Journal of Pediatric Nursing (2014) 29, 281–283
TECHNOLOGY DEPARTMENT Editor: Karen Goldschmidt MSN, RN
Karen Goldschmidt MSN, RN
Let Me Introduce You to Your First Virtual Patient Sandra A. Friedman CNM, MSN, Karen Goldschmidt MSN, RN ⁎ Drexel University College of Nursing and Health Professions, Philadelphia, PA Received 3 February 2014; revised 22 February 2014; accepted 7 March 2014
IN THE RECENT film Her, Joaquin Phoenix's character develops a relationship with a computer operating system named Samantha. Similarly, students now have the ability to develop a relationship with a virtual patient (VP). Gone are the days of nursing students honing their skills solely on live patients or mannequins in a simulation lab. Today, there is software available for students to interact with a VP online, in a simulated clinical environment (Figure 1). Interestingly, VPs have been around for over 35 years; however, the technology has not been widely utilized, and there is a lack of research confirming learning outcomes (Cook & Triola, 2009). Nonetheless, VP technology has advanced considerably in recent years, is comparable to advanced video gaming systems, and interactivity of artificial intelligence. Today, students can interact with a VP online with text or with their voice, choose how to proceed in a virtual clinical environment, and receive immediate feedback on their performance. Undoubtedly, the impact of online education and the use of Web-based technologies have profoundly affected education and learning. In the in fall of 2012 there were 7,100,000 students taking at least one online course (Allen & Seaman, 2014). Nurses are also choosing online learning to advance their education with the intent to advance their expertise; however, questions remain as to whether nursing practice can be learned in an online environment. Of course, not all advanced practice skills can be learned online, and interaction with live patients is necessary; however, given the shortage of clinical sites, and gaps in clinical experiences
⁎ Corresponding author: Karen Goldschmidt MSN, RN. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2014.03.021
for students, the thought of using a VP is intriguing (Credan & Lok, 2011). This article will provide an overview of the use of VPs to bridge gaps in learning and to share our experience integrating VP technology into an online course for registered nurses (RNs). After working with
The Value of the Virtual Patient
the virtual patient, RNs reported increased confidence in assessment, history taking, and documentation skills.
Working with a VP in a virtual clinical environment is based on Kolb's (1984) theory of experiential learning. The actual learning occurs with a direct encounter with a situation, and subsequently, in situ problem solving occurs. This type of learning occurs “by doing.” Kolb's theory has 4 aspects: conceptualization, active experimentation, concrete experience (in the virtual environment) and back to a period of reflection. The value of experiential learning lies in the ability to touch and affect all types of learners. Those who prefer to talk, conceptualize, or actively participate, benefit from experiential learning. Students can engage with a VP in experiential learning through an unfolding simulated case. There is no time pressure to complete a case, so students may pause, reflect, and choose alternative paths and decisions. After completion of a case, students receive immediate computerized feedback on their performance. Students have the opportunity to repeat their practice and gradually refine their performance. This deliberate practice cycle is a sequence of practicing through repetition, and providing feedback, with the opportunity to improve (Ericsson, 2004).
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S.A. Friedman, K. Goldschmidt assessment safely and accurately utilizing the appropriate technology. In addition, students worked with a VP in a virtual clinical environment to perform a physical assessment, complete a health and psychosocial history, practice documentation, and engage in reflection after each interaction. Students were then asked to identify various interventions that could be used to promote health and prevent disease for the VP.
Student Reflections on the Virtual Patient Figure 1 Tina Jones a Digital Standardized Patient™ created by software developer Shadow Health™ (2014).
As students dig deeper to discover the content embedded in each case, they engage and assume more responsibility for learning. Students begin to explore other resources beyond the online experience and basic content. As students spend more time in the virtual clinical environment, they build upon previously learned skills and report applying new skills when they return to patient care; this is where meaningful learning and change in nursing practice takes place (Weigel, 2002). Most importantly, a VP experience allows nurses to learn in a safe, virtual environment in which time can be paused. Overall, the pause allows time for self-analysis. This ability to take time to reflect on one's clinical performance, and evaluate strengths and weaknesses, plays a major role in becoming a safe practitioner and demonstrating clinical judgment and reasoning skills (Cook & Triola, 2009; Lasater, 2007). Novice students, lacking in foundational knowledge, may have difficulty working with a VP (Cook & Triola, 2009). VPs are well suited for practicing RNs, as they require application of knowledge, while at the same time building upon previously learned knowledge and experience. RNs are challenged in the unstructured virtual clinical environment; whereas novice students may benefit more from a sequential problem based learning module (Cook & Triola, 2009).
