By
William A. Matcham, PhD, RN, CCRN-K
Assistant Professor
Cleveland State University
Matcham.1@osu.edu

Cindra Holland, DNP, RN, RNC-OB, ACNS-BC
Assistant Professor
Wright State University
Cindra.holland@wright.edu

Matthew Davis, BS
Web Developer/Systems Administrator
Wright State University
Matthew.davis@wright.edu

Todd Pavlack, M.Ed
Manager, Distance Learning and Instructional Designer
Wright State University
todd.pavlack@wright.edu

Ann Bowling, PhD, RN, CPNP-PC, CNE
Assistant Professor
Wright State University
ann.bowling@wright.edu

Abstract

Technology is incorporated into all aspects of nursing education. This article explores the interdisciplinary process of developing a novel software platform called the Nursing Innovation Lab (NIL). The NIL was created using an adapted agile software design allowing conceptualization to implementation in less than twelve months. The NIL was custom coded instead of using off-the-shelf software to ensure all feature specifications were met. The system will host dynamic simulation-based learning experiences in an online environment that utilize unfolding case studies to actively engage participants. A discussion of the project goals is followed by descriptions of each step used in the conceptual design of the project and the software development process. The paper breaks down the project into functional steps to help readers design their own projects. Functional testing and pilot testing results provide guidance for software modification to meet the needs of nursing students. The NIL will provide a robust adaptable platform to engage students in course content and support nursing student success.

Introduction

Active learning strategies are an effective way to engage students. One active learning strategy used in the classroom to encourage critical thinking is the unfolding case study (Ulrich & Glendon, 2005). Unfolding case studies involve patient-based scenarios where students process the information in a sequential manner to apply didactic content and use problem solving skills in simulated clinical practice experiences (Glendon & Ulrich, 1997; Ulrich & Glendon, 2005). Simulation-based learning experiences, such as unfolding case studies, can also be conducted through the use of online technology allowing the case to come to life in the classroom through the visual and audio elements of the video scenarios.

Through a collaboration of nurses, instructional designers, digital artists and programmers, a novel software platform called the Nursing Innovation Lab (NIL) was created to host dynamic simulation-based learning experiences in an online environment. The online platform incorporates unfolding case studies in an effort to improve first year nursing students’ success and retention. The software hosts a variety of learning objects that engage learners in a fun and meaningful way. This paper will outline the interdisciplinary process of designing the software platform including a discussion of benefits, challenges and rationale for design decisions.

Background

Active learning is an important aspect of the andragogical approach to effective teaching which engages adult learners in the classroom. Students who are actively engaged in the classroom have improved retention of knowledge (Knowles, Holton, & Swanson, 2015). Online simulation-based learning experiences represent actual situations where students are able to enhance their knowledge, skills, and attitudes in an online environment (Meakim et al., 2013). Online simulation-based learning experiences are techniques that can be used to actively engage students in the classroom to promote understanding of content. Integrating technology-enhanced experiences, such as the NIL into the active learning classroom allows students to interact with important content. These strategies may help students evaluate, synthesize, and apply course content to problem-solving activities they will encounter in professional practice.

When developing an online simulation-based experience, it is important to consider best practices.  The International Nursing Association for Clinical Simulation and Learning (INACSL) has published standards of best practice. The first guidelines were released in 2011, the second version in 2013, and two additional standards were added in 2015 (Sittner et al., 2015).  These standards of best practice provide a foundation to ensure development of high quality simulation experiences.

Instructional Design Features

Electronic simulations in the medical education field have been well documented in the literature (Issenberg, Mcgaghie, Petrusa, Gordon, & Scalese, 2005; McGaghie, Issenberg, Petrusa, & Scalese, 2010). This project was designed utilizing five instructional design features of effective simulations identified as best practices in the literature for all disciplines (Cook et al., 2013). These features include: providing feedback, repetitive practice, curriculum integration, a controlled environment, and individualized learning (Issenberg et al., 2005).

Providing feedback is generally considered the most important feature of effective simulation-based education (Cook et al., 2013). Given the target population (first year nursing students) for this project, the design incorporated specific feedback throughout every step of the program. If the user correctly completed a step, positive feedback was provided immediately in the form of a notification box. When an incorrect action was performed, feedback was provided in the form of teachable moments that reinforced the correct path of action. Feedback, in the form of debriefings, was also given to users after the simulation was completed to reinforce important concepts and behaviors.

Users had the ability to repeat scenarios. Repetitive practice allowed for skill acquisition in a shorter amount of time than learning via traditional methods (Issenberg et al., 2005). The unfolding case studies were delivered in a controlled, online environment. This environment allowed learners to make errors regarding patient care without negative consequences. This type of education allowed the learner and the instructor to focus on teachable moments without distraction, and it allowed them to take advantage of valuable learning opportunities (Issenberg et al., 2005).

While this project utilized an individual, independent learning strategy, it was also designed to allow for flexibility based on learner input. This feature made each user an active participant in their own learning instead of being a passive bystander. The project allowed for complex tasks to be broken down into smaller steps for learners to master at their own pace. Learners were able to take responsibility for their own educational progress which is an important feature in educational simulations (Issenberg et al., 2005).

Learning Styles

Active learning strategies that incorporate various learning styles are vital to impacting student success (Andreou, Papastavrou, & Merkouris, 2014; Michael, 2006). Students in nursing programs have many different learning styles. Traditionally beginning nursing courses utilize a lecture format with minimal student interaction. Generational differences exist that alter how learners engage with technology for communication, daily living and education. Older learners tend to have less interest in online learning and find online technologies less user-friendly (Van Volkom, Stapley, & Amaturo, 2014). Younger learners tend to be more technologically savvy, have increased familiarity with daily technology and prefer multisensory methods of information presentation (Feiertag & Berge, 2008; Skiba & Barton, 2006; Van Volkom et al., 2014).

The project was designed to engage students of varying generations with different learning styles including kinesthetic (tactile), visual, and auditory (Doyle, 2011). The project utilized a learning styles conceptual framework based on Kolb’s work with student experiential learning (Kolb & Fry, 1974). The software engaged visual learners with animations, video interviews and high resolution images. Audio learners benefited from realistic assessment sounds (heart, lung …) and recorded voice interactions including a talking glossary of medical terminology. Kinesthetic learners interacted with the software through the use of virtual skill performance, selection of answers to questions and receiving immediate feedback (Kolb & Kolb, 2005). All students benefited from learning through answering critical thinking questions and participating in activities that integrated content from prior coursework into the unfolding case study at hand.

 Software Design Methodology

Traditional software methodologies enforce a strict series of linear steps including requirements definition, software design, implementation, testing, and deployment. The main purpose of traditional design is to visualize the entire project before a single line of code is written. This is helpful for managing large, complex projects where the business logic is well known in advance. Developers can focus on how to implement the logic rather than what logic to implement.

Agile development methodologies take this concept of visualizing software before writing code, but utilize it cyclically in rapid succession rather than in one long drawn out procedure. After each of these cycles, a prototype incorporating some new set of features is produced for critique by the full project team, including software developers and subject matter experts, and features or goals for the next cycle are decided. The process continues until you arrive at a product that meets all of the subject matter experts needs or you hit the project deadline. This modification of the traditional methodology allows the software development team to build the product that the subject matter experts want iteratively, without knowing exactly what that final product looks like at the onset of the project. An added benefit of these rapid cycles is ample opportunity to change course when undesirable elements of the design are noticed. This helps to maximize the development team’s efforts and reduce overall production time (Pathak & Saha, 2013).

Project Design

The project concept developed from a vision by faculty teaching beginning nursing students in two consecutive courses. Students struggled with transferring knowledge from didactic content to clinical practice. In addition, students had difficulty with application of concepts and critical thinking in clinical scenarios. The goal of this project was to develop a software platform that would enable students to make choices about patient scenarios through the use of unfolding case studies. The project was reviewed for human subjects’ protection by the institutional review board before being tested and implementation with students.

Custom Platform vs. Off-The-Shelf Product

There are a few commercially available products that provide the functionality needed to build interactive case studies. A majority of these products are limited in terms of adaptive content delivery, accessibility, scalability, and data reporting. Many off-the-shelf platforms are not cost effective for a limited program budget. Based on these considerations and the availability of personnel with technical expertise, the team decided to design a custom platform. Development of the custom solution allowed the subject matter experts and instructional designers to ensure that the final product incorporated best-practices of pedagogy and functional design. The result was a platform capable of delivering rich multimedia content and videos in an interactive case study format where an end-user can dictate their own path through the scenario. Critical thinking questions were dispersed between video vignettes to allow students to reflect on important concepts and practice problem-solving skills while applying course content. Additional modules allowed for formative assessment, feedback and remediation. The platform was adaptable for use with any style of educational case study.

Storyboarding

The initial concept for each case study was developed by content experts using a storyboard framework in PowerPoint. Multiple features were combined into a concept map that demonstrated the relationships between major points. The storyboards were reviewed in a team meeting and an integrated scenario flow diagram was created on a large white-board. To facilitate production, the scenario was divided into a task list and assigned to appropriate team members. Before production could begin, detailed actor scripts were drafted and reviewed.

Scripting of Content 

The scenario was designed to stimulate critical thinking and application of course content. The script was adapted from paper-based case studies validated in an introductory nursing course. Content experts adapted the scripts for the actors to guide their depiction of nursing scenarios to facilitate the students’ learning. The script was composed to realistically represent the actor that was chosen for the role (elderly man with hearing problems, etc.).

The script was then divided into small scenes to accommodate actor memorization and facilitate video recording of the vignettes. It is also important to match the actor with the script to achieve the desired outcome. Many times a student is recruited to play the role of an older person which is unrealistic, because there is not enough fidelity to immerse the students in the learning activity.

Video Production

Production of each video vignette required capturing scripted scenes from multiple angles to provide enough footage to produce smooth transitions and close-up detail for use in post production to make a polished final cut. Professional grade cameras were used to record the scenes. The technical requirements for video recording these vignettes included any camera capable of recording in 1920x1080p resolution at 30 frames per second. Any style of camera could be used; for example, most common cell phones possess cameras with enough resolution and processing power to produce useable video segments.

Sound was a vital part of the project. A studio quality microphone was essential to capture high quality audio from the actors. Other high quality audio samples, such as breath sounds, were sourced from websites that allow free use such as the National Library of Medicine and Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, Office of the Associate Director for Communications, & Division of Public Affairs, 2016; U.S. National Library of Medicine, National Institutes of Health, & U.S. Department of Health and Human Services, 2014). Adobe Premiere software was used for editing and post-production of sound and video; however, any non-linear editing program could be used (e.g. Final Cut Pro, Sony Vegas, etc.).  Edited videos were enhanced with animation and compositing graphics by a motion graphic artist.

Animated effects

Motion graphics were created with the video compositing software Adobe After Effects, however any standard video compositing software could have been used. The completed animations were processed by Adobe Premiere software for final export and compression. Finalized videos were exported as H.264 MP4 files compressed to 3.0 Mbps for streaming delivery over HTML5 compliant web browsers. Once videos were finalized, additional platform features such as the talking glossary and reporting were designed.

Talking Glossary

A talking glossary was developed for use in the software. Lists of words that either captured essential concepts or were hard for students to understand were chosen from each scenario. Each word was included in the glossary with a standard phonetic spelling, dictionary definition and audio file (.wav) that voiced the correct pronunciation. Unlike most online talking glossaries, these words also had a descriptive paragraph linking their importance to the practice of nursing. This assisted students with application of the vocabulary to professional practice. Although developed with all students in mind, this feature has been especially helpful for students who are not native English speakers. The glossary can be easily updated and expanded through the database interface.

Reporting Features

As users proceeded through the online simulation experience, data was collected about their navigational decisions and question responses. Data elements collected included which scenario node the user entered, how long each node was viewed, question responses, and other important events. Data was exported from the database in a simple comma separated variable (.csv) file, allowing for further manipulation and analysis using standard analysis software. The reporting feature was designed using an agile process that allowed for quick modifications as researcher data needs changed based on new observations of user patterns and behaviors.

Software Design Process

This software platform was developed utilizing an agile software development model rather than a traditional, rigid software development process. Given the short development timeframe, available personnel, and dynamic design, an agile approach to software design was chosen over a more traditional, predictive method which is slow, costly and does not easily adapt to changing software specifications.

At the onset of the project, basic functionality was outlined with an expectation that additional features would be added as the project advanced through the steps of the agile development cycle. The software platform began with a basic prototype using an adapted SCRUM-like pattern to add features incrementally to build the software around the case study scenarios (Schwaber, 1997).  Short programming steps ranging from one to two weeks were used to develop modules that were rapidly critiqued by the team to provide guidance and structure for the next step (see figure 1). The results of this process were the completion of the core software functionality from conceptualization of the project to implementation in the classroom in less than 12 months. Feedback from each iteration of the development cycle informed the team about the need for additional features not originally included in the design.

Technical/Engineering Specifications

The project’s nonfunctional requirements focused on maximizing accessibility and scalability by reducing client-side computational overhead and bandwidth use as much as possible. The platform was developed using PHP version 5.6 and deployed on a standard virtual Linux-Apache-MySQL-PHP (LAMP) stack. The instance used for this project was deployed with limited resources; however, the platform can accommodate thousands of concurrent connections with no performance impact. Pages were delivered in standard HTML, CSS, and JavaScript that can be rendered in any modern browser. The video content used in the platform was delivered in H.264 MPEG-4, using a standard HTML5 video element.

End User Requirements

The project was designed to be used on a wide range of hardware to allow for maximum access. The end user requirements included a computer capable of displaying a minimum resolution of 1280×1024 pixels and an internet connection capable of a 3.5 Mbps download rate and a 512 Kbps upload rate. The online simulation experience will run on all current modern web browsers without any special plugins or extra software required. The decision to not require additional software was important, as third party plugins such as Flash and Java routinely have to be updated due to security vulnerabilities. Some of these plugins are also in the process of being phased out of active web development projects.

