Multimedia Web-based Courseware in Intellectual and Developmental Disabilities Nursing: From Concept to Development

Joan Earle Hahn, DNSc, RN, CDDN, CS and Mary Alice Willis, MS, RN

Abstract

Nurses play a vital role in the health care of all people, but nurses report receiving little education in nursing school or as continuing education about the care of people with intellectual and developmental disabilities (IDD). Teaching methodologies that make use of computers and the Internet are being used increasingly in nursing education as a means of developing and distributing nursing education. This paper reviews development of a curriculum for nurses that began as a paper outline and evolved into multimedia, Web-based courseware that teaches about the nursing care of people with IDD.

Keywords:

INTRODUCTION

Nurses in the United States traditionally have learned about caring for people with IDD through limited educational opportunities provided in basic nursing education programs, by participation in interdisciplinary training, or by experience in working with people with intellectual and developmental disabilities (IDD)^{1, 2}. Undergraduate and graduate nursing students in nursing programs affiliated with University Centers for Excellence in Developmental Disabilities (UCEDDs), formally called University Affiliated Programs, can participate in interdisciplinary training and continuing education in developmental disabilities, but the number of nurses who participate is small compared to the number of nurses graduating from nursing programs each year^{3 4, 5}. A small number of graduate programs in nursing offer master’s degrees in nursing with a specialization in the nursing care of people with IDD, primarily children and adolescents (i.e. Universities of Washington, Colorado, and Minnesota). A series of six National Workshops for nurses provided continuing education about developmental disabilities for nurses between the early 1960s and the mid 1970s⁶. Some nurses have joined organizations, such as the Developmental Disabilities Nurses Association (DDNA)⁷ and/or the Nursing Division of the American Association of Mental Retardation (AAMR)⁸, and have participated in annual meetings that provide continuing education in IDD. Despite opportunities, most nurses today report that they learned little about IDD nursing before entering this practice area ^{1, 2}. This paper reviews the research-based development of multimedia, Web-based courseware that teaches about the nursing care of people with intellectual and developmental disabilities (IDD), a project driven by the need to address the lack of comprehensive nursing education about IDD in nursing education programs in the United States.

WEB-BASED CURRICULUM DEVELOPMENT

In 1998, the Developmental Disabilities Nurses Association (DDNA) developed a paper curricular outline that addressed topics about the nursing care of people with intellectual and associated developmental disabilities⁹. The University of California at Los Angeles (UCLA) School of Nursing piloted the DDNA curriculum with about 150 nurses in a six-day series of three 2-day continuing education workshops¹⁰. Concurrently, DDNA partnered with a developer of educational software to develop multimedia instruction about the nursing care of people with intellectual disabilities, and to test whether using technology could provide an effective means of distributing this education¹¹. The development occurred in two phases and culminated into 75.5hours of Web-based courseware. This paper presents findings from Phase I of the project, which provided validation of the need for and interest in this courseware, and details the initiation of Phase II of the project, which led to the final design of the Web-based curriculum.

PHASE I

Methodology

The project was funded as Phase I of a Small Business Innovation and Research (SBIR) grant by the National Institute of Health, National Institute of Nursing Research (Grant # R43N04738-01A1). Phase I began with development and testing of educational materials that focused on the care of people with Down syndrome, one common cause of IDD and a survey of nurses in IDD nursing practice.

Four nurses with expertise in working with people with Down syndrome met with the educational software developer for training on writing computer-assisted instruction (CAI) to create a series of four CAI modules about the lifespan nursing care of people with Down syndrome^{12, 13, 14, 15}. Each of these four modules was tested using a pre/post test design with groups of nurses from nurse educational programs and practice settings with patients across the lifespan. Nurses at each site were randomly assigned to experimental or control groups. In the experimental group, each nurse completed a pre-test, an instructional module, a post-test, and an evaluation. In the control group, each nurse completed only a pre-test and post-test.

Also, as part of Phase I, a needs assessment survey was mailed to a random sample of nurses working with individuals with developmental disabilities. The survey was designed to determine nurses’ access to computers, their interest in CAI for learning and teaching, and their self-identified priority learning needs for nurses in the field of developmental disabilities nursing.

Human subject participation in the summative evaluation in Phase I was considered by National Institute of Health’s Office of Professional Research Integrity as exempt from IRB review because the research was conducted in established or commonly accepted educational settings and involved normal educational practices. No information was obtained or recorded in such a manner that human subjects could be identified, directly or through identifiers linked to the subjects, and there was no possibility that disclosure of the human subjects responses outside the research could reasonably place the subjects at risk.

