The Virtual Patient--development, implementation and evaluation of an innovative computer simulation for postgraduate nursing students.

"The Virtual Patient is like a student pilot learning to fly--it draws
all your assessment skills together and increases your confidence."
(Student user)

The Virtual Patient, an interactive multimedia learning resource using a critical care clinical scenario for postgraduate nursing students, was developed to enhance flexible access to learning experiences and improve learning outcomes in the management of critically ill patients. Using real-time physiological animations, authentic content design and local online clinical experts, The Virtual Patient replicates the way in which clinical cues and patient data are presented in the critical care environment, allowing students to work in their own time, at their own pace, with expert support and without ever compromising real patients. This article reports the project's development, design features, and user-evaluation data, concluding with design recommendations.

PROJECT BACKGROUND AND AIMS

The complex and ever changing clinical contexts in which nursing students practice necessitates the introduction of innovative and flexible teaching strategies in order to improve student access to learning opportunities and learning outcomes. Postgraduate critical care nursing students are, in particular, required to develop advanced health assessment skills and knowledge of diagnostic and therapeutic interventions essential in caring for patients within highly technological environments. For the postgraduate student committed to the demands of her/his clinical workplace, the development of these competencies through course work requires engagement with clinically relevant case study content in contexts which facilitate learning and do not place real patients at risk.

The Virtual Patient was produced for rural and metropolitan postgraduate nursing students studying in critical care, emergency, and high dependency courses at Monash University's School of Nursing. The Virtual Patient is an interactive computer simulation that provides students with the opportunity to manage a complex clinical case study in critical care nursing. The aims of the project were to:

* provide students with the opportunity to manage complex clinical situations which they may not otherwise experience in their clinical practice; and

* enable students to interact with colleagues and leading nurse practitioners, who are not formally associated with the curriculum, via an online discussion group.

The educational objectives of The Virtual Patient were to facilitate professional learning by enabling students to:

* become familiar with the critical care workplace environment;

* develop clinical problem-solving abilities including:

** an understanding of assessment concepts and the significance of assessment findings;

** diagnostic interpretation skills;

** confidence in decision making;

** identification of appropriate therapeutic interventions; and

* participate in collaborative learning.

To achieve these objectives, the project's pedagogical approach used a student centred, case-based learning model, which required the students to take responsibility for constructing their own understanding of the clinical scenarios. This approach is premised upon two notions; students' professional learning is most effective when they are actively involved in creating their new understandings and competencies and learning is retrieved and remembered longer if undertaken in the context in which it is to be applied (Boud & Feletti, 1991). Use of a clinical case benefits the learners by providing them with an opportunity to reason in context, generate experiences that they may not otherwise have, and engage in problem solving with support and feedback from colleagues and experts (Sutyak, Lebeau, Spotnitz, O'Donnell, & Mehn, 1996; Thomas, O'Connor, Albert, Boutain, & Brandt, 2001). In particular, case-based learning locates students in a specific situation crafted so as to be similar to the work with which they will be confronted in their professional career. The importance of developing these problem solving skills and the ability to deal with a variety of related situations is paramount to effective professional learning (Frost, 1996). In light of this, The Virtual Patient was designed to replicate a challenging real situation as closely as possible, thus raising the students' awareness of the complexity of actual clinical workplace decision making.

The clinical nature and complexity of critical care nursing supports the use of simulated events to enable students to gain experience in complex patient care management without directly compromising care. With multimedia simulations, students can familiarise themselves with the clinical environment prior to actual work experiences without harming patients (Simpson, 2002). In a review of computer-based simulation Ravert (2002) revealed positive effects of simulation on skill and/or knowledge acquisition. Simulations can, therefore, provide an alternative learning environment to real-life settings so that academic knowledge can be developed and applied, thereby promoting learner autonomy and professional expertise. The Virtual Patient provided a simulated learning experience so that students could explore clinical data in their own time and with minimal anxiety in an attempt to understand environmental features and identify issues for discussion.

