Virtual Teaching in Second Life Enhancing Retention of Knowledge In Providing Perioperative Care to Laparoscopic Cholecystectomy Patients

Submitted to:

Mrs. Margaret Natividad Nursing Research Adviser

Submitted by: Melgar, Mark Crisostomo 09177075257 Mascardo, Grace Karen Josue Matandac, Ann Garces Mayo, Gica Jean Chavez Medina, Joseph Martin Anthony Perez Mendoza, Arnelene Ramos

CHAPTER 1: 1.1 Introduction

PROBLEM RATIONALE

The extent to which information can be processed is indicative of the learners capabilities (Bastable, 2008). With the correct learning styles, the educator will be able to correctly match the level of behavioral objectives to the cognitive ability of the learners. According to Fleming and Mills, an individual learns most effectively and comfortably either visually (visual learners), aurally (aural learners), kinesthetically (kinesthetic learners) or through reading and writing (read/write learners). Visual learners like graphical representations such as flowcharts with step-bystep directions. Aural learners enjoy listening to lectures, often need directions read aloud, and prefer to discuss topics and form study groups. Read/Write learners like the written word by reading or writing with references to additional sources of information. Kinesthetic learners enjoy doing hands-on activities, such as role playing and return demonstration. In a study made by Cutiongco (2006), 59% of the fourth year Filipino high school students understood reading selections through the use of graphic organizers. Therefore, proving that Filipino people learn visually rather than any other types of learning. In the process of learning, students not being able to learn visually face many problems such as experiencing difficulty imagining and comprehending what is needed to be learned. The same goes in the field of Nursing. Nursing students face the challenges of imagining how an intervention will be done and visualizing what its effects would be on their clients. However, the advancements in technology allow the Nursing body to visualize such things through the use of virtual simulation to provide a more effective and safer care to their clients. Using virtual simulation in this field would not only foster active participation between the teachers and their students but help them easily achieve teaching and learning objectives easily as well. All clients cases are unique. All of them has their own level of difficulty especially when it comes to providing them the kind of care that the clients need. Nursing

students, being advanced beginners, sometimes fail to provide them the kind of care that they need during their exposure in the clinical setting due to low level of knowledge retention. With this, the clients conditions worsen therefore leading them to a longer hospital stay. Kenneth and Melissa (2008) health care errors resulting in patient harm are a leading cause of morbidity and mortality for tens and thousands of deaths occur each year in the United States. This is when virtual teaching comes into place. Nowadays, the use of virtual teaching is gradually being utilized in the field of Nursing. In this study, the researchers will make use of Second Life in training nursing students on how to provide perioperative care to Laparoscopic Cholecystectomy patients. In the study made by McConagh and Troy (2011), Second Life is best used for knowledge transfer and collaboration. Second Life contains a 3D virtual environment in which online users can interact with the objects they come across with. With this, nursing students may easily visualize how their interventions will be done and what their effects would be on their clients. Given this situation, the choices made on the appropriate type of teaching style must be considered for it is a crucial part in the field of nursing. With the appropriate teaching style given to the nursing students, future nurse practitioners would provide the kind of care that their clients need. Errors will then be minimized and hospital-associated morbidity and mortality will be lessened. Nursing administrators would also provide nurses the up-to-date information they need through online trainings. Even without being personally in front of the nurses, high quality of care can still be given to the latters clients. Improvements on teaching nursing students will be the effect of the use of a virtual simulation which can be a basis for nursing educators to teach their students the appropriate care to be rendered to Laparoscopic Cholecystectomy patients.

This can provide more information about researches that make use of Second Life and identify its role in enhancing the competence of nursing students to handle situations. At the same time, this research will also motivate other researchers to conduct similar studies making use of different settings and subjects. A new virtual environment can also be created and manipulated to expand their knowledge on the correct nursing intervention to be applied in the clinical setting. 1.2 Research Impediments With the involvement of incoming third year students taking their summer classes, the group may encounter difficulties in conducting the study due to their differences in their class schedules. Medical-Surgical Professors would also be difficult to find since the curriculum of the college doesnt involve Medical-Surgical Nursing in its summer classes. As part of the creation of the virtual environment in Second Life, time would be a big factor in contributing to the difficulties in conducting the study. Its creation may or may not involve collaboration with an Information Technologist (IT). More time will be consumed in the creation of the environment without an IT whilst lesser time will be allocated with the aid of an IT. Involvement of an IT in the success of the study may then result to increased expenses of the researchers.

