Educational Application Design Process Experiences

Case Perioperative Nursing

Minna Silvennoinen and Antti Pirhonen

Department of Computer Science and Information Systems, University of Jyväskylä, Jyväskylä, Finland

Keywords: Perioperative Nursing, Game Development, Nursing Competencies, Learning Objectives, Educational

Application Success.

Abstract: From an educational point of view, the only relevant basis for the design of an educational application is the

learning objectives of the content area. In the development process of an educational application, there are

also other people involved besides educational experts. This paper describes a project which primarily aims

at developing an application for the needs of enhancing perioperative nursing skills’.

Besides application development, the project included research about the process. The research task was to

discover how the real – not only the formal – objectives could work as the starting point for the construction

of an educational game-like application. This paper presents the study process based on the panel

discussions of nursing teachers. In the panels, the teachers elaborated the objectives. The transcribed

discussions were analysed in terms of conceptions of learning and teaching of perioperative nursing.

The outcomes, the elaborated objectives, were aimed to be used as a basis for the implementation of an

educational game. In addition, the discussions were analysed from the perspective of the learning paradigm

they reflected. It is argued that views of learning are necessary to be understood in order to make

appropriate choices of educational strategy throughout the development process. Finally, this paper presents

initial observations of a user study of the game. They are discussed from the point of view of project success

and the potential of the chosen approach. It is concluded that the construction of this kind of game is a much

more effective means of learning than the playing of it, thus suggesting that students themselves should be

used as authors.

1 INTRODUCTION

The purpose of constructing an educational

application is – or at least should be – to promote

learning. Therefore, learning objectives should be

the primary criteria in all stages of the development.

However, it is far from clear regarding what the

objectives are when educating perioperative nurses.

We know that perioperative nurses’ work in

operating department and their role at the hospital is

to provide care to the patients independently and

responsibly together with other healthcare

professionals. These nurses provide care and

support to patients before, during, and after surgery

(pre- intra- and post-operatively). Perioperative

nurses’ responsibilities prior and during surgery are,

for example, instrument and sterile environment

preparation and maintenance, and assisting surgeons

during the operation (Mitchell and Flin, 2008).

Perioperative nursing skills include cognitive, social

and technical components such as using various

operating theatre (OT) equipment. Sometimes highly

automatised technical skills are needed; sometimes

fast reasoning and reaction should be applied to

constantly changing treatment situations and a wide

variety of different patients. Therefore decision-

making skills, adaptability to new situations, as well

as competence in evaluating rapidly changing and

challenging situations are important. Also ethical

considerations and problem solving is needed.

Perioperative nurses are required to work in teams

with other healthcare professionals, including multi-

professional teams, thus group work skills are

essential. Perioperative work environment is also

stressful and often physically straining, which

should be taken into account in their education.

Patient safety and patient care are core elements

of perioperative nursing. Nurse education is a central

means to reduce or prevent noticeable risks and

errors in perioperative work (McConnell and

545

Silvennoinen M. and Pirhonen A..

Educational Application Design Process Experiences - Case Perioperative Nursing.

DOI: 10.5220/0004960505450550

In Proceedings of the 6th International Conference on Computer Supported Education (CSEDU-2014), pages 545-550

ISBN: 978-989-758-020-8

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

Hillbig, 2000; Pirhonen and Silvennoinen, 2011).

All these requirements should be acknowledged

when designing and implementing new ways to train

perioperative nurses. Suitable means for responding

to these requirements should be explored.

There are studies presenting the perioperative

nurse’s skills and requirements in the forms of

required competences which should be developed

through clinical learning activities such as

knowledge, skills and values. These are presented in

Table I (AORN, 2007).

Table 1: Perioperative Nurse's Competencies.

Knowledge

Applying knowledge on anatomy, physiology,

and pathophysiology to understand the

procedure, its effects on the patient and patient

needs

Recognising ethical and legal responsibilities,

the nurse’s accountability to the patient, the

profession of nursing and team work

Applying research findings to planning and

implementing effective perioperative care

Skills

Learning and refining aseptic techniques

Improving patient assessment, communication,

organisation, coordination, critical-thinking,

and decision-making skills in an environment

where such activities must be performed

quickly and accurately

Providing opportunities to assess own interest

and talents

Values

Developing the role of advocate for the patient

by identifying the patient’s expressed and

unexpressed needs

Responding to those needs through the action

of facilitating or mediating among all providers

involved in the care process

Recognising diverse career opportunities in

perioperative settings

Participating as a member of multi-

professional health care team that develops and

promotes the continuity of patient care in an

environment that reinforces an understanding

of a nurse’s independent and interdependent

function

Perioperative nurses’ core competencies are critical-

thinking and sound clinical judgment which should

be used effectively to meet patient needs (Cafira and

Janiszewski Goodin, 2011). Critical-thinking and

clinical decision-making skills are essential

components which are acquired in perioperative

work. These can be learned for example with

concept mapping which is a tool for efficiently

perceiving relationships between concepts (Noonan,

2011). Critical-thinking and decision-making skills

could also be learned with the help of educational

games which foster collaboration and critical-

thinking among peers and associates (Cafira and

Janiszewski Goodin, 2011).