Simulations hold particular potential for enhancing learning when applied as supports, or scaffolds (Grisham & Molinelli, 1995), for a learner at the limit of her/his understanding. Vygotsky (1978) regards such a learner as being within her/his unique "Zone of Proximal Development" (ZPD), a cognitive state characterised by the potential for significant growth, subject to the availability of purposefully designed learning supports or "scaffolds." The Virtual Patient was designed with three levels of scaffolding to sustain the students' learning. First, the clinical case and its associated learning cues provided an explicit organizational framework for the students' learning. Second, the use of a discussion group, as an adjunct to the case potentially enabled students to interact with other students, colleagues, and expert clinicians within and external to the course regarding patient management strategies. Figure 1 presents the three main learning scaffolds available within The Virtual Patient. Butterworth and Faugier (1992) viewed the interaction between an experienced nurse and a novice as "an exchange between practicing professionals to enable the development of professional skills" (p. 12). This type of exchange was designed to be facilitated by The Virtual Patient learning experience to test and increase the students' knowledge of current nursing care interventions and promote reflection and clarification of ideas.

[FIGURE 1 OMITTED]

According to Paz Dennen (2000), collaborative learning utilises social interaction for the purpose of developing the learners' knowledge, thereby moving the locus of responsibility for learning from the teacher to the learner. In The Virtual Patient environment, the learners were able to collaborate in partnership (Dillenbourg, 1999) with other students and experts in their development of knowledge, understanding and skills, a key characteristic of collaborative learning contexts (McInnerney & Roberts, 2004). Just as the combined ZPD of two or more learners working collaboratively is greater than a single individual's, the learning outcome of the group will be similarly greater (Grisham & Molinelli, 1995; LeJeune, 1999). Wilson (1996) also identified collaboration between learners and other key players as a critical component of constructivist learning environments designed to scaffold each learner's transition across their ZPD.

A significant proportion of multimedia learning materials are linear mastery learning programs characterised by prespecified learning pathways. In contrast, The Virtual Patient facilitated self-directed learning that was authentic within the workplace context and characterised by multiple response options. Another unique aspect of The Virtual Patient was its ability to portray a complete set of realistic data as would be viewed by clinicians working in actual Australian critical care settings. The creation of real-time physiological animations and other realistic visual cues stimulate the viewer, provide a basis for self-directed decision making and facilitate the achievement of learning objectives. The use of real data to inform decision making, together with the testing of these decisions against expert opinion, were regarded by The Virtual Patient designers as elements integral to the effective achievement of the educational objectives.

DESIGN FEATURES

The Virtual Patient consisted of a series of 11 episodes, each comprised of a number of scenes (Table 1). At the conclusion of each scene the students were given a learning cue that prompted them for a response to be entered into the Virtual Patient discussion group.

The Case Study

The Virtual Patient was Mr. Mike Roberts who experienced a range of critical incidents, which were demonstrated through text, video, real time physiological animations, sound and photographs. The CD-ROM incorporated vital signs, arterial blood gases, breath and heart sounds, chest X-rays, an electrocardiograph, haemodynamic waveforms and other clinical and diagnostic information. The content was based on the clinical trajectory of the one patient experience. Figures 2 and 3 show some of the screen features of The Virtual Patient.

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[FIGURE 3 OMITTED]

The Discussion Group

After viewing the features of The Virtual Patient, students accessed the discussion group to ask and/or answer questions related to the case study. Clinical experts were given the opportunity to respond and offer their expert advice to the students in this forum. The discussion group was available for students and experts to access at any time. The project leader functioned in a facilitator role, monitoring the discussion and redirecting learning as necessary.

DEVELOPMENT PROCESS

The Virtual Patient was written and developed over a two year period and was funded by an Australian Commonwealth University Teaching and Staff Development Grant. The development process consisted of three phases: web development, beta testing, and student/expert orientation.

Phase One: Development of the Web Based Package

The development stage of the project consisted of script development and storyboarding of the scenario, collection of resources and programming the web interface.