Implementing the Virtual Patient in an Online Course In the summer of 2013, 25 students were enrolled in an online RN–BSN course at Drexel University's College of Nursing and Health Professions (CNHP), Health Assessment for Diverse and Vulnerable Populations. All students were experienced RNs with diverse backgrounds. Course objectives focused on the RNs' ability to narrate and elicit a full health history and perform an entire head-to-toe physical
After working with the VP in the course, the RNs were asked to reflect on their experience and comment in an online discussion board. Surprising findings were evident. Even though students are practicing RNs, they identified that both comprehensive history taking and physical assessment had become areas of weakness. For example, socioeconomic history and relationship history with family and support networks were often lacking. In their current practice, RNs stated that they take patient health histories by asking a prescribed list of questions from computerized templates. RNs realized that their history and physical assessment experience had become rote and limited to their specialty area of practice. For example, a nurse working on a cardiac step down unit took histories and performed physical assessments related to the cardiovascular system, but had limited time and lacked adequate skills to perform a neurological exam. There were several positive outcomes afforded by RN interacting with the VP. Even after practicing as an RN, students came to recognize the vital importance of taking a thorough patient history and identified the crucial linkages to patient safety, accurate diagnosis, health prevention, and health promotion. RN students grew in confidence in their knowledge to accurately communicate assessment findings to other members of the health care team. This was evident as RN reflections on the discussion board revealed that they were applying newly learned techniques to real patients when they returned to the bedside. RNs reported incorporating new ways of communicating with physicians in patient rounds or teaching other nurses what they had learned when they returned back to their patient care areas. At the completion of the course, RNs were asked to reflect and share their experiences working with the VP in the virtual environment. Overall, the RNs enjoyed the course and the experience working with VP; some RNs realized that over time they had lost some of their assessment skills either because they had not used them or because they had become comfortable with a very specific skill set. After working with the VP, RNs reported increased confidence in assessment, history taking, and documentation skills. One nurse reported decreased anxiety with having to “float” to another unit; the virtual clinical environment helped her gain confidence in the neurologic assessment required to treat patients on another unit.
Virtual Patient “Performing health assessment on the VP was an enriching experience for me. The program was engaging and I feel that corresponding with the artificial intelligence aspect of the VP made me look at communicating with patients in a different way. At the end, I was subconsciously constructing my questions in the clearest way to acquire feedback from the VP. I hope to utilize this skill with my patients. I will miss her” (Anonymous, RN).
Summary The use of VP software enhances learning and builds skills for RNs in a fun and creative ways. More importantly, their perspectives about the “why” and the “how” of learning were broadened. RNs engaged in the process and began to use time differently and to their advantage. RNs also began to see the link between accurate and in depth history taking to accurate diagnosis and on to targeting a specific patient's need for health promotion education. The VP in the virtual clinical environment appears promising for expanding the knowledge, behavior, and skill set of RNs learning in the online environment.
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References Allen, I. E. & Seaman, J. (2014). Grade Change: Tracking Online Education in the United States. Babson Survey Report. Retrieved from http:// sloanconsortium.org/publications/survey/grade-change-2013. Cook, D., & Triola, M. (2009). Virtual patients: A critical literature review and proposed next steps. Medical Education, 43, 303–311, http://dx. doi.org/10.1111/j.1365-2923.2008.03286.x. Credan, J., & Lok, B. (2011). The use of virtual patients in medical school curricula. Advances in Physical Education, 36, 48–53, http://dx.doi.org/ 10.1152/advan.00054.2011. Ericsson, A. K. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains, (Conference Proceedings) Academic Medicine. Research in Medical Education Proceedings of the 43rd Annual Conference. 79 (10), (Supplement pp. s70-s81). Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood, NJ: Prentice Hall. Lasater, K. (2007). Clinical judgment development: Using simulation to create a rubric. Journal of Nursing Education, 46, 496–503. Shadow Health™ (2014). Concept labs: Immersive tutorials illustrating complex nursing subjects, Retrieved from http://shadowhealtheferences. Weigel, V. B. (2002). Deep learning for a virtual age: Technology's untapped potential to enrich higher education. San Francisco, CA: Jossey-Bass.
