tekemään myös jotain muuta. Äiti ja Isä. Veljet perheineen. Ystävät. Kirsi O., Tanja H., Sirpa, Marjukka, perhe Rousi. Olette tosi tärkeitä!

Ja miten voisi edes tarpeeksi kiittää teitä, jotka olette lähietäisyydellä tätä pro-sessia kanssani eläneet. Mahdollistaneet kotitöistä vapaan kokopäiväisen hiljaisen työrauhan, jolloin on voinut keskeytyksettä tutkimustyölleen omistautua. Juhlineet täysillä onnistumisen hetkillä, ´kakkua ja kuohuvaa´, ottaneet vastaan äkäisiä kom-mentteja ja hiljaisuutta haasteita kohdattaessa. Sietäneet pitkin kotia lojuneita pa-pereita, kansioita ja keskeneräisiä suunnitelmia. Antaneet aikaa pitkiin puhelinkes-kusteluihin ja osallistuneet retorisiin pohdintoihin. Kuljettaneet harrastuksiin ja muihin arjen rientoihin. Tarjoilleet väsymätöntä lenkkiseuraa niin sateella kuin paisteellakin. Rakastaneet pyyteettömästi ja samalla nauttineet siitä, että äiti tekee töitä kotona.

Kovin luonteva tämä tutkimus- ja kirjoitusprosessi on ollut. Huikeinta se, mi-ten paljon olen oppinut! Monet näkevät väitöskirjatyön jonkun suuren päätöksenä. Minä näen sen paljon vahvemmin jonkun uuden ja merkittävän alkuna. Vaikka tai-val on ollut hetkittäin raskas, se on kuitenkin ollut todella antoisa!

Elämä. Rakkaimpani. Ville, Sulo ja Vieno, Äiti ja Isä. Tämä on teille! Seuraavaksi tehdään jotain muuta!

Helsingissä 21.3.2018

Mari Virtanen

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Acknowledgements

In some level, this research has started already years ago. The interest in research has been present throughout my whole career with a constant desire for lifelong learning. This doctoral study was a natural extension to gain the competence. The starting decision was easy; it was just waiting for the right time, place, and a rele-vant, engaging topic. And just as the saying goes, it found me when I least expect-ing it. This study smoothly integrated my strongest interests in histopathology, ed-ucational technology and technology-enhanced pedagogical development.

My deepest thanks go to my supervisors. Professor Maria Kääriäinen, who was enthusiastic about the research topic, even though it is still innovative and some-times difficult to understand. Professor Elina Haavisto, who has been tirelessly, firmly and constructively criticizing and guiding me towards the outcome. I have stated many times that every Ph.D. candidate needs a supportive person, who em-braces that role with 100% passion. That is you, Elina. My grateful thanks also to principal lecturer Eeva Liikanen with whom we have been able to develop the ed-ucation of histotechnology from the view of the biomedical laboratory scientist stu-dent studying in a University of Applied Sciences. Thank you so much for your patient input. I value your work and your knowledge infinitely high. Thank you that you have been always able to see a bit further!

Thank you Docent Vesa Taatila and Docent Sini Eloranta for your intelligent comments as pre-supervisors. You have helped me to make my thesis even better. Now I have corrected even the smallest mistakes. Thanks to the members of the follow-up team, Helvi Kyngäs, Satu Elo and Leena Rekola, for systematically fol-lowing my progress. Our annual meetings have moved my process on as surely as any other signs of spring.

Thanks Päivi Helanto and Jukka for the annual meeting of the informal follow-up team on the rocks of Suomenlinna. With you, I became inspired by pedagogical development. Thank you for your warm friendship that has enabled the sharing of a wide range of ideas on the topic and around it. Without you, this research would just be pathological :).

Thanks for the whole team in Nursing Science and Health Care Research Unit in the University of Oulu. With you, this work has been easy. You all have played an important role in this process. Thank you Kristina for peer support. Your positive words and enthusiasm have been contagious. In addition, you are a nice traveling companion.

Thank you all who have showed with your own example that this process is even possible. I have got a lot of strength from You. After this process, I know I will appreciate every dissertation much more than you ever could imagine. Now I know that the process is incredibly demanding.

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Thanks to my colleagues in Metropolia University of Applied Sciences who have supported me. There are so many of you. You have been genuinely interested in my work and delighted about my accomplishments. Thanks for enthusiastic per-sons in the digimentor network with whom I feel like at home. Thank you Elina Haavisto, the three Päivis Haho, Haapasalmi and Haarala, who have made my re-search possible in Metropolia UAS. Thank you Hannele for hiring me in the first place :).

Huge thanks to the financiers such as The Finnish Association of Histotechnol-ogy, The Finnish Nursing Education Foundation, The Laboratory Medicine Foun-dation LABES and The University of Oulu Scholarship Foundation. Without your financial support this research would not have been possible or at least it would not have been completed that fast.

Great thanks to all of you, who keep me connected to life and do something else than research with me. Thank you, mom and dad. Brothers and extended family. Friends. Kirsi O., Tanja H., Sirpa, Marjukka, Family Rousi. You are so important! And finally, how could I ever thank enough those who live with me. Thank you, dear family, for allowing full-time, uninterrupted and silent working time without stress about housework. For sharing joyful moments of success, with ´cakes and goodies´, the grumpy comments and silence when facing great challenges. You have tolerated papers, folders, and unfinished plans laying all over the house. You have given time for endlessly long conversations and participated in rhetorical re-flections. You have taken the kids to hobbies and taken care of daily routines. You have offered tireless walks in the sun and in the rain. In the midst of all confusion, you have enormously enjoyed that I got to work at home. You have loved me end-lessly.

This research process has somehow felt very natural. The biggest achievements I have seen are in my increased competence. I have learned so much! Often a dis-sertation is seen as a great ending for something, but I see it much more as a sig-nificant beginning. Although the battle has been heavy at times, for the most parts it has been really rewarding!

My life. My dearest ones. Ville, Sulo and Vieno, Mother and Father. This is for You! Next, we will do something else! In Helsinki 21.3.2018

Mari Virtanen

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Abbreviations

360° 360° spherical panorama image technique

360° ULE ubiquitous 360° learning environment

AR augmented reality

BLS biomedical laboratory scientist

CLS clinical laboratory scientist

CVI content validity index

ECTS European Credit Transfer and Accumulation

HT histotechnology

LE learning environment

LMS learning management system

m-learning mobile learning

MLS medical laboratory scientist

MT medical technologists

QR quick response barcode

RFID radio frequency identification

UAS university of applied sciences

ULE ubiquitous learning environment

u-learning ubiquitous learning

WLE web-based learning environment

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List of figures and tables

LIST OF FIGURES

Figure 1. Model for educational evaluation

Figure 2. Framework of the study

Figure 3. The selection of eligible publications

Figure 4. 360° panorama image with digital objects

Figure 5. Functional objects in HT laboratory

Figure 6. The 360° ubiquitous learning environment

Figure 7. The web-based learning environment

Figure 8. Summary of the results

LIST OF TABLES

Table 1. The design of the study

Table 2. Component production and contributors

Table 3. Learning objectives

Table 4. Data collection instruments

LIST OF APPENDICES

Appendix 1. The instrument for assessing the level of students´ satisfaction

Appendix 2. The knowledge test for assessing histotechnology

Appendix 3. The self-evaluation instrument for histotechnological knowledge

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List of Original Publications

In the Summary original publications are referred to in their numerals (I-IV):

I Virtanen M, Haavisto E, Liikanen E & Kääriäinen M (2017) Ubiquitous learning envi-ronments in higher education: A scoping literature review. Education and Information

Technologies, 23(2), 985-998. DOI: 10.1007/s10639-017-9646-6 II Virtanen M, Haavisto E, Liikanen E & Kääriäinen M (2018) Students´ perceptions on

the use of ubiquitous 360° learning environment in histotechnology: A pilot study. Jour-nal of Histotechnology. DOI10.1080/01478885.2018.1439680

III Virtanen M, Kääriäinen M, Liikanen E & Haavisto E (2017) The comparison of stu-dents’ satisfaction between ubiquitous and web-based learning environments in clini-cal histotechnology. Education and Information Technologies, 22(5), 2565-2581. DOI:10.1007/s10639-016-9561-2

IV Virtanen M, Kääriäinen M, Liikanen E& Haavisto E (2017) Use of ubiquitous 360° learning environment enhances students´ knowledge in clinical histotechnology: a quasi-experimental study. Medical Science Educator, 27(4), 589-596. DOI: 10.1007/s40670-017-0429-x

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Table of contents

Tiivistelmä

Abstract

Kiitokset 9 Acknowledgements 11 Abbreviations 13 List of figures and tables 15 List of Original Publications 17 Table of contents 19 1 Introduction 21 2 Theoretical framework 23

2.1 Medical laboratory science and histotechnology .................................... 23 2.2 Ubiquitous learning environment ............................................................ 25 2.3 Educational effectiveness ........................................................................ 27 2.4 Summary of the literature........................................................................ 29

3 Aim, research questions and hypotheses 31 4 Materials and methods 33

4.1 Developmental phase .............................................................................. 35 4.1.1 The scoping review (Article I)...................................................... 35 4.1.2 The production of 360° ULE ........................................................ 36 4.1.3 The implementation of 360° ULE (Article II) ................................ 40

4.2 Evaluation phase ..................................................................................... 44 4.2.1 Level of satisfaction (Article III) .................................................. 44 4.2.2 Changes in histotechnological knowledge (Article IV) ................ 45

5 Results 49 5.1 Developmental phase .............................................................................. 49

5.1.1 The criteria for ULE (Article I) .................................................... 49 5.1.2 The students´ perceptions on 360° ULE (Article II) .................... 49

5.2 Evaluation phase ..................................................................................... 50 5.2.1 Level of satisfaction (Article III) .................................................. 50 5.2.2 Changes in histotechnological knowledge (Article IV) ................ 51

5.3 Summary of the results ........................................................................... 52 6 Discussion 55

6.1 Discussion of the main results ................................................................. 55 6.2 Ethical considerations ............................................................................. 57 6.3 Validity and reliability ............................................................................. 57

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6.4 Contributions and practical implications ................................................. 62 7 Conclusions 65

7.1 Recommendations ................................................................................... 65 7.2 Future studies .......................................................................................... 66 7.3 Closing words ......................................................................................... 66

References 69 Appendices 79 Original publications 87

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1 Introduction

Digitalization of education is a globally relevant topic, which has been actively

studied over the years. Digitalization enables a wide range of activities to transform

conventional services with digital technologies, devices, resources and various sets

of flexible, personalized and effective opportunities. (Jones & Jo 2004, Huang et al. 2011, Potkonjak et al. 2016). The ubiquitous learning have seen an extension of

electronic and mobile learning (Shih et al. 2011) transcending the barriers between

in-class and out-class activities with possibilities to study anytime and anywhere,

and to participate beyond the limitations (Martin et al. 2013).

