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How effective is CBT in maintaining control over learning processes and training
content? Provide your rationale.

Question:   How effective is CBT in maintaining control over learning processes and training
content? Provide your rationale.

Definition and Characteristics of CBT
CBT (computer-based training) and CAI (computer-assisted instruction). An interactive learning experience in which the computer provides most of the stimuli, the learner responds, and the computer analyzes the responses and provides feedback to the learner. Components most often consist of drill-andpractice, tutorial, or simulation activities offered alone or as supplements to traditional instruction.

Various terms are used to describe the educational use of computers --“computer-based training”(CBT) to refer to training in which the subject matter is primarily presented through a computer, as opposed to traditional training led by a facilitator or instructor.
Types of CBT
There are four levels of CBT,each based on the application’s complexity and its level of interactivity with the user
■ L v e C e e t Training similar to a standard PowerPoint overhead presentation with little interactivity
■ L v e I u - , n e t Training by a facilitator accompanied by navigation through the information on the computer,without the use of multimedia
■ L v e F a t - a . A multimedia presentation accompanied by classroom-based training
■ L v e : S a . A multimedia presentation that trainees use independently with minimal assistance (also known as“stand-alone training”). Individuals can train at their own pace,either at an outside lab or on their own desktop computer,and complete the exam provided in the program.
Levels II,III,and IV are the types of CBT that would be most effective in addressing performance gaps among international health workers. To qualify for these levels,a CBT program must meet the following commonly accepted criteria :
■ Be easy to enter and exit
■ Provide a simple way to move forward and backward (i.e., from screen to screen)
■ Be consistent in its key conventions
■ Offer context-sensitive prompts and helps
■ Provide tracking feedback (e.g.,Where have I been? Where am I now? How much more is there to go?)
■ Offer bookmarks (i.e.,quit now,resume later)
■ Always offer a way out

Generally,CBT application design can be grouped: prescriptive,democratic,and cybernetic
PRESCRIPTIVE  Programs that are usually developed as tutorials,drill-and-practice,and games. Typically,they are not flexible; that is,the application cannot sense the user’s level of knowledge and adjust the presentation accordingly. The trainees can access different areas of the application based on progress and skill but must proceed through a specific module or area before advancing to the next step.
■ P e i ve
■ Democratic::::: Programs that permit the learner to influence

Programs that permit the learner to influence what is learned and how it is learned,or at least the order in which it is learned. Thus,learners have the option of selecting sections according to their preference and moving along different pathways toward the same final goal.
■ Cybernetic:::::
Cutting-edge systems that use artificial intelligence to teach
Advantages and disadvantages of CBT
CBT offers learners the ability to use a computer independently or with fewer interactions with an instructor than usual. This is a promising innovation,especially for health care settings located far from a training facility in areas with poor transportation. However,CBT also has its disadvantages, particularly in the developing world
Advantages Disadvantages
■ Self-paced. Each learner can progress at his or her own pace, control the rate and sequence of instruction, and select repetition and feedback.
■ Interactive. Microcomputer systems incorporating various software packages are extremely flexible and maximize learner control.
■ Just-in-time. Easy access to training (for those with computers) means workers can immediately apply knowledge and skills to the job, thus quickly improving performance.
■ Inexpensive. Computer innovations are constantly emerging, while related costs are dropping. Cost savings increase over time as up-front development costs are absorbed. Because CBT usually takes less time than traditional training, students may complete their course of study without suffering the loss of salary due to having to attend lengthy courses or relocating.
■ Accessible. Students in rural areas can learn without incurring lengthy transportation costs.
■ Satisfying. The computer is nonjudgmental and nonthreatening. It provides a privacy that reduces learners. embarrassment about doing remedial work or making mistakes when answering questions.
■ Consistent quality. Students can be exposed to the expertise of the most qualified faculty, with minimum variation from instructor to instructor or class to class.


■ Technical support necessary. Multimedia always requires appropriate hardware and software such as processor, video card, sound card, speakers. Computers need to be maintained by skilled personnel. Obviously, a stable electric supply and surge protectors are key. For certain developing country settings, these conditions are not currently feasible.
■ High development costs. The time it takes to develop, review, revise, pilot test, debug, and finalize the program is extensive. Implementing the programs and getting them to the users is expensive, and the more interactive the program, the more expensive it is.
■ Rapid change in technology. Computer technology evolves so quickly that training solely focused on innovation requires constantly updated equipment that can keep pace with technical advancements.
■ Poor knowledge of computers/technophobia. Widespread computer illiteracy and fear of computers still exist in many settings.
■ Poor access. Although computers have been widely used since the 1960s, many learners do not have access to them or computer networks. In developing countries, computers are typically found only in the capital cities.
■ Inadequate programs. Individuals not directly responsible for teaching students frequently develop CBT programs.