Human subject participation for the DDNA membership survey also was exempt by OPRI because it consisted of a survey procedure that used voluntary participants; information was not recorded in a manner than could be identified directly or through identifiers linked to the subjects; and there was no possibility that disclosure of human subject responses outside the research could reasonably place the subjects at risk.

Results

Summative Evaluation of CAI Modules

Testing of the four modules about individuals with Down syndrome across the lifespan occurred at eight sites around the US that reflected four different practice sites across the lifespan (acute obstetrics, school nursing, ambulatory care and long-term care) and four educational sites in nursing (ADN program, BSN program, MSN program, and a University Center for Excellence in Developmental Disabilities). Nurses or nursing students at each of the eight sites participated in a summative evaluation of one of the four modules that measured cognitive learning gains, nurses’ attitudes toward CAI, and nurses’ satisfaction. Only 50% of test subjects reported any previous education about caring for people with Down syndrome. Results comparing pre- and post-test scores for both experimental and control groups indicated robust learning gains, subject satisfaction with the CAI, and interest in using CAI for learning about IDD nursing¹¹. See Tables 1, 2, and 3 for a summary of the results of Phase I.

Table 1.

Demographic Information for the Respondents
Average Age	39.9 Years
Male	7.6%
Female	91.3%
Black, Not of Hispanic Origin	10.1%
White, Not of Hispanic Origin	84.8%
Asian or Pacific Islander	3.8%
Hispanic	1.3%
LPN	12.5%
RN	77.5%
Student	11.3%
Associate	13.8%
Masters	22.5%
LPN/LVN	10.0%
Baccalaureate	38.8%
Prior education on caring for people with Down syndrome	50%
Prior experience on caring for people with Down syndrome	62.8%
Prior education on caring for people with other disabilities	62.8%
Prior experience on caring for people with other disabilities	60.3%
Previous use of computer assisted instruction	60.3%

Table 2. Results of the Univariate Hypotheses Tests for the Treatment and Comparison Groups on the Pre- and Posttests

MODULE		TREATMENT		COMPARISON
		Mean	Std. Dev.	Mean	Std. Dev.	N	U(P)1
Module #1
PRE POST		11.3 19.7	1.2 .71	12.8 12.0	2.5 2.5	10 9	.13 .00
Module #2
PRE POST		5.3 11.5	1.3 1.3	5.4 5.3	1.5 1.6	10 10	.88 .00
Module #3
PRE POST		10.3 17.3	2.5 2.2	9.3 8.8	2.3 .78	9 10	.25 .00
Module #4
PRE POST		12.4 17.5	2.1 1.3	11.8 11.7	3.1 2.8	9 10	.84 .00

¹Univariable probability

Table 3. Results of the Evaluation of the Course Material and Computer Assisted Instruction (N=37)

Question		Mean	Std. Dev.
Q1	Learning objectives clearly stated.	4.62	.49
Q2	Program content accurate and current.	4.61	.51
Q3	Program content culturally diverse.	4.22	.79
Q4	Program content person/family centered.	4.72	.51
Q5	Content organized and clearly presented.	4.67	.47
Q6	Scope and depth of content appropriate.	4.56	.50
Q7	Content adequately covers learning objectives.	4.56	.50
Q8	Enter answers to questions without problems.	4.54	.80
Q9	Feedback to questions asked helpful.	4.73	.45
Q10	Use program independently with minimal instruction.	4.83	.37
Q11	Program held interest.	4.46	.47
Q12	Program ran smoothly with no problems.	4.71	.46
Q13	Artwork in program is appropriate.	4.35	.82
Q14	Screen design is clear, well spaced and effective.	4.62	.54
Q15	Instructions accompanying program are useful.	4.63	.48
Q16	Learned about Down Syndrome.	4.67	.52
Q17	Recommend program to other nurses.	4.75	.43
A1	Enjoy using computer for educational purposes.	4.29	.88
A2	Feel apprehensive using computers.	1.95	1.23
A3	Prefer learning from a computer vs. lecture/videotape	2.95	1.05
A4	Prefer learning self-paced vs. instructor-led.	3.78	.91
A5	Computer assisted instruction effective way to learn.	4.22	.56
A6	Learn better from lectures and textbooks.	3.11	.93

Likert Scale: 1– 5 (Highly disagree to Highly agree)

Needs Assessment Survey

In mid-March 1999, a survey was mailed to 500 nurses randomly selected from DDNA’s membership. The response rate (n=248) represented a response rate of nearly 50%. The survey data provided information about the demographics of the sample, their access to computers, and their interest in CAI for learning and teaching.