Multiple improvements have been reported when digital information has been

used in education to enable universities to meet a broader range of student needs

and mix in-class and online learning possibilities anywhere and anytime (European

Centre for Parliamentary 2014). Prominent improvements have been recognized

when learning environments, teaching methods and the pedagogy have been mod-

ernized by digitalization. The Finnish policy of higher education and science has

promoted the open development of effective and efficient teaching methods and

learning environments to raise the level of quality and competitiveness. (Ministry

of Education and Culture 2017). Similar governmental agendas have been formu-

lated in other European countries for example in Norway, Netherlands and Ger-

many (Government of Norway 2016, Government of Netherlands 2016, The Fed-

eral Ministry of Education and Research of Germany 2017). These agendas and

needs have encouraged the research and writing of this doctoral thesis.

Ubiquitous learning environments (ULE) are based on ubiquitous technology

(Weiser 1991, Yahya et al. 2010, Shih et al. 2011). Ubiquitous learning can be seen

as an expansion of electronic and mobile learning (Casey 2005) based on ubiqui-

tous computing with high mobility and tight integration into the learning environ-

ment. The seamless communication between users, learning spaces, devices and

embedded functional objects allows learning while moving, attaching learners to

the current learning situation in the current place with highly accessible omnipres-

ent digital resources and approaches for knowledge creation and communication

(Cope & Kalantzis 2009, Liu & Hwang 2010, Yahya et al. 2010).

The composition of ULEs can vary. In general, ULEs combine authentic learn-

ing spaces, digital resources, technologies and devices as one learning environment.

In particular, ULEs enhance flexible, personalized, interactive and context-aware

learning and support the transition of theory in to practice (de Freitas & Neumann

2009).

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ULE supports learning processes and seamless interactions. High accessibility,

flexibility, permanence, personalization, and interactivity have been perceived as

necessities (Weiser 1991, El-Bishouty et al. 2007, Huang et al. 2008, Ogata et al. 2008, Yahya et al. 2010, Huang et al. 2011, Chin & Chen 2013). The ubiquitous

learning environments are not widely used or reported in health or medical science

contexts.

The histotechnology and the histotechnological (HT) knowledge forms a part

of the competence of biomedical laboratory scienctist educated in biomedical la-

boratory science degree. HT knowledge forms the context of this study and is one

of the main competences of biomedical laboratory scientists. HT knowledge is re-

quired in the histopathology laboratory where the scientists prepare the tissue sam-

ples for microscopical examination for diagnosis made by the pathologists, identi-

fying tumors, autoimmune, inflammatory and degenerative diseases. HT centers on

the detection of tissue abnormalities and the treatment of the diseases. (Karttunen

& Pääkkö 2013, NSH 2017.) In this study, the HT knowledge is focused on HT

processes as part of diagnosis and patient treatment, pathological basis of diseases,

normal cell structure and tissue morphology, tissue sampling techniques and labor-

atory processes.

The teaching methods used through the ages have been strongly based on

teacher’s strong competence, instructional lecturing (Davis 1998 in Taekman and

Shelley 2010), teacher-centered in-class activities, self-directed learning activities

and hands-on training. The educators in the field of HT have taken advantage of all

these conventional methods.

In this study, a ubiquitous 360° learning environment (360° ULE) was devel-

oped on HT education and its effectiveness was evaluated through student satisfac-

tion and HT knowledge. Furthermore, this study provides systematical and trans-

parent information on the development process, which has previously remained

unreported in higher education or in the HT context.

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2 Theoretical framework

The theoretical framework is based on previous literature. The key concepts include

ubiquitous learning, criteria of ubiquitous learning environments (ULE), histotech-

nology (HT), educational effectiveness and 360o technology. The theoretical frame-

work is based on literature searches conducted in multiple phases during years

2013-2017. The searches focused on higher education, learning environment de-

velopment, health and medical sciences, biomedical/ medical laboratory science,

pathology, histology, histopathology and HT, ubiquitous learning and learning en-

vironments, learning outcomes, and on assessment methods. The literature searches

were conducted by using multiple search terms and combinations of terms. Inter-

national databases such as ScienceDirect, ProQuest, PubMed and EbscoHost were

used. Grey literature was searched by using web-browsers such as Google Scholar,

Mozilla Firefox and Google Chrome. All relevant references are listed in the refer-

ence list.

2.1 Medical laboratory science and histotechnology

Medical Laboratory Science is the study of the scientific principles and disciplines

practiced in hospital and medical research laboratories. It is a combination of health

disciplines and technological understanding of diagnostics in clinical health care

and an important link between healthcare professionals, diagnostics and the public.

(IFBSL 2008, Andersen & Kjærgaard 2012.)

The professionals of medical laboratory science provide information from la-

boratory analyses, assisting physicians in patient diagnosis, disease monitoring,

disease prevention and treatment. Educated professionals use technologies, instru-

mentations and methods to perform laboratory testing from blood, cell and tissue

samples and body fluids. Laboratory testing includes disciplines such as clinical

chemistry, hematology, immunology, immunohematology, microbiology, physiol-

ogy, neurophysiology, cell and molecular biology, cytology and histology. (Aus-

tralian Institute of Medical Scientists 1994, Metropolia 2016, ASCLS 2017.) Most

of the Medical Laboratory Scientists (MLS) are generalists, skilled in all disciplines.

However, the qualification by unique education or additional training is possi-

ble in specific fields such as biochemistry, hematology, coagulation, immunohema-

tology, microbiology, bacteriology, virology, parasitology, mycology, toxicology,

immunology, histopathology or histology, histocompatibility, cytopathology, cyto-

genetics, electron microscopy and IVF (in vitro fertilization) labs.

24

The medical laboratory science profession has various career tracks based on

the level of education and the regulations of different countries. The terminology

used by different professionals is colorful. In the United States where the profes-

sions such as medical laboratory scientist (MLS), medical technologist (MT) and

Clinical Laboratory Scientist (CLS) are known, the education of medical laboratory

technician takes 2 years while the education of medical laboratory scientist takes 4

to 5 years (ASCLS 2017.) In Australia, medical laboratory scientists complete an

education taking 3 to 4 years (Australian Institute of Medical Scientists 1994). In

Finland the biomedical laboratory science degree program takes 3.5 years (210

ECTS) and leads to a Bachelor Degree (B.Sc.) and for registered qualification of

BLS. The education is provided by the Universities of Applied Sciences (UAS)

where around 230-250 students finish their BLS degree every year. At the end of

2016, there were 4150 members in The Association of Biomedical Laboratory Sci-

entists in Finland. (2017.)

The International Federation of Biomedical Laboratory Science (IFBLS) has

described the core competencies (IFBLS 2008, IFBLS 2011, Almås & Ødegård

2016) including the knowledge, skills, and abilities. The core competencies are the

combination of knowledge, skills, abilities and attitudes, knowledge as a set of facts,

principles, regularities and the success of adopting information, skills and activities

in practice. (Ďurišová et al. 2014.) The required competences within the occupa-

tional standard expected are the following:

1. preparation and analysis of biological material,

2. correlation, validation and interpretation of the results,

3. reporting,

4. maintenance of equipment, device and supplies,

5. working safety,

6. continuous improvement of the services,

7. participation in education and training of other healthcare workers,

8. participation in research and development activities and in continuous profes-

sional development.

Histology is a study of the microscopic anatomy of various tissues (MeSH 2017).

Histopathology is the microscopic study of diseased tissues. Histotechnology is the

employment of histolocigal techniques to diagnose diseases or conduct research.

(NSH 2017.) Histotechnological (HT) knowledge is one of the core competences

required from registered BLS. Education is a combination of theoretical knowledge

and practical training focused on understanding the basis of pathological diseases,

25

on pathological basis of diseases, general and organ pathology, tissue morphology

and practical skills needed in laboratory processes such as fixation, crossing, pro-

cessing, embedding, sectioning, and staining, including quality assessment, legis-

lation and working safety. In this study, the HT knowledge was summarized as

pathological basis of diseases, normal cell structure and tissue morphology, tissue

sampling techniques and HT laboratory processes as part of diagnosis and patient

treatment. (Metropolia 2016, Turku AMK 2016, TAMK 2016.)

Learning HT has been strongly based on conventional methods such as lectures,

information sharing, self-directed learning activities in digital learning manage-

ments systems (LMS) such as Moodle and hands-on activities in HT laboratories.

The learning has historically been based on a strong master-apprentice relationship

(van Bodegom et al. 2013) and web-based online histology or histopathology

courses have not been widely provided. No online courses can be found in Finnish

but a few international courses were found in English (FutureLearn 2017).

Alongside the used conventional methods the educational institutions are heav-

ily investing in digital technologies to support self-directed out-class activities and

to facilitate the quality of learning. (Mahdizadeh et al. 2008, Liu & Hwang 2009.)

Multiple devices, networks, software and applications are invading the students’

routines challenging the educational methods and practices, enriching learning ef-

fectiveness, expanding opportunities, enhancing learning satisfaction, reducing

costs, helping teachers and motivating the students (Johnston et al. 2005, Rodriquez et al. 2008, Sivula 2011, Duque 2014, Dündar & Akcayir 2014, Schmid et al. 2014,

Orus et al. 2016). However it should be remembered that each learning environ-

ment has its specific contents and the used methods can wary from the use of email

and PowerPoint files (Collis et al. 2001, Ong & Lai 2006) to the use of scientific

virtual laboratories (Potkonjak et al. 2016).

2.2 Ubiquitous learning environment

A learning environment can be any environment where the students can study and

learn. It is a combination of different settings supporting the learning by utilizing

technology in a pedagogically meaningful way. The learning environment can sim-

ulate the diverse authentic learning spaces with virtual and digital contents (Shear et al. 2011, Kankaanranta et al. 2012) and the learning can be supported by various

technologies promoting the effective, personalized, interactive learning experi-

ences regardless time or place. Learning is about changing, adopting new

knowledge, skills and habits. Teaching is about helping learning. Learning can be

26

observed as a change in the behavior according to the behavioristic view. Accord-

ing to constructivists the individual's activity is seen as meaningful, while in socio-

constructivism the meritorious social processes and the meaning of learning net-

works are underlined (Rauste-von Wright & von Wright 1994, Palincsar 1998, Sie-

mens 2006). Together with improved learning outcomes, the purpose of teaching is

to enhance critical thinking, problem solving, communication and co-operation by

using relevant methods. (SchoolNet SA 2017, Griffin et al. 2012).