CHAPTER 2: 2.1 Review of Related Literature

THE RESEARCH QUESTIONS

2.1.1 Care of Patients Undergoing Laparoscopic Cholecystectomy Laparoscopic cholecystectomy is a minimally invasive surgical removal of the gall bladder and gallstones with the use of laparoscopic technology or keyhole. The understanding of surgical nurses regarding the gallstone disease and the surgery itself is very crucial in ensuring an empathic, safe and effective care for patients (Graham, 2008). Preoperative Care Each client having surgery responds differently that is why a care plan is based on his or her needs. Nurses obtain a complete health history composing of previous surgeries and experiences with anesthesia, serious illnesses or trauma, any drugs and alcohol abuse as well as the current discomforts of the patient. Moreover, medication history, psychological tolerance of perioperative stress, lifestyle habits and social history are included. It is also during the preoperative phase that the nurse does specific body systems assessment (cardiovascular, respiratory, musculoskeletal, and integumentary systems) Preoperative health teaching is geared toward individual needs be it sensory, psychosocial or procedural. Medications prior to surgery are also administered and the patient is transported to the operating room (Black & Hawks, 2008). Intraoperative Care Intraoperative care is care rendered from the time the patient is transferred to the Operating Room table until the patient is admitted to the Post-Anesthesia Care Unit. This is also called Operating Room Nursing. The patient is monitored all throughout the surgery. The nurse serves as an advocate for the client and implements care individually designed for each client including proper positioning, maintaining surgical asepsis, monitoring vital signs, potential emergencies and controlling equioments and supplies. Anesthesiologist or anesthesia providers are the ones to participate in sedation of the client, called monitored anesthesia care The effects of anesthesia are

crucially monitored throughout the surgery from stage 1 to stage 3 or even stage 4 of anesthesia (Black & Hawks, 2008). Postoperative care The patient is now released from the PACU and transferred to an inpatient nursing unit where assessment and nursing interventions are similar to those performed in PACU. Nurses and other health care professionals establish postoperative goals. The health care team monitor the respiratory status of the patient including patent airway, breath sounds, and breathing pattern. Circulation is also included where the vtial signs, skin color and temperature are monitored. These are assessed frequently depending on the doctors order or the demand of the post-operative condition. The neurologic status, specifically the level of consciousness, orientation and lingering effects of anesthesia are assessed in the first 24 hours. When there is wound, wound care is performed and contraptions post-surgery are maintained for patency, infusion, right drug and other protocols observed in the hospital institution. It is also during this phase that the patient applies the preoperative teaching given such as deep breathing exercises, proper positioning and ambulating, and diet (Black & Hawks, 2008) 2.1.2 Student knowledge retention Perioperative nursing involves three phases in which each phase, different interventions are given to the patient preoperatively, intraoperative and postoperatively. However nursing students are also affiliated in operating rooms to assist in the surgery. Thus, it is very important for the student to learn and remember all the necessary perioperative care and assistance for the patient and the other health care providers. In Tintos theoretical model of persistence, when a student integrates into the institution both academically and socially, persistence has occurred. Moreover, integration influenced several factors, namely: pre-college characteristics and goals, interactions with peers and faculty, and out-of-classroom factors (Tinto, 1975; Jensen, 2011). Factors influencing knowledge retention are divided into three. First is the individual level which includes academic performance (e.g. GPA, academic selfdiscipline) and attitudes and satisfaction (positive attitude about academics,

commitment to college). Second, institutional level comprises of academic engagement (e.g. undergraduate research activities). Lastly is the social and external level which mainly refers to the social and family support (e.g. faculty and staff support, sense of belonging and community (Jensen, 2011). A study was conducted among 26 pharmacy students in determining knowledge retention and comfort level with patient-case simulation from written case simulation. The students were given immediate post-test after the case and retention test 25 days later. There was a decrease in test scores in the collective group from post-test to retention test but it was considered not significant and students post-test scores remained to be higher than pre-test scores. Test scores of the written-case group decreased slightly from post-test to retention test. On the other hand, the test scores remained the same in the simulation group. However the difference in scores was not significant. The comfort level of students in the written case increased when tested 25 days while the simulation groups decreased. Therefore, Raye, Wylie, Rowe, Heidel, & Franks (2012) concluded that there is no difference in knowledge retention in both groups. In the student retention analysis of Wang and Beck (2010), mastery learning notion is one cause of a long term effect in learning. The authors confirmed that long term knowledge is varied by the student himself and the skill and how often the skill is being practiced. And the intelligent tutoring system (ITS) in which the student is presented with sequence of problems and evaluated right after the student finishes the problems to observe if the student mastered the given skill, can lead to higher mastering rate though it is based on a short performance. 2.1.3 Virtual community as a teaching strategy Over the past decade, there has been a huge emphasis in the field of nursing education literature in relation to much desired changes in educational delivery. All around the world, various changes have been taking place, from curricular redesign to the development and evaluation of innovative and contemporary learning applications (Giddens, Carlson-Sabelli, & Fogg, 2010). Effective learning environments have been

