Running head: TRANSFORMED LEARNING VIA MOTIVATIONAL DUAL-CODING

Transformed Learning via Motivational Dual-Coding in a Graduate Nursing Course

Kevin Tressler

James Madison University

Transformed Learning via Motivational Dual-Coding in a Graduate Nursing Course

Instructional Focus

Transforming a learning environment presents various challenges on multiple levels. In

the process from conception to implementation, instructors and instructional designers are not

only striving to transform the mode of delivery for one course, but also working to shift the

broader culture of learning that is in place. Long-held teaching practices create a standard of

expectation for learners. Many times, this expectation includes active lecture by the instructor

and passive attentiveness by the learner. The teaching practices of the graduate-level nursing

professors in my school vary, but the majority follow the didactic strategies used on them while

they were students – lecture and exam in class with hands-on in lab or clinical placement. While

this teaching practice has a necessary place, it should not be the only learning experience

provided for students. The professor I am working with attempted to make active learning

changes to this course last year and was met with critical opposition from students. She believes

strongly in the flipped learning design and hopes to make this course an exemplar of the power

of active student engagement without a weekly lecture in graduate nursing studies. According to

Tucker (2012), a flipped course attempts to make the class a place “to work through problems,

advance concepts, and engage in collaborative learning” and to “maximize the scarcest learning

resource – time” (p. 82). As a result, my instructional focus is the support of successful

instructional shift of Advanced Health Assessment from expected traditional lecture delivery to a

flipped, hybrid environment. I have been working with the course professor throughout the

semester to implement instructional changes using theories proposed by Deci and Ryan and

Paivio as frameworks for design.

We evaluated the course standards and strategies in place from the last two instances of

the course offering, looking for ways to advance an active learning environment with technology

integration for both in-class and out-of-class experiences. The class meets weekly in person for

the didactic portion, along with the required lab for skills practice and assessment. The

instructional changes for the didactic moments are in the initial implementation phase as this is a

recurring course with the next iteration taking place this summer. Our flipped model consists of a

recorded lecture and review exercise to be completed prior to the weekly class meeting. Weekly

class meetings consist of the professor providing instruction based on the formative assessment

exercise completed by students to open, a time for questions and further instruction as needed,

and group case studies for practice of health history taking and diagnosis.

Applied Learning Theories

Self-determination theory (SDT)

Motivation is a critical aspect in learning. Deci and Ryan propose the construct of self-

determination theory in looking at the way intrinsic motivation influences individuals (1985).

The three critical aspects of SDT identified to create success for students are autonomy,

competence, and relatedness (Niemiec & Ryan, 2009). A student’s willing devotion to study and

preparation for class is a form and example of autonomy. The instructor becomes a facilitator

who provides an effective learning environment while not imposing control factors into the

learning experience. As students devote their time and energy to study, they must also feel a

level of competence. Competence within the SDT framework refers to a student’s belief that

he/she is able to meet the challenges and requirements of the classwork. Designing assessments,

both formative and summative, must be done with the learner in mind. If a student does not

believe success is possible, competence is not attainable. Niemiec and Ryan conclude that
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without both feelings of autonomy and competence in place, students will not be able to succeed

within the learning environment (2009).

Relatedness stands as the third critical aspect of SDT. Within the theory, relatedness

expresses the desire for students to feel a connection to other students, the instructor, and/or the

contexts in which they are learning. Students who feel feelings of connectedness rather than

disconnection are more likely to internalize the values and practice of the class or course (2009).

Building community is paramount for relatedness to assume a significant component within a

learning environment. Even in contexts where material is imposed as required, the ability of the

teacher/facilitator to provide avenues of connection can expand intrinsic motivation for students

to want to continue or complete their learning. SDT establishes the imperative that learning

environments should offer autonomy, competence, and relatedness if intrinsic motivation to learn

content is going to take place.