The descriptions and definitions of ubiquitous learning and ubiquitous learning

environments (ULE) have varied and the terminology around the research area has

been wide and colourful and have mixed with multiple phenomena such as mobile

and augmented learning (McCall et al. 2011, Cheng & Tsai 2013). Distinguishing

the differences between mobile and ubiquitous learning environments has been

seen as challenging because of unconfirmed terminology (Yahya et al. 2010). In

general, m-learning can be defined as any form of learning mediating through a

mobile device (Alexander 2004). In educational use, mobile devices offer portabil-

ity and ubiquitous access providing situated learning opportunities and changes the

way to study and learn just-in-time. M-learning enables social interactivity and

connectivity between individuals, devices, networks, and other technologies.

(Melhuish & Falloon 2010). The first m-learning environments were published al-

ready in 2000 (Quinn 2000, Soloway et al. 2001), followed by descriptions of ubiq-

uitous LEs (Ogata & Yano 2004). This study focuses on ULEs, which have not

been widely studied or published in the higher education context. The differences

between m- and u-learning environment have stated as context-aware and person-

alized learning activities with the use of functional objects, sensing technologies,

mobile devices and wireless networks. Thus, the ULE is generally seen as a broader

entity than the use of mobile devices in learning.

Ubiquitous learning environment (ULE) integrates the authentic learning space,

omnipresent digital resources, functional objects, sensing technologies, mobile de-

vices and wireless networks with the functional characters. It enables studying and

learning on demand, based on students’ personal needs and own activity. ULEs are

flexible, interactive, context-aware and personalized (Ogata & Yano 2004, Huang et al. 2008, Yahya et al. 2010, Hwang et al. 2011, Marinagi et al. 2013, Martin &

Ertzberger 2013), learning resources provided in relevant location and time. (Saka-

mura & Koshizuka 2005, Hwang et al. 2008, Hwang et al. 2009, Yahya et al. 2010).

Context-aware actions have been found as relevant (El-Bishouty et al. 2007) as

well as the use of sensing technologies (Küpper 2005). Interactivity and collabora-

tion have been reported as supportive for learning (Lin et al. 2005, El-Bishouty et

27

al. 2007, Hwang et al. 2009, Hwang et al. 2011, White & Turner 2011). Personal-

ized support and instructions have been seen as relevant (Johnston et al. 2005,

Huang et al. 2012), and immediate feedback has promoted the effectiveness of

learning performance (Zary et al. 2006, Huwendiek et al. 2009, Fonseca et.al. 2015,

Tsai et al. 2015). The lack of proper support has hindered learning (El-Bishouty et al. 2008, Miyata & Kozuki 2008, Hwang et al. 2011).

ULEs can be developed by using multiple technologies. The use of 360° technol-

ogy is stated as one of the most interesting method of displaying education (Eye-

revolution 2017). Viewers of 360° panoramic image become as a virtual participant

immersed into observed scene, mimicking the real life learning environments

within virtual environment allowing the users view the environment from different

angles and directions. Included digital and functional objects transforms 360° pan-

orama image from passive material on interactive learning resource where user can

decide the actions currently played by navigation as rotating and zooming functions

(Huang et al. 2008, Kwiatek & Woolner 2009, Ozkeskin & Tunc 2010).

The development or use of 360° panorama technology is not widely reported

in educational use, instructional material and virtual tours in hotels and museums

can be found (Bastanlar 2007, Louvre Museum 2007, Ozkeskin & Tunc 2010). Any

research concerning the development or use in biomedical laboratory science or

HT education context has not been published.

2.3 Educational effectiveness

The effectiveness of educational activities can be evaluated by using multiple mod-

els. The most famous models are the ones by Kirkpatrick (1998, 2006), Phillips

(1997) and Kaufman (in Kaufman et al. 1995). Kirkpatrick’s (1998, 2006) four-

level model is a widely used framework for objective evaluation of the educational

settings. In the Phillips (1997) and Kaufman (in Kaufman et al. 1995) models the

evaluation of investments and the effects on society have been included. (Fig. 1.)

28

Fig. 1. Model for educational evaluation. (Modified from Kirkpatrick 1998, Phillips 1997

and Kaufman 1995.)

As shown in Figure 1, according to Kirkpatrick the educational settings should be

evaluated at least in the first two levels (Farjad 2012). Changes in practice, contri-

bution for the organization, investments and impacts on costs may be evaluated in

the organizational level. Impacts on the whole society should be assessed in a

higher level, for example by the government. In this study, the evaluation focused

on levels 1 and 2.

In educational settings, satisfaction can be understood in various ways and the

various outcomes can be used in the evaluation of teacher's expertise, facilities,

relevance of instructions, feedback, flexibility, convenience, self-directed opportu-

nities, customized contexts, interactivity or enjoyment. (Looney et al. 2004, Eom et al. 2006, Jones & Chen 2008, Butt & Rehman 2010, Jung 2014.) The desirable

level of satisfaction has been achieved when technology enhanced learning meth-

ods have been implemented in education (Sun et al. 2008, Ramayah & Lee 2012,

Jung 2014). In this study, satisfaction was defined as 1) satisfaction on technologi-

cal and 2) pedagogical aspects and 3) in instructions and feedback and 4) perceived

enjoyment. In addition, the aspect of self-motivation was included. The level of

satisfaction can be assessed by using multiple methods such as questionnaires,

quizzes, observations and interviews. (Sun et al. 2008, Novo-Corti et al. 2013, Jung

2014.) In this study, the electronic questionnaire was used.

29

The changes in knowledge has conventionally been assessed or measured by

using quantitative methods such as written tests, exams and practical testing. The

testing has focused on numbers, grades and scores. (Coldwell et al. 2008, Fitzgerald

2008, Oermann & Gaberson 2009.) Versatile forms of assessment include multiple

aspects (Norman et al. 2002, Bing-Johansson et al. 2013, Ďurišová et al. 2014) to

ensure the subjective and objective perspectives. In the health education context,

questionnaires and tests are commonly used (Polgar & Thomas 2008).

2.4 Summary of the literature

Learning is transferring out from the classrooms faster than ever, and any environ-

ment can be seen as a learning environment. ULEs are the new era of learning

environments supporting seamless learning regardless of time and place. Flexibility,

content personalization and context-awareness are perceived as necessities when

digital learning environments are being developed. The meaning of interactivity,

interaction and collaboration are seen as crucial.

An authentic learning space, omnipresent digital learning resources, functional

objects, sensing technologies, mobile devices, wireless networks, social media

tools and cloud-based approaches were combined in this study to build an effective

learning environment for the students to learn about HT. The pathological basis of

diseases, tissue morphology, sampling techniques and laboratory processes formed

the context of this study and formed the basis of the evaluation of learning

effectiveness. The level of student satisfaction was assessed from the technological,

pedagogical, instructions, feedback and enjoyment points of view as a part of learn-

ing effectiveness. Figure 2 shows the theoretical framework of the study.

30

Fig. 2. Framework of the study.

31

3 Aim, research questions and hypotheses

The aim of this study was to develop a ubiquitous 360° learning environment (360°

ULE) on histotechnology (HT) education and evaluate its effects on students´ sat-

isfaction and on HT knowledge in biomedical laboratory science degree. In addi-

tion, the purpose was to provide systematic and transparent information on the de-

velopment process based on the developmental and evaluation phases. The study

answers the following research questions (RQs):

Developmental phase

1. What are the criteria for ULE in higher education context? (Article I)

2. How did the students perceive the use of ULE? (Article II)

Evaluation phase

3. How is the level of satisfaction assessed by the students and how does it differ

between experimental and control groups? (Article III)

Hypothesis 1: The level of satisfaction is higher in the experimental group than in

the control group.

4. How has HT knowledge changed and differed among and between the experi-

mental and control groups? (Article IV)

Hypothesis 2: The HT knowledge is better in the experimental group than in the

control group.

Hypothesis 3: There are significant interaction effects between groups and time.

33

4 Materials and methods

This study was conducted in two phases, namely development and evaluation with

sub-phases. The phases were based on the Medical Research Council model for

complex intervention development (MRC 2008), 1) with theoretical background,

2) piloting and feasibility testing 3) evaluating and optimization and 4) reporting

and implementation. In this study, the MRC (2008) phases 1 and 2 were com-

pounded as developmental phase and phases 3 and 4 as evaluation phase. (Table 1).

The developmental phase started by defining the criteria for ULE, and the

framework for the development was built. The definitions for ULEs, previously

reported development processes, outcomes and assessment methods were defined

by using a scoping review method (Article I). Based on the results, the first version

of ULE was developed by combining the following elements by using the 360°

panorama technique:

1. authentic learning space (HT laboratory),

2. omnipresent digital learning resources,

3. functional objects used with sensing technologies and

4. mobile devices and wireless networks.

The 360° ULE was piloted in HT education. Student perceptions, positive effects

and developmental needs were assessed and analyzed (Article 2). The results were

reflected and minor changes were made. The optimized version of 360° ULE was

used in the evaluation phase. The level of student satisfaction and the changes in

HT knowledge were assessed (Articles III and IV). A detailed description of this

study is shown in Table 1 and further described later in this chapter.

34

Ta

ble

1. T

he

de

sig

n o

f th

e s

tud

y.