Due to the extremely diversified contents of

perioperative nursing skills, it is relevant to consider

the application of computers in this education. This

paper discovers the potential of interactive

technology in the education of perioperative nursing.

The paper draws on an application development

project, in which the authors participated particularly

as experts of education.

In the current case study, the application of

interactive technology was inspired by previous,

successful application of computers in the teaching

of nursing skills (Huff, 2003; Cafira and Janiszewski

Goodin, 2011). In these studies, computer-based

educational games, such as web-based courses

including quizzes, examinations and reviews were

applied and some learning benefits discovered. In

the teaching of perioperative nursing, using games to

teach, learn, and reinforce perioperative material

through experiential techniques has potential in

promoting critical-thinking (Sewchuk, 2005; Cafira

and Janiszewski Goodin, 2011).

1.1 Related Project

The current study is based on an assignment, in

which a prototype of an educational game for the

educational needs of perioperative nursing was

supposed to be implemented. The development

project group consisted of specialists from three

large organisations. The teachers of nursing

education (University of Applied Sciences),

education and usability researchers (University) and

nurses working in the field (hospital), as well as

other IT and management professionals. In addition,

there was a project leader and responsible leaders of

each participating organisation. The main realiser of

the game construction was an independent IT

software company which was selected based on an

open bidding competition.

2 THE ORGANISATION

OF THE STUDY

The organisation of teaching is a complicated

process in which learning is the primary objective.

Typically, the role of an individual teacher is central

– his or her conception about what learning is and

how it could be promoted. Also, the teacher’s view

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546

of the curriculum is obviously pivotal in terms of

what content is important and what is not. The

conclusion is obvious: more important than what is

told in the formal curricula is the teacher’s

interpretation or conception of the curricula.

In the current study, we combined the handling

of curricula and learning conceptions in one single

empirical setting. We first prepared a tentative set of

learning objectives for perioperative nursing. By

learning objectives we mean both the formal

objectives which are written in curricula, as well as

the objectives that the teacher is implementing,

which arise from numerous sources, such as formal

documents. In the current study, we seek the so-

called ‘hidden curriculum’ as well. The tentative set

of objectives was based on the formal objectives of

the local school which educates nurses (JAMK

University of Applied Sciences, see

http://www.jamk.fi/). These tentative objectives

were then elaborated by two expert panels, each of

which consisted of three experienced nursing

teachers from JAMK. The panels were moderated by

a researcher, who recorded the discussions. In the

panel sessions, the objectives were discussed in the

order of objective categories. Each panel session

took about 60 minutes. After the panel sessions, the

objective table was finalised by the researcher.

The recordings of the discussions were

transcribed. The transcriptions were analysed in

terms of conceptions of learning. The expressions

that the teachers used were classified according to

the perspective of learning that they reflected;

behaviourist, cognitivist, or constructivist. This set

was then presented to two independent teacher

panels, in order to discuss and elaborate the

proposed objectives.

3 CASE STUDY: OBJECTIVES IN

STUDYING PERIOPERATIVE

NURSING

The tentative table of objectives was elaborated by

two expert panels. The structure of the table follows

the widely used categorisation: Knowledge, skills

and attitudes, each of which is handled concerning

theoretical, professional, social and ethical aspects.

We now present the elaborated version of the

objectives in four separate tables: theoretical (Table

II), professional (Table III), social (Table IV), and

ethical (Table V). The objectives in the tables should

be read by starting each objective with “After

studying perioperative nursing, the student…” The

numbers in the parentheses at the end of each

category in Tables 2-5 indicate the number of

comments in the transcription.

Table 2: Theoretical Aspects.

Knowledge

Has acquired the core concepts of perioperative

nursing to the level required for the construction

of theoretical knowledge in the area. (13)

Skills

Utilises relevant literature in the area of

expertise in order to construct knowledge. Is

capable of critically assess references and is able

to apply the constructed knowledge in an

appropriate manner. (10)

Attitudes

Is interested in nursing practices and science

related issues in diverse contexts. Understands

the significance of continual construction of new

knowledge in the development of him/herself

and his/her expertise, as well as in the securing

and promoting of the function of his/her group

and the whole organisation. (1)

Table 3: Professional Aspects.

