Preparing students to function as novice health care providers is increasingly challenging. The curriculum is crowded with complex content and the time frame for students to master the knowledge is shorter. The student population is not only culturally diverse, but is multi-generational, with our students ranging in age from 18-60 years, with a mean age of 27 years.

And students are more technologically savvy and demand the use of such technology in the classroom. Generation Y students in particular have vast experience with gaming utilizing video games. They enjoy and expect interactive forms of learning versus traditional lecture formats.¹

To address these challenges, the faculty of the Christ Hospital School of Nursing, Jersey City, NJ, adopted the use of clickers in the classroom in the fall of 2008. This technology traditionally has been used in large enrollment classrooms, but faculty believed that clickers could benefit students in smaller classes as well.

Click & Respond
Clickers are a form of an audience response system, in which the instructor uses a computer with a projector to interact with students, projecting a question onto the screen. Students use their clickers to select an answer.² The distribution of answers is then projected and a discussion of the concepts in the question ensues.

Faculty selected this strategy for several reasons.

• This technology enables the instructor to assess student understanding of content in real time. Questions are incorporated into the lecture to evaluate student understanding of difficult content. Concepts can be clarified before introducing new content.
• Clickers promote active learning in a non-threatening environment. Students answer the questions anonymously and therefore feel it's safe to get the answer wrong.
• The faculty hoped that the incorporation of NCLEX-style questions in their lectures would help students develop good test-taking strategies and ultimately make them successful in the program.

Faculty have been very satisfied with the use of the clickers in the classroom. Students are more engaged in class discussions, which make lectures more enjoyable and interesting. Using clickers is a non-intimidating way of assessing knowledge. It also is a method for students to self-evaluate and learn at the same time.

Student Opinion
While faculty are very satisfied with using the clickers, what do our students think?  Faculty developed an evaluation tool utilizing a five-point Likert scale to assess student perceptions of the use of clickers in the classroom. Students were also asked to provide additional comments regarding their use. The survey was distributed to students at the end of the fall 2008 freshman fundamentals nursing course. Results are illustrated in Table 1.

Table 1:  Fall 2008 Student Responses

Student comments included:

• It's a quick, easy evaluation that helps determine weak spots or gaps in understanding.
• Great learning tool. Promotes understanding and fun.
• We need more, every lecture and after viewing videos.
• I think it allows for the lecturers to view how the class is comprehending the material. It forces us to think instead of just waiting for answers.

Overall, the student response to the use of clickers was very favorable, although not all students found the use of clickers beneficial, especially when asked if clickers should be incorporated throughout the curriculum. Two students commented that there was considerable wasted time inherent in their use.

As a result of this survey, the utilization of clickers was implemented throughout the curriculum. To address student concerns, students are required to pick up their clicker prior to the start of lecture. Faculty sets up the system well in advance of the start of lecture. This eliminates using class time to set up and distribute the clickers.

Faculty re-evaluated the use of clickers after implementing this change, 1year later. Freshman students took a survey on clickers in the fall of 2009, at the end of the first semester. Results are illustrated in Table 2.

Table 2:  Fall 2009 Student Responses

Student comments included:

• Need more questions for clicker sessions.
• Do not get rid of the clickers.
• They're awesome.
• Excellent learning tool.

Once again, overall student response was favorable.

Utilization of the clickers has achieved dual purposes. From the faculty perspective, utilization of clickers has met its objectives. It allows the faculty to identify student understanding of difficult content. Confusion on the part of the students is easily identified and content clarified before moving on to new concepts. Clickers facilitate active learning in a non-threatening environment as questions often spark meaningful discussions. Finally, by incorporating NCLEX-style questions into the lecture, faculty are able to introduce strategies to improve test taking skills.

From the student perspective, clickers have been well received as an excellent learning tool. The majority of students agree that using clickers helped them to understand and apply the concepts being discussed in class. In 2008 and 2009, 96% and 87% of students, respectively, agreed that using the clickers helped them to do better on exams and quizzes.

Student comments overwhelmingly reinforced that this strategy promotes understanding of concepts and, moreover, they're fun! The majority of students would like to have more clicker questions in the lectures.

Since incorporating the clickers into the fundamentals course, attrition from the course has declined slightly, from 13.6 in 2007 to10% in 2009. Given the success of using this technology in the fundamentals course, clickers are now being utilized in all courses in the curriculum at the Christ Hospital School of Nursing.

References
1. Billings, D.M. & Halstead, J.A. (2009). Teaching in nursing. A guide for faculty (3^rd ed.). St. Louis: Sanders Elsevier.

2. Skiba, D.J. (2006). Got large lecture hall classes? Use clickers. Nursing Education Perspectives, 27(5), 278-280.

Lori Byrd and Mary Ellen Cvek are nursing instructors at Christ Hospital School of Nursing, Jersey City, NJ.