Pha

se, r

esea

rch

ques

tion

and

year

s

Des

ign

Sam

plin

g D

ata

colle

ctio

n A

naly

sis

Out

com

es

Dev

elop

men

t pha

se,

Arti

cle

I,

2013

Sco

ping

revi

ew

Orig

inal

pub

licat

ions

fulfi

lled

incl

usio

n cr

iteria

Orig

inal

stu

dies

(n=7

) C

onte

nt a

naly

sis

Crit

eria

for U

LE

Arti

cle

II,

2014

-201

5

Qua

si-e

xper

imen

tal

post

-test

des

ign

All

elig

ible

BLS

stu

dent

s (n

=57)

in o

ne U

AS

, exp

erim

enta

l (n=

29)

and

cont

rol (

n=28

) gro

up

Ele

ctro

nic

ques

tionn

aire

(n=

24 it

ems)

Exp

lora

tive

fact

or

anal

ysis

, M

ann-

Whi

tney

U-te

st

Stu

dent

per

cept

ions

on th

e us

e of

360

°

ULE

2013

-201

5

Eva

luat

ion

phas

e, A

rticl

e

III,

2015

-201

6

Qua

si-e

xper

imen

tal

pret

est-p

ost-t

est

desi

gn

All

elig

ible

BLS

stu

dent

s (n

=115

)

in th

ree

UA

Ss,

expe

rimen

tal g

roup

(n=6

1) a

nd

cont

rol (

n=54

) gro

up

Ele

ctro

nic

ques

tionn

aire

(n=2

7 ite

ms)

Con

tent

ana

lysi

s,

Man

n-W

hitn

ey U

-test

The

leve

l of s

tude

nt

satis

fact

ion

Arti

cle

IV,

2015

-201

6

Qua

si-e

xper

imen

tal

pret

est-p

ost-t

est

desi

gn

All

elig

ible

BLS

stu

dent

s (n

=112

)

in th

ree

UA

Ss,

exp

erim

enta

l

(n=6

0) a

nd c

ontro

l (n=

52) g

roup

Ele

ctro

nic

ques

tionn

aire

,

know

ledg

e te

st (n

=45

item

s) a

nd s

elf-e

valu

atio

n

(n=6

8 ite

ms)

Man

n-W

hitn

ey U

-test

,

Wilc

oxon

test

, tw

o-

way

AN

OV

A

The

leve

l of

stud

ent´s

HT

know

ledg

e

35

4.1 Developmental phase

4.1.1 The scoping review (Article I)

The aim of the scoping review was to identify the criteria and use of ULEs in higher

education and to provide a wide view on the research area, provide an adequate

knowledge base and point out the gaps in the existing literature. The literature re-

view followed the Joanna Briggs Institute’s guidelines (JBI 2015). The review fo-

cused on determining the criteria for ubiquitous learning, learning environments,

and to clarify the use of ULE (contents, components and outcomes). Systematical

literature searches were conducted with the aid of the specialist of the medical li-

brary and were based on predefined inclusion and exclusion criteria, focused on

ubiquitous learning and the previous use of ULEs in higher education contexts with

quantitative study setting and participants such as university students, peers or ac-

ademic staff members. The literature searches were conducted by using multiple

international databases including health, nursing, medical, educational and peda-

gogical journals and limited to publication years between 2006-2013. The grey lit-

erature was not included in the final review. The titles (n=889), abstracts (n=78)

and full texts (n=30) were independently screened by two researchers by using pre-

defined inclusion and exclusion criteria. After the screening, the quality appraisal

was performed for eight studies by following the JBI (2015) guidelines. The eligi-

ble original publications with high quality were selected and included (n=7) in the

final review as shown in Figure 3.

36

Fig. 3. The selection of eligible publications.

An inductive content analysis was used for analysis. The extracted descriptions

were listed and condensed from each study. Extracts were organized into subcate-

gories and subsequently into final categories and the main categories. (Elo &

Kyngäs 2008.) The results were reported by using the PRISMA Statement (Moher et al. 2009). (Article 1).

4.1.2 The production of 360° ULE

The ULE was produced custom-made by using multiple software. The 360° tech-

nique was selected based on the researcher’s vision and previous knowledge (El-

Bishouty et al. 2007, Peng et al. 2008, Hwang et al. 2009, Hwang et al. 2011, Wu et al. 2011, Wu et al. 2012, Li et al. 2013). The need for flexible and interactive

learning environment replicating real life learning situations was seen as a vital

aspect. The costs, time consumption, agile development, easy use and content pro-

duction were the criteria for the selected method.

37

The purpose was to produce the development method, which can be easily ap-

plied to various educational contexts by other educators. The 360° panorama was

embedded with digital objects including texts, videos and audio files (Fig. 4). Se-

lected learning resources were tagged on the panorama by using HTML5, CSS and

JavaScript techniques to produce the user interface. (Article II.)

Fig. 4. 360° panorama image with digital objects.

Functional objects, quick response barcodes (QR), sensing technologies such as

barcode scanners, wireless networks and mobile devices were included, as shown

in Figure 5.

Fig. 5. Functional objects in HT laboratory.

The produced components, contents and contributors are described in Table 2.

38

Table 2. Component production and contributors.

Component Technology used in production Contributor

Authentic learning

space

Histotechnology laboratory Metropolia UAS &

Researcher

360° panorama,

user interface, icons

and control buttons

Adobe Lightroom, Adobe Photoshop,

GardenGnome, Pano2VR, Kolor Autopano,

PTGui, HTML5, CSS, JavaScript

Visumo Ltd. &

Researcher

Online webinars

and video lectures

Web conference system Researcher

Tutorials and

demonstrations

Apple iPad, iMovie, Explain Everything Researcher

Video distribution YouTube Researcher

Assignments, tasks,

exams

Moodle 2.7 Researcher

E-books Electronic library Metropolia UAS

Virtual microscope WebMicroscope® Fimmic Ltd &

Researcher

Quick Response codes Code generator Researcher

Interaction with teacher

and peers

Social media tools, Cloud applications, Web

conferencing

Researcher

The ULE was utilized with a mobile device (iPad2, Apple) provided by the UAS

or could be used by any smart device with an internet connection. Interaction be-

tween teacher, students and peers was supported by using cloud-based approaches

and social media tools.

The produced 360° ULE, the contents and the structure were evaluated by the

experts and stated as relevant. The entity of 360° ULE is shown in Figure 6.

39

Fig. 6. The 360° ubiquitous learning environment.

The web-based learning environment, WLE, was produced and managed in LMS

(Moodle 2.7) and was provided as files and folders based on information sharing

(Fig.7.). All of the same learning resources were presented as in the ULE

Fig. 7. The web-based learning environment.

40

4.1.3 The implementation of 360° ULE (Article II)

The first version of 360° ULE was produced and implemented in the HT context.

HT knowledge was based on previous knowledge (El-Bishouty et al. 2007, Peng et al. 2008, Hwang et al. 2009, Hwang et al. 2011, Wu et al. 2011, Wu et al. 2012, Li et al. 2013) and curricula of different universities in Finland, US and New Zealand

(NSH 2017, Metropolia 2016, Turku AMK 2016, TAMK 2016, Indiana University

2016, Tennessee University 2016, Otago University 2016). The learning objectives

focused on 1) histotechnological processes as a part of diagnosis and patient treat-

ment, 2) normal cell structure and tissue morphology, 3) tissue sampling techniques

in theory and 4) laboratory processes of histological tissue sample. The weekly

program was scheduled (Table 3.) and the intervention duration was set at eight

weeks based on local curricula. The studies were divided in theoretical (3 ECTS)

and practical (3 ECTS) parts. The theoretical studies included orientation, work-

shops, and the summative session.

Table 3. Learning objectives.

Week Objective Item

I-III Histotechnological processes as a part of diagnosis

and patient treatment

Normal cell structure and tissue morphology

Pathological basis of

diseases

Organ pathology,

Neoplasms

IV-V Tissue sampling techniques in

theory

Tissue sampling,

histotechnological

processes

VI-VIII Laboratory processes of histological tissue sample Histotechnological

processes, safety and quality

management

The aim of the pilot study was to assess the student perceptions when 360° ULE

was used and compared with conventional web-based learning environment. A

quasi-experimental study design was used with experimental (ULE) and control

groups (WLE) where the experimental group studied via 360° ULE (Fig. 6.) and

control group via a conventional web-based learning environment (Fig.7.).

In the ULE group all learning resources and devices were in free use, and in-

teraction was supported by using communicative tools. In the WLE group, the use

41

of 360° panorama image, functional objects, mobile devices, communicative tools

or virtual microscopy were not present. The pilot study was performed in one UAS

by the researcher. The students were eligible to participate if their studies had ad-

vanced as planned in the curriculum, with studies in anatomy, physiology, patho-

physiology, laboratory methods, and mathematics completed before enrolment.

Participants

A total of 100 students enrolled in the HT course of which 57 students voluntarily

participated in the experiment. The participants were divided in the experimental

(n=29) and control (n=28) groups. 86 % of the participants were women, with an

average age of 28.5 years. Significant differences in background information were

not revealed between groups. The participants were divided in groups based on

semester. The participants were informed of the used study protocol, resources and

methods. Thus, participation took place with informed consent.

Data collection

The data was collected with questionnaire electronically in years 2014-2015. The

student perceptions were assessed in the end of the study period by using the data

collection instrument developed in this study (Article II). The criteria for ULE were

used as a theoretical background for the instrument development (Article I). The

instrument included 24 items and background information. All individual items were

rated on a 5-Likert scale, from strongly agree (scored as 5) to strongly disagree (scored

as 1). The instrument was based on the following variables:

1. flexibility (including possibility to study anywhere, anytime, on demand, just

in time, omnipresent and permanent learning resources, high accessibility)

2. personalization (including information, learning content and time management

including personalized learning content, self-paced time management, learning

activities based on the learners’ own activity)

3. context-awareness (including embeddedness and use of functional objects in-

cluding information provided on the learners’ request, controlled by the context

such as user, time or location, use of functional objects, sensing technologies

and mobile devices) and

42

4. interactivity (including collaboration and feedback and interactivity including

collaborative and interactive learning methods supported with relevant tools

and approaches)

The reliability of the instrument was examined by using Cronbach alphas for inter-

nal consistency. The construct validity was examined by exploratory factor analysis

and the content validity by the experts. (Article II). The process of the instrument

development is described in Table 4.

43

Ta

ble

4. D

ata

co

lle

cti

on

in

str

um

en

ts

Pha

se, I

nstru

men

t, ar

ticle

Fa

ctor

/ Sub

scal

e Ite

ms

(n)

Sca

le

Rel

iabi

lity

both

gro

ups1

ULE

a , W

LEb

Dev

elop

men

t pha

se,

stud

ents

´ per

cept

ions

,

artic

le II

flexi

bilit

y

pers

onal

izat

ion

cont

ext-a

war

enes

s

inte

ract

ivity

4 5 9 6

Like

rt 1-

52

.841

.83

.76

.84

Eva

luat

ion

phas

e,

leve

l of s

atis

fact

ion,

artic

le II

I

peda

gogi

cal m

etho

ds

tech

nolo

gica

l met

hods

inst

ruct

ion

and

feed

back

enjo

ymen

t

self-

mot

ivat

ion

posi

tive

aspe

cts

and

deve

lopm

enta

l nee

ds

6 3 7 6 3 2

Like

rt 1-

52

open

-end

ed

.83

.61

.84

.84

.64

Eva

luat

ion

phas

e,

HT

know

ledg

e, te

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44

Data analysis

Data was analyzed by using IBM SPSS statistical software version 21 (SPSS, Chi-

cago, IL). Non-parametrical, statistical tests were used to determine the differences

in four subscales: flexibility, personalization, context-awareness and interactivity.

Statistically significant differences between the experimental and control groups

were examined by using Mann-Whitney U-test for independent samples. The p-

value, <.05, was used to describe statistical significance.