Script. The project leader developed a draft version of the script based on a clinical trajectory of a patient who was to be admitted into hospital for emergency surgery. This patient was to develop a range of complications resulting in admission into an Intensive Care Unit. Numerous consultations with clinical experts from industry (clinical nurse specialists and the medical director of the local intensive care unit) enabled the script to be refined for accuracy of content.

Resources. Resources were collected over a six-month period. This included a one-day session at a Medical Simulation Centre to capture most of the interactive multimedia such as audio, video and photographic images. An actor and moulage expert were engaged to create Mike Roberts as The Virtual Patient. Some of the resources collected included anonymous chest x-rays obtained from a local hospital, heart and breath sounds (audio); physiological simulations provided by the simulation centre (video) and photographic images.

Web Development Process. The web development process comprised four stages. Stage one required completion of a web starter pack. This incorporated an analysis of the requirements and computer platforms to be used in the project. The design stage consisted of creating and documenting the site structure, the interface design and site functionality. The production stage involved integrating the text, audio, video, and graphical components of the program. The final stage involved delivery of the beta version of the program.

Phase Two: Beta Testing

Beta testing of the program was conducted with a small number of academic and clinical experts and provided data on which final editing could be based. Frequent liaison between the project leader and members of the project team occurred during this phase.

Phase Three: Orientation of Student and Experts

The Virtual Patient was located in the critical care nursing subject Acute Cardio-Respiratory Management. This generic subject formed one of three core units within the Acute Care Graduate Certificate courses at Monash University's School of Nursing. A subject guide, which included information about the CD-ROM and outlined the expectations of the students, was provided at the commencement of the semester.

IMPLEMENTATION

The Virtual Patient was implemented over one semester with students accessing The Virtual Patient independently either at home or in the campus computer laboratories. The students were expected to view each episode of The Virtual Patient over one week. Each episode built on the previous week in terms of increased complexity and severity of illness. Several learning cues were provided for each critical incident that prompted the students to enter responses into the Virtual Patient discussion group. The learning cues were designed to stimulate student-driven learning objectives and to guide clinical decision making.

The discussion group enabled the students to ask and or answer questions related to the case study. A small number of clinical experts from various fields of acute care nursing practice were invited to participate in this forum. These clinicians contributed to the discussion group whenever possible. This enabled the students to interact and learn from peers and other expert critical care clinicians.

EVALUATION

The first year of implementation (2001) was a pilot year. Formal evaluation was conducted in 2002. The evaluation was aimed at determining if the educational outcomes of The Virtual Patient had been achieved.

Sample

Twenty-six students enrolled in the following postgraduate courses at the Peninsula and Gippsland campuses of Monash University: Graduate Certificate of Nursing (Critical Care), Graduate Certificate of Nursing (Emergency), and Graduate Certificate of Nursing (High Dependency). All students used the resource in 2002.

Method

The evaluation method used a self-administered questionnaire instrument mailed to all 26 students. Completed questionnaires were received from 24 of these students. Two focus interviews of groups selected from within the 26 students were conducted at the Gippsland (n=9) and Peninsula (n=8) campuses. Each of these methods explored the students' experiences of using the resource.

Questionnaire items provided the structure of the focus group interviews, the interview itself providing an opportunity for participants to reflect upon both their own responses to these items and those of their colleagues prior to discussion. In the event of an individual student providing a response during focus group interview, the interviewer sought affirmation or negation of the comment from the other group members, thereby establishing a simple quantitative measure of the extent to which the individual student's perspective was held by the other students. Only those comments affirmed by the majority of students are reported here.

RESULTS AND DISCUSSION

Results were aimed at determining if the educational outcomes had been met. Issues related to technical aspects were also explored.

Workplace Authenticity and Relevance of the CD-ROM

The authenticity of the clinical situation presented in The Virtual Patient multimedia resource was affirmed unanimously by all participants, with one student highlighting Mike's respiratory agitation as noteworthy in this regard. Another respondent observed that the experience of being presented with Mike's results in the absence of a prior history and not being able to follow Mike through to some sort of closure was similar to acute event nursing. "All of the scenes were real life--like as though it was happening on my ward." "Very realistic sounds and images--kept you interested and stimulated."

