The precise role played within case studies by a review of existing literature depends on the particular approach adopted by the researcher. In this study, the literature is an essential interactive component (Mason 1989, Merriam 1988, Yin 1989), relating existing work on CMC to the study, and assisting in the initial framing and subsequent refining of the research questions, which "evolve naturally as the details of the case study are focused and sharpened" (Mason 1989:57). This is congruent with an interpretive approach to research, and with Sullivan & Porter's (1993) view of research as praxis, integrating "relevant information on a topic, whether the information is from previous investigations, theory, or methodology" (Merriam 1988:62).
Given the substantial amount of literature available relating to CMC generally, although not to nursing aspects, I will adopt the method used successfully by Mason (1989) to structure the review. The literature is categorised by themes (see figure 4.1), and selected areas addressed in depth, indicating aspects which, while relevant, cannot be addressed in detail in this study. This method aims to draw "out what is common in each branch to the proposed case study, [so that] the questions motivating this thesis can be framed and elucidated" (Mason 1989:58).
Figure 4.1 Organisation of literature review (after Mason 1989)
| |technological issues
-------------------- |
|||
| ----| | |psychological aspects
----------------------- |
||
| |applications
------------------------> |
|discourse/linguistic
------------------- |
||
| | | |educational
------------ |
||
| |real world use of cmc
-----------------------------> |
|organisational
-------------- |
||
| | | |conjecture
----------- |
||
| |nursing
-----------------------------> |
| | ||
| |actual
------ |
The technology enables people to communicate faster, an 'amplifying' effect (Kiesler 1991), although it is suggested that, more importantly, CMC allows for, or even promotes, changes in social relations. It:
Two aspects that are frequently addressed are the effects of the spatial
and temporal separation of people involved in the communication. Mason
(1989, 1994a) summarised the effects of such distancing, and saw the advantages
of spatial distance as being anonymity, social equalisation, reduction
of distractions, and the increased importance of development of logical
argument. Disadvantages included reduction in feedback due to loss of communicative
nuance, and social distancing. The advantages of the temporal separation
of components of the utterances included the opportunity to contemplate
at length the message and the response to be made, and physical convenience.
Disadvantages included writers block or non-response, due to a lack of
pressure to respond immediately (Smith 1988, Mason 1994a), and reduction
of phatic aspects of communication. Mason (1994a) also found that the asynchronous
nature and lack of pressure to respond could produce very prolonged exchanges.
Some of these issues will now be addressed in more depth.
Western culture still generally subscribes to the Platonic ascendancy
of speech over writing, responding differently to spoken or written communications
(Feenberg 1989), although, interestingly, academia values the detached
written word, in suitable academic prose, over other forms of communication.
Writing is typically viewed as only an imitation of speech and so a less
authentic form of communication, due to the absence of participants' physical
presence. Despite other forms of communication being measured against it,
the "ideal" of FTF communication is rarely questioned (Jones 1995, Schudson
1978). Walther (1992) and Walther & Burgoon (1992) are particularly
critical of many of the early studies comparing CMC with FTF, for not examining
all aspects, particularly the non-verbal, of FTF communication. Mason (1994)
asserts that the dynamics of interactions via CMC may not be as different
from FTF interactions as some studies have indicated, and as speculation
on the medium suggests.
Perrolle (1991:357), taking a different view, which may be an effect of the greater use of CMC over time since the publication of Sproull & Keisler's work, suggests that CMC "reduces the social solidarity in existing social groups, but it facilitates conversations among strangers". If this is true, it may explain some of the sense of community felt by disparate subscribers to lists, who have never met each other and may know that they are unlikely ever to meet physically.
The orthodox view that the lack of non-verbal cues in CMC inhibits or adversely influences communication is being challenged by researchers such as Holden & Mitchell (1993), who found from a Delphi study of the opinions of experts in using CMC that few felt the absence of non-verbal cues was an obstacle to communication. The strongest criticism comes from Walther (1992), arising from his close study of the research into CMC. He argues that most of the work resulting in the orthodox view of impaired communication arose from experimental studies, and when field research is undertaken on real electronic communities, much more positive effects are found, indicating that "users may develop relationships and express multidimensional relational messages through verbal or textual cues" (Walther 1992:52). He criticises the experimental researchers for not considering the different contexts within which CMC occurs and the different purposes for which it is used, as well as their attempts to generalise experimental findings to all forms/contexts of CMC. He is particularly critical of the time-limitation of many experiments, which, because of the slower speed of message exchange (due to typing speeds etc.) when compared with FTF communication, he feels have not allowed equivalent time for relationships to develop.
Walther (1992) closely examined many of the studies comparing CMC with FTF communication, and found that, while researchers had discussed the lack on non-verbal cues in CMC, "no CMC research to date has examined the nonverbal visual behaviors of face-to-face groups" (Walther 1992:63). He concludes that evidence "that CMC is less socioemotional or personal than face-to-face communication is based on incomplete measurement of the latter form, and it may not be true whatsoever, even in restricted laboratory settings" (Walther 1992:63).