4.2 Evaluation phase

The data from development phase was carefully analysed and reflected and the fol-

lowing minor changes were made in the final version of 360o ULE. The interven-

tion duration was shortened from 8 weeks to 5 weeks. The technical usability was

optimized by the programmer. The password protection in 360° ULE was removed.

Interactivity was strengthened by using cloud based approaches and social me-

dia tools such as Facebook, Google Drive and YouTube. All video files, tutorials

and demonstrations provided were shortened to a maximum length of around 6

minutes per each video. Content in both interventions remained the same. The op-

timized version of the 360° ULE was implemented in the final study.

4.2.1 Level of satisfaction (Article III)

In the final study, the level of student satisfaction was assessed by using Kirkpat-

rick’s (2008) evaluation model (Fig. 1.). The aim was to assess the satisfaction re-

garding the use of the 360° ULE and compare it to the conventional WLE.

Participants

Totally 115 students, in three UASs (n=49/34/32), participated voluntarily in the

experiment and were divided in the experimental, ULE (n=61) and control, WLE

(n=54) groups. 82 % of the participants were women, 18% men, and the average

age was 27 years. Significant differences in the background information between

groups were not revealed.

45

Data collection

The data was collected in years 2015-2016 by using an electronic questionnaire.

The level of satisfaction was assessed in the end of the intervention by using the

data collection instrument developed in this study (Article III). The assessment

measured the level of students´ satisfaction, defined as technological and pedagog-

ical satisfaction, satisfaction with instructions and feedback, perceived enjoyment

and self-motivation assessed by the students (Article III, Table 2.) These factors

were used as sub-scales in data analysis. The assessment included background in-

formation, 25 items (Likert 1-5 scale) and two open-ended questions to determine

positive aspects and the developmental needs of the learning environment (Appen-

dix 1). The internal consistency was evaluated by using Cronbach’s alpha for the

whole instrument, for all subscales, in both groups. (Table 4.). (Article III, Table 2.)

Data analysis

Data was analyzed by using SPSS statistical software version 21 (SPSS, Chicago, IL).

The differences in subscales were examined by using non-parametrical statistical

tests such as Mann-Whitney U-test to determine statistically significant differences

between the groups. The level of statistical significance was set at p-value <.05.

The open-ended questions were analysed by using inductive content analysis (Ar-

ticle III). The analysis was performed in three phases: preparation, organisation and

reporting. In the preparation phase, the raw data was read multiple times and the

findings were compared against the research questions. The analysis unit and for-

malized categories were defined. The sub-categories were formed and organized

under the higher categories. The results were presented as charts and original cita-

tions (Article III, Fig. 5 and Fig. 6).

4.2.2 Changes in histotechnological knowledge (Article IV)

The aim was to assess the changes in HT knowledge within and between the exper-

imental, ULE and control, WLE groups.

Participants

Totally 112 students, in three UASs (n=46/34/32), participated voluntarily and were

divided in the experimental, ULE (n=60) and control, WLE (n=52) groups. 84 %

46

of the participants were women, 16% men, and average age was 28 years. Signifi-

cant differences in the background information between groups were not revealed.

Data collection

The data was collected in years 2015-2016 by using electronic questionnaire. The

level of HT knowledge was assessed by pre- and post-tests with the instrument

developed in this study (Table 4.) (Article IV). The instrument was developed in

iterative cycles with multiple experts as students, lecturers, medical laboratory

technologists, specialists and pathologist. The learning outcomes were defined

based on internal (n=3) and international (n=3) curricula of biomedical laboratory

science (Article IV.) The learning outcomes were defined as follows:

– Histotechnological processes as a part of diagnosis and patient treatment

– Normal cell structure and tissue morphology

– Tissue sampling techniques in theory

– Laboratory processes of histological tissue sample

The instrument was divided in two sections, including knowledge test (n=45 items)

and self-evaluation (n=68 items) (Table 4.) (Article IV, Figure 2, Appendix 2 and

3). Items for the knowledge test (n = 81) were formed by the researcher and criti-

cally evaluated by senior lecturer (n=1), pathologist (n=1), medical laboratory tech-

nologists (n=13), specialists (n=2) and students (n=5). CVI (content validity index)

was computed and items lower than 0.78 (n=36) were excluded from the final in-

strument (Article IV, Fig. 2). The maximum score of knowledge test was set at 60

points. Items for self-evaluation (n = 153) were formed by the researcher and eval-

uated by medical laboratory technologists (n=9) and specialist (n=1). CVI was

computed and 85 items were excluded from the final instrument (Article IV, Fig.2.).

The maximum score of self-evaluation was set at 340 points, HT knowledge total

as 400 points. The internal consistency was evaluated by Cronbach alphas´ for all

subscales in both groups. (Table 4.)

Data analysis

The data was analyzed by using SPSS statistical software version 21 (SPSS, Chicago,

IL.) The differences between groups were examined by using Mann-Whitney U and

Wilcoxon tests. The two-way ANOVA was used to compare the mean differences

between groups and time (pretest vs. posttest) and to understand the interactions

47

between the variables. Differences within the groups were tested by using Wil-

coxon’s test. The level of statistically significant difference was set at p-value

<0.05.

49

5 Results

The development phase answered research questions, RQ1 and RQ2. The results

are reported in detail in the original articles I and II. The evaluation phase answered

research questions RQ3- RQ4 and are reported in the articles III and IV.

5.1 Developmental phase

5.1.1 The criteria for ULE (Article I)

The criteria and reported use of ULE was summarized as a result of the scoping

review (Article 1, Table 1). All reviewed publications defined ULE as a combina-

tion of authentic learning spaces and digital environments, web-based learning

management systems, use of functional objects, sensing technologies and mobile

devices. (Article I, Table 3.) The main criteria were summarized according to flex-

ibility including high accessibility and permanence, context-awareness including

location basis activities and embeddedness, personalized learning content, infor-

mation and feedback, and interactive collaboration with teachers and peers. Flexi-

bility was noted in 7 publications, context-awareness in 6, content personalization

in 7 and interactivity in 3 publications of the publications reviewed (n=7) (Article,

Table 3.). All ULEs were developed for specific use in specific contexts such as

nursing (n=1), language learning (n=2), chemistry (n=1), computing (n=2) and

ecology (n=1). The measured outcomes focused on learning effectiveness in 6 pub-

lications, on cost-effectiveness in 1, on student satisfaction in 2 and on usefulness

in 3 of the reviewed publications (n=7). Custom-made instruments were used in all

studies to measure the outcomes. All included studies were experimental with par-

ticipants as university students or academic staff. The study design used was ex-

perimental with comparisons in all publications. The most used data analysis meth-

ods were quantitative.

All reviewed publications indicated positive effects of ULE and the use was

recommended as supportive for learning efficiency and better performance.

5.1.2 The students´ perceptions on 360° ULE (Article II)

The pilot study assessed student perceptions when the 360° ULE was used and

compared them to perceptions when conventional WLE was used. Students in the

50

ULE group (n=29) assessed the use of LE as highly positive in all measured sub-

scales. The overall mean was 4.3 (Likert 1-5). The highest estimations were given

to personalization (mean 4.5) and context-awareness (mean 4.5). The flexible use

of ULE was assessed lower (mean 4.1), the interactivity subscale as the lowest

(mean 3.9). (Article II, Table 2.)

In the WLE group (n=28) the student perceptions on the use of LE were highly

positive, with an overall mean of 4.4. The highest estimations were given to per-

sonalization, the mean being 4.5, and in context-awareness, with a mean of 4.6,

which were also the highest in the ULE group. The flexible use of WLE was as-

sessed lower, the mean being 4.3, and the interactivity as the lowest, with a mean

of 4.1. (Article II, Table 2.)

The estimations given were higher in almost every subscale in the WLE group

than in the ULE group. At any rate the differences between and among groups were

very small in all subscales. Any statistically significant differences were not ob-

served between the groups.

5.2 Evaluation phase

5.2.1 Level of satisfaction (Article III)

The final study assessed the level of student satisfaction and compared the differ-

ences between the groups in ULE (n=61) and WLE (n=54). The level of satisfaction

was assessed as high in both groups. In the ULE group, the overall mean was 3.8

(Likert 1-5) and in the WLE group 4.0. In the ULE group, the students were most

satisfied with the used technology, the mean being 4.2, and pedagogical methods

that received a mean of 4.0. Lower satisfaction were assessed in enjoyment, mean

3.7, and self-motivation, mean 3.8. The students were most dissatisfied with items

in instructions and feedback subscale, the mean being 3.6 for both. In the WLE

group, students were the most satisfied also with the used technology, with a mean

of 4.1, while the mean for pedagogical methods was 3.9. Also the instructions and

feedback subscale was assessed as high, with a mean of 4.1.

The lowest estimations, in WLE group, were given in the enjoyment subscale

that received a mean of 3.8. (Article III, Table 2.) The differences between groups

were small in every subscale.

51

A statistically significant difference between groups was seen only in the in-

structions and feedback subscale (p>0.001) where the mean was 4.1 in the WLE

group and 3.6 in ULE group. (Article III, Table 2 and Table 3.)

The results from open-ended questions revealed both positive aspects and

developmental needs of ULE. The diverse, re-usable, flexible learning content, per-

sonalized and flexible timetables, and use of the digital learning resources were

noted as positive aspects. In addition, the use of mobile devices and selected appli-

cations were described as relevant. Developmental needs were seen in technologi-

cal usability and in instructions. The responses also revealed the need for more

structured course planning, detailed instructions, general supervision and technical

support. The detailed results are reported in Article III, Fig. 5 and Fig. 6.

Student satisfaction was hypothesized (Hypothesis 1) to be higher in the ex-

perimental group than in the control group. The results did not, however, support

the hypothesis. Satisfaction was on a high level in both groups in all subscales but

not significantly higher in the experimental group in any subscale.

5.2.2 Changes in histotechnological knowledge (Article IV)

The final study assessed the level of the students’ histotechnological (HT)

knowledge at the beginning and at the end of the study term and compared the

differences in HT knowledge between and within the ULE (n=60) and WLE (n=52)

groups. All students within the ULE and WLE groups, scored significantly higher

after the studies than before them (p<0.001) when pre-test and post-tests were used.

The total HT knowledge was assessed as a sum of knowledge test and self-evalua-

tion scores. In the ULE group, the total HT knowledge was 41% higher in the post-

test than in the pre-test, and in the WLE group the scores were 37.5% higher. The

knowledge test scores in the ULE group were 29 % higher and in self-evaluation

43 % higher in the post-test than in the pre-test. In the WLE group, knowledge test

scores were 25% and self-evaluation scores 40% higher in post-test than in the pre-

test. (Article IV, Table 3.)