The demographic characteristics of the sample closely approximated the gender and ethnicity of the total population of registered nurses in the United States based on HRSA data in 1996¹⁶. The majority were female (92.7%) , slightly lower than the national average of 94.6%; and 91.1% were white, non-Hispanic, which closely approximates the national average of about 10% of nurses coming from racial/ethnic minority backgrounds. On average, respondents were 46.6 years old, with 21.6 years of nursing experience. The national average age is about 44.3 years¹⁶. Survey data about the sample subjects’ IDD-specific education indicated that only 11.3% reported receiving any information about developmental disabilities in their basic nursing program; 57.3% reported receiving IDD education through continuing education; and 79.8% stated that they learned about IDD through on-the-job experience.

Most respondents reported that they had access to a personal computer with Internet capability, used the Internet for nursing research, or expected to have access to the Internet at their work sites within the next two years. Approximately 45% of those who returned the survey had some experience with CAI. Ninety-one percent expressed an interest in learning more about developmental disabilities using interactive CAI, and 88.5% felt that CAI would facilitate their learning.

In the needs assessment survey, developmental disabilities nurses were asked to identify the ten priority topic areas they believed to be of highest importance in meeting the educational needs of nurses entering the field of developmental disabilities. Responses were collated into 10 major categories (see List 1). Survey respondents also identified the need for nurses to engage in clinical experiences with people with IDD in order to gain a greater understanding of their care requirements (see List 2).

List 1: Priority Content Areas Identified by DD Nurses

• Person and Family Centered Approaches to Lifespan Care in the Community
• Ethical and Legal Issues
• The Management and Direction of Challenging Behavior
• A Framework for Caring Communication
• Promoting a Circle of Caring: The Interdisciplinary Team, the Nurse, and the Direct Care Given
• Understanding Developmental, Functional, and Neurological Assessment
• The Management and Direction of Care to Prevent Disuse Syndrome
• The Management and Direction of Nutritional Care
• Management and Direction of Medication Administration
• The Management and Direction of Seizure Care
• Developmental Disabilities and Specific Syndromes
• Developmental Disabilities Nursing as a Career

 

List 2: Suggested Clinical Sites for Nursing Students

• Public schools
• Group homes
• Home health care
• Well-child clinics
• High-risk infant settings
• Schools designated for children with IDD
• Intermediate care facilities – residences specifically for persons with IDD
• Skilled nursing care facilities
• Orthopedic clinics

 

DDNA survey respondents reported their main work roles to be client care (13.7%), administration (20.6%), education (23.8%), research (0.4%), or a combination of these roles (32.2%). The nurses who stated that their roles were “other” (7.1%) listed jobs that reflected administrative or educational functions, such as quality assurance, supervisor, client program coordinator, regulatory officer, medical redesign specialist, consultant, state inspector, coordinator of medical services, and functional evaluation coordinator. The data highlighted that the majority of DDNA members who responded to the survey had work roles that involved the management and supervision of care, rather than work roles that involved direct client care.

PHASE II – DESIGN

Methodology

Funding from the National Institute for Nursing Research (Grant # R44NR04738-02) was secured for the second phase of courseware development, with the purpose of modifying the entire person-/family-centered, transcultural, lifespan-inclusive DDNA curriculum using a research-based approach, and developing it into courseware for Web-based delivery. The proposed courseware design for Phase II was based on the findings and process in Phase I, and included the need for:

• basic introductory education about IDD nursing of appropriate scope and depth for inclusion in undergraduate nursing programs
• content that reflected nurses’ primary identified roles in IDD nursing, which are administrative and educational;
• tools that licensed nurses can use to educate and guide caregivers and families of people with developmental disabilities; and
• a conceptual framework to guide the instructional design of the courseware.

 

Several methods were proposed for Phase II to assist in reaching a consensus on the proposed instructional design and content areas for the Web-based courseware. First, the content selected for instructional design would be guided by the data collected in the Phase I needs assessment survey of nurses who care for people with IDD (reported above).