Strengths of SDT. Self-determination theory offers a usable framework for designing

learning experiences across all age groups, with particular strength for adult learners. Many adult

learners take courses to achieve a goal selected and chosen without external impetus. In some

cases, an employer may impose continuing education requirements for employees, but it is still

the choice of the adult learner to complete the course. Adults function from a place of autonomy

in most instances. Daily choices are made concerning time allotment, energy expenditure, and

attentive engagement. For younger learners, experiencing autonomy within a learning

environment can help develop strategies for planned management of time and energy to meet

goals. Navigating personal choice in a way to maximize achievement can increase self-

awareness and competence.

Another strength of SDT is the significance of relatedness for each learner. Relationships

between students, the students and the professor, and the students and the content are all included

within relatedness (Niemiec & Ryan, 2009). Community identity and belonging fulfills a need

for learners, one in which a safe learning environment can develop. Minimizing risk within the

social aspects removes barriers and situations students to engage with content more easily.

Equally significant to social dynamics is the way that students relate to real-world, meaningful

content. Material that is disconnected from the learner’s reality can drastically decrease

motivation, and in turn, decrease learning. Understanding relatedness allows instructional

designers such as myself to be mindful of community and authenticity. Structuring learning

experiences within a relatedness perspective are minimal steps that can lead to maximum impact.

Weaknesses of SDT. A limiting weakness of SDT is the fact that almost all

environments of learning have external impositions in place. For SDT to have the most benefit,

external control influences should be removed. The environments in preK through graduate

studies dictate requirements for success, whether that be a basic review of letters or a dissertation

defense. Autonomy, as defined by SDT, is not able to be fully realized due to the constraints.

Instances of autonomy may still appear within these constraints, but the less personal choice

available, the less effective the learning. As a result, adult-learner environments seem to benefit

the most from SDT application. Personal choice has driven the majority of adult learners into

further study. Peer-to-peer and student-to-instructor relational skills are also more advanced and

developed, expanding the effectiveness of relatedness. Younger learners are developing identity

at the same time as knowledge. Navigating relationship may tend to overshadow learning for

adolescent students. Confidence levels (competency) connect more to peer response than

reflection as a learner for younger students as well. The ability to self-assess and self-reflect may
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still be a skill that has not been introduced. Therefore, adult learners are more likely to have the

psychological capacity for autonomy, competency, and relatedness to be realized.

SDT’s individualistic approach is a strength but also a weakness. It is unrealistic to

conceive that an instructor could design a learning environment to provide autonomy,

competence, and relatedness to every learner in a class. Learning scaffolds may provide a

foundation for competence, but social dynamics within a class may prevent learners from feeling

a connection. Personality often dictates the manner in which social interactions take place.

Relatedness falters when an individual disconnects from peers or the instructor, causing a

faltering in the SDT framework. Culture furthers the wrinkles of relatedness by requiring applied

diversity awareness in the design. Worldview influential factors (racial, religious, national, etc.)

fold into learners in a manner that moves beyond design allowances. While SDT provides a

framework to design from, it lacks the fullness to encompass all potential needs.

Dual-coding theory

According to Clark and Paivio (1991), dual-coding theory examines the “associative

networks of verbal and imaginal representations, and the…development and activation of those

structures” (p. 151). A positive correlation can be found between two-fold information

presentation and long-term retention. Linguistic modes such as text and oral delivery convey

meaning but rely upon the receiver to properly interpret the language. Well-planned and well-

designed visual representations of concepts couple with linguistic formations to create a more

complete presentation of information. Dual-coding works in a reciprocal manner through

referential connections (1991). Some information is best delivered as a visual representation first,

followed by the linguistic nomenclature to follow. For instance, complex scientific content such

as cells may not be best understood with verbal descriptions being delivered first. Learners who
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are new to the concept have no reference to what the tiny formations within a cell resemble other

than shapes, which are by nature visual constructs. Stating that the nucleus is a circle requires the

receiver to have a visual of “circleness” existing in their mind already. Presenting the visual

representation of a cell in combination with the textual identifiers allows the learner to engage

content with both components working together. Similarly, some information can be delivered as

linguistic representations first, followed by the visual representation. Learners are not at a

disadvantage when the initial content delivery is linguistically not dependent upon a visual

referent. Even though this may be minimally effective, dual-coding theory emphasizes the

significant of the power in dual representation.