A statistically significant difference was seen between the ULE and WLE

groups in pre-test scores (p<.001). The ULE group scored 37% of total in the pre-

test and 78% in the post-test. The WLE group scored 40% in the pre-test and 78%

in the post-test. The changes between the pre- and post-tests scores and groups were

statistically significant when pre-test and post-tests scores were compared. Changes

in HT knowledge were significantly higher in the ULE group (p=0.05).

52

Statistically significant two-way interactions were revealed between the time

and groups. The students’ HT knowledge improved significantly more in the ULE

group than in the WLE group in relation to time (p=0.01). (Article IV, Tables 4 and

5.)

The HT knowledge was hypothesized (Hypothesis 2) to be stronger in the ex-

perimental group than in the control group. When the actual post-test scores were

compared between the groups the results did not support the hypothesis. Significant

differences between the groups were not revealed.

It was hypothesized (Hypothesis 3) that there are significant interaction effects

between groups, time and used LEs. The results supported the hypothesis. Students

in the ULE group scored significantly lower in the pre-test than the students in the

WLE group, whilst in the post-test the ULE group scored significantly higher than

the WLE group. The change in actual scores was significantly higher in the ULE

group than in the WLE group. Significant interaction was seen between groups and

time.

5.3 Summary of the results

The aim of this study was to develop a ubiquitous 360° learning environment on

histotechnology (HT) education and evaluate its effects on student satisfaction and

on HT knowledge in biomedical laboratory science degree. Development of 360°

ULE was based on the criteria reported as the main result of the scoping review

(Article I). Criteria such as flexibility, personalization, context-awareness and in-

teractivity were perceived as necessities.

Based on the results, the 360° ULE was produced as a combination of authentic

learning space, omnipresent digital learning resources, functional objects, sensing

technologies and mobile devices. The 360° ULE was implemented and piloted in

the HT context.

The results confirmed the positive perceptions when the 360° ULE was used in

pilot study (Article II). Minor changes were done before the 360° ULE was imple-

mented in the final study for the evaluation.

In the final study, the students in the experimental group were as satisfied with

the use of pedagogical and technological methods as part of the new and innovative

learning environment as the students in the control group (Article III). The HT

knowledge improved significantly in both groups (p<0.001) when the pre-test and

post-test results were compared. Students in the experimental group scored lower

in the pre-test than the students in the control group. In the post-test, the differences

53

had disappeared and the changes in the scores between the groups were statistically

borderline (p=0.05). Significant interactions between group, time and learning re-

sults were revealed (p=0.01) in the experimental group. (Article IV).

The results indicate that the use of ULE may enhance learning with high satis-

faction but is not significantly more effective than conventional WLE. Student sat-

isfaction was in the same level in the control group than in the experimental group

or even higher in the control group. Based on these facts, the developed learning

environment can be used as an effective learning method in the HT context (Fig.

8.) and should be developed further to confirm the results. The importance of sys-

tematic and transparent development and evaluation processes was highlighted as

one of the main results of this study.

Fig. 8. Summary of the results

55

6 Discussion

6.1 Discussion of the main results

The development process was systematic, transparent and based on theoretical and

empirical knowledge (Article I and II). All ULEs found from previous literature

were custom-made for specific purposes and produced in universities without trans-

parent reporting, practical implications or relevant possibility to reimplement (El-

Bishouty et.al. 2007, Peng et.al. 2008, Hwang et.al. 2009, Hwang et.al. 2011, Wu

et.al. 2011, Wu et.al. 2012, Li et.al. 2013).

The produced entity can be stated as effective when compared to the results

from the scoping review (Article I), Pervasive and seamless learning opportunities

were provided and they were flexible with high accessibility. Context-aware and

personalized learning contents were provided and controlled by the user or location.

Interaction between teachers and peers were supported. (Article II.) The results

confirmed that flexibility, personalization and context-awareness were at a relevant

level. Clear objectives, personalized contents, detailed scheduling, information

sharing and context-aware aspects were found as supportive for learning.

The results revealed critical developmental needs in the interaction between

the teacher and students (Article II.) which have been stated as relevant also in the

previous studies. Also the meaning of personalization, interaction and feedback

have been stated as relevant (Johnston et.al. 2005, Zary et.al 2006, Huwendiek et al. 2009, Huang et al. 2012, Fonseca et al. 2015, Tsai et al. 2015). The enhanced

interaction, self-regulated learning situations, and the provision of personalized ser-

vices have been described as undeniable benefits (Hwang et al. 2008, Ogata et al. 2008, Peng et al. 2008). Based on the previous studies the apparent lack of techno-

logical literacy among educators may interfere with the implementation critically.

(Watty et al. 2016, Lewis et al. 2013.) Problems in technical usability may also

cause problems. The resistance to innovation, lack of interest, preference of con-

ventional methods, lack of resources and knowledge of technology have been listed

as key barriers for successful implementation by Senik & Broad (2011). All these

aspects were seen in this study.

The ULE was developed by using a number of experts, technologies, methods

and approaches. The used 360° panorama technique was stated as very interesting

and relevant for educational use. It has been reported as the most interesting method

in current educational development and many companies in Finland and countries

56

worldwide are focused on these technologies in educational use. Thus, the selected

technology for the development can be seen as relevant.

The results showed that the use of the 360° ULE improved the HT knowledge

at the same time with the students' high level of satisfaction (Article III). The in-

crease of HT knowledge was stated as statistically significant in both groups when

the changes in pre-test and post-test scores were compared (p=0.01). The statisti-

cally significant interactions between groups and time were stated in the experi-

mental group (p=0.05). In the pre-test scores, significant differences were seen be-

tween the groups. The students in the ULE group scored significantly lower in the

beginning than the students in the control group. In the post-test, the differences

between the groups were leveled off. The interpretation of the results poses many

challenges based on the non-linear nature of learning influenced by several factors

such as motivation, learning style or underperforming. Based on these facts, the

increased knowledge in the ULE group may have been caused by the bias and lead

to critical misinterpretations. Due to the small sampling size, the results should not

be seen anything more than indicative.

Satisfaction was seen as a relevant quality factor, similar to previous studies

(Navarro et al. 2005, Mai 2005, Douglas et al. 2008). Defining and assessing sat-

isfaction is a multidimensional issue which cannot be unambiguously explained.

In this study, students were eager to use new technologies, enjoying adequate in-

structions, supportive guidance and instant feedback as also stated in Arbauch

(2000) and Sun et al. (2008) studies where instructor feedback and timely response

has influenced significantly on student satisfaction. The high quality of resources

have increased student satisfaction and the use of learning material (Li et al. 2013).

The distribution of versatile learning resources have been recommended in previ-

ous studies (Rodriquez et al. 2014) and the knowledge gaining has stated easier

when a wide range of learning resources were provided. Therefore, the content pro-

duction was versatile also in this study.

Although the students were highly satisfied with studying via the 360° ULE,

the students were more satisfied when conventional WLE was used. The results

might be explained by the increased cognitive load when new methods were used.

In fact, significant interactions between increased cognitive load and use of new

technologies have been reported in previous studies (Hwang et al. 2011, Wu et al. 2012).

When studying in digital environments rather than in conventional ones, more

activity from the students’ part has been stated (Owston et al. 2013). The lack of

57

proper technological skills or resources may also slow down and interfere the learn-

ing processes. Also the lack of adequate information has been seen as a negative

factor for learning effectiveness (Wu et al. 2012.)

6.2 Ethical considerations

This research was carried out according to the ethical guidelines and good scientific

practices (Polit & Beck 2016, TENK 2012). The ethical values considered were

privacy, anonymity, confidentiality, self-determination and fair treatment (Burns &

Grove 2005). All experiments were carried out with the permission of the directors

of the universities.

Students participated voluntarily and participation was confirmed by informed

consent. The students were informed about the research objectives, contents, meth-

ods of data collection, analysing and reporting. In addition, students were informed

about the course evaluation. They were also told that they can withdraw from the

study at any time. The anonymity of individuals was ensured by using the student

ID numbers. Names were not used at any phase. The identification of the individ-

uals was not possible at any time. The collected data was treated and stored confi-

dentially and password-protected. The data was analysed with the student ID num-

bers and the identification of individuals was not reported. After the final report,

the raw data will be stored for five years before disclosure. All publications in-

cluded in this study were published as original studies. Any conflicts of interest

have been disclosed between the authors. The permission of republication of the

original studies, as part of this summary, has been obtained.

6.3 Validity and reliability

The study was designed carefully to ensure the validity and reliability of the results.

All original publications included are peer-reviewed by the international scientific

committees and published without conflict of interest by the authors. The validity

and reliability issues are discussed in detail in this chapter. More detailed validity

and reliability interpretations can be found in the original publications, articles I-

IV.

58

Developmental phase

The scoping review method was selected for the literature review. The method was

suitable for scoping and summarizing the existing literature from the area not well

known and in the area where the number of publications was limited. The literature

searches were carried out systematically through predefined search criteria and

search terms. The phenomena of ubiquitous learning and learning environment

were included in the scope due to flexible possibilities to combine authentic learn-

ing space with digital resources, functional objects, sensing technologies and mo-

bile devices. The m-learning environments were excluded based on the desire to

study the phenomenon more broadly than from the view of utilized mobile devices

or other implemented technologies.

In the systematical literature searches, no 360° implementations in the field of

education were found. The searches were carried out with the aid of informatics of

the medical library. Multiple international databases were used and the manual

searches were done to obtain the most comprehensive search results. The relevance

of the literature search process was stated as high. The gray literature was thor-

oughly searched but not included into the final review. Due to the very limited

number of relevant references, the focus was set on high quality original publica-

tions. (Arksey & O'malley 2005.) The quality was evaluated by using Joanna

Briggs Institute’s protocol for the scoping reviews (JBI 2015). The study with low

quality score (>50%) were excluded (n=1) from the final review. The data analysis

process was carried out by two researchers independently to reduce bias. Data ex-

traction, preparation, condensation, and reporting were made by the researchers and

verified with the research group. The reporting followed systematically the

PRISMA framework (Moher et al. 2009). The systematically conducted review

process ensured the high reliability of the scoping review results. Although the

method used was regarded as very reliable, a few limitations were pointed out. The

most relevant limitation in the scoping review was the number of eligible studies

included, reported by the three sets of authors in two countries. The heterogeneity

of the selected publications may interfere with the interpretations and cause a bias

in the results. The not well-defined terminology of the ULE may hide relevant pub-

lications under other terms such as mobile or augmented learning. These terms were

not searched, reviewed or analyzed systematically but were unofficially searched

thoroughly during 2013-2017. Any publications describing the same kind of study

design as in this doctoral study were not found during these years. Because of the

delayed publication process systematical searches with the original search terms

59

were repeated in 2017. The search results did not differ significantly from the re-

sults in 2013 and thus no changes on the review were made. Although the sampling

of the scoping review was modest and the number of eligible publications low, does

not cause significant harm for the learning environment development or interfere

significantly with the interpretation of the results.

