Learning refers to the acquisition of skills, knowledge, ability, and attitudes. Education refers to the core content and curriculum objectives designed to achieve the desired learning. Training refers to the specific process by which learning of the specific core content and curriculum objectives is achieved. Achieving and sustaining a level of learning with the desired impact on skills, knowledge, ability, and attitudes depend on the effectiveness of the training process to impart the core content and curriculum objectives to the student.

Individual students learn in a variety of ways. Three learning theories are briefly examined for consideration. These involve the behavioral approach, the cognitive approach, and social learning. Any one of a combination of these theories may or may not be relevant to a given technological application to learning. An understanding of how individuals learn may be useful when considering a specific technological application.

The behavioral approach (power of rewards) involves the repeated pairing of a stimulus and response that yields a reward. Pavlov’s (1) groundbreaking work with dogs demonstrated that pairing the ringing of a bell with a meal several
times eventually caused the dog to salivate with the ringing of the bell alone. Positive reinforcement of a stimulus was shown to produce a desired (conditioned) behavioral response. Training in a new work process must therefore involve positive reinforcement of a stimulus when the desired outcome is achieved. Likewise, negative stimulus should be reserved for an undesired outcome.

The cognitive approach uses the internal mental process and involves various cues in the environment to form a mental map. In early cognitive experiments, for example, rats learned to run through a maze to reach a goal of food (2). Repeated trials caused the rats to develop and strengthen cognitive connections that identified the correct path to the goal. People can also develop cognitive maps that show the path to a specific goal. Repeated use of an algorithm for assessment and treatment builds the association with an internal map and the desired outcome. Training in a new work process should therefore result in a new cognitive map of job performance. With increasing application, the individual should develop and sustain new links between the tasks that comprise the job and optimal ways of linking and performing them. Advances in technology provide a great opportunity for automated training. Such systems must use cues inherent in the situation to help learners develop cognitive maps around specific tasks.

People can also learn by modeling or imitating behaviors, as described in social learning theory (3). This theory integrates the behavioral and cognitive approaches and involves the following steps:

Studies analyzing the impact of social learning indicate an average gain of 17% in performance (4). Different types of reinforcement produce different outcomes. For example, performance feedback had a greater impact than monetary reinforcement in manufacturing organizations, whereas the reverse was true in service organizations (3).

Modeling and imitating behaviors as a way of learning can apply to both on-the-job and off-the-job training. Trainers present models of good performance, and the trainees see the relationship between these desirable behaviors and the consequences. Trainees then rehearse the behaviors and consequences, building cognitive maps that intensify the links and set the stage for future behavior. The learning impact occurs when the subject tries the behavior and experiences a favorable result. The learner develops a cognitive image of the situation, which provides a way of thinking about the steps in acquiring new skills, knowledge, ability, or attitudes (5).

The bottom-line question becomes “How can learning be encouraged?” The answer, fundamentally, is as follows: It must involve energetic presentations, provide information in an easily accessible manner, and provide some enjoyment or positive stimulus. Successful learning has been shown to involve the appropriate conditions, reinforcement of the desired learning behaviors, environmental cues that encourage learning, and a modeling strategy (6).

Education and training within the health sciences is increasingly using a performance-based or competency-based theory of design. In the computer science field, for example, Cisco System’s RIO (Reusable Information Objects) project is explicitly performance based. Based on work from Ruth Clark (7) embracing contemporary learning theory, RIO views all training as a means to enable a worker to complete a task successfully (8). This process follows three steps:

Using the RIO model, learning is based on outcome rather than content. It focuses on what people need to do, rather than on what there is to know.

Suppose, for example, a medical equipment company produced a new device. The content approach to training would list the product’s features, develop instruction on these features, and then quiz for recall of the features. In contrast, an outcome approach would begin by assessing the patient’s indications for use of the device and then match the patient’s needs to the device’s capabilities. The quiz would be performance based and involve the ability to use the device correctly in appropriate patient scenarios.

As technology applications are woven into the learning process, it becomes clear that suitable tools and resources depend on the overall core content and objectives of learning and how to achieve a successful performance-based outcome.

Within the context of rapid technological change and shifting market conditions, the American education system is challenged with providing increased learning opportunities, often with decreased budgets. Many educational institutions are answering this challenge by developing distance learning. The United States Distance Learning Association (USDLA) defines distance learning as “the acquisition of knowledge and skills through mediated information and instruction, encompassing all technologies and other forms of learning at a distance” (9). At its most basic level, distance learning takes place when a teacher and student(s) are separated by physical distance and technology (i.e., voice, video, data, and print), often in concert with face-to-face communication, is used to bridge the instructional gap (10). Distance learning therefore encompasses all technologies and supports the pursuit of lifelong learning for all (11).

