Degree and grade of hydronephrosis and its description.
\r\n\tThis book intends to cover major mineral deficiency problems such as calcium, iron, magnesium, sodium, potassium and zinc. These minerals have very important task either on intracellular or extracellular level as well as regulatory functions in maintaining body homeostasis.
\r\n\r\n\t
\r\n\tBoth macrominerals and trace minerals (microminerals) are equally important, but trace minerals are needed in smaller amounts than major minerals. The measurements of these minerals quite differ. Mineral levels depend on their uptake, metabolism, consumption, absorption, lifestyle, medical drug therapies, physical activities etc.
\r\n\tAs a self-contained collection of scholarly papers, the book will target an audience of practicing researchers, academics, PhD students and other scientists. Since it will be published as an Open Access publication, it will allow unrestricted online access to chapters with no reading or subscription fees.
",isbn:"978-1-83881-085-6",printIsbn:"978-1-83881-081-8",pdfIsbn:"978-1-83881-086-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"8bc7bd085801296d26c5ea58a7154de3",bookSignature:"Dr. Gyula Mozsik and Dr. Gonzalo Díaz-Soto",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8935.jpg",keywords:"Calcium, Iron, Magnesium, Potassium, Sodium, Zinc, Diagnostic tools, Treatments, Food Fortification, Malnutrition, Metabolic Disorders, Lifestyle",numberOfDownloads:900,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 26th 2020",dateEndSecondStepPublish:"June 16th 2020",dateEndThirdStepPublish:"August 15th 2020",dateEndFourthStepPublish:"November 3rd 2020",dateEndFifthStepPublish:"January 2nd 2021",remainingDaysToSecondStep:"10 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Professor Emeritus of Medicine at Univesity of Pecs, Hungary, and recipient of Andre Roberts award from the International Union of Pharmacology in 2014. He published 360 peer-reviewed papers, 196 book chapters, 692 abstracts, 19 monographs, and edited 32 books.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.jpg",biography:"Gyula Mózsik, MD,PhD, ScD(med) is a professor emeritus of medicine at First Department of Medicine, Univesity of Pécs, Hungary. He was head of the Department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition. His research fields are biochemical and molecular pharmacological studies in gastrointestinal tract, clinical pharmacological and clinical nutritional studies, clinical genetic studies, and innovative pharmacological and nutritional (dietetical) research in new drug production and food production. He published around 360 peer-reviewed papers, 196 book chapters, 692 abstracts, 19 monographs, 32 edited books. He organized 38 national and international (in Croatia ,France, Romania, Italy, U.S.A., Japan) congresses /Symposia. He received the Andre Robert’s award from the International Union of Pharmacology, Gastrointestinal Section (2014). 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He finished his specialisation on Endocrinology and Nutrition Hospital Clinic of Barcelona. 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From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"3317",title:"Current Topics in Gastritis",subtitle:"2012",isOpenForSubmission:!1,hash:"f771281e35f030a6438b269e736f910d",slug:"current-topics-in-gastritis-2012",bookSignature:"Gyula Mozsik",coverURL:"https://cdn.intechopen.com/books/images_new/3317.jpg",editedByType:"Edited by",editors:[{id:"58390",title:"Dr.",name:"Gyula",surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7943",title:"Nutrition in Health and Disease",subtitle:"Our Challenges Now and Forthcoming Time",isOpenForSubmission:!1,hash:"bf9135b4940c5e9bf0f7de103e543946",slug:"nutrition-in-health-and-disease-our-challenges-now-and-forthcoming-time",bookSignature:"Gyula Mózsik and Mária Figler",coverURL:"https://cdn.intechopen.com/books/images_new/7943.jpg",editedByType:"Edited by",editors:[{id:"58390",title:"Dr.",name:"Gyula",surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3860",title:"Capsaicin - Sensitive Neural Afferentation and the Gastrointestinal Tract",subtitle:"from Bench to Bedside",isOpenForSubmission:!1,hash:"62e71e4f81c52b92224c231016a34231",slug:"capsaicin-sensitive-neural-afferentation-and-the-gastrointestinal-tract-from-bench-to-bedside",bookSignature:"Gyula Mozsik, Omar M. 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It was initially used in the evaluation of radiolucent stones only however, Smith et al. [1] in 1995 showed CT has superiority over intravenous urography (IVU). CT KUB subsequently became the first choice in the diagnostic imaging of urinary tract for obstruction of stones. It has replaced IVU almost completely in the last two decades [2]. It is usually considered the initial imaging modality for suspected acute renal colic and dipstick positive haematuria in an emergency setting and initial diagnostic evaluation of upper tract obstruction. CT KUB has certain clear advantages over other urinary tract imaging for stones. It is not dependent on stone chemical composition; all stones are well seen on CT except for the Indinavir stones [3], it does not require contrast, it can be rapidly performed and can be used in planning endourological treatment.
\nActual protocol of CT KUB for evaluation of stone disease and haematuria will vary depending on institutional guidelines. The general parameters are (i) non-contract examination is performed on multi-detector computed tomography scanner; (ii) supine or supine and prone patient positioning (prone has the advantage of assessing stones near the VUJ); (iii) data interpretation with the use of axial, coronal, sagittal and sometimes curved oblique images for proper evaluation; (iv) scan parameters which includes slice thickness(recommended 5 mm or less), field of view: patient size algorithm: standard technique ( 120 kV/Auto MA .5 rotation); Anatomical start point: 1 cm above the liver Anatomical stop through inferior pubic rami).
\nCT KUB is a quick non-invasive technique for diagnosis of stone disease. It is usually considered the initial imaging modality for suspected acute renal colic and dipstick positive haematuria in an emergency setting. Unenhanced CT is also increasingly being used for treatment planning and post-treatment surveillance for stone recurrence.
\nThis is a study without intravenous or oral contrast, relatively low-dose (in CT terms), and has a very high sensitivity for the detection of renal and ureteric stones. CT KUB allows a rapid, contrast-free, anatomically accurate diagnosis of urolithiasis with a sensitivity of 97–98% and a specificity of 96–100%.
\nThe effective dose of a standard CT KUB examination has been estimated to be between 3 and 5 mSv, which is up to three times that for intravenous pyelography. However, radiation dose in CT KUB is gradually decreasing with the introduction of ultra-low radiation dose CT KUB (0.5–0.7 mSv). These doses are almost comparable to plain film KUB and have shown favourable outcomes similar to standard radiation dose CT KUB. Reductions in CT dose inherently create an increase in image noise. Therefore, a balance has to be found between image quality (signal-to-noise ratio) and restraining the radiation dose.
\nIn comparison to conventional CT, spiral CT is significantly faster. It thus allows acquisition of a complete data set in a single breath-hold and prevents the misregistration of slice location that is typical of conventional CT. In addition, multi-slice spiral CT reduces the time needed for image acquisition, allowing for thinner slice collimation and retrospective reconstruction of thin slices to review challenging areas of analysis.