Conversely, other respondents expressed frustration at the lack of closure in relation to Mike's outcome: "All we did didn't seem to have any effect on Mike--were our interventions effective?"

Only three participants regarded the content as lacking relevance to their particular workplaces. Nevertheless, one respondent recognized the relationship of the CD-ROM's content to her/his workplace by observing: "While not having an emergency focus, many of the concepts (e.g., intubation, Chest X-Ray interpretation, etc.) are used in emergency nursing."

The evaluation identified the students' unanimous belief in the authenticity of the CD-ROM's representation of the critical care clinical context and its capacity to develop the user's confidence in working within that context. Students were capable of constructing their own meaning from the case study and to relate these meanings to their own clinical workplaces. In doing so, The Virtual Patient as a simulated learning experience enabled students to become familiar with the critical care setting in a safe environment to facilitate the transfer of knowledge from theory to practice without ever harming the patient.

Clinical Problem-Solving Ability

With only one exception, the participants regarded as adequate the data available to them through the CD-ROM for their assessment of The Virtual Patient's condition. Some difficulties in understanding the patient's presentation were reported: "I was unfamiliar with some of the normal values for the pathology results. I found some of the haemodynamic monitoring difficult to understand because at that stage I had not had much exposure to these machines and equipment."

Four of the respondents (16.6%) regarded ascertainment of the abnormal assessment findings as too complex, a difficulty attributed to the lack of feedback on each episode. Specific comments in relation to difficulties associated with chest X-rays included: "I found the chest x-rays hard to diagnose, especially the tension pneumothorax, I would have liked to see the chest X-ray component expanded upon."

Despite the conceptual difficulties in relation to the haemodynamic content, two participants provided clear evidence of The Virtual Patient's capacity to facilitate professionally appropriate study responses:

      Haemodynamics [were difficult to understand] possibly due to [my]
      not having worked in that area. However, it was easy to research
      and find the answers. But then again that's what the package is
      all about--finding out.

      As I had no prior exposure to haemodynamic monitoring I found this
      area difficult to grasp and found this episode took a long time to
      work through. Some of the pathology results I found difficult to
      interpret, again because they were new to me--prompted me to do
      wider reading though.

Although 75% of the respondents reported that they doubted their assessment interpretations at times, on reflection, 96% believed their assessment interpretations were correct. The majority of the respondents (83%) regarded The Virtual Patient as having contributed to increased confidence with one interviewee observing: "[The Virtual Patient has] increased [my] confidence in [my] assessment abilities and a beginning increase in confidence of the reliability of my interpretation skills has been provided by utilisation of this tool."

The ability to identify problems within the clinical case study was unanimous. The majority (83%) of respondents believed that The Virtual Patient had improved both their confidence and skills in being able to systematically interpret assessment findings and then define a clear plan of action appropriate to real clinical situations in a workplacee context. The opportunity to apply a significant level of analysis and formulate a rationale for treatment decisions, free of the time constraints of the real workplace, was believed to be particularly valuable influences on users' confidence.

Although the participants regarded the resource as being overly time consuming, its capacity to facilitate a level of analysis not possible in their workplaces was recognised. This facilitation was made possible by the sequential nature of the unfolding patient scenario and the possibility of stopping the program when further analysis and/or research were required. Integrating knowledge from a variety of clinical areas also facilitated users' reinforcement and extension of their knowledge and decision-making competencies. By sequentially increasing the complexity of the case it was possible to explore more physiologically complex factors as well as wider issues such as support for the patient's family. "In the ICU you don't learn as much because you don't have time to look at details. [The Virtual Patient] allows you to look at the broader picture, including the family, etc."

The program was therefore sufficiently complex to create some degree of uncertainty and challenge for the students while still allowing them to make correct judgements by drawing on their clinical expertise. The scaffolding provided in this web-based instructional design clearly contributed to student learning by organizing information as would be needed in reality, broadening the clinical learning experience in ways that actual clinical situations may not, instilling confidence and making visible the students' clinical reasoning processes. This is consistent with the evaluation study conducted by Thomas et al. (2001) who found similar benefits of using web-based cases. It is also an implementation of Vygotsky's ZPD model in that it challenges learners' thinking while supporting them in their transition to greater expertise.