Second, data collected during Phase II from a survey of deans of basic nursing education programs would be used to determine how much content on the nursing care of persons with IDD currently was being taught in their nursing programs; whether their nursing school would be interested in using IDD nursing content delivered as Web-based courseware; and what content areas in IDD nursing were most important to teach nursing students. In mid-September 2000, a survey was mailed to 100 deans of undergraduate nursing schools, with one associate degree and one baccalaureate degree school selected at random from each state in the United States. The survey instructions informed deans that participation was voluntary and that they had the option to return the survey with or without individual or site-specific identifying information. Deans were informed that any identifying information submitted would be regarded as confidential, viewed only by the PI and Administrative Assistant, and used only to compile the data necessary for the Evaluation Consultant. Participants were guaranteed that there was no possibility that disclosure of any survey response could result in any detriment to respondents’ financial standing, employment, or reputation.

Third, expert consensus about the courseware design and the content to be included would be achieved through joint consultation among a team of IDD clinicians, educators, and curriculum consultants at the beginning of Phase II. Thus, the aim of the courseware design was to reflect the content areas that were identified by both the experienced IDD nurses in practice settings and by deans of nursing schools as being of highest importance to nurses entering the field of IDD. The design also was intended to reflect a notable need of the majority of practicing IDD nurses, which was the need to learn skills related to the competent management and direction of care for people with IDD, for whom most daily care is provided by unlicensed caregivers.

Results

Survey of Deans of Nursing Programs

Twenty-seven responses (27%) were received from deans of 17 associate degree programs and ten baccalaureate degree programs. The deans’ responses indicated that student access to content on developmental disabilities nursing varied greatly by school. All baccalaureate programs addressed the content, averaging 10 hours of instruction, which was almost exclusively "integrated" into the curriculum in maternal/child and/or psychiatric mental/health courses. However, 53% of associate degree nursing programs reported teaching no content on developmental disabilities nursing, with the majority of the remaining programs reporting 1 to 3 hours of education integrated into pediatric and/or mental health courses.

All schools (with one exception), including associate degree programs not currently including this content in their curricula, indicated an interest in allotting approximately five dedicated hours, on average, to teaching nursing students about IDD using CAI. When given a list (derived from the DDNA survey responses about the top ten areas of importance in developmental disabilities nursing), deans of schools of nursing made recommendations about courseware content areas that were consistent with those identified by experienced developmental disabilities nurses.

Expert Team Consultation

A four-day meeting with a team of IDD clinical and nursing education experts, a curriculum consultant, and a technology team was convened to collaborate on the instructional design and content for the Web-based interactive education for nursing. Nursing team experts included nursing educators with expertise in working with persons with IDD, expert nurse clinicians, a former dean of an associate degree program with curriculum and instructional design expertise, a consultant curriculum expert experienced in integrating a nursing theoretical framework (Watson’s Theory of Human Caring)^{17, 18} into curricula, and the Principal Investigator (PI), who had extensive experience in the developmental of interactive education for technological delivery.

Using consensus to validate instructional design, first, the team formulated a theoretical model and applied it to five key concepts they determined were integral to IDD nursing practice. They then validated the content areas to be included in the courseware. The model, named “The Role Partnership Context Model of Caring” (See Figure 1)¹⁹ builds upon and integrates the World Health Organization (WHO) model of disability, (a social-environmental model)²⁰, the US federal definition of developmental disability²¹, the four domains of nursing practice (health, person, environment, and nursing), and Dr. Jean Watson’s Model of Human Caring (a nursing theoretical framework)^{17, 18}. This model describes a caring partnership approach to nursing care (among the person with a developmental disability, his or her caregiver, and the nurse). This partnership exists within the context of personal factors that reflect each partner’s values and preferences, and within the context of social and environmental factors that affect each partner’s ability to participate fully in living, and achieve optimal health status and quality of life (see Figure 1 at the end of the article)¹⁹.

The team organized the courseware modules into three general categories. The categories divided the modules in the courseware into:

• content for undergraduate nursing programs.
• key content areas for nurses managing and directing care with people with IDD.
• a tool for supporting caregivers in making health observations about clients.
• health care protocols for nurses to use as educational examples to help guide decision making about client care needs based on reported health observations.