The used 360° technology can be seen as a limitation in this study. The method

was selected based on the researcher’s vision and on the simple, fast and cost-ef-

fective development process simulating real world learning situations as well as

possible, managed by the educators. These requirements led to the decision that the

possibilities of augmented or virtual reality methods were not systemically evalu-

ated. Other relevant methods that educators could quickly and easily produce and

implement were not found during the years of research. This is why the develop-

ment of virtual worlds or virtual simulations were not in the scope at any phase.

Moreover, the virtual world development was seen as very time-consuming and

costly, and the researcher or the research group did not have the necessary skills

required for the development. The aim of this development process was to provide

a low-threshold method for the educators to implement 360° ULE easily in any

educational context in higher education. For that purpose, the used method was

stated as appropriate. For the same reason, the game-based learning environments

(GLE) were not included. The development of GLE requires much more

knowledge than the health science educators can be expected to have. The purpose

was to develop versatile LE combining authentic learning spaces with flexible, in-

teractive and context-aware digital environment, not to develop a GLE.

The context, content and the entity of 360° ULE were developed by the re-

searcher also an expert of the HT and were confirmed by the research group. The

dominant role of the researcher in development process can be seen as a limitation

and might lead on misinterpretations. The researcher did not have a particular rea-

son to emphasize the meaningfulness of the chosen 360° technology and she does

not gain any economic benefits of the development process.

The study design was selected based on the used teaching methods. Study de-

signs comparing ubiquitous and conventional methods have not been widely pub-

lished (Aljohani et al. 2012). The conventional WLE was used as a control group.

The intention was to refresh the web-based learning methods using the 360° ULE,

not to replace widely used conventional, lecture-based methods. The purpose was

not to replace conventional lecture based teaching methods as students seem to be

quite satisfied with the use of conventional methods. The need for teacher-centered

60

lectures is still present but can be evolved with innovative and ubiquitous possibil-

ities. The web-based self-directed learning activities have become dominant in

many UASs. This was the main reason for the use of WLE in the control group.

Additionally the selection was based on the fact that the researcher has used con-

ventional web-based LEs and methods for years.

Evaluation phase

A non-randomized quasi-experimental study design was selected as a method for

the pilot and the final study. The method has been widely used in health science

education (Campbell et al. 1966, Fraser et al. 2011). The study design was used

without the randomization of individuals, whole groups were enrolled into experi-

mental or control groups by the semester. The division was done to avoid any ex-

periences of inadequacy by the students, and to reduce the possible bias between

the groups if the LEs had been used alongside each other. Randomization is recom-

mended to reduce the bias caused by the researcher, participant, instrument, data

collection or analyzation (Schulz & Grimes 2006).

The researcher carried out all experiments, data collections and analyses with

the aid of the research group and the specialists to reduce potential bias and misun-

derstandings. The role of the researcher was as an educator and researcher without

seeing a major contradiction between the roles. The students in any participating

university were not familiar with the researcher beforehand.

The number of participants was seen as a major limitation of this study and

may cause bias toward results and interpretations. The number of participants was

limited to the number of students in the degree programs of biomedical laboratory

science in Finland. Due to the small number of possible participants, the final study

was conducted in three UASs, between the years 2015 and 2016, to reach a proper

sample size, representing the whole population as well as possible. Another option

for proper sampling would have been to prolong the data collecting time, which

was considered effective. Data collection would have been easier in any other field

of health science, where the number of students is considerably higher e.g. nursing,

than in biomedical laboratory science. This option was not considered viable as the

researcher's strongest competence was in the field of histotechnology and thus the

development, production and implementation would have been impossible in any

other contexts.

The unique practices of each UAS were seen as a limitation. Local practices,

knowledge, skills, attitudes, motivation and previous level of technology may have

61

differed between UASs and may have interfered the results. The differences be-

tween universities were evaluated by the experts, following good scientific prac-

tices. No significant differences between the UASs were observed in the curricula,

learning objectives or contents. However, the sample size represented the study

population moderately and thus the results can be stated as indicative. To strengthen

the results it is recommended to repeat the study with a larger population in one

UAS.

The instrument development formed a large part of this research. Several ex-

perts such as students, senior lecturers, principal lecturers, biomedical laboratory

technologists and pathologists assisted the researcher in the instrument develop-

ment. The background for all instruments was systematically formed by previous

literature. The reliability and validity of all instruments were evaluated by using

multiple statistical methods. The construct validity was evaluated by using explor-

atory factor analysis, and reliability by using Cronbach’s alpha to measure internal

consistency. In all instruments, the alphas were between 0.61 and 0.99. (Table 4).

Almost all alphas were in the accepted level when the criteria was set on 0.70 (Con-

nelly 2011, Tavakol & Dennick 2011.) Two alphas were lower than 0.70 (0.61 and

0.64) but did not critically affect the final results. Content validity was assessed by

calculating the content validity index, CVI. The CVI was based on expert ratings

of item relevance and the items lower than 0.78 were excluded. (Polit et al. 2007.)

Content and construct validity as well as internal consistency were assessed in all

instruments. All data collection instruments were developed in this study and were

used the first time. This was seen as a limitation. However, the validity and relia-

bility of the instruments were assessed as high. The first time use may cause a bias

in the results.

All used instruments were questionnaires. The assessment of perceptions, sat-

isfaction and knowledge were based on scores. More objective research methods

such as interviews or observations were not used which can be seen as a limitation.

The observations or interviews were not used. As the researcher conducted the

learning environment development, content production, quasi-experimental inter-

ventions, data collection and analyzing in three UASs during the years 2014-2016,

observation activities were not reasonably well included. The observation would

have taken an unreasonable amount of time as 172 students in total participated in

the study in different phases. To ensure objective assessment, open questions and

self-assessments were used. To gain a broader perspective on the research area

more objective research methods should have been utilized.

62

The data collection and analysis were made by the researcher with experts and

were confirmed by the research group to reduce bias. Nonparametric, statistical

tests were used to determine the main effects of independent variables, differences

between and among the groups and interactions between independent and depend-

ent variables. The data analysis methods were versatile and the method selection

was carried out by the researcher and verified by the research group. Due to the

large scale of the used methods, the validity and reliability of the pilot and final

study were considered high.

As a conclusion, the research target was seen as challenging. Firstly, existing

research in the context of the study was very limited. Secondly, previous use of

ULE in higher education and HT context was nonexistent. Thirdly, the selected 360°

technology had not been utilized previously in educational use. Finally, the phe-

nomenon of ubiquitous learning or the concept of ULEs were not widely known.

6.4 Contributions and practical implications

This study highlighted the unique entity of 360° ULE in educational use. It demon-

strated the slowly increasing popularity of ULEs in higher education. The system-

atic process provided a logical framework for the development and evaluation and

generated new scientific knowledge to support educators in the future. The study

provided insight into technological constructs and key factors of effective learning

environments, and provided a concrete example.

For students the 360° ULE offered flexible opportunities to study and learn in

real-life learning situations digitally, regardless of time and space. Students in-

creased their histotechnological knowledge in an easy-to-use environment with

high motivation and satisfaction. The feedback from students was encouraging and

should lead to continuous development and use in the future. For educators, it offers

new perspectives on pedagogical development.

For the health care organizations, the use of 360° ULE may offer talented stu-

dents in the future. Real-life learning situations may be used to support student’s

orientation in their work placements. The 360° ULE can be implemented in work-

life environments and effect on coaching patterns of work life in the future.

For the society, the use of ubiquitous learning environments may provide ef-

fective and flexible possibilities to rearrange and widen the higher education. Re-

duced resources can be targeted more accurately by using novel methods to support

learning activities. Globally, the development of ULEs can support education ex-

port and build up new clusters of knowledge in higher education development. The

63

use of ULE rearranges learning environments and provides positive learning expe-

riences and performance with almost equal student satisfaction compared to con-

ventional methods.

Although the research was performed in the HT context it is recommended to

implement 360° ULEs also in other contexts in higher education. Based on the re-

sults of this study, the 360° ULE has already been implemented in degree programs

of radiography, oral health and midwifery in Helsinki Metropolia UAS. The imple-

mentations have been made by following the development process of this study.

65

7 Conclusions

This section provides conclusions for this dissertation with detailed

recommendations based on the results. In addition, it offers recommendations for

future studies. Below is a list of the most important findings and observations of

this study:

1. The criteria for ULE were summarized as flexibility, context-awareness, per-

sonalization and interactivity

2. The relevant components of ULE are the following: authentic learning space,

omnipresent digital learning resources, functional objects, sensing technolo-

gies, mobile devices and wireless networks.

3. The 360° ULE showed its pedagogical potential and significant benefits for

students. It can be used as supportive for learning, and results as indicative for

future development.

4. Student satisfaction with the use of 360° ULE was at a high level.

5. The use of 360° ULE may enhance learning and increase students’ HT

knowledge.

6. The process was described transparently to guide educators in learning envi-

ronment development. The study offers a practical example on successful im-

plementation.

Based on these observations and findings, the following subsection sums up the

most important recommendations.

7.1 Recommendations

The conclusions form a basis to six recommendations of which four require action

and two refraining from action. Based on the results I recommend

1. that conventional WLEs based on information sharing will be transformed to

flexible, personalized, interactive and context-aware ULEs in the future.

2. that the developed 360° ULE will be adopted permanently in HT curricula to

provide supportive, effective and diverse learning experiences.

3. further studies to strengthen the results including larger study populations in

the HT and other health science contexts.

4. further development and optimization of ULE to ensure the interaction, includ-

ing feedback and instructions, between teacher, students and peers.

66

Based on the results, I do not recommend

1. total replacement of conventional methods.

2. any rearrangements in practical training or hands-on activities.

7.2 Future studies

The developed 360° ULE showed its pedagogical and technical potential with sig-

nificant benefits for the students, teachers and educational organisations. Thus, fur-

ther studies and development should be encouraged as follows. The future studies

should validate the developed instruments in a larger study population in HT con-

texts. The study should be replicated to ensure the results and to increase credibility.

Interactivity between teachers, peers and students should be supported more care-

fully by using cloud based tools, social media and other relevant approaches.

Implementation in other health science contexts is recommended in the future.