TECHNOLOGY DEPARTMENT Editor: Karen Goldschmidt MSN, RN
Karen Goldschmidt MSN, RN
Let Me Introduce You to Your First Virtual Patient Sandra A. Friedman CNM, MSN, Karen Goldschmidt MSN, RN ⁎ Drexel University College of Nursing and Health Professions, Philadelphia, PA Received 3 February 2014; revised 22 February 2014; accepted 7 March 2014
IN THE RECENT film Her, Joaquin Phoenix's character develops a relationship with a computer operating system named Samantha. Similarly, students now have the ability to develop a relationship with a virtual patient (VP). Gone are the days of nursing students honing their skills solely on live patients or mannequins in a simulation lab. Today, there is software available for students to interact with a VP online, in a simulated clinical environment (Figure 1). Interestingly, VPs have been around for over 35 years; however, the technology has not been widely utilized, and there is a lack of research confirming learning outcomes (Cook & Triola, 2009). Nonetheless, VP technology has advanced considerably in recent years, is comparable to advanced video gaming systems, and interactivity of artificial intelligence. Today, students can interact with a VP online with text or with their voice, choose how to proceed in a virtual clinical environment, and receive immediate feedback on their performance. Undoubtedly, the impact of online education and the use of Web-based technologies have profoundly affected education and learning. In the in fall of 2012 there were 7,100,000 students taking at least one online course (Allen & Seaman, 2014). Nurses are also choosing online learning to advance their education with the intent to advance their expertise; however, questions remain as to whether nursing practice can be learned in an online environment. Of course, not all advanced practice skills can be learned online, and interaction with live patients is necessary; however, given the shortage of clinical sites, and gaps in clinical experiences
⁎ Corresponding author: Karen Goldschmidt MSN, RN. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2014.03.021
for students, the thought of using a VP is intriguing (Credan & Lok, 2011). This article will provide an overview of the use of VPs to bridge gaps in learning and to share our experience integrating VP technology into an online course for registered nurses (RNs). After working with
The Value of the Virtual Patient
the virtual patient, RNs reported increased confidence in assessment, history taking, and documentation skills.
Working with a VP in a virtual clinical environment is based on Kolb's (1984) theory of experiential learning. The actual learning occurs with a direct encounter with a situation, and subsequently, in situ problem solving occurs. This type of learning occurs “by doing.” Kolb's theory has 4 aspects: conceptualization, active experimentation, concrete experience (in the virtual environment) and back to a period of reflection. The value of experiential learning lies in the ability to touch and affect all types of learners. Those who prefer to talk, conceptualize, or actively participate, benefit from experiential learning. Students can engage with a VP in experiential learning through an unfolding simulated case. There is no time pressure to complete a case, so students may pause, reflect, and choose alternative paths and decisions. After completion of a case, students receive immediate computerized feedback on their performance. Students have the opportunity to repeat their practice and gradually refine their performance. This deliberate practice cycle is a sequence of practicing through repetition, and providing feedback, with the opportunity to improve (Ericsson, 2004).
282
S.A. Friedman, K. Goldschmidt assessment safely and accurately utilizing the appropriate technology. In addition, students worked with a VP in a virtual clinical environment to perform a physical assessment, complete a health and psychosocial history, practice documentation, and engage in reflection after each interaction. Students were then asked to identify various interventions that could be used to promote health and prevent disease for the VP.
Student Reflections on the Virtual Patient Figure 1 Tina Jones a Digital Standardized Patient™ created by software developer Shadow Health™ (2014).
As students dig deeper to discover the content embedded in each case, they engage and assume more responsibility for learning. Students begin to explore other resources beyond the online experience and basic content. As students spend more time in the virtual clinical environment, they build upon previously learned skills and report applying new skills when they return to patient care; this is where meaningful learning and change in nursing practice takes place (Weigel, 2002). Most importantly, a VP experience allows nurses to learn in a safe, virtual environment in which time can be paused. Overall, the pause allows time for self-analysis. This ability to take time to reflect on one's clinical performance, and evaluate strengths and weaknesses, plays a major role in becoming a safe practitioner and demonstrating clinical judgment and reasoning skills (Cook & Triola, 2009; Lasater, 2007). Novice students, lacking in foundational knowledge, may have difficulty working with a VP (Cook & Triola, 2009). VPs are well suited for practicing RNs, as they require application of knowledge, while at the same time building upon previously learned knowledge and experience. RNs are challenged in the unstructured virtual clinical environment; whereas novice students may benefit more from a sequential problem based learning module (Cook & Triola, 2009).