\nFrom the top of the kidneys through the base of the bladder (mid-liver [T-12] through symphysis pubis), data acquisition is uninterrupted using a maximum of 5-mm collimation with table speed of 5 mm/s. Slice collimation with multi-slice CT is usually 2.5–3 mm with table speed up to 5 mm/s.
\nMultislice technique allows slices as thin as 1 mm to be obtained for problem solving. The thinner slices can be viewed retrospectively without rescanning the patient. Thin slices enable identification of extremely small sized calculi that may be overlooked if the slices are thicker.
\nTurning the patient to a prone position permits differentiation of stones impacted at the ureterovesical junction from stones that have already passed into the bladder.
\nActual protocol of CT KUB for evaluation of stone disease and haematuria will vary depending upon institutional guidelines but following are the general parameters:
\nNon-contrast examination is performed on multi-detector computed tomography scanner.
Supine or prone patient positioning. Prone has the advantage of assessing stones near the VUJ. Some institutions may perform a limited pelvic scan in prone if the supine scan shows a calculus near the VUJ.
Data interpretation with the use of axial, coronal, sagittal and sometimes curved oblique images for proper evaluation.
Scan parameters:
\nSlice thickness: 5 mm
Field of view: patient size
Algorithm: standard
Technique: 120 kV/Auto MA .5 rotation
Anatomical start: 1 cm above the liver
Anatomical stop: through inferior pubic rami
Filming/windowing: soft-tissue window with 3 mm coronal and sagittal reconstructions.
Dual-energy CT scanning is a new technique that can more correctly distinguish different stone types. It involves acquiring CT data at two different X-ray energies (80 and 140 peak kilovoltage [kVp]). Post-processing software can make use of the different attenuation properties of calculi of various chemical compositions at low and high X-ray energies.
\nDecreased exposure is most commonly achieved by modifying tube current and applying new image reconstruction algorithms. Low-dose CT has been shown to maintain diagnostic accuracy compared with standard-dose CT, even in overweight and obese patients when using automated tube current modulation.
\nA clinical decision to order CT KUB has to be made in two different clinical presentations. First is a patient with flank pain presenting in emergency department. The classic clinical presentation of a young man writhing in pain is usually distinctive. However, atypical presentations are not uncommon. CT KUB is still reasonable first-line investigation for all patients presenting in emergency with flank pain as it increases diagnostic accuracy in atypical cases and can detect other pathologies. In a study of 1500 consecutive CT examinations in patients with flank pain, 14% had CT findings other than stone requiring immediate or deferred treatment [4]. Although this diagnostic superiority of CT KUB for flank pain is well established, recent studies have questioned whether it influences management decision in emergency setting. A multicentre, randomised controlled trial of carefully selected patients with suspected nephrolithiasis compared ultrasound with CT KUB and concluded that initial ultrasound decreases cumulative radiation exposure by obviating need of CT in some patients without significant difference in missing high-risk diagnoses, serious adverse events and re-admissions [5].
\nIn a clinical setting, the choice of CT KUB versus ultrasound for initial diagnostic imaging in patients with flank pain should be individualised. Patients who are obese, clearly sick or have associated gross/microscopic haematuria are more likely to benefit from CT scan. On the other hand, children, pregnant women and those assessed to have musculoskeletal pain clinically are more appropriate for ultrasound first approach. Available local resources, for example, expert sonologist should also be taken into account when making this decision.
\nSecond clinical setting requiring CT KUB is incidental finding of hydronephrosis on ultrasound. The decision to request CT KUB will depend on information available on ultrasound and suspected cause of underlying obstruction. In some cases, ultrasound will provide sufficient information to decide further management. For instance, in classic ureteropelvic junction obstruction (UPJO) in a child, ultrasound alone would provide enough anatomical detail to proceed for radionuclide imaging. Similarly small ureterovesical junction stone seen clearly on ultrasound combined with clinical picture is usually sufficient to proceed for management decision. CT KUB is suitable if renal or ureteric stones are suspected as underlying cause of hydronephrosis or a benign pathology, for example, ureteric stricture/retroperitoneal fibrosis is presumed after history and examination. If an upper tract tumour or extrinsic malignant obstruction is suspected, a contrast-enhanced study is more appropriate.
\nUpper tract obstruction may lead to derangement in renal function and it is not uncommon to find raised creatinine in such patients especially if obstruction is bilateral. European Society of Urogenital Radiology recommends that an estimated glomerular filtration rate (eGFR) of less than 45 ml/min/1.73 m2 particularly with other risk factors, for example, diabetic nephropathy and dehydration increases the risk of contrast-induced nephropathy (CIN) [6]. This effectively precludes contrast-enhanced study in such patients. CT KUB is helpful in excluding calculi and may even provide a definitive diagnosis in up to 40% cases of non-calculus obstruction [7]. MR urography will be required for making a definitive diagnosis in remaining cases.
\nCT KUB is currently considered as the first line imaging in the evaluation of stone and obstruction (Figure 1) and is preferred over an IVU [2]. This is in view of high sensitivity and specificity of CT over other imaging modalities. It is particularly useful in the diagnosis of ureteral stones (Figures 1 and 2) with sensitivity of 95–98% and specificity of 96–98% [8, 9]. It is of particular value in patients with renal failure, which precludes use of intravenous contrast, and ultrasound has limited value [10]. The sensitivity of ultrasound in the evaluation of ureteral stones when compared with CT KUB is only 46% and for hydroureter in half of the cases. CT KUB in the evaluation of ureteral stones is able to identify ureteral dilation in 83%, hydronephrosis in 80% and perinephric oedema in 59%, and ipsilateral nephromegaly in 57.2% of cases [11].
\n(a) Hydronephrosis (asterik), reduced peripelvic fat (white arrow) and increased perinephric fat stranding (black arrow) as compared to contralateral side and (b). CT KUB axial, sagittal and coronal sections demonstrating multiple calcific densities near the bulbar urethra likely representing urethral diverticulum with stone formation.
CT KUB axial and coronal sections demonstrating an obstructing right proximal ureteric calculus.
In addition to diagnosis of stone and obstruction, it is also used in the work up haematuria. Asymptomatic micro-haematuria (AMH) is relatively common and is often not associated with urinary tract malignancies. The current guidelines indicate evaluation of upper urinary tract with contrast-enhanced CT (CECT). This often leads to identification of extra-urinary tract abnormalities. The diagnoses of such conditions often require extensive work for most conditions, which are inconsequential [12]. These are often observed on non-contrast CT imaging as well [13]. In vast majority of cases, ASH is idiopathic followed small renal stones (Figure 3) and other benign causes. Ultrasound is often the initial imaging, however, CT KUB can be used in lieu.
\nCT KUB axial and coronal sections demonstrating a left renal pelvis calculus (a and b) and left distal ureteric calculus (c).