Strengths of Dual-coding theory. Interpreting a concept, idea, or object is a subjective

process. The receiving individual will base interpretation on prior knowledge or experience.

Words alone activate both simple and complex neurological connections with some leading away

from an objective ability to separate the emotional response from the cognitive response. Applied

dual-coding theory can eliminate moments such as this through the concrete visual representation

that pairs with the language presented. The variance of responses may lead to confusion within

the group as well as each individual learner. Including multiple visual representations of the idea

further guarantees the concept is internalized correctly across the student population. Isolating

language or visuals weakens content delivery and as a result, learning falters due to subjective

response and interpretation.

Another strength of dual-coding theory is the clarity with which information can be

delivered. Ferdinand de Saussure’s 1916 lecture Course in General Linguistics (2011)

demonstrated the subjective nature inherent in language through the relationship of the sign,

signifier, and signified. A word as simple as apple ignites any variety of apples in the receiver’s
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mind. One may imagine a red delicious apple hanging from a tree while another thinks of the

Apple computer company and their iPhone. The more associations the receiving individual has

with a word, the more complex the network becomes within the mind. Love, for instance, may

invoke emotions that connect to an event or an individual, along with the names and faces of that

person. Dual-coding theory can help eliminate these free associations and lessen the clarity that

language alone has to supply through extended context. Pairing the word apple with an image of

a red delicious apple leaves no room for the imagining of the Cupertino company.

Visual learning via tools like mind-mapping move the strength of dual-coding theory

from instructional delivery to learner representation of conceptual understanding. A concept map

engages the linguistic and visual in a tightly woven platform. Often times, words are embedded

into color-coded shapes that are grouped by branching theme. Branching themes bridge together

through strategically placed connecting lines which may or may not also include words

themselves. Abstract, complex ideas are broken down into strands of more accessible pieces

through this type of dual coding.

Weaknesses of dual-coding theory. Some concepts do not offer means of representing

themselves through dual-coded representations. Just as a concept map can help break down

abstract concepts, so the same abstract concepts may be difficult to effectively dually code.

Complex language suggests an equally if not more complex visual representation. An idea such

as compassionate care can look and be expressed in multiple ways, but no one visual

representation will capture compassionate care.

Implementing Frameworks

Part of the challenge in delivering a flipped classroom is developing a design which

offers the environment for activating intrinsic motivation. Traditional lecture-based classes allow
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for more passivity by students. Knowing that content will be delivered in-person eliminates

autonomy, a critical component identified in the SDT framework. Learners know the one choice

available is to sit in a seat and listen to the instructor teach. Lecture-heavy learning experiences

also leave little time for students to show competence of understanding, whether through self-

reflection or instructor feedback. Relatedness, the third critical component of the SDT

framework, suffers in all facets as student connections to each other and the professor are limited

to before or after class. Disconnection from the content can also result in lecture-only courses

because students do not have the time to discover personal touchpoints. Lynch, Salikhova, and

Salikhova (2018) found that university supports that address autonomy, competence, and

relatedness were “significant contributors to students’ internal motivation for scholarly and

academic activity” (p. 256). According to this finding, if our course redesign is effective,

students will have advanced success in their nurse practitioner courses.

Since the majority of the course content will be delivered via video lecture, dual-coding

representations take on a higher-level of importance. Designing a video lecture around health

assessment must include effective visuals of both the physical body system (thorax, HEENT,

etc.) and the proper tool and technique positioning for the examination. In-person lectures also

benefit from effective visuals, but an instructor could choose to demonstrate proper and improper

techniques while lecturing. Additional resources must also be evaluated for significant effective

dual-coded representations. Consistency across the course materials enhances the potential for

long-term student retention and appropriate application.

Performance Standards

The performance standards for this course reflect the nature of health assessment skills

that nurse practitioner students need to be successful in the clinical setting. All students in the
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course are expected to have a working knowledge of body systems and be able to effectively

demonstrate the standard skills for nursing. A total of six performance standards are in the course

listing. I chose two of the six standards that the transformation of content delivery will impact

the most. These also reflect the two most significant standards in the final assessment for the

course leading towards a licensing exam for all students within the nurse practitioner program.