In a traditional educational system, the unit of progression is time and it is teacher-centered. In a CBT system, the unit of progression is mastery of specific knowledge and skills and is learner- or participant-centered. Two key terms used in competency-based training are:
•   Skill—A task or group of tasks performed to a specific level of competency or proficiency which often use motor functions and typically require the manipulation of instruments and equipment (e.g., IUD insertion or Norplant ® implants removal). Some skills, however, such as counseling, are knowledge- and attitude-based.
•   Competency—A skill performed to a specific standard under specific conditions.
There appears to be substantial support for competency-based training. Norton (1987) believes that competency-based training should be used as opposed to the “medieval concept of time-based learning.” Foyster (1990) argues that using the traditional “school” model for training is inefficient. After in-depth examinations of three competency-based programs, Anthony Watson (1990) concluded that competency-based instruction has tremendous potential for training in industry. Moreover, in a 1990 study of basic skills education programs in business and industry, Paul Delker found that successful training programs were competency-based.
A competent clinician (e.g., physician, nurse, midwife, medical assistant) is one who is able to perform a clinical skill to a satisfactory standard. Competency-based training for reproductive health professionals then is training based upon the participant’s ability to demonstrate attainment or mastery of clinical skills performed under certain conditions to specific standards (the skills then become competencies). Norton (1987) describes five essential elements of a CBT system:
•   Competencies to be achieved are carefully identified, verified and made public in advance.
•   Criteria to be used in assessing achievement and the conditions under which achievement will be assessed are explicitly stated and made public in advance.
•   The instructional program provides for the individual development and evaluation of each of the competencies specified.
•   Assessment of competency takes the participant’s knowledge and attitudes into account but requires actual performance of the competency as the primary source of evidence.
•   Participants progress through the instructional program at their own rate by demonstrating the attainment of the specified competencies.
Characteristics of CBT
How does one identify a competency-based training program? In addition to a set of competencies, what other characteristics are associated with CBT? According to Foyster (1990), Delker (1990) and Norton (1987) there are a number of characteristics of competency-based programs. Key characteristics are summarized in Table 1.
Table 1. Characteristics of Competency-Based Training Programs
•   Competencies are carefully selected.
•   Supporting theory is integrated with skill practice. Essential knowledge is learned to support the performance of skills.
•   Detailed training materials are keyed to the competencies to be achieved and are designed to support the acquisition of knowledge and skills.
•   Methods of instruction involve mastery learning, the premise that all participants can master the required knowledge or skill, provided sufficient time and appropriate training methods are used.
•   Participants’ knowledge and skills are assessed as they enter the program and those with satisfactory knowledge and skills may bypass training or competencies already attained.
•   Learning should be self-paced.
•   Flexible training approaches including large group methods, small group activities and individual study are essential components.
•   A variety of support materials including print, audiovisual and simulations (models) keyed to the skills being mastered are used.
•   Satisfactory completion of training is based on achievement of all specified competencies.
Advantages and Limitations of CBT
One of the primary advantages of CBT is that the focus is on the success of each participant. Watson (1990) states that the competency-based approach “appears especially useful in training situations where trainees have to attain a small number of specific and job-related competencies” (page 18). Benefits of CBT identified by Norton (1987) include:
•   Participants will achieve competencies required in the performance of their jobs.
•   Participants build confidence as they succeed in mastering specific competencies.
•   Participants receive a transcript or list of the competencies they have achieved.
•   Training time is used more efficiently and effectively as the trainer is a facilitator of learning as opposed to a provider of information.
•   More training time is devoted to working with participants individually or in small groups as opposed to presenting lectures.
•   More training time is devoted to evaluating each participant’s ability to perform essential job skills.
While there are a number of advantages of competency-based training, there also are some potential limitations. Prior to implementing CBT, it is important to consider these limitations:
•   Unless initial training and followup assistance is provided for the trainers, there is a tendency to “teach as we were taught” and CBT trainers quickly slip back into the role of the traditional teacher.
•   A CBT course is only as effective as the process used to identify the competencies. When little or no attention is given to identification of the essential job skills, then the resulting training course is likely to be ineffective.
•   A course may be classified as competency-based, but unless specific CBT materials and training approaches (e.g., learning guides, checklists and coaching) are designed to be used as part of a CBT approach, it is unlikely that the resulting course will be truly competency-based.
Models and Simulations in CBT
Models and simulations are used extensively in competency-based training courses. Airplane pilots first learn to fly in a simulator. Supervisors first learn to provide feedback to employees using role plays during training. Individuals learning to administer cardiopulmonary resuscitation (CPR) practice this procedure on a model of a human (mannequin).
Satur and Gupta (1994) developed a model which facilitates skill development in performing and evaluating coronary anastomoses with an angioscope. The results of their study indicate that models are proving invaluable as a training tool. George H. Buck in a 1991 historical review of the use of simulators in medical education concluded that “Given the developments in this technology within the last 50 years, it is possible that the use of simulators will increase in the future, should the need arise to teach new concepts and procedures at set times to large groups of individuals” (p. 24). Researchers in two different experimental studies involving training people to perform breast self-examinations (BSE) compared several methods and found that using models was the most effective training method (Campbell et. al., 1991 and Assaf et. al., 1985). In a multicenter evaluation of training of physicians in the use of 30-cm flexible sigmoidoscopy, Weissman et al (1987) found that they were easily trained by first practicing on plastic colon models.
Norton (1987) believes that participants in a competency-based training course should learn in an environment that duplicates or simulates the work place. Richards (1985) in writing about performance testing indicates that assessment of skills requires tests using simulations (e.g., models and role plays) or work samples (i.e., performing actual tasks under controlled conditions in either a laboratory or a job setting). Finally, Delker (1990) in a study of business and industry found that the best approach for training involved learner-centered instruction using print, instructional technology and simulations.
Evaluation and Assessment in CBT
Evaluation in traditional courses typically involves administering knowledge-based tests. While knowledge-based assessments can certainly be used in CBT to measure mastery of information, the primary focus is on measuring mastery of skills. In keeping with this, Thomson (1991) reports that the decision to recognize a performance as satisfactory and to determine competence should be the basis for success of a competency-based program. Moreover, Foyster (1990) argues that assessment in competency-based programs must be criterion-referenced with the criterion being the competencies upon which the program is based. Finally, Richards (1985) indicates that simulation and work sample performance tests should include a checklist or some type of rating scale.
Implications for Using CBT
In a 1990 study of three operating competency-based programs, Anthony Watson identified a number of implications for organizations considering implementing a CBT system:
•   Organizations must be committed to providing adequate resources and training materials.
•   Audiovisual materials need to be directly related to the written materials.
•   Training activities need to match the objectives.
•   Continuous participant interaction and feedback must take place.
•   Trainers must be trained to conduct competency-based training courses.
•   Individuals attending training must be prepared for CBT as this approach is likely to be very different from their past educational and training experiences.
JHPIEGO’s Approach to CBT
JHPIEGO Corporation has adopted a competency-based approach to conducting clinical training in selected reproductive health practices. Based on the principles summarized in this paper, JHPIEGO’s approach to CBT involves key activities which occur during the design, delivery and evaluation of training courses. These activities are summarized here and explained in detail in JHPIEGO’s Clinical Training Skills for Reproductive Health Professionals and Advanced Training Skills for Reproductive Health Professionals reference manuals.
The key activities around which JHPIEGO’s competency-based training is built include design, delivery and evaluation activities. The components of each are summarized in Table 2 and Table 3.
Table 2. Design Activities
•   Identification of the specific clinical skills (e.g., IUD, Norplant implants, counseling, infection prevention or minilaparotomy) that will form the basis of a competency-based training course.
•   Identification of the conditions (e.g., using models, role plays, clients) under which the skills must be demonstrated.
•   Development of the criteria or standards to which the skills must be performed.
•   Development of the competency-based learning guides and checklists which list each of the steps and sequence (if necessary) required to perform each skill or activity.
•   Development of reference manuals which contain the essential, need-to-know information related to the skills to be developed.
•   Development of models (e.g., Zoe pelvic model, Norplant implants training arm) to be used during training.
•   Development of training objectives which outline what the participant must do in order to master the clinical skills.
•   Development of course outlines which match a variety of training methods and supporting media to course objectives.
•   Development of course syllabi and schedules which contain information about the course and which can be sent to