The view that CMC cannot be used for conveying personality and emotional
content is also criticised by Walther (1992) and others. Zimmerman (1987:827),
for example, studying the use of CMC by severely disturbed adolescents,
found it "was more expressive of feelings and made more frequent mention
of interpersonal issues [than FTF]...and appeared to diminish certain traditional
gender differences in group communication". Feenberg (1987) also suggests
that personality may be clearly discerned in purely textual communication.
The loss of effect of normal mechanisms of influence and control within groups, often associated with status (Kiesler et al 1984, McLaughlin et al 1995) is best expressed by Feenberg (1989), who says:
Mason (1994a:21), in discussing whether CMC has removed disadvantages to participation in communication often experienced by women, minorities, the disabled etc., believes that women's participation in on-line discussions is more equal that in equivalent FTF settings. Similarly, Grint (1992) found that students' initial lack of knowledge of the gender of CMC participants did not affect communication, but that reversion to conventional assumptions about computer literacy occurred once gender was revealed.
The question of whether CMC generally aids communication by helping to overcome barriers associated with gender, ethnicity, culture etc., will only become clearer as more diverse people around the world use CMC. At present, it is estimated 95% of Internet users are male (Grant 1994), while Ryan (1993) found CMC to be used predominantly by educated, white professionals. While the majority of respondents to her study did not consider cultural or national differences of importance, some said that if they knew the person was of another culture, to avoid cultural differences resulting in potential misunderstandings, they took greater care over how they expressed themselves (Ryan 1993).
Many of the issues addressed in this section are of direct relevance
to the use of CMC by a group comprised largely of women, and will be discussed
in analysing the case. The next section considers issues of discourse relating
to CMC.
As the previous section has indicated, many frequent CMC users dispute the lack of socio-emotional content in messages. Godwin (1994) emphasises that, when reading text on-screen or on-line, there are no other distractors about the person to affect reception of the message as there are in FTF communication, but "everything you see is a product of that person's mind" (Godwin 1994:69). He continues "It's hard to read many classics of English literature without being overcome by language's capability to express emotional states, complex ideas, sensory experience, humor. Text is almost telepathic in its power." While this may be true for some writers, one has to bear in mind that not everyone who commits their thoughts to keyboard is a Dostoyevsky or a Naguib Mahfouz, although "even the poorest writers manage to invest something of their souls in what they send out to the Net" (Godwin 1994:70).
It is not feasible here to address all issues relating to CMC discourse;
the remainder of this section will consider primarily the literature relating
to issues that are addressed in the analysis of the corpus. These include
the question of the existence of turn taking in CMC, where frequently several
simultaneous discussion threads exist, the similarity of CMC to speech
or writing, and the social or linguistic strategies used to maintain the
discourse and including the question of the existence of an on-line community
(Graddol 1989).
CMC has been likened to speech, and to writing, and considered to be both and neither simultaneously, although Yates (1994) in particular is dismissive of this approach. He is one of the growing number who view CMC as essentially a new and different form of communication (Yates 1994), with essential differences from other forms (Kaye 1991), and incorporating a range of styles or genres. Poster (1990:76) also criticises the oral/literate dichotomy, believing that it "obscures the uniqueness of electronic language by subsuming it under the category of writing".
CMC messages undoubtedly appear to the reader in written form, albeit as ephemeral phosphorescent dots on a screen that may disappear or forever be removed by a single keystroke, rather than as immutable ink on a page (Leslie 1993). Despite this, many have noted that the discourse often resembles speech in its flexibility and informality (Kaye 1989, Leslie 1993).
While many CMC messages may exist ephemerally and are never saved, many lists archive all contributions, so that a "group which exists through an exchange of written texts has the peculiar ability to recall and inspect its entire past. Nothing quite like this is available to a community based on the spoken word." (Feenberg 1989:25) This ability to recall and examine the exact form of a communication has profound significance for research conducted on or using CMC (McConnell 1988). Any FTF interview, even if audio or video taped, when transcribed inevitably loses some communicative content. No such loss occurs if a CMC interview is transcribed, as transcription means simply printing the messages, the total communication.
In true post-structuralist style, Bolter (1989:129) suggests that the
"computer promises to redefine the relationship between author, reader
and writing space", while Aycock & Buchignani (1995), drawing on Foucault's
work, question conventional views of the authority of the writer.
Kaye (1989) is among the many who see greater equality in turn-taking in CMC, due to the textual nature and general absence of power mechanisms, while Graddol (1989) sees informal turn taking existing. A detailed analysis of turn taking is provided by Graddol (1989:239-240), who says:
Inasmuch as a form of turn taking exists in lists and computer conferences (as opposed to e-mail), one has to conclude that the second of Sacks et al's (1974) rules generally applies, i.e. anyone may self-select as the next contributor. It is not possible, in a large list or conference with multiple simultaneous threads, to select the next contributor, as the "chronological sequence of the messages does not partake of the logic of spoken or written discourse...The results, and the meaning...are the fruit of a collective endeavor." (Henri 1991:118) This state of affairs has been compared to an "impromptu dramatic dialogues between actors on a virtual stage" (Howard 1993:40).