Knowledge

Is aware of his/her professional strengths and

recognises areas which require further

development. (31)

Skills

Is able to work by applying the approaches,

methods and principles of perioperative nursing,

in terms of his/her own role, in a patient-centric

manner, taking care of patient safety. Applies

his/her professional skills and knowledge, such

as clinical skills, medication, infection

prevention, pain treatment and decision-making

skills in an appropriate way. Detects problems

and uses creative problem-solving in decision-

making. High pressure tolerance. Monitors,

assesses and reflects his/her own work critically.

Promotes mental and physical well-being in

work and occupational health and safety through

his/her own activity. (27)

Attitudes

Is willing to learn new things in the domain of

nursing. Understands the importance of his/her

expertise from the point-of-view of the work

community and society as a whole, and is proud

of it. Understands his/her own personal

responsibility as an expert of nursing. (24)

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Table 4: Social Aspects.

Knowledge

Conceptualises nursing as human-centred and,

in particular, patient-centred work, in which

social interaction plays a central role.

Understands the aspects of group forming and

functioning. (6)

Skills

Is able to work all-round and interact as a

member of diverse groups. Is able to work in

different kinds of patient related situations in an

interactive manner, taking the individuality of a

patient into account. Is capable of contributing

constructively to the forming of a group, as well

as to the achieving the of objectives of the

group. Is able to act according to his/her own

role in the group work context. Is able to utilise

and provide feedback. Recognises phenomena

relating to group dynamics, and reacts to them

appropriately (context sensitivity). (20)

Attitudes

Understands his/her personal role as a member

of a group and the significance of working

together in order to achieve the common

objectives. Understands his/her role from the

patient’s perspective. Accepts differing

viewpoints. (7)

Table 5: Ethical Aspects.

Knowledge

Is aware of the ethical issues and perspectives of

nursing. Knows the commonly agreed and

contradictory values related to nursing.

Understands the challenges and opportunities of

multicultural settings from the point-of-view of

own work community. (6)

Skills

Recognises and is able to analyse ethical issues

of nursing, and is able to solve and apply them

appropriately. Follows the widely accepted

ethical principles of nursing. Is able to assess

his/her own work against ethical criteria. Dares

to tackle detected flaws and solve them

constructively. (3)

Attitudes

Considers ethical issues pivotal for nursing. Is

willing to promote community discussion about

ethical issues through his/her part in his/her

work. Interprets the treatment of patients,

colleagues and other members of the work

community primarily as an ethical issue. (1)

As can be seen, professional knowledge, skills and

attitudes clearly evoked the most discussion. It

appears that attitudes other than purely professional

ones did not get much attention. On the basis of our

data it is difficult to say whether this indicates lower

prioritisation or whether it is simply an area that is

more difficult to verbalise, and in turn difficult to

discuss. Ethical issues induced surprisingly little

discussion – again, the reason is difficult to see on

the basis of the current data.

4 FORMULATING

INTERACTIVE APPLICATION

OBJECTIVES FOR LEARNING

PERIOPERATIVE NURSING

The central education research aim in this project

was to produce knowledge and test how the real –

not only the formal – objectives could work as the

starting point for the construction of an educational

game. Applying these discovered objectives into the

game development was the subsequent goal after

this study. The game development had already

begun before the research results were finished.

However, the purpose to form a basis for an

educational application based on these learning

objectives still seemed possible, because no actual

content of the game had been build. Some central

decisions, such as programming language and

platform of the game had already been decided

within the leading organisation, based on the

recommendations of the software company. The

university researchers in this game development

project operated as consultants making suggestions

and recommendations based on the study. These

recommendations for the game execution were

presented in the project group meetings. For

example, the learning objective tables were

suggested to be used while combining the content of

the game such as tasks for the students to solve

during playing. Also, content examples were offered

to the content providers (specialists in nursing

science). The most important recommendation was

that the objectives of perioperative nursing

education should be the basis of the whole

application. Or if the application would only cover a

portion of the educational objectives, the minimum

requirement would be that the application is not in

contradiction with the objectives. In other words, it

is overly ambitious to aim at covering the whole

content of education with one single application.

Yet, still it should follow the principles that the

over-all objectives indicate.

When we first prepared a tentative set of

objectives on the basis of the formal curriculum and

then elaborated it with the teachers, we found that

teachers’ conceptions were well in line with the

formal objectives. In other words, this study did not

reveal a dominant hidden curriculum, but the formal

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curriculum has been developed in parallel with

practical needs, thus making a lot of sense for the

teachers. While the discussions concerned the

existing learning objectives, it can be concluded that

the teachers think that perioperative nurses need

several sorts of skills, ranging from highly

automatised routines to the ability to act creatively

when necessary.