 

The Role Partnership Context Model and the five key concepts (see Figure 1) provided a framework for the courseware modules developed for use with basic nursing students in undergraduate nursing programs. Content included an overview of common syndromes and conditions associated with developmental disabilities, an overview of the history of developmental disabilities nursing, current concepts in developmental disabilities for nurses, and a series of scenarios that depicted the partnership triad of people with IDD, caregivers, and nurses. Each scenario was selected to reflect: at least one of the key concepts in developmental disabilities nursing; nursing roles in a variety of practice settings; a lifespan approach to care; different etiologies or syndromes and conditions associated with IDD; varying limitations caused by IDD (e.g., speech, mobility, cognition); and the context of personal, social, and environmental factors affecting each partnership triad. The proposal for scenarios resulted in the development of the following modules (see List 3 for a list of scenarios and see Figure 2 for sample screens from a module about a middle-aged man with Down syndrome).

List 3: Courseware Scenarios about Persons with IDD

(Course titles listed link directly to the corresponding course page at http://healthsoftonline.com)

• Susan Webster: A Fifteen Year Old with Spina Bifida
• James Russell: An Adult with Down Syndrome
• Tammie Johnson: A Three Year Old with Lead Poisoning
• Sabrina Jackson: A Young Adult with Cerebral Palsy
• Jimmy Young: A Four Year Old with Cerebral Palsy
• Matthew Green: A Young Adult with Asperger's Syndrome
• Howard McGuire: A Middle-Aged Man with Mental Retardation and a Mental Health Condition
• Tommy Banks: An Eight Year Old with Fragile X Syndrome
• Marta Perez: A Young Adult with Phenylketonuria
• Katie Allen: An Eight Year Old with Fetal Alcohol Syndrome
• Jessica Rubinger: An Adult with Tuberous Sclerosis
• A Summer Camp Experience for Children with AIDS
• Gene Cosens: A Young Adult with Prader-Willi Syndrome
• Ruth Fingold: An Older Adult with Mental Retardation in a Long Term Care Setting
• James Dunn: A 50-Year-Old Man Who is Deaf/Blind and Has Mental Retardation
• Davey Lee: A Four Year Old with Tay-Sachs Disease
• An Infant With Down Syndrome: From Hospital to Home
• Four Students With Down Syndrome: A Day in the Life of a School Nurse
• Care of the Young Adult with Down Syndrome: A Time of Transition
• Walter Makuch: An Aging Adult with Down Syndrome

 

The curriculum team also confirmed that the topic areas identified by developmental disabilities nurses and deans of nursing programs were of high priority for the education of nurses working with persons with IDD. These topic areas guided development of modules that are specifically designed to increase nurses’ skills in the management and direction of care with caregivers or unlicensed persons who provide support (see List 4).

List 4: Courseware on Directing and Managing Care

(Course titles listed link directly to the corresponding course page at http://healthsoftonline.com)

• A Caring Approach to Behavioral Issues
• A Framework for Caring Communication
• Promoting Caring Partnerships: Delegation to Direct Care Staff
• Promoting Understanding of Neurological Assessment
• Promoting Understanding of Developmental and Functional Assessment
• A Caring Approach to Medication Administration Tasks
• A Caring Approach to Seizure Care

 

The final section of the courseware contains education about a tool for daily head-to-toe observation of people with IDD by caregivers, and three modules on health care protocols that can be used to guide the nurse as he or she responds to reported observations of changes in health status in people with IDD (see List 5). These tools and protocols are based on materials originally developed by UCLA School of Nursing^{22, 23}.

List 5: Courseware on Tools and Healthcare Protocols

(Course titles listed link directly to the corresponding course page at http://healthsoftonline.com)

• The Head-to-Toe Observation Form
• Health Care Protocols 1
• Health Care Protocols 2
• Health Care Protocols 3

 

PHASE II-COURSEWARE DEVELOPMENT

During the instructional design meeting, subject matter experts (SMEs) for each content area were identified from among the team members to serve as authors. The project's PI, who is also an educational software developer, presented a workshop about how to develop interactive content for Web delivery, and then worked individually with each SME to assure that submitted content was appropriate in design and scope, correct and current, and consistent with the Role Partnership Context Model. The PI also was responsible for editing and assuring expert content review of each module by an outside group of nursing content reviewers.

Each module included “Learning Opportunities,” which provided Internet links and additional related, but optional, information (See Figure 3). For example, in a module about a young adult with Asperger’s syndrome being seen by a nurse in a college health setting, learning opportunities included a first-person account about having Asperger’s syndrome (see Figure 4), as well as multiple links to Web sites that provide information about Asperger’s syndrome and transition issues for young adults with developmental disabilities. Resources and references in the courseware are linked directly to sites from which they can be accessed. Each module is enriched with photographs of people with IDD, nurses and other professionals, direct care staff, and families – all of whom gave permission to use their photographs in the courseware.