The developed 360° ULE can be utilized in any educational context in any level of

education from elementary to continuous education. The pedagogical benefits can

be ensured in various contexts by following the development process described in

this study.

Further studies will be needed also to ensure national and international gener-

alization. After validation, the developed 360° ULE can be implemented in the in-

ternal and international curricula in the histotechnology context.

The most interesting aspect in future studies relates to the utilization of the 360°

ULE in a histotechnology laboratory as a part of real life processes where the learn-

ing transfer can be supported.

From the technical view, the development should be expanded with augmented

reality learning and game-based activities. The utilization of functional objects and

sensing technologies should be supported more systematically. The future studies

may focus on the use of RFID tags and Bluetooth options to support more seamless

interaction between the students, learning resources and authentic learning space.

7.3 Closing words

Conducting a doctoral thesis successfully in five years at the same time while pur-

suing a challenging career and living out active family life was a demanding task,

but one that will hopefully inspire colleagues and co-workers in educational and

academic institutions, companies and health care, in many ways.

67

This study project has relevance for the different stakeholders when changing

conventional teaching and learning processes towards innovative, flexible, person-

alized, context-aware and interactive learning experiences with high satisfaction

and effectiveness.

To sum up, the doctoral thesis was a turning point in my career as an educator

and pedagogical expert. This process aspires to encourage educators worldwide to

evaluate their own operations in relation to present possibilities.

69

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Appendices

Appendix 1. Data collection instrument for assessing the level of students´ satis-

faction

Instructions and feedback (Likert 1-5) LE was technically easy to use The learning material was clear The learning material was interesting The learning material was supportive The instructions were clear The role of teacher was supportive The use of LE was supportive Pedagogical methods The methods used allowed deep understanding The methods used provided challenges The methods used gained learning The assignments used supported learning The contents were practical Multiple teaching methods were used Technological methods The used methods were innovative The used methods were up-to-date The used devices were supportive Perceived enjoyment Satisfaction with implementation Satisfaction with studies in general Expectations fulfilled LE was useful LE eased my studying Use of LE suggested to other courses Self-motivation LE motivated learning I was actively responsible of my studies Interest towards occupation increased

Open-ended questions

80

The positive effects of used ULE The developmental needs of used ULE

81

Appendix 2. The knowledge test for histotechnology

Individual items in Finnish, not translated in English at any phase. Pathological basis of diseases Bronkoskopia on.. (multiple choice)

Ihon koepaloissa marginaali on merkityksellinen. (true-false)

Ihonäytteitä merkitään lankamerkeillä.. (multiple choice)

Ihon koepalan ei tarvitse yltää ihonalaiseen rasvakudokseen, ollakseen edustava.

(true-false)

Karkeaneulanäytteitä ei voi ottaa sisäelimistä (maksa, perna, haima, munuainen).

(true-false)

Rinnasta voidaan ottaa.. (multiple choice)

Rinnan muutosten diagnosointiin suositellaan karkeaneulanäytettä. (true-false)

Rinnan ohutneulanäyte soveltuu.. (multiple choice)

Mastektomia tarkoittaa.. (multiple choice)

Leikkauspreparaatit.. (multiple choice)

Histotechnological processes Kudosnäytteen prosessi kestää nopeimmillaan 2-3 päivää? (true-false)

Pikatutkimuksena (jääleike) tehtävällä näytteellä diagnoosi saadaan puolessa tun-

nissa? (true-false)

Pikatutkimuksen indikaationa on.. (multiple choice)

Histologinen diagnoosi perustuu valomikroskopiaan? (true-false)

Histologisen kudostutkimuksen indikaatiot ovat.. (multiple choice)

Negatiivinen löydös poissulkee pahanlaatuisen löydöksen mahdollisuuden? (true-

false)

Benigni muutos ja sen diagnosointi pois sulkee malignin muutoksen mahdollisuu-

den? (true-false)

Normal cell and tissue Mikä kudos? n=6 (image + multiple choice)

Mikä rakenne? n=2 (image + multiple choice)

Mikä värjäys? n=2 (image + multiple choice)

Hematoksyliini toimii sytoplasmavärinä (true-false)

Eosiini toimii sidekudosvärinä (true-false)

AB-PAS värjäystä käytetään.. (multiple choice)

82

Laboratory processes Fiksatiivin tarkoitus on.. (multiple choice) Formaliinifiksaatiota voidaan nopeuttaa viileässä. (true-false)

Patologi makroleikkelee.. (multiple choice)

Bioanalyytikko makroleikkelee keskisuuria preparaatteja. (true-false)

Näytteiden käyntiinpanossa on tärkeää.. (multiple choice)

Kudosprosessoinnin tarkoituksena on.. (multiple choice)

Valun tarkoituksena on.. (multiple choice)

Mikrotomilla kudosleikettä leikattaessa on tärkeää, että.. (multiple choice)

Kudosleikkeiden parafiini poistetaan ennen kudoksen värjäystä. (true-false)

HE-värjäys on kolmen värin värjäysmenetelmä. (true-false)

vanGieson-värjäys toimii.. (multiple choice)

Giemsa-värjäystä käytetään helikobakteerin osoittamiseen. (true-false)

Formaldehydi ei ole karsinogeeni. (true-false)

83

Appendix 3. The self-evaluation instrument for histotechnological knowledge Pathological basis of diseases (n = 18) Histotechnological processes as a part of diagnosis, incl. tissue sampling (n = 8) Normal cell and tissue morphology (n = 23) Laboratory processes for histological sampling (n = 19)

Individual items in Finnish, not translated in English at any phase.

1. perustella histologian merkityksen potilaan kokonaishoidossa

2. histologian merkityksen tautien diagnostiikassa

3. nimetä eri näytetyypit

4. selittää näytteenottomenetelmät

5. ymmärtää näytteenottomenetelmien merkityksen laboratorioprosessille

6. selittää histologisen kudosnäytteen vaihe vaiheelta

7. fiksaation periaatteet ja merkityksen

8. selittää dissektion ja näytteiden käynnistämisen teoriassa

9. kuvata kudosnäytteen lähetteeseen

10. tunnistaa dissekoinnin virhelähteitä

11. tarkastella näytteen makroskooppisesti (teoriassa)

12. kudosprosessoinnin periaatteet

13. ymmärrän kudosprosessoinnin merkityksen näytteelle

14. ymmärrän valun merkityksen

15. tunnistaa valussa tapahtuvia virheitä

16. arvioida valun laatua

17. selittää eri mikrotomien toimintaperiaatteet

18. arvioida leikkeiden laatua

19. tunnistaa leikkaamiseen liittyviä virhelähteitä

20. HE- värjäyksen periaatteen

21. tunnistan osoitusvärjäysten käyttötarkoituksen valinnan periaatteet

22. PAS-värjäyksen periaatteen

23. AB-PAS värjäyksen periaatteen

24. arvioida HE- värjäyksen laadun mikroskoopissa

25. arvioida PAS- värjäyksen laadun mikroskoopissa

26. arvioida HE- värjäyksen ladun mikroskoopissa

27. arvioida AB-PAS- värjäyksen laadun mikroskoopissa

28. immunohistokemian merkityksen diagnoosissa

29. pika-/jääleikkeiden merkityksen diagnoosissa

84

30. ymmärrän histologian merkityksen obduktion osana

31. ymmärrän työturvallisuuden merkityksen yksityiskohtaisesti prosessin eri vai-

heissa

32. sisäisen laadunarvioinnin periaatteet

33. ulkoisten laadunarviointikierrosten merkityksen

34. tunnistan työturvallisuusriskejä

35. tunnistan mikroskoopissa maksan, histologisen näkymän perusteella

36. tunnistan mikroskoopissa munuaisen, histologisen näkymän perusteella

37. tunnistan mikroskoopissa sydämen, histologisen näkymän perusteella

38. tunnistan mikroskoopissa keuhkon, histologisen näkymän perusteella

39. tunnistan mikroskoopissa ihon, histologisen näkymän perusteella

40. tunnistan mikroskoopissa ruoanasulatuskanavan epiteelin, histologisen näky-

män perusteella

41. tunnistan mikroskoopissa HE-värjäyksen

42. tunnistan mikroskoopissa PAS-värjäyksen

43. tunnistan mikroskoopissa vG/Herovici värjäyksen

44. tunnistan mikroskooppisesti levyepiteelin

45. tunnistan mikroskooppisesti rauhasepiteelin

46. tunnistan mikroskooppisesti sidekudoksen

47. tunnistan mikroskooppisesti rasvan

48. tunnistan mikroskoopisesti ruston

49. tunnistan mikroskooppisesti laskimon

50. tunnistan mikroskooppisesti valtimon

51. verenkierron anatomian ja fysiologian

52. verenkierron häiriöiden mekanismit

53. tulehdusten aiheuttamat reaktiot teoriassa

54. solun sisäiset kertymät teoriassa

55. solun sopeutumismekanismit

56. solujen vaurioitumisen mekanismit

57. solujen kuoleman mekanismit

58. paranemisen mekanismit

59. kasvaintautien ominaispiirteet

60. karsinogeneesi

61. kasvainten nimeämisen periaatteet

62. elimistön kudos- ja solutyypit

63. sydämen rakenteen ja toiminnan

64. hengitysteiden rakenteen ja tominnan

85

65. ruoansulatuskanavan rakenteen ja toiminnan

66. maksan rakenteen ja toiminnan

67. munuaisen rakenteen ja toiminnan

68. ihon rakenteen ja toiminnan

87

Original publications

I Virtanen M, Haavisto E, Liikanen E & Kääriäinen M (2017) Ubiquitous learning envi-ronments in higher education: A scoping literature review. Education and Information

Technologies, 23(2), 985-998. DOI: 10.1007/s10639-017-9646-6 II Virtanen M, Haavisto E, Liikanen E & Kääriäinen M (2018) Students´ perceptions on

the use of ubiquitous 360° learning environment in histotechnology: A pilot study. Jour-nal of Histotechnology. DOI10.1080/01478885.2018.1439680

III Virtanen M, Kääriäinen M, Liikanen E & Haavisto E (2017) The comparison of stu-dents’ satisfaction between ubiquitous and web-based learning environments in clini-cal histotechnology. Education and Information Technologies. DOI:10.1007/s10639-016-9561-2

IV Virtanen M, Kääriäinen M, Liikanen E& Haavisto E (2017) Use of ubiquitous 360° learning environment enhances students´ knowledge in clinical histotechnology: a quasi-experimental study. Medical Science Educator. DOI: 10.1007/s40670-017-0429-x

Reprinted with permission from Springer International Publishing AG (article I, III

and IV) and Taylor and Francis (article II).

Original publications are not included in the electronic version of the dissertation.


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