Implementing the Virtual Patient in an Online Course In the summer of 2013, 25 students were enrolled in an online RN–BSN course at Drexel University's College of Nursing and Health Professions (CNHP), Health Assessment for Diverse and Vulnerable Populations. All students were experienced RNs with diverse backgrounds. Course objectives focused on the RNs' ability to narrate and elicit a full health history and perform an entire head-to-toe physical
After working with the VP in the course, the RNs were asked to reflect on their experience and comment in an online discussion board. Surprising findings were evident. Even though students are practicing RNs, they identified that both comprehensive history taking and physical assessment had become areas of weakness. For example, socioeconomic history and relationship history with family and support networks were often lacking. In their current practice, RNs stated that they take patient health histories by asking a prescribed list of questions from computerized templates. RNs realized that their history and physical assessment experience had become rote and limited to their specialty area of practice. For example, a nurse working on a cardiac step down unit took histories and performed physical assessments related to the cardiovascular system, but had limited time and lacked adequate skills to perform a neurological exam. There were several positive outcomes afforded by RN interacting with the VP. Even after practicing as an RN, students came to recognize the vital importance of taking a thorough patient history and identified the crucial linkages to patient safety, accurate diagnosis, health prevention, and health promotion. RN students grew in confidence in their knowledge to accurately communicate assessment findings to other members of the health care team. This was evident as RN reflections on the discussion board revealed that they were applying newly learned techniques to real patients when they returned to the bedside. RNs reported incorporating new ways of communicating with physicians in patient rounds or teaching other nurses what they had learned when they returned back to their patient care areas. At the completion of the course, RNs were asked to reflect and share their experiences working with the VP in the virtual environment. Overall, the RNs enjoyed the course and the experience working with VP; some RNs realized that over time they had lost some of their assessment skills either because they had not used them or because they had become comfortable with a very specific skill set. After working with the VP, RNs reported increased confidence in assessment, history taking, and documentation skills. One nurse reported decreased anxiety with having to “float” to another unit; the virtual clinical environment helped her gain confidence in the neurologic assessment required to treat patients on another unit.
Virtual Patient “Performing health assessment on the VP was an enriching experience for me. The program was engaging and I feel that corresponding with the artificial intelligence aspect of the VP made me look at communicating with patients in a different way. At the end, I was subconsciously constructing my questions in the clearest way to acquire feedback from the VP. I hope to utilize this skill with my patients. I will miss her” (Anonymous, RN).
Summary The use of VP software enhances learning and builds skills for RNs in a fun and creative ways. More importantly, their perspectives about the “why” and the “how” of learning were broadened. RNs engaged in the process and began to use time differently and to their advantage. RNs also began to see the link between accurate and in depth history taking to accurate diagnosis and on to targeting a specific patient's need for health promotion education. The VP in the virtual clinical environment appears promising for expanding the knowledge, behavior, and skill set of RNs learning in the online environment.
283
References Allen, I. E. & Seaman, J. (2014). Grade Change: Tracking Online Education in the United States. Babson Survey Report. Retrieved from http:// sloanconsortium.org/publications/survey/grade-change-2013. Cook, D., & Triola, M. (2009). Virtual patients: A critical literature review and proposed next steps. Medical Education, 43, 303–311, http://dx. doi.org/10.1111/j.1365-2923.2008.03286.x. Credan, J., & Lok, B. (2011). The use of virtual patients in medical school curricula. Advances in Physical Education, 36, 48–53, http://dx.doi.org/ 10.1152/advan.00054.2011. Ericsson, A. K. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains, (Conference Proceedings) Academic Medicine. Research in Medical Education Proceedings of the 43rd Annual Conference. 79 (10), (Supplement pp. s70-s81). Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood, NJ: Prentice Hall. Lasater, K. (2007). Clinical judgment development: Using simulation to create a rubric. Journal of Nursing Education, 46, 496–503. Shadow Health™ (2014). Concept labs: Immersive tutorials illustrating complex nursing subjects, Retrieved from http://shadowhealtheferences. Weigel, V. B. (2002). Deep learning for a virtual age: Technology's untapped potential to enrich higher education. San Francisco, CA: Jossey-Bass.