Acute onset flank pain suggestive of ureteral obstruction is a common presentation in the emergency room (ER) setting. Introduction of CT has decreased the time in decision-making [14] about the possible aetiology of cause of flank pain [15, 16]. Clinical evaluation and ultrasound often makes it difficult to differentiate ureteral obstruction from other pathologies. However, CT not only quickly identifies urolithiasis but also identifies other causes of flank pain [17]. This includes both genitourinary and extra-genitourinary abnormalities. Stones from ureter-vesical junction sometimes pass into the urethra (Figure 4) without significant changes in symptoms, these can be diagnosed by careful inspection of the CT.
\nCT KUB axial, coronal and sagittal sections demonstrating a calculus in the prostatic urethra.
Initial clinical evaluation including dipstick test for micro-haematuria also lack sensitivity. Li et al. [18] noted during the period of 4 years that there were 159,083 emergency visits. During this period, 397 had urolithiasis, in these patients absence of haematuria was noted in 9% (95% confidence interval 7–12%). The next step in the management of patients with stone is to determine the extent of obstruction and of any complications from obstruction and stone. None of the conventional imaging, that is, IVU, ultrasound and plain X-ray KUB is sensitive enough to answer the question. CT KUB due to its high specificity and sensitivity to diagnose ureteral stones is ideal imaging in such a situation. However, CT without contrast has limitations being a non-contrast study. Secondary signs of obstruction like perinephric, periureteral stranding and unilateral nephromegaly are sometimes helpful. Bird et al. [19] in a study assess the significance of secondary signs of obstruction on CT KUB and noted that they do not correlate with degrees of obstruction on MAG-3. The authors suggested use of CT KUB in combination with radioisotope scans [9]. This is cumbersome particularly in an emergency room setting. As an alternate, Kravchick et al. [20] suggested the use of dynamic renal sonography in combination with CT KUB, particularly in patients with raised white cell count and stone larger than 4 mm. This is particularly useful in triaging patients who need admission in the hospital.
\nModern endourological interventions are becoming increasingly minimally invasive. Percutaneous nephrolithotomy is performed with 24–30 Fr. Amplatz; however, finer nephroscope has led to the introduction of mini (2001), micro (2011) and ultra mini (2013) [21]. Planning for these interventions require precise pre-operative assessment of stone size, location and anatomical abnormalities including caliceal narrowing, presence of caliceal diverticulum, etc. CT can be instrumental in making pre-operative assessment. It has been seen that increasing stone volume can influence post-operative complication rate. It is being observed that >4 cm stones are associated with significantly higher rate of post-operative pyrexia and need for transfusion [13].
\nThe sensitivity and specificity of CT in the diagnosis of stone is well established. Even small stones, which would otherwise be missed on most other imaging, can be identified on CT. However, CT has utility beyond recognising the presence of stone in the urinary tract. It can be used in planning endourological interventions. Stone size, composition, location, skin to stone distance, etc. are some of the well recognised parameters used in the risk stratification and predicting success of treatment [22].
\nShock wave lithotripsy (SWL) is the most minimally invasive treatment in the management of urolithiasis. Prediction of success for renal stones is often done on a CT KUB using estimation of stone volume, density (using Hounsfield Units) and skin to stone distance [23]. In a recent work, Park et al. [24] noted that BMI and perinephric oedema in addition to stone density are independent predictors of success of SWL. Ureteral stones requiring interventional treatment are either treated by SWL or ureteroscopy. Success of ureteral stone is dependent on stone size [25]. The success of treatment is assessed not only by stone free rate but also need for ancillary treatment and number of sessions required to clear the stone [26]. One important factor responsible for failed medical SWL for ureteral stone is stone impaction, defined as stone stuck in one location for over 1 month. Sarica et al. [27] recently noted that of all the evaluated stone- and patient-related factors, only ureteral wall thickness at the impacted stone site independently predicted shock wave lithotripsy success.
\nStone size is one of the most important parameter in deciding the management of ureteral stone. In a recent work, Soomro et al. [28] compared the mean stone size, as measured on bone window versus standard soft-tissue window setting using multi-detector computed tomography (MDCT) in patients with a solitary ureteric stone. They noted that the stone size measured using the soft-tissue window setting on a MDCT is significantly different from the measurement on the bone windows. Earlier work also indicated that the transverse stone diameter on axial images of CT KUB underestimates the size of ureteric stone [29]. The authors suggested that coronal re-formatted images be used for size estimation.
\nPercutaneous nephrolithotomy (PCNL) is a minimally invasive treatment modality used in the management of >20 mm kidney stones, and as such, is considered as the primary modality by EAU and AUA guidelines [30, 31]. Predicting complications and success of percutaneous surgery for urolithiasis can now be reliably done using one of the several nephrolithometry scores [22]. Nephrolithometry scoring systems are based on pre-operative stone and patient features and they demonstrate and stratify relationships between kidney’s anatomy and stones. Currently there are three scoring systems; Guy’s score [32] described in 2011, S.T.O.N.E. nephrolithometry system [33] and CROES nephrolithometry nomogram [34] in 2013. In a recent work by Choi et al. comparing these three scoring systems for tubeless PCNL, noted that Guy’s stone score was the only significant predictive factor for stone free and complication rates. However, Tailly et al. [35] earlier noted no difference in the ability to predict stone free rate comparing the three scoring systems after PCNL.
\nPCNL is safe surgical procedure and is not associated with high grade on Clavien grading. The most frequently reported complication following PCNL is infection and haemorrhage, however one of the most devastating complication is a surrounding organ injury including bowel injury. According to the Clavien-Dindo classification of surgical complications, colonic injury is regarded as a stage IVa complication. The incidence of colon injury is reported to be 0.3–0.5%, however in a large recently reported series, AslZare et al. [36] noted 11 cases in 5260 cases of PCNL. Colonic injuries are seen in patients with retro-renal colon, the prevalence of retro-renal colon in males to be 13.6% on the right and 11.9% on the left, whilst in females it was 13.4% on the right and 26.2% on the left [37]. CT KUB is instrumental in recognising retro-renal colon prior to PCNL. Most of the colonic injuries are now managed conservatively with drainage of colon via percutaneous drain, insertion of JJ stent to drain kidney, intravenous antibiotics and bowel rest by giving intravenous nutrition.
\nOnce a CT KUB abdomen is ordered for suspected upper tract obstruction, it should be reviewed for secondary radiological signs of obstruction, site of obstruction and underlying pathology. Moreover, associated findings, for example, dilated appendix, ovarian cysts, spinal pathologies should be considered and systematically reviewed.
\nClassic secondary radiological signs on CT KUB suggesting upper tract obstruction include: dilatation of renal pelvis, dilated ureter and perinephric stranding (Figure 1a and b). Renal pelvis is identifiable as area of low attenuation compared to adjacent renal parenchyma. Dilatation of renal pelvis (hydronephrosis) usually appears as anterior and medial bulging of this low attenuation structure. In some cases, dilated renal pelvis may be difficult to differentiate from a prominent extra renal pelvis. However, dilated calices that obliterate the renal sinus fat help in making this differentiation. CT is also valuable in differentiating between stone and stent (Figure 5), particularly with the use of bone windows.
\nCT KUB axial, coronal and sagittal sections demonstrating a left-sided double J stent in place.
An assessment of degree of obstruction can also be made on CT KUB (Table 1). The Society of Foetal Ultrasound first described the grading system for hydronephrosis [38]. Similar description has also been applied to other imaging modalities like intravenous urography and CT [39].
\nGrade | \nDegree | \nDescription | \n
---|---|---|
Grade 0 | \n\n | No dilation caliceal walls opposed to each other | \n
Grade 1 | \nMild | \nDilation of renal pelvis without dilation of the calyces | \n
Grade 2 | \nMild | \nDilation of renal pelvis and calyces, no cortical thinning | \n
Grade 3 | \nModerate | \nDilation of the renal pelvis and calices with blunting of papillary impression with or without cortical thinning | \n
Grade 4 | \nSevere | \nGross dilation of the renal pelvis and calices with associated cortical thinning | \n
Degree and grade of hydronephrosis and its description.
Dilatation of ureter when present should be traced down to the site of obstruction, to differentiate between phlobolith and stone (Figure 6). The dilated ureter is usually traceable from ureteropelvic junction when viewing coronal sections at a workstation. However, combining information from both axial and coronal images may be needed, especially for the lower ureter obscured by bowel loops or iliac vessels (Figure 6). Curved planar re-formatted images have been utilised to provide images mimicking a contrast-enhanced study and improve diagnostic yield for ureteric lesions [40]. UVJ stones could be differentiated from vesical stones by prone CT of the bladder area (Figure 7).
\nCT KUB axial and coronal sections demonstrating s in the pelvis.
CT KUB axial supine and prone positions demonstrating a left-sided VUJ calculus.
Once tracing the dilatation of ureter identifies site of obstruction, it should be reviewed for intraluminal, luminal or extra luminal obstructing lesions. Intraluminal pathologies include stones, blood clot and papilla. Fortunately the most common obstructing lesion, that is, stone is almost always CT dense and easily identifiable. In the absence of obstructing stone and positive radiological signs of obstruction, one should consider differential diagnosis of passed stone, pyelonephritis or obstruction caused by lesion not visible on CT KUB. Such lesions include blood clot, papilla and Indinavir stone. Reviewing clinical picture can narrow these differentials. For instance, Indinavir stone occurs only in patients treated with this protease inhibitor for HIV and papillary necrosis is more common in diabetic patients with analgesic nephropathy.
\nPresence of ureteric thickening or narrowing at the site of obstruction is suggestive of ureteric stricture. Differentiating benign from malignant strictures would require a contrast-enhanced study or endoscopy. Extramural lesions causing obstruction include pelvic tumour, retroperitoneal mass and retroperitoneal fibrosis. Retroperitoneal fibrosis is classically seen as irregular, well-defined iso-dense mass surrounding aortic bifurcation. It usually follows the common iliac arteries and expands laterally to trap ureters. Differentiation from retroperitoneal malignancies may be difficult even after contrast-enhanced study. Enhancement after contrast administration is variable and depends on degree of metabolic activity and on-going fibrosis. Presence of bone destruction and displacement of major vessels will be suggestive of malignant process [41].
\nLimitations of CT KUB include the fact that CT has limited spatial resolution. Therefore, its negative predictive value in completely excluding sub-millimetre calculi and small stone fragments is significantly less than its negative predictive value in excluding larger calculi (>4 mm). In addition, repeated use of CT in patients with recurrent urolithiasis can result in a substantial cumulative dose.
\nDetails of pelvicalyceal anatomy may not be apparent on non-contrast-enhanced study. Intravenous urography or CT urography may be required if specific anatomical details are needed for making a management decision, for example, bifid system, stone in a calyceal diverticulum or narrow lower pole infundibulum.
\nCT KUB is a static study and the abnormalities related to urinary dynamics, that is, UPJ obstruction, obstructive versus residual dilatation of the collecting system, etc. cannot be appreciated. Complementing CT KUB with either MAG3 scan or dynamic Doppler ultrasound are some of the modifications recommended.
\nThe other major limitation of the CT KUB is the risk of radiation exposure. Dose reduction by various technical modifications has been recommended [42]. In a systematic review, Xiang et al. [43] noted that lowering the dose of radiation of CT does not negatively impact the sensitivity and specificity in the diagnosis of stone and obstruction. They noted that low dose CT KUB has a cumulative sensitivity of 93% and specificity of about 97% [19].
\nIn a meta-analysis reported by Niemann and colleagues [44] some 9 yeas back, they noted that dose reduction attempts resulted in mean dose of less than 3 mSv without jeopardizing the pooled sensitivity (97%) and specificity (95%). However in the last decade, there has been significant interval improvement with iterative reconstruction techniques, detector series and arrangements. These modifications have allowed a further reduction in dose to <1 mSv [45]. This is quite comparable to plain X-ray KUB at 0.7 mSv [46].
\nNon-contrast CT abdomen has emerged as first line investigation in suspected upper tract obstruction. Underlying cause can usually be ascertained on CT KUB. However, further investigations may be required to delineate/confirm underlying pathology like UPJ obstruction, differentiation between obstruction and residual dilatation, etc. CT KUB is not only extremely sensitive and specific in the diagnosis of stone; it is now used in the pre-operative nomograms in predicting success of various endourological interventions like PCNL an SWL. Determination of stone density, stone volume, stone composition, skin to stone distance, presence of ureteral wall oedema, perinephric oedema are highly predictive of stone free rate. CT recognition of various anomalies, presence of retro-renal colon, horse-shoe kidney, malrotation, etc. can help in better planning to avoid complication. One of the major limitations of CT is the radiation dose. Modification in technique and technological innovation has resulted in significant dose reduction from 4.5 mSV to about 1 mSv.
\nThe 21st century is, according to Dede [1], quite different from the 20th in regard to the skills people need for work, citizenship, and self-actualisation. Proficiency in the 21st century differs primarily due to the emergence of sophisticated information and communication technologies (ICTs). All over the world, ICT in education has been incorporated into formal national guidelines of the degree requirements of teacher education as an official policy. Digital technology in itself is often seen as a catalyst for educational change, and technology as a symbol for change is often understood as something positive, as investments in technology supports development in society [2].
\nDespite the fact that a fifth of the 21st century is behind us, it seems we are not up to speed regarding the skills anticipated as central for our digital era. Furthermore, there is a lack of clarity regarding what 21st century skills really are. The digital revolution is part of the change making 21st century skills different from those learned in schooling through the 20th century. ICT is changing the nature of perennial skills that are valuable in the modern world, as well as creating new contextual skills necessary for digital societies [1]. The world has changed fundamentally in the last few decades, and in effect, the role of learning and education has changed. Many of the skills needed in past centuries, such as critical thinking and problem solving, are, according to Trilling and Fadel [3], even more relevant today. How these skills are learned and practiced in everyday life in the 21st century though, is rapidly shifting.
\nThis chapter presents a critical perspective on how learners’ information, media and technology skills can be understood, and how they are connected to learning and innovation skills. Data for this chapter is based on qualitative in-depth interviews of ten teaching educators at the University of Waikato in New Zealand and ten teaching educators from UiT, the Arctic University of Norway. Both countries are facing similar educational challenges when teaching in digital environments, as both must educate teaching students in digital-rich environments with high access to various ICTs and educational resources at home [4]. The universities are similar in size and student numbers.
\nThis comparative study of Norwegian and New Zealand teaching education has led us to question how we educate students to meet the future and whether the educational systems are adapting sufficiently to new digital learning contexts. Is teaching students’ deep learning and critical thinking at risk of being limited in digital learning environments? In short, are students sufficiently prepared for the future?
\nThere is widespread agreement among educators and the public about the importance of the traditional fundamental building blocks that underpin student learning. These skills are often referred to as the 3Rs—reading, writing and arithmetic [5]. These are important skills, but as Crockett et al. [6] have argued, for students to progress from the foundations of learning, teachers need to expand their thinking outside their ‘primary focus and fixation on the Three Rs (3Rs)—beyond traditional literacy to an additional set of 21st century fluencies, skills that reflect the times we live in’.
\nThe notion that the 3Rs are not sufficient when preparing students for the future is not a new idea. Broader skills are needed and have been discussed since the first half of the 20th century. One example is an informal meeting of college examiners attending the 1948 American Psychological Association Convention in Boston, which was the start of the development of the theoretical framework known as Bloom’s taxonomy. This is a well-known and commonly used system of classifying the goals of the educational process beyond the 3Rs [7]. A common ground in the search for 21st century skills is by Keane, Keane and Blicbau [8] described as the 4Cs:
Critical thinking
Communication
Collaboration
Creativity
This understanding is based on three influential organisations associated with education, management, and industry developed definitions for 21st century learning. These organisations are the Ministerial Council for Education, Employment, Training and Youth Affairs (MCEETYA), the American Management Association (AMA), and AT21CS, a public and private partnership among governments, educators, academics, and industries [8]. While basic skills such as numeracy and literacy remain essential building blocks for learning, higher order skills such as the 4Cs are equally vital for learning and employment in the 21st century. Keane and Blicbau [5] write that 21st century skills are about fusing the 3Rs and the 4Cs, but the contextual aspect is also of great importance because context contributes to defining and affecting how different skills are used.
\nStudents in the 21st century live in a technology- and media-rich environment with access to a wide range of information, powerful digital tools, and the ability to collaborate and communicate with others. This affects what form of critical thinking is required. Fundamental to the development of 21st century skills is the importance of ICT for learning [8]. A discussion paper prepared for the European Union stated that information and communication technology (ICT) is at the core of 21st century skills. It is regarded as both an argument for the need for these skills, and a tool that can support the acquisition and assessment of them. The rapid development of ICT also requires a whole new set of competences related to ICT and technological literacy [9].
\nKeane, Keane, and Blicbau [8] write that using these technologies in education matter because students need to be prepared this digital world, in which they require a skillset that is broader than the traditional foundations of the 3Rs. Tucker and Courts [10] claim that teachers who mainly concentrate on a fixed curriculum that focuses on learning through repetition and memorisation find it difficult to connect new technologies to the traditional view of classroom learning.
\nTo be effective, teachers and students need to be able to demonstrate both the 3Rs and the 4Cs in relation to an online world. Government policy has been somewhat based on the assumption that access to technology is the key to achieving success. However, simply providing students with digital technology will not lead to development of these skills. How the teacher utilises these devices in the classroom is important for improved student outcomes [5]. Dede [1] claims that we need to move from consensus about the vision of 21st century learning to a thorough understanding of and commitment to the outcomes of 21st century learning. In reality, he claims, the ability to use digital devices in no way means that students know anything about global awareness or health literacy, learning and innovation skills, life and career skills, or even media literacy skills.
\nThere are new skills to master, and they must be understood intertwined with changing contextual skills. Trilling and Fadel [3] have an extended model, where the 4Cs are part of a skillset called learning and innovation skills. They propose two extended sets of skills: information, media and technology skills; and career and life skills (see Table 1).
\n1. Learning and innovation skills | \n2. Information, media, and technology skills | \n3. Career and life skills | \n
---|---|---|
\n
| \n\n
| \n\n
| \n
Three components of 21st century skills [3].
It is important to keep in mind that digital technology in itself is just a tool. Keane and Blicblau [5] state that without an understanding of learning theory, the use of transformative technology may actually be ineffectual. So, to have digital competence for learning, technological skills must be understood intertwined with other sets of skills and knowledge, like learning and innovation skills (the 4Cs).
\nThis has been an ongoing discussion for centuries, and yet it seems like educational practices and systems are having trouble adapting to the espoused learning theories, required formal policy, and understanding of the need for these skills [11]. Keane and Blicbau [5] criticise education for using technology in schools at the enhancement rather than the transformative stage, meaning that tasks could be completed satisfactorily without using technology, and without really changing the task. They claim we need to better provide the appropriate situations that will allow students to develop skills using the 4Cs. Lund [12] claims that schools either lack a view of technology or operate with a view of technology that is at best reductionist. A central control and management mechanism in schools is a standardised test. These tests provide some insight into students’ learning outcomes, but if used unilaterally, may also risk the development of a limited dynamic practice. As Resnick [13] writes, when preparing children for the future, how learning outcomes are assessed must be reconsidered. We need to focus on what is most important for children to learn, not what is easiest to measure and evaluate. The same concern is expressed when discussing digital technology and education. If we are only concerned with measuring the effects of the use of technology, instead of examining how digital technology changes the school culture, we risk cultivating a reductionist approach and ignoring possibilities for innovation [12]. These challenges are not exclusively related to digital practices, as school traditions for learning have in general been criticised for being pacifying. Jordet [14] writes that Norwegian schools are characterised by sedentary activities where the students are placed in the role of passive recipients of handed down knowledge. Such educational practices give students few opportunities to unfold their relational, meaning-seeking, creative, exploratory, and intentional natures. He states that for schools to be able to contribute to children mastering their lives and becoming participants in work and society, the schools’ traditions, thinking, and practices must be changed to better support students’ self-realising and active natures. Oostveen, Oshawa, and Goodman [15] found that meaningful learning is far more likely if new technologies are recognised as providing transformative opportunities.
\nElstad [16] claims that young people born after 1980 have digital capabilities and are therefore regarded as digital natives, in contrast to older teachers who are described as digital immigrants when born earlier than 1980 [17]. Digital immigrants are in governing positions in education, both as policymakers and educators. Could important stakeholders’ lack of digital technology be the reason education is not keeping up to date with new learning theories? Most teaching students referenced in this study were born in 1980 or later and are considered digital natives. Prensky describes digital natives as ‘native speakers of technology, fluent in the digital language of computers, video games, and the internet’ [18]. In this chapter, we present teaching educators’ evaluations of their students and their learning processes. In other words, so-called digital immigrants are evaluating digital natives, but it is not merely their technological skills being evaluated. As mentioned, these skills must be understood as intertwined. Students’ learning and innovation skills, like critical thinking, are intertwined with their information, media, and technology skills, and both sets of skills must be trained. Combined, it creates the need for new contextual skills. Keane, Keane, and Blicblau [8] write that simply using technology does not guarantee that deep learning will occur. The use of technology needs to align and adapt with our knowledge of learning to be able to operate in a transformative space.
\nA study of teaching students and their educators showed that teaching educators scored higher on professional digital competence than their students, but were more critical towards the technology in educational contexts than their students [2]. The differences between teaching educators and teaching students in this study were mostly unrelated to being digital immigrants or natives. They were connected to the complex competence gained through professional practice, regarding the interaction of content knowledge, pedagogical knowledge, and technological knowledge [19].
\nKnowledge of technology is only one critical component of teachers’ use of technology in their practice; they also need to know how to use it for successful integration in teaching and student learning. Being critical is not necessarily about being behind and not up to date, but about taking steps aside to gain a deeper perspective. Successful teaching is not only about finding the right technology, but also the values, norms, and attitudes that reside within the academic staff in teacher training organisations [2].
\nOne group of digital natives is defined as Generation Z. Tucker and Courts describe Generation Z as those who were born after 1990 [10]. This generation is described as ‘technically savvy, well adapted at communicating via the internet, and used to instant action due to the internet technology they have always known’. The traditional education model has, according to Tucker and Courts [10], been slow to adapt to the learning styles of these students, and researchers across the globe seem to agree on this. What seems more unclear is an understanding of what form of adaptation is needed, and how we get there. How do Generation Z’s learning styles and strategies affect learning processes in education?
\nDeep learning involves paying attention to underlying meaning. It is associated with the use of analytic skills, cross-referencing, imaginative reconstruction, and independent thinking. In contrast, surface learning strategies typically place more emphasis on rote learning and simple descriptions [20]. Deep approaches differ from surface approaches, where reproducing knowledge and syllabus-bounded practices is central. A third approach is the strategic approach, which is based on a competitive form of motivation and attempts to maximise academic achievement with minimum effort [21]. One tool for understanding deep learning is Biggs and Collis’ [22] developed structure of observed learning outcomes (SOLO), which form the basis of the SOLO taxonomy. The SOLO taxonomy focuses on the development of surface understanding to deep understanding, with a continuum of complexity and response to learning across the hierarchy of its levels of understanding. The SOLO taxonomy illustrates different levels of understanding:
Prestructural understanding is described as incompetence.
Unistructural understanding where relevant aspects can be identified.
Multistructural understanding where aspects are combined and described.
Relational understanding integrated in multistructural understandings. Being able to analyse, apply, argue, and compare aspects of one’s understanding.
Extended abstract is when the learner is able to create, formulate, generate, hypothesise, reflect, and theorise based on a relational understanding.
The higher the levels of understanding in the SOLO taxonomy, the higher the level of critical thinking, creativity, and communication. Critical thinking is the discipline of actively and skilfully conceptualising, applying, analysing, synthesising, and/or evaluating information gathered from, or generated by observation, experience, reflection, reasoning, or communication [5, 8]. All these aspects are central for 21st century skills and deep learning.
\nWhen teaching educators are asked about students’ learning processes, there is great concern regarding their ability to apply deep learning approaches. This is a complex field with a range of perceptions and understandings. Many of the teaching educators expressed conflicting views, where they addressed challenges and described how digital technology was fostering learning. In this chapter, we focus on the challenges of teaching with digital technology, and not so much on the benefits, which are many.
\nThis study is based on an explanatory sequential design, in which a conducted survey comprises the first phase of a sequence of methods. It is a comparative study involving 64 Norwegian participants from UiT, the Arctic University of Troms, and 44 New Zealand participants from the University of Waikato, with a response rate of 83.8% and 73.4%, respectively. The survey builds on Argyris and Schön’s theory of action [23] and consists of three main constructs: professional digital competence, professional attitudes towards digital technology in education, and professional application of digital tools.
\nBased on their results, ten participants from each university were invited to participate in an in-depth qualitative interview.
\nThe first step in strategically selecting interview participants was to ensure that all participants had
Selection of Norwegian teaching educators.
Selection of New Zealand teaching educators.
A total of 20 semi-structured interviews were conducted to understand and elaborate upon the results of the survey. The transcribed interviews were subsequently analysed using NVivo. One must consider the uncertainty arising when translating from one language to another. The survey, interview guide, and participant statements were translated from Norwegian to English. There are nuances when translating and analysing that may be lost, and these could have influenced the results. An ongoing collaboration with New Zealand researchers throughout the process was very helpful in concept- and language-related clarifications.
\nThis builds on a comparative study, but findings showed that the challenges experienced were evident in both countries. Despite being from different sides of the globe, teaching educators from both Norway and New Zealand expressed a concern regarding students’ learning in digital contexts. Overall, 13 of the 20 interviewed teaching educators expressed a concern regarding students’ deep learning, critical thinking, and source criticism. They link the students’ lack of learning and innovation skills with their level of digital literacy skills (cf. Trilling and Fadels’ model of 21st century skills). If their learning and innovation skills are not high enough, their use of digital technology seems to be at risk of not being used at a transformative level, and in some instances limits the quality of their learning processes.
\nOne of the teaching educators was quite astonished that students could be very technically competent without being able to search the web for knowledge. He explained that he had bachelor students not able to find literature, and when he demonstrated, the students were blown away as if it was magic. The ability to make use of keywords when searching for information and relevant articles was poor among students, he said, and he was surprised by the fact that they were not able to use the knowledge they ought to have attained during their education.
\nAnother teaching educator claimed that the students’ learning approaches were superficial and based on surface learning. She explained the reason was that they had not learned or practiced deep learning processes. ‘When asked to read a text, they do not extract what is important and relevant. They just dutifully read to complete the task’. She said it was fine that they were using Google when studying, but the worry was that the content seemed to move straight from the screen and out of their mouths, bypassing the students’ own relevant reflections. Another teaching educator claimed that there was an evident difference between students who had studied media and communication at the senior level in school and those who had not. They understood that there was quite a lot of work involved in being able to utilise the digital tools in a productive way, while the rest was basing their learning processes on a copy-paste strategy. She explained that students tended to express a strategy of searching for readymade abstracts online. This was very unfortunate because the type of learning we want to promote in our teacher education is largely based on reflection, not just reproduction of readymade connections between levels of understanding.
\nI asked the teaching educators if it was a challenge to get students to engage in deep learning when readymade answers were easily assessable online. The teaching educator replied, ‘Of course’. He explained how he had noticed that students were often using online references instead of the syllabus. ‘It can be the same keywords as is described in our syllabus, but they would rather google it. So, that is when I question what source criticism they have applied to secure their information’. He explained that the students were not concerned with this, and uncritically used this on tests and exams. One critical question to be asked was: When using a traditional lens when assessing the students, what are we measuring as new tools and contexts for learning have transformed learning activities and outcomes? Do we have practices for evaluation that aligns with the new learning activities and intended outcome?
\nThe same teaching educator’s experience with digital tools was that they were not always helpful. Furthermore, he felt it somewhat distorted/disabled the learning processes. This understanding was confirmed by another educator who explained that she thought of digital technology as a detour. ‘Sometimes we use digital technology like PowerPoint, when traditional methods like using a black board can work as a better tool’. She explained that students expressed their preference for educators using PowerPoint, as they found it better not having to write everything down.
\nIn New Zealand, teaching educators were also vocal regarding this challenge. One teaching educator explained how she had noticed that students were increasingly entering search words in Google to access what she referred to as ‘easy takeaway knowledge’. The consequence, she explained, was that the students did not have to engage deeply or really work with the content. ‘Students can access it very easily, and it almost replaces thorough research, like reading academic articles,’ she said. She explained how this availability of a lot of information on the internet undermined students’ capacity to read critically, do research, and read academic journals or chapters. She elaborated that this aspect of availability, quick easy access, was undermining the development of academic capacities and serious research for assignments. A critical selection of information takes more time. ‘You have to actually digest those harder articles, and it seems to me that students read less of those […] even if they use them in their assignment it is superficial.’ Another one supported this perception and explained: ‘the easiness of technology creates a false notion of what learning is about, that you don’t have to work for knowledge. I don’t think that’s true. If you look at anyone who is good at something, they have put in a lot of work and practice. I think digital technologies might be kind of responsible for this notion of learning’.
\nSome research shows that students who often use technology tend to do worse when compared with students who use less of such tools [4, 25, 26, 27]. Mueller and Oppenheimer [28] conducted a study in which they concluded that the use of a laptop negatively affected the students’ test results. They focused on the students’ use of laptops instead of traditional writing during lectures. They argued that note taking by hand calls for different cognitive processes than writing on a laptop. One can write faster on a laptop and take more notes. ‘Although more notes are beneficial, at least to a point, if the notes are taken indiscriminately or by mindlessly transcribing content, as is more likely the case on a laptop than when notes are taken longhand, the benefit disappears’ [28]. Writing by hand is slower, and one cannot take verbatim notes in the same way as with a laptop. Instead, students listen, digest, and summarise so that they can succinctly capture the essence of the information. Taking notes by hand forces the brain to engage in deeper learning, which fosters comprehension and retention [29, 30, 31]. As May points out, ‘even when technology allows us to do more in less time, it does not always foster learning’. This is in line with the teaching educator who claimed that that learning has a tendency to be too easy. When students are copying and pasting from the internet and using digital technology uncritically, they miss out on the constituting process of struggling with individual concepts and developing their 21st century skills, like reflecting, generating, being creative, theorising different concepts, and communicating independent ideas. It seemed like the teaching educators had trouble engaging students in deep learning processes as digital technology created a learning environment that fostered the strategic approach, and they experienced challenges where students attempted to maximise academic achievement with minimum effort. Perhaps they did this unaware of the consequences these approaches could have on their potential learning outcomes.
\nDeep learning strategies cannot be externally imposed and must be interest-led. Interest can be stimulated by placing less emphasis on curriculum content and more on contextual interpretation, in other words, the 4Cs [20]. Learning activities need to be interesting and engaging and allow critical reflection and dialogue with peers and mentors [32].
\nCritical thinking is vital for problem solving, but one teaching educator explained that students’ critical thinking skills were virtually non-existent, and that a lot of effort was put into trying to develop those skills alongside their digital skills. Another explained that as much as digital tools were creating opportunities in teaching, they were also creating challenges. Those challenges were related to teaching students to be critical. When is it useful to use it, and what resources are usable in academic settings?
\n‘The students’ ability to use and utilise digital tools shocks me, because it is very poor. They are consumers; they are not producers. The job we do here is about making them able to become producers as well, so that they can utilise the learning resources available. They need to be prepared better through high school in relation to the critical use of digital tools; there are many who have major shortcomings. I think it has gotten worse really, because it’s like if it’s not on Facebook or Google, then it does not exist. It’s a little scary. It seems that they are becoming less and less aware that it is just a person who has written this, and that information could have been written with underlying agendas. The critical reflections are something we have to work quite a lot with, and more for each new class just the three years I have been here.’ (translated from interview).
\nOne teaching educator related the challenge to the fact that it was very easy to retrieve information, without necessarily understanding what it means. One can just type in a word or look something up, ‘then you just read exactly what comes out, because you typed in a word’. The problem, she explained, was that the students were not able to see the whole picture. It was noticed in their presentation on exams, or in things they wrote, that they did not fully understand the concepts they were writing about. Their presentation was really just reformulation of something copied from the internet, and was not coherent.
\nOne challenge is related to what extent they understand the concepts they are writing about; another is whether the source is trustworthy. The students were warned both in writing and orally, one teaching educator explained, not to use bloggers’ opinions and secondary interpretations as a basis for academic writing. The students still handed in papers with hardly any syllabus literature or academic references. One teaching educator explained that she had been teaching for so long that she remembered well the time when education was much more book centred.
\n‘One had to search for and order different articles at the library, and so on. Now it is all online, and that is great. It makes things easier. From that perspective, the students have accepted the possibilities online, and that is good. Nevertheless, there is a negative side to this. I do not find that students’ source criticism has developed or increased according to this change. For instance, I do not accept references to Wikipedia in my papers, even if there is a lot sensible information written there. I encourage them to start there to get an overview. It can function as a platform for relevant references. But they have to be critical regarding what they are basing their arguments on, and the skills to do this are lacking.’
\nThe same perception is widespread among the New Zealand teaching educators. One explained that one of the things they were focusing on was critical analysis and information literacy. He said, ‘The information is at our fingertips, but we need to really think about when we’re using it and how it’s being used, and be able to seek out robust information for what we need, and understand exactly what we’re using’. Another participant explained that she had noticed that there was an overreliance on inaccurate media rather than knowing that they could go to a particular resource and have more valid information.
\n‘So they can’t make those kind of judgements about what is valid and what isn’t valid to cite, because there’s been no role models for them to look at and learn from. So the whole concept to any kind of academic approach to writing, whether it is through social media or other aspects of writing, is a very big learning curve for them… they struggle.’
\nThe same challenge was exemplified by an interaction with another teaching educator and a student.
\n‘One of my postgraduate students this week wanted to know what I meant by “doing critical review”, which is an instruction for an assignment. And she copied something in, and I said: Where did you get this from? She said: Oh, I got it off Mr. Google, and I’m sort of thinking is this really, you know… This is a postgraduate student who is saying that, and doing that. That is actually pretty problematic. So, you can’t make too many assumptions about where people are at.’
\nShe explained that the biggest challenge was that the students needed to develop their critical perspectives on what they were seeing, and referred to this as ‘very patchy’. She was trying to encourage academic writing, thinking, and discussion, to make students extract knowledge and the underpinning ideas. To ‘have the students in the position where they can tell the good from the bad, the useful from the not so useful information. That has been a problem.’
\nOne teaching educator challenged the notion of students as superficial in their learning because of digital technology; she claimed that the challenge was about the need for a different set of skills.
\n‘I certainly don’t feel that students are more superficial because they\'re using them, or because they can access Wikipedia or… I think they need to learn a different set of skills, but I think that once you have developed those skills, I think you can actually get into deeper learning, and I think digital technology enhances those skills. I think we can be superficial in whatever we do. But, it’s not because of digital technology we become superficial.’
\nBased on what the teaching educators explained, it seems like digital learning environments are enabling advanced multi-structural learning at such a high level that their lack of relational understanding and ability to create extended abstracts have been overlooked. Digital tools make students appear skilled in handling information as they can copy ready-made text online by googling keywords. This apparent skill in writing could be misleading for teachers in their assessment of the student. When students reach higher education, they are perceived as unskilled and uncritical, as higher education reveals a worrying lack of learning strategies that would enable them to reach deeper levels of understanding [22]. It seems that through primary and secondary education, they develop an imbalance between learning and innovation skills, and information, media, and technology skills [3]. Furthermore, this imbalance seems to create an asymmetrical reinforcing effect as digital environments make it easy to present multi-structural understanding at a high level, which can disguise the need to work with students’ ability to think critically, a central part of the higher order of thinking in the SOLO taxonomy.
\nThat ‘everything used to be better’ is a claim made by all generations. One teaching educator pointed out that ‘students in the past have also written things they do not understand themselves. I do not think that is new. Everyone just wants to find the easiest way to a good grade, maybe.’ However, if seeking the easiest way is a fundamental human trait, it is a challenge for teaching and learning now that knowledge is more easily accessible and presented, without engaging critical thinking and deeper cognitive processes. Wajcman [33] states that ‘Rather than simply saving time, technologies change the nature and meaning of tasks and work activities, as well as creating new material and cultural practices’. We need to adapt to these changing practices and learning activities, and adjust how we educate our students to be prepared in this new learning context. The teaching educators in this study had some suggestions.
\nTeaching educators in this study expressed a worry regarding the digital format versus traditional books. As information is more easily accessible, students tend not to read the books and research the greater context information it was gathered from. In a book, you often have to read larger sections to get a grasp of the concepts. When googling keywords, it is easy to find a lot of ‘hits,’ and then mix a selection of copied sections. This can apparently look like a reasonable text, but it is surface learning and without deep understanding of the content. Reading a book will perhaps create deeper learning, even though the text produced is less polished than a copy-paste text from already digested sections online.
\n‘I mean obviously, students have different skills, but I am thinking that critical thinking skills, reading hard information is definitely undermined, that is what I am thinking. I am noticing that with students.’ (New Zealand teaching educator)
\n‘I do not think their digital skills have become any higher in the last five years, I think almost on the contrary. They are very good at watching videos and looking for things online, but I do not think they are good at retrieving relevant information. They are not as source-critical as I would like. We probably have a job to do to make them able and skilled.’ (Norwegian teaching educator)
\nThe two skillsets, learning and innovation skills and digital skills, are connected. Students will not flourish in their digital skills if they are not intertwined with the 4Cs. Digital natives and Generation Z have a good technical understanding, but integrating that with the skills of being creative and critical is central to achieving deep learning processes in digital learning environments.
\n‘They (students) are not able to transfer those skills and understandings into their learning environment. I would say the key thing again here is that the students might come in with skills and abilities, but not necessarily pedagogical understanding of how to actually implement that in their teaching practice. I think that\'s the key thing that we, initial teacher education lecturers, need to really focus on, and I think we need to come up to the plate and think about the digital literacies our students have… and actually think about being responsive to those as well.’ (New Zealand teaching educator)
\nOne teaching educator who perceived students as getting shallower in their learning was vocal about the value of structuring education around the use of books as well as digital devices.
\n‘I require them to read a textbook, because I think that doing lectures actually, online, is actually not a satisfactory way to get one’s point across. So instead, what I do is I weave my points across all the ways that I teach each week, so all the things I present, all of my interactions and discussion groups and… I think it works up to a point, but I\'m expecting them to read the textbook quite well, really.’
\nTo round up this chapter, I leave the final word to one of the New Zealand teaching educators who summed up most of the main findings in our study.
\n‘I think digital technology can be a lot more passive at times, and in terms of students, I think they just see technology as providing the answer. I think it is important to challenge them and say, “There may not be an exact answer to the question; you have to keep challenging and questioning.” I sometimes believe they have become a lot more passive, and just accepting what comes via the technology as being the one and only, or the right way of doing things. Rather than challenging. I think it is due to the way the world has shifted. Where it is a lot easier for them to go online and get something, rather than physically having to go somewhere and think about it, like a library or hunt out a book, or… Everything is right there. Therefore, I think that passive learning most probably happens a lot more because of the technology, because they can just access wherever they are. In terms of preparation, coming through from high school, yes, I think there are some definite skills in terms of being critical of information that needs to be taught, prior to coming into higher education. Particularly in the sense of questioning the information they are accepting. I believe some disadvantages are that most probably the students do not challenge enough, they just accept technology, and I think that might be the way technology has been introduced over the years. “Here it is, here is the answer.” “If you don’t know, just google it, and you’ll get something.” So that passive, not questioning, not challenging… I think is a real disadvantage.’
\nIt seems that students’ development of critical thinking and deep learning is challenged in digital learning environments. A high level of ICT literacy seems to challenge the lens traditionally used to assess students’ capabilities and needs. Furthermore, ICT skills and learning and innovation skills seem to mutually influence each other, as low learning and innovation skills make the students’ ICT skills stagnate when assessing their critical use of online resources. We find that learning in a digital environment complicates the development of critical thinking, but we also believe that this can be corrected by redefining what it takes to prepare students for the future. For a long time, the focus has been on developing their digital skills. However, it would seem like we have not paid enough attention to what the digital transformation requires of interwoven aspects related to learning in digital societies. We need to develop the traditions in education, where the focus has been on technical skills more than on interdisciplinary competencies. If we are able to better secure and develop students’ abilities to be critical and creative, and to collaborate and communicate, digital learning environments could act as learning resources for all students. Without this skillset, there is a risk of students using digital resources in a way that prohibits deep learning and the development of higher order thinking. Based on the input of the teaching educators, it is essential that education is structured in a way that a lack of the 4Cs is noticed by educators and teachers, and that learning is structured to develop such skills. It is unfortunate if students acquire a high degree of information, media, and technology skills, as digital immigrants do, without the learning and innovation skills required to manoeuvre constructively in the overwhelming and easily accessible landscape of digital learning. Education needs to structure learning that challenges students to connect different skillsets, so new contextual skills and knowledge are developed. Just like critical thinking in digital spaces.
\nThe publication charges for this article have been funded by a grant from the publication fund of UiT The Arctic University of Norway.
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