It is impossible and undesirable to treat all of CMC as a single genre,
the differences in production and consumption of e-mail sent to individuals
and to lists, and of computer conferences, being only some of the factors
that influence the different styles of message (Murray 1988, Porter 1993b).
As will be seen in discussion of the corpus, list messages can be as diverse
as the genres that exist in written and spoken communication, as any message
can be "like a memo [but] could be written in the style of a journal article,
or it could be a short "chatty" reply resembling face-to-face oral discourse"
(Porter 1993b:42).
In analysing CMC, it is generally accepted that the unit of analysis must, of necessity, be the individual message from the single person, even if that message is received by the reader as part of a larger set of messages, as in a listserv digest. In view of this, it may appear that the concept of the utterance, as a unit of communication taking account of prior utterances (Bakhtin 1986), is under threat. This is not, however, the case; even though a response may not immediately follow an utterance, in most cases, interpretation of e-mail messages is dependant on preceding messages (Howard 1993).
It should, however, be recognised that individual messages vary considerably,
with some addressing single, simple issues, while others may be highly
complex. Henri (1991) suggests it may be more appropriate sometimes to
divide messages into smaller units of meaning for analytic purposes.
The next sections address specific educational, organisational, and
finally, nursing examples of real-world use of CMC.
Emms & McConnell (1988) discuss using e-mail and computer conferencing to provide tutorial support for distance learners, while Davis (1992), Holden & Mitchell (1988) and Mason (1988) address its general educational use in the UK and elsewhere. While Mason (1988) sees the main value of CMC as in increasing learners' autonomy, Steinberg (1992) sees it as suitable for developing writing skills and for tasks that require higher order thinking. D'Souza (1991) found greater communication among the class members using e-mail, through counteracting the tendency of a few students to dominate classroom interactions, and facilitating contributions from shyer students, who might be inhibited in FTF situations.
Hiltz (1986:104) advocates that "rather than merely trying to replicate
the traditional classroom electronically", CMC should be used to explore
new, exciting, alternative environments for learning and teaching. Most
recently, Mason (1994c:5) has described the development of on-line courses
and of "trying to push the medium to the limits".
Studies of nurses' use of the Internet are sparse, the main exceptions being the work of Anthony (1994), Taylor (1990), Taylor et al (1990) and Wyatt (1989) in the UK. A number of American authors have also provided descriptions of their use of CMC for educational, research and clinical purposes, e.g. Holtzclaw (1993), Lyness & Raimond (1992), and Ripich (1992).
The following section briefly discusses some of the limited number of
practical examples and studies available.
Lyness & Raimond (1992) used CMC for teaching consensus-building skills to nurses, while Holtzclaw et al (1993) describe a research group's use of CMC for research collaboration, communication, planning; and teaching activities. They discuss how, using the Internet, students were able to maintain contact when teachers were abroad, and the use of e-mail in a research methods course, whereby students sent statistics output files to the teacher, which were scrutinised and feedback sent, all via e-mail. One advantage was that the students "liked the idea of being able to communicate with the teacher and not having to work around appointments" (Holtzclaw 1994). Holtzclaw et al (1993) also describe the use of CMC for writing and collaborating on their paper, in similar fashion to Taira (1993:219), who "sent a query for this article by e-mail. The editor replied, indicating interest and offering suggestions. I then submitted the manuscript by e-mail".
Other practical applications of CMC by nurses include the development of care planning skills by group collaboration in synchronous computer conferencing (Sleightholm-Cairns 1990) and the development of health education information for school students (Billings & Phillips 1991). Russin & Davis (1990) investigated CMC as a vehicle for delivery of continuing education in the USA, but found two major impediments to be funding costs (of start-up and maintenance) and the profession's lack of preparedness, particularly the numbers of nurses capable of using on-line facilities.
In the UK, the short-lived ENB CAL project (Winders 1993) used e-mail for assignment work and promised the development of computer links between clinical and educational areas (Winders 1993). This potential was not pursued, and UK nursing is now far behind North America in this field.
While British nurses have been slow to appreciate the implications of, and potential for use of, CMC this has not been lost on others involved in healthcare provision. Laporte (1994) discusses the use of CMC for information sharing and distance education among, primarily medical, public health workers and the use of existing technology to develop a world-wide infrastructure for improving health.
Anthony (1994a) analysed the use of WWW (World Wide Web) and gopher servers in the Warwick-based NURSE service, to determine the value of such subject-specific servers. The study indicated that the service was used more to facilitate contact than as an on-line database (Anthony 1994a). He found few nurses using the server, at the time of his study one of only two sites world-wide providing nursing-specific services; "10 times as many users are accessing a local service in one university than the entire nursing population worldwide are accessing a specialised nursing service" (Anthony 1994a) (note 2). Surveying nurses on the need for such a server, he found, as would be expected, that they tended to be more computer-literate than most nurses, and probably more highly-educated, as most accesses were from educational sites (Anthony 1994a). The utility of such services is equivocal at present, and
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