created in all levels of education by infusing active learning strategies into usual course activities (Zepke & Leach, 2010). Virtual community is now regarded as an emerging pedagogy in nursing education. It is used as a tool in stimulating students interests, voluntarily engaging themselves in the learning process (Giddens, Hrabe, Carlson-Sabelli, Fogg, & North, 2012). Two proposed descriptions of virtual community have been introduced. The above authors define virtual community as an online teaching application using a fictional environment aided by characters displaying intersecting relationships and sharing unfolding stories about health-related issues as the main focus. From the disclosure of information regarding the characters heath issue, nursing students then select concepts during the disclosing process. In two years virtual community has been simplified as being a web-based teaching tool with fictional characters and their story lines in an unreal setting (Giddens, Hrabe, Carlson-Sabelli, Fogg, North, 2012). A characteristic that delineates virtual communities over the technologies used in the classroom like videoconferencing, Webinars, and group chats, in which studentfaculty interaction serves as its focal point, is the emphasis on observation of and engagement with the characters, including their community and life situations. Upon obtaining the stories of these virtual patients during the engaging process, students then exhibit the essential component in nursing care which is according to Curran, Elfrink and Mays (2009), a personal engagement between the nurse and patient to gain more insight of the health and experiences of the patient. In learning these complexities, health-related contents revealed during the interaction, the virtual community aids the students in the acquisition of these contents through learning in a manner of contextualization. Therefore, virtual communities, emphasizing the power of context (Benner, Sutphen, Leonard, Day, 2010), are the means to transform skills and theories into a higher level of thinking (Giddens, Hrabe, Carlson-Sabelli, Fogg, & North, 2012). Further, 120 baccalaureate nursing students from the first semester at two campuses in a large university in southwest were assessed for the impact of virtual community on student engagement and learning with the use of third-party observational measurement, end-of-class student/faculty surveys, and knowledge items

in student examinations for the class. The t-test used for the latter two showed results that the experimental group yielded more engagement more often and communication exchanges. The same test combined with chi-square statistics yielded results that preadmission academic achievement has no impact and demographical data on age, gender, marital status, race/ethnicity, and previous academic degree have no significant difference between the controlled and experimental groups. Findings from this study add to a growing body of evidence that learner engagement is an outcome of using the innovative virtual communities strategy (Carlson-Sabelli et al., 2011, Giddens, Fogg et al., 2010; Giddens, Shuster et al., 2010; Shuster et al., 2011) and that they can learn in classroom sessions when faculty do not resort to the traditional way of teaching which is lecturing behind a podium. In addition, the perceived benefits increased among all students regardless of race/ethnicity when there is a greater use for virtual communities as classroom learning activities (Giddens, Carlson-Sabelli, & Fogg, 2010). 2.1.4 Second Life (SL) a simulated experiential learning Virtual worlds are three-dimensional environment with multi-users with a social context. An online, or virtual, environment characterized by the use of digital artifacts for interaction, avatars to represent the users, enablement of communication among participants, inclusion of self in shared experiences that can be similar to those in real world context, and with virtual access that can be accessed by multiple users simultaneously is called multiuser virtual environment (MUVE). In 2003, Linden Lab developed an online three-dimensional virtual world that is free, open access and a downloadable program, a virtual world with multiuser virtual environment called Second Life (Aldridge, 2009; Dieterle & Clarke, 2009). In SL a user is able to join different user groups based on either social or educational interests. The user can also travel to different areas called islands where the user can meet other people, socialise with them (e.g., dancing) or take part in meetings, support groups, or educational opportunities (e.g., genome island). Quite a number of universities and corporations have islands in SL where they conduct their business transactions as well as hop staff meetings and educational sessions. Currently, SL has its own currency which is called Linden dollars. This allows users to

buy items of their choice such as clothing for their avatar or furniture for their office. Users can also communicate among themselves with the use of a text chatting method or a voice chat method which requires computer headphones. The computer keyboard