When we reflected on the objectives in light of

the strengths of educational games, it became

evident that only certain kinds of objectives can be

covered with a game, no matter how sophisticated it

may be technically or pedagogically. The widely

acknowledged strength of an educational game is

that it is a motivating means to train skills which

require a large amount of repetition. As discussed

above, perioperative nursing includes these kinds of

skills which are typically highly automatised

routines. At least in the training of these routines,

games have potential. From the point-of-view of the

application to be designed, this would mean that all

the objectives of perioperative nursing education are

not appropriate for inclusion into the pedagogical

requirements of the forthcoming application.

5 APPLYING THE LEARNING

OBJECTIVES

During the game development, the nursing teachers

and student groups were acting as the main content

providers. This task however proved very

challenging, in spite of the previously defined

learning aims. The content providing was heavily

restricted by the technological limitations of the

software. As a result, only certain types of computer

assisted learning could be implemented, such as

multiple choice questions. In order to cover all the

aspects of the perioperative nursing skills addressed

earlier, this is obviously not adequate. Formulating

the questions which address, for example, ethical

attitudes and the learner’s inner state of mind could

be rather complicated to put into practice this way.

Even though the game technology also afforded

open questions, the analysis of the success or failure

of the learner’s answers became impossible.

Therefore, the questions applied in the game

prototype covered almost solely professional skills

and theoretical knowledge. This gave the game a

certain form of written examination with multiple

choice questions, even though videos and pictures

were added to provide variation.

There are several risks for the success of learning

with this kind of game. It is overly ambitious to

assume that the players would maintain a high level

of motivation after playing a few times. The

questions measuring only superficial learning or

memory are hardly challenging. The problem-

solving tasks which require applying own reasoning

and reflection and which do not necessarily have

only one right or wrong answer would be much

more practical within this learning context. Game-

type learning always requires some kind of

measurement of success or failure. It should also

include some form of competition in order to be

motivating and addictive for the player. It can be

stated that the objectives of perioperative nursing

skills learning are hardly always issues which can be

used in a competitive form or measure at all.

Sometimes this issue and the issue of game playing

could even be in contradiction to one another.

The success of the project can be measured by

varying criteria. A suitable one in this

developmental project context is the result and

product success. The different stakeholders, e.g.

contractors, sponsors, project managers, team

members, users, ICT developers etc. might see the

project goals as well as the product success in a

number of ways (Pirhonen, 2013). According to

Pirhonen (2013), product success is a longitudinal

measurement which can be assessed according to

several criteria: whether it meets the organisational

strategic objectives, how satisfying it is for users and

stakeholder needs, what the business success is and

what the financial rewards are. These can be

completely verified once the product, in this case an

educational game, has been utilised. The result from

the various viewpoints can be that the objectives of

the game development project are not solely the

same as the objectives of the education research

aiming at maximal skills and learning objective

attainment. Sometimes the game development

project is guided by a strict budget and objectives to

develop visibly measurable results for the financing

organisation as fast and efficiently as possible. The

consequences of the differing aims and viewpoints

should however be acknowledged and understood

while evaluating both the product and the entire

success of the project. In this project, the

development of a prototype of an educational game

was in many ways successful and the quantitative

requirements were fulfilled. Yet, the acknowledged

shortcomings relating to learning content were

clearly an issue to address when the follow-up

project was launched at the beginning of 2014.

One definite conclusion is that at the beginning

of the project, the technical implementation of the

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application was seen as the major challenge. Having

recently conducted a concise user study with six

students, we argue, however, that the real challenge

is in the authoring of the content, not the technical

issues. The application itself mainly supports low

level learning. The construction of the content, on

the contrary, may be much more demanding. If the

students of nursing are contributing to the content of

the game, this authoring process may be a much

more rewarding learning process than the actual

playing of the game. In other words, the authoring of

the relatively primitive game works as a framework

or excuse for an activity, during which higher order

thinking skills are applied.

In the near future we will analyse the work of

student groups: How they generate game ideas and

how the application supports the implementation of

the ideas.

ACKNOWLEDGEMENTS

The work is funded by European Social Fund (ESF)

in Finland.

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Cafira, L., Janiszewski Goodin, H., 2011. Using games to

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Huff, M., 2003. Web-enhanced learning for perioperative

nurses. SSM, 9(3), 53-55.

McConnell, E. Hillbig, A., 2000. A National Study of

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Mitchell, L., Flin, R., 2008. Non-technical skills of the

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