Distance learning has the distinct advantage of providing students with limited time, distance, or physical disability the opportunity to update their knowledge at the place of
their employment or even at home. The scheduling of courses for distance learning often takes into consideration that most of the students are working professionals who participate in continuing education programming in addition to their full-time job responsibilities. Therefore, a distinct advantage of distance learning is the ability to schedule at the learner’s discretion regarding time and location.

Providing access across a wide geographical area involving not only the urban setting but also rural, remote, and wilderness areas makes the application of distance learning methodologies essential. Regardless of the classroom setting, a wide range of instructional methodologies is available to facilitate interaction on site or through distance learning. The decision regarding which methodology will be applied is often driven by cost, flexibility for the faculty and students, objectives, content, and outcomes supported by available technology.

Research comparing distance education to the traditional classroom setting indicates that teaching and studying at a distance can be as effective as traditional instruction when methods and technologies used are appropriate to the instructional tasks, there is student-to-student interaction, and there is timely teacher-to-student feedback (12,13). According to the USDLA, research studies have found consistently that distance learning classrooms can be as effective as traditional instruction methods. In addition, research studies often point out that student attitudes about distance learning are generally positive (14).

Distance learning has become increasingly common. Most students who enroll in distance education courses are over 25 years old, employed, and have previous college experience. More than half are women. As a group, distance learners are highly motivated (15). Therefore, the successful distance learner is, by definition, a committed student who will establish a schedule and adhere to it. A wide range of employers are finding it difficult to release employees for on-campus study and discovering it is a good investment to bring the classroom to their work sites. According to a survey conducted by the International Foundation of Employee Benefits Plans, employees rank continuing education as more important than child care, flextime, and family leave (15). Faced with retraining 50 million American workers, corporate America is using distance learning, both internally and externally, for all aspects of training (14).

A wide variety of technological options is available for distance learning. The four major categories of delivery, based on the University of Idaho College of Engineering Outreach overview (16), are as follows:

The four categories just listed form a basic model, but technology is rapidly leading to new applications as the World Wide Web related software and hardware expands with opportunities, speed, and access. Web-based instruction (WBI) is a hypermedia-based instructional method that utilizes the attributes and resources of the Web to create a meaningful learning environment where learning is fostered and supported. Kahn (17) reports that WBI should include many resources, support collaboration, implement web-based activities as part of the learning framework, and support both novices and experts in the context of the Web’s potential in relation to instructional design principles. E-mail in a WBI instructional program can provide asynchronous communication among students and instructor. Likewise, e-mail, listserves, newsgroups, and conferencing tools can jointly contribute to the creation of a virtual community on the Web.

Although technology plays a key role in the delivery of distance learning, educators must remain focused on instructional outcomes, not the technology of delivery. The key to effective distance learning is focusing on the needs of the learners, the requirements of the content, and the constraints faced by the instructor before choosing a delivery system. Effective distance learning programs develop with careful planning and evolve with hard work and dedicated efforts of many individuals, including the integrated efforts of students, faculty, facilitators, support staff, and administrators. Meeting the instructional needs of the students to master the education content is the litmus test by which the effectiveness of distance learning programs must be judged.

Distance learning has the promise of being more efficient from a time and cost per student perspective. The USDLA reports that major corporations save millions of dollars each year using distance learning to train employees more effectively and more efficiently than with conventional methods (14). Effectiveness of achieving cognitive skills has been validated (12,13,14), but effectiveness related to psychomotor skills is not yet widely reported. Until recently, applications of distance learning in health sciences have been most suited to cognitive aspects of learning and are now widely reported
in the literature (18,19,20,21,22,23,24,25). With the development of fiber-optic and satellite communication systems involving simultaneous audio and visual capabilities has come the possibilities of patient consultation, instruction, and oversight of diagnostic and surgical techniques and patient follow-up connecting the rural/remote/wilderness physicians and their patients with tertiary referral centers and their specialists. Medical literature is now beginning to report success stories regarding the psychomotor aspects of distance learning (26,27,28,29,30,31,32,33,34,35,36,37,38,39). The concept of a virtual medical campus is now breaking the barriers of time and space, a revolution that has great capacity to influence every aspect of medicine, the advent of which may prove crucial to meet current needs for disaster medicine training.