Overall, The Virtual Patient was of definite benefit to the confidence of those who were unfamiliar with key concepts. The resource reinforced the existing knowledge of those for whom the clinical context was familiar with almost all the participants expressing a belief in the resource's capacity to extend their knowledge of unfamiliar concepts. The process of formulating a rationale for their treatment decisions was believed by the learners to be a particularly valuable formative influence on their confidence.

As a means of elaborating her belief in the resources positive effect on her confidence, one participant observed: "The Virtual Patient is like a student pilot learning to fly--it draws all your assessment skills together and increases your confidence."

Participation in Collaborative Learning

Use of the discussion forum allowed for collaborative learning to occur through student-student and expert-student interaction. Respondents were equally divided in their desire for increased student-student interactions in future versions of The Virtual Patient. Negative comments about the discussion group in general included: "Too much time involved. If more time it would have been a good resource, however I thought looking at other students' answers was cheating--didn't feel comfortable."

Generally, focus group data revealed a belief on the part of those who did use the online conference that it increased their confidence in working within the real world of the unit. The conference experience was particularly effective for the participants who shared their workplaces with other class members, in which case The Virtual Patient generated discussions both with their fellow students and with nonstudying colleagues.

Despite valuing the process of feedback, 75% of respondents were not aware of the experts' existence with the same proportion regarding their influence on learning as negligible. This potentially rich learning process was also under utilized for the following reasons:

      Having feedback about each episode would be a good way to
      determine how well I was interpreting and understanding each
      concept.

      No email was directed personally, and the responses were made
      after I had submitted my responses and I didn't go back and check.
      Perhaps if their response were more prompt then I would be more
      interested in their discussion ideas.

Not enough responded and when they did a couple of comments were very negative.

Clearly this level of support was not successful in this cohort of students. Despite success with students engaging with the actual case and its associated features and learning design (an example of effective scaffolding), collaboration with peers was only moderately effective and student collaboration with clinical experts was not effective at all. This clearly needs to be addressed for future implementations of The Virtual Patient. Suggestions for improvement include; recruiting motivated experts, offering incentives for them to be involved, orientating experts and students to the learning objectives and process of the learning program and providing more faculty support during implementation.

Technological Access

Although The Virtual Patient was rated highly by the respondents as a means of facilitating achievement of the learning outcomes, technical difficulties related to CD-ROM access constituted the most significant difficulties encountered by the students (54% of respondents reported such difficulties). The extent to which these access difficulties resulted in a forward transfer of negativity to the students' experiences of learning from the resource itself was not quantifiable.

More remote based participants reported significantly greater difficulties accessing the resource, observing that the effort required to access the CD-ROM and complete the program was not reflected in the 10% assessment allocation.

It should be noted, however, that 60% of survey participants regarded The Virtual Patient learning experience as enjoyable with a unanimously affirmative response to the question: "If you were responsible for managing your course next year, would you use The Virtual Patient?'

Student Suggestions for Improvement

A small number of students made suggestions on how the program could be improved for example, creating an additional CD-ROM to provide answers to questions and outcomes, enabling copy and paste functions for student discussion group postings (this was particularly a problem when computer connections dropped out) and to enable printing of student generated interpretations. In terms of the program structure and sequence one student wanted the program to be separated into three different areas, that is, emergency admission, intensive care and the "step down" ward. Another student wanted "Mike version 2" so that even more complex issues could be explored.

More generally, both focus groups suggested that lecturing staff should be clear in their rationale for using The Virtual Patient resource; is it being used for the purpose of introducing new content or to reinforce, through application, that which has been learned previously?