Standard 1: Elicit a comprehensive health history from individuals of various

developmental levels and diverse groups. For many of the students in the course, eliciting

patient health history is a new skill to acquire. The experiences they have had as nurses are, for

the most part, in supporting roles. Transitioning to the provider role not only requires attaining

new knowledge, but also understanding the correct application of the knowledge. When asking

patients questions for health history, word choice can determine a correct or incorrect diagnosis.

Recognizing characteristics of each patient is critical to addressing them appropriately.

Standard 2: Perform a safe and accurate comprehensive physical examination in a

logical sequence, adapting the approach appropriately for patients of varied developmental

levels and diverse groups. Following the verbal health history is the physical examination.

Again, these skills will be new for most of the students in the course. They need to be able to

gain confidence in their ability while recognizing the characteristics of each individual patient. A

clinical lab section of the course follows each didactic experience, but without the proper

delivery of methodology in class students will not be able to apply these new skills within the lab

setting.

Appropriate Instructional Strategies based on Theories

The instructional strategies include those implemented in the spring 2019 semester along

with those to be implemented in the summer 2019 semester. These are indicated within the
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description, along with the connected learning theory for the strategy (SDT or dual-coding) and

which standard they support.

Flipped classroom design Initially implemented in the spring 2019 semester, the flipped

classroom strategy will continue into the summer 2019 course and applies most directly to

standard 1. All course modules and material are made available in the university LMS. Our

design consists of weekly required work to be done prior to the in-class meeting time. For each

system module, a recorded Powerpoint lecture, applicable readings, and an online review

exercise are required. Videos are chunked into small, manageable pieces. As stated earlier,

intrinsic motivation is necessary in a flipped classroom environment. Leveraging SDT’s concept

of autonomy, we have attempted to provide choice to the students for when they engage the

material (Niemiec and Ryan, 2009). If a student prefers to watch the videos all at once, they can.

If they only have time to watch one, they are able to do so without trying to remember where

they left off. The students can also decide if they want to engage the required text first or watch

the lecture video. While students understand the expectation that they complete these prior to the

in-class session, they are free to choose the order and time in which they do.

Transitioning to a flipped design also enhances competence for the learners. Perpetual

lectures reinforce the idea that the professor knows all and students are to take it all in as empty

vessels to be filled. Developing nurse practitioner students to have confidence in their skill and to

elevate their self-perception is critical for their clinical success. In an attempt to build this

competence, all lecture videos are available throughout the entire semester. If a student feels as

though he/she does not recall specific details or an examination process, he/she can return and

watch the applicable video. Each module contains a review exercise to be completed after the

readings and video lecture, but before the in-class meeting. The exercise is an interactive, web-
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based experience that provides immediate feedback upon submission. Students can reflect on

their understanding based on their score and the feedback. Each review exercise counts as a

participation grade, eliminating the risk factor in missing questions. In the spring 2019 semester,

various students have taken the review exercises multiple times as means of self-assessment.

Self-determination theory indicates the significance for autonomy and competence to work

together for student success. It is our hope that by flipping the classroom, student success will

increase.

Dual-coding theory has been an effective framework for redesigning the lecture slides

and additional resources. The professor I am working with had already created the Powerpoint

decks for her initial instruction several years ago. Each presentation contained visuals of the

physical body system and the tools and techniques for assessment. In reviewing them for

recording, we concluded that any of the visuals that were not clear and realistic would not be

effective for delivery of content. Clip art styled visuals were removed and replaced by photos or

artist renderings of the applicable system or technique. Because proper positioning is critical to a

proper physical exam, labeled photos were added in each section. Students could then hear the

instructor teaching and see the exact positioning for the assessment.

Based on student feedback from a mid-semester survey, as well as the upcoming end of

course evaluation, we plan to further sharpen the flipped learning experience for students. One of

the ways in which we hope to achieve this is through the integration of Flipgrid. Flipgrid is a

video-based discussion board created to garner a community of learners. In a flipped design,

student interaction still takes place but is limited to the once-weekly meeting. Knapp (2018)

suggests that many online flipped environments use an LMS, but do not have interactive spaces

for students to collaborate, discuss, and learn with each other. Using Flipgrid will increase
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relatedness for learners and be a way we can have each of the three components of self-

determination theory working in the course.

Case-based learning experiences Case-based learning is not a new experience for

nursing students, but the manner in which case-based learning experiences are designed varies.

In a case study students take on the role of a nurse practitioner and evaluate a case by applying

the learned knowledge and skills. This is an in-class experience that bridges the content to the

hands-on lab experience (standard 2). Some designs have students working independently, while

others have students in groups. Our design looks to increase the competence and relatedness

found in the SDT framework. We created a protocol for the weekly case learning experience

with four roles that rotate to each member of the group. Students relate to one another and the

content from various viewpoints, moving them outside of an isolated perspective. In doing this,

we also hope they become more aware of tendencies in language choice and delivery. Relating to

their assigned role, relating to each other, and relating the content to the assessment will enhance

their competence and confidence for the physical assessment practice. Nicol, Owens, Le Coze,

MacIntyre, and Eastwood (2018) propose that if a student is not connecting with the material

effectively, working with others who are more deeply engaged may influence the social dynamic

and result in a heightened interest in the learning. Through the group-based case study,

interactions with others students has the potential to increase learning.

For each presented case study, severity levels may vary. As a result, dual-coding theory is

significant for our design. If the case states that someone has fluid in his/her abdomen, a visual

representation becomes necessary for the group to successfully complete the assessment. A

technique taught within the course is for the patient to lie down and move from his/her back to

his/her side. The abdomen lecture video contains multiple annotated photos of the transfer of the
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fluid and what that means when a patient has fluid buildup. Since dual-coding was used in the

instruction as a means of representing the concept, it would serve to show similar photos of a

patient in the case study. These photos will not be annotated to allow the teams to assess and in

doing so, self-reflect and build competence.

In the upcoming summer course, we plan on adding concept mapping as a means of

connecting systems and diagnoses. Students will be given several model exemplars and then

tasked with creating their own map. Dual-coding principles will be in place as they connect

language and visuals together. This will also enhance relatedness as they visualize verbal

connections between various systems and potential diagnoses.

It is our hope that our summer students will find the design as an enhancement to their

learning experience. Each following iteration will continue to build upon these principles and

research that either supports or refutes these practices.

References

Clark, James M. and Paivio, Allan. (1991). Dual Coding Theory and Education. Educational

Psychology Review, 3 (3), 149-210.

Deci, E.L., & Ryan, R.M. (1985). Intrinsic Motivation and Self-determination in Human

Behavior. New York: Plenum.

Knapp, Nancy Flanagan. (2018). Increasing Interaction in a Flipped Classroom through Video

Conferencing. TechTrends, 62, 618-624. https://doi.org/10.1007/s11528-018-0336-z

Lynch, Martin F., Salikhova, Nailya R., & Salikhova, Albina B. (2018). Internal Motivation

among Doctoral Students: Contributions from the Student and from the Student’s

Environment. International Journal of Doctoral Studies, 13, 255-272.

https://doi.org/10.28945/4091

Nicol, Adelheid AM, Owens, S.M., Le Coze, Stephanie SCL., MacIntyre, A., & Eastwood, C.

(2018). Comparison of high-technology active learning and low-technology active

learning classrooms. Active Learning in Higher Education, 19 (3), 253-265.

https://doi.org/10.1177/1469787417731176

Niemiec, Christopher P., & Ryan, R.M. (2009). Autonomy, competence, and relatedness in the

classroom: Applying self-determination theory to educational practice. Theory and

Research in Education, 7 (2), 133-144. https://doi.org/10/177/1477878509104318

Saussure, F.d., Baskin, W., Meisel, P., & Saussy, H. (2011). Course in general linguistics. New

York: Columbia University Press.

Tucker, B. (2012). The flipped classroom. Education Next, 12 (1), 82-83.