Table 3. Delivery and Evaluation Activities
•   Administration of a precourse questionnaire to assess the participants’ knowledge and attitudes about course content.
•   Administration of precourse skill assessments using models to ensure participants possess the entry level skills (e.g., able to perform a pelvic exam if learning to insert IUDs) to complete the course successfully and role plays to determine the level of their communication (counseling) skills.
•   Delivery of the course by a trainer/facilitator using an interactive and participatory approach.
•   Transfer of skills from the trainer to the participants through clinical and counseling skill demonstrations using slide sets, videotapes, models, role plays and finally, clients.
•   Development of the participants’ skills using a humanistic approach, which means participants acquire the skill and then practice until competent using anatomic models and role plays.
•   Practice of the skills following the steps in the learning guide until the participant becomes competent at performing the skill. During this time the trainer functions as a coach providing continuous feedback and reinforcement to participants. Only when participants are assessed and determined to be competent on a model do they work with clients.
•   Presentation of supporting information and theory through interactive and participatory classroom sessions using a variety of methods and audiovisuals.
•   Administration of a midcourse questionnaire to determine if the participants have mastered the new knowledge associated with the clinical skills.
•   Guided practice in providing all components of the clinical service.
•   Evaluation of each participant’s performance (i.e., knowledge, attitudes, practice and clinical skills) with clients. The evaluation by the trainer is performed using competency-based checklists. The participant is either qualified or not qualified as a result of the knowledge, attitude and skills assessments.
•   Presentation of a statement of qualification which identifies the specific clinical service the individual is qualified to provide.
Transfer of Training
JHPIEGO uses a four-step process to transfer specific clinical skills and knowledge from experts to service providers. These steps are part of the process of developing a family planning training system within a country. The four steps include:
•   Standardizing provision of clinical services and modifying and adapting JHPIEGO training materials as necessary
•   Training service providers to provide these services competently, according to the approved standards
•   Identifying and preparing proficient service providers to function as clinical skill trainers so they are able to train other service providers
•   Identifying and preparing clinical skill trainers to function as advanced and eventually master trainers so that they are able to train other clinical skill trainers, evaluate training and develop or revise course materials
The first step is to standardize the clinical skill(s) to be used in the delivery of family planning services. For example, in a country there may be a need to train clinicians to perform IUD insertions and removals. The first activity conducted is to identify and observe a group of clinicians who are performing these procedures. The steps the clinicians perform are observed and compared to the standard approach outlined in JHPIEGO’s competency-based IUD learning guides and checklists. This observation process gives JHPIEGO trainers an idea of the skill levels of those who will be trained to be service providers. As necessary, JHPIEGO’s learning guides and checklists are modified to meet the specific service delivery standards or norms within the host country. The standardized procedure then forms the basis for the service provider training courses conducted within the country.
The second step is to train a specific group of service providers to perform the standardized clinical skills. The clinical skills course is based on a training package   consisting of a reference manual, supporting audiovisuals, anatomic models, and trainer and participant handbooks (which contain the learning guides and checklists based on the standardized procedure). Following the clinical skills course, these competent service providers provide clinical services to clients. After providing services for a period of time, a group of the most proficient service providers who have demonstrated an interest and willingness to become clinical trainers undergo training skills training.