The completed courseware provides approximately 75.5 hours of computer-based instruction (excluding the Learning Opportunities) that can be completed at the learner’s pace. Since each module stands alone, an instructor and/or student can select specific modules that are relevant to the specific course content or clinical area of practice.

DISCUSSION

Teaching methodologies that make use of computers and the Internet are being used increasingly in nursing education as a means of developing and distributing nursing education.²⁴. As more nursing faculty seek to incorporate online teaching strategies, faculties report satisfaction with Web-based learning as a teaching methodology, including the use of the Internet to support highly interactive, student-centered learning²⁵. This project used a research design to develop multimedia Web-based courseware for nurses about the care of people with IDD that validated the:

• need for education in this specialty area of nursing.
• interest of nurses and deans of schools of nursing in having access to content in IDD nursing via the Internet.
• content areas required for comprehensive courseware in this specialty area, and
• the effectiveness of using the CAI to produce cognitive learning gains.

 

Phase I of the study piloted the courseware about the care of people with Down syndrome and validated cognitive learning gains in nurses and nursing students who used this CAI (Phase II summative evaluation results are pending). These findings were consistent with other nursing research that shows that nurses can learn effectively from CAI^{26, 27}.

The design and content of the Web-based courseware flowed from nurses’ responses to survey questions about important topic areas in IDD nursing. The survey findings documented that most nurses working actively in the specialty of IDD learned “on the job,” or had little basic educational preparation in developmental disabilities nursing, which is a finding noted in other surveys ^{1, 2}. These findings helped to establish the need for basic content in IDD nursing that would be appropriate for use in undergraduate nursing schools. Furthermore, demographic information gathered from practicing IDD nurses indicated that most nurses had work roles in management and education, which highlighted the importance of providing knowledge and skills related to directing caregivers to provide optimal care for people with IDD. Using the Internet as a delivery method for the IDD courseware was supported by the fact that most nurses responding to the survey indicated that they had Internet access. Survey data from the deans of nursing programs indicated a need for and an interest in CAI in IDD nursing for undergraduate nursing programs and provided consensus on the needed content areas. No other surveys were found that assessed deans’ points of view about using or integrating curriculum in IDD nursing in basic nursing education.

One of the unique features of the Web-based courseware is its grassroots development by nurses in practice in collaboration with nurse educators, curriculum consultants, and software designers. Another unique feature is that this courseware is based on a nursing conceptual framework that is integrated with current concepts and frameworks used to describe disability. This courseware has opportunities for worldwide dissemination via the Internet.

To date, this is the first completed Web-based courseware that has used a research-based approach to development and that has provided extensive coverage of content in this nursing specialty. The need for educational material has driven the ongoing work to develop curriculum for nurses about IDD, with several curriculum projects being developed concurrently by nursing associations and universities²⁸. It is anticipated that the methodology and design of the CAI Web-based courseware may provide a model for developing curriculum in other nursing specialties. A limitation in this study, however, was the failure to compare the effectiveness of the CAI to more traditional classroom teaching. Testing the use of this courseware as it actually is implemented in a variety of basic nursing education settings would be a ripe area for future nursing research.

Another limitation of the study may be the lack of participation in the design and instructional development process by persons with IDD. However, the courseware content was informed, in part, by the nurse authors’ clinical practice experiences, which are likely to reflect, with a high degree of accuracy, actual common social and environmental issues and problem areas encountered by persons with IDD. Further, the nurse authors’ unique perspectives have created a contextual courseware environment in which persons with IDD are not identified simply by their syndrome or condition, but as people first. Continuing to seek input from people with IDD in response to the courseware might add valuable dimension to the courseware update process and future instructional design and development of IDD nursing courseware. Additional research would include a participatory research focus by persons with IDD.

The data from this research-based approach for the courseware’s development were collected from convenience samples of nurses in practice or nursing programs, and from a relatively small sample of deans of schools of nursing. Therefore, the findings cannot be generalized to the population of deans of nursing programs or to the population of nurses at large. However, preliminary data do support that nurses have access to the Internet; that they have an interest in learning more about care of persons with IDD (as validated by other studies)^{1, 2}; and that they were satisfied with the courseware and demonstrated cognitive learning gains. The data indicate that this Web-based courseware about nursing care of people with IDD, and the potential for its widespread use via the Internet, may fill a historical gap in existing nursing education.