CONCLUSION

Designing and implementing a complex multimedia learning resource for nursing students is a demanding, resource intensive but valuable process. The Virtual Patient was a result of a team effort inclusive of educational designers, web developers, multimedia artists, a talented actor and content experts. The Virtual Patient experience has shown that designing and completing such a resource can be achieved as long as considerable time and effort is directed into establishing the learning outcomes, careful planning of the case study, fastidiously collecting resources, fostering a team approach and ensuring that content and web design experts are consulted at all stages of the project.

The case study coupled with the discussion group provided opportunities for the students to reflect critically on their learning and to elaborate on their knowledge. However, the dialogue and interactions between students and expert clinicians was not successful in this cohort of students. Clearly this is an area warranting further attention in future implementations, in particular the critical importance of orientating experts to their role in this forum. Finally, The Virtual Patient is a useful exemplar of a learning environment applicable both to other health content areas and to other professionally related disciplines such as engineering and law.

The evaluative data revealed The Virtual Patient to be a learning resource highly regarded by the majority of the students sampled in 2002. The evaluation identified the students' unanimous belief in the authenticity of the CD-ROM's representation of the Intensive Care clinical context and its capacity to develop the user's confidence in working within that context.

Results of this evaluation have reinforced the importance of teachers and learners having a shared understanding of the purpose of multimedia educational resources. The intent and desired outcomes of the program need to be clearly articulated to students and clinical experts before it is implemented. This would promote a deeper engagement in the learning process by all participants, make the learning experience more enjoyable and improve learning outcomes.

In summary, the use of The Virtual Patient, coupled with the discussion group provided students the opportunity to explore issues related to the management of critically ill patients in their own time, at their own pace, with expert support and without compromising patients.

References

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Butterworth, T., & Faugier, J. (Eds.). (1992). Clinical supervision and mentorship in nursing. London: Chapman and Hall.

Dillenbourg, P. (Ed.). (1999). Collaborative learning: Cognitive and computational approaches. Oxford, UK: Elsevier.

Frost, M. (1996). An analysis of the scope and value of problem-based learning in the education of health care professionals. Journal of Advanced Nursing, 24, 1047-1053.

Grisham, D.L., & Molinelli, P.M. (1995). Cooperative learning. Westminster, UK: Teacher Created Materials.

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McInnerney, J.M., & Roberts, T.S. (2004). Collaborative or cooperative learning? In T.S. Roberts (Ed.), Online collaborative learning: Theory and practice (pp. 203-214). Hershey, PA: Information Science Publishing.

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Sutyak, J.P., Lebeau, R.B., Spotnitz, A.J., O'Donnell, A.M., & Mehne, P.R. (1996, September). Role of case structure and prior experience in a casebased surgical clerkship. The American Journal of Surgery, 172, 286-289.

Thomas, M.D., O'Connor, F.W., Albert, M.L., Boutain, D., & Brandt, P.A. (2001). Case -based teaching and learning experiences. Issues in Mental Health Nursing, 22, 517-51.

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Acknowledgements

The authors gratefully acknowledge the Committee for University Teaching and Staff Development (Commonwealth Department of Employment, Training, and Youth Affairs, Australia) for the funding to develop The Virtual Patient. Associate Professor Geoffrey Parkin (Director of Intensive Care, Monash Medical Centre, Melbourne, Australia), Jenny Harris and Fiona Munro provided content expertise. We also thank Glenn Tracy and Eric Goh (Monash University, Centre for Learning and Teaching Support) for their outstanding contribution in multimedia design and web development.

DEBRA KIEGALDIE

Monash University

Australia

[e-mail]

GEOFF WHITE

Monash University

Australia

[e-mail]

Table 1 Summary of episodes in The Virtual Patient

Episodes

Episode 1: Hypoxia
Episode 2: Continuous Positive Airways Pressure (CPAP)
Episode 3: The Intensive Care Unit
Episode 4: Intubation
Episode 5: The Chest X-Ray
Episode 6: Haemodynamic Monitoring
Episode 7: The Electrocardiograph (ECG)
Episode 8: Pathology results
Episode 9: Medications
Episode 10: Mechanical Ventilation
Episode 11: The Outcome