The third step in the transfer process is to prepare a group of proficient service providers to be clinical skill trainers. These service providers attend a clinical training skills course which also is based on a training package. During this course, participants will have their clinical knowledge updated and skills assessed and standardized to ensure they are proficient at performing the clinical skill. Participants will then learn how to demonstrate clinical skills, transfer knowledge and skills during training, function as clinical coaches, and use competency-based learning guides and checklists to assess participant performance. Following the clinical training skills course these clinical skill trainers conduct service provider training courses. During their first service provider course they either co-train with an advanced (or master) clinical trainer or are observed by a training skills trainer.
The final step in the process of transferring skills is to prepare a small group of proficient clinical skill trainers to become advanced trainers. These clinical skill trainers attend an advanced training skills course which is also based on a training package. During this course, participants learn how to conduct needs assessments, design training courses, facilitate the group dynamics occurring during a course, and evaluate training. Following the advanced training skills course these advanced trainers conduct clinical training skills courses. During their first several training courses they cotrain with a master trainer. After successfully delivering several training skills courses these individuals can be qualified to function as a master trainer.
Based on the concepts and principles presented in this paper, the key features of JHPIEGO’s approach to training include:
•   Development of competencies (knowledge, attitude and practice) is based on national standards.
•   Quality of performance is built into the training process.
•   Emphasis of the training is on development of qualified providers, not on the number of clinicians undergoing training.
•   Training builds competency and confidence because participants know what level of performance is expected, how knowledge and skills will be evaluated, that progression through training is self-paced, and that there are opportunities for practice until mastery is achieved.


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