Mobile platform support is not available at this time due to limitations of the underlying software stack(s). For instance, the simulation depended on auto playing video in the browser, a feature intentionally not supported by iOS in order to protect end-users from data overage charges. As soon as these foundational features are available on mobile platforms, the online simulation experiences can be accessed on these devices with little additional development effort.

Functional Testing and Pilot Implementation Results

Functional testing on the online simulation experience was completed by six volunteers from multiple disciplines (nursing, psychology and engineering). Functionality was tested by having volunteers navigate the simulation and make decisions without prompting. Major themes identified in the functional testing results included: spelling and grammar errors, lack of audio on one term in the talking glossary, and a few broken hyperlinks. Feedback from the functional testing was used to implement appropriate changes prior to release of the pilot program.

The online simulation experience was pilot tested with 79 nursing students in an active learning classroom during an hour long session. Due to a delay in the review of human subjects’ protection application, implementation of the full research plan consisting of a pre/post test and surveys could not be implemented. Formative feedback was collected during the session. Feedback about the software platform was very positive. The students liked the interactive nature of the online simulation experience, were engaged during class and felt the experience was a good review of important course concepts. Some students commented that the nurse actor in the case study modeled professional behavior that would benefit their future practice. The feedback was used to inform revisions for production of a final version for full research implementation.

Future Plans

Initially two scenarios and an introduction were developed and implemented on the electronic platform. More scenarios have been storyboarded and scripted for future implementation. Future scenarios will utilize cutting edge technology including an innovative process to create 3D images by digitizing data from the Visible Human Project sponsored by the National Library of Medicine (U.S. National Library of Medicine et al., 2014). Virtual 3D organs will be reconstructed from slices of a human cadaver for realistic interactive modeling of pathophysiology concepts. Additionally images will be supplemented from the Centers for Disease Control and Prevention Public Health Image Library (PHIL), both of which are free of charge (Centers for Disease Control and Prevention et al., 2016).

The next step for this application is to conduct the full research protocol with a new cohort of first-year nursing students. Once the data has been collected to inform modifications to the software, it could be implemented in different disciplines. The versatile software platform can host content adapted to any specialization and be implemented in an active learning classroom, with online courses or as a stand-alone educational product. 

Conclusion

This paper discussed the development of an interactive online simulation experience software platform for use in educational settings. The team used agile software design methodology to produce a functional product within twelve months of initial conceptualization. The novel software platform provides functionality not found in commercially available off-the-shelf products. The online simulation platform and scenarios were designed to use standard HTML 5 features allowing for maximum distribution without platform or software restrictions. Initial implementation with nursing students produced positive feedback and enhanced understanding of course content. The platform was developed for easy updating and expansion for future implementation of additional scenarios. This technology has potential to improve student engagement through active learning in the classroom and online.

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Biographical Statements of Authors

William A. Matcham, PhD, RN, CCRN-K

William is an Assistant Professor at Cleveland State University. Dr. Matcham, has a diverse background in nursing, technology and genetics. His research explores how technology can enhance or improve nursing practice to improve patient outcomes and facilitate nursing student transition to professional practice.

Cindra Holland, DNP, RN, RNC-OB, ACNS-BC

Cinder is an Assistant Professor at Wright State University. Dr. Holland’s expertise includes effective teaching strategies, and adult health nursing including a specialty in obstetrics. Her passion is to implement evidenced-based strategies to promote professional development of nurses and future nurses along their practice journey.

Matthew Davis, BS

Matthew is a software engineer working in the Center for Teaching and Learning at Wright State University.  His work focuses on the implementation and development of innovative solutions to enhance online education.  Mr. Davis has a B.Sc. in Computer Engineering from Wright State University (2014).

Todd Pavlack, M.Ed.

Todd is the Manager of Distance Education at Wright State University. He has over 14 years of experience supporting teaching and learning through the use of innovative technology. Mr. Pavlack focuses his expertise on the areas of instructional design and using technology to support teaching and learning.

Dr. Ann M. Bowling

Ann is an Assistant Professor at Wright State University in Dayton, Ohio.  She completed her doctoral studies at Case Western Reserve University in Cleveland, Ohio.  She is certified as a primary care pediatric nurse practitioner and nurse educator.  Her research focus is on using simulation enhance nursing competency.  

Acknowledgement of funding

Funding for this project was provided by the Wright State University Office of the Provost through the 2015 Teaching Innovation Grants for Student Engagement and Alternative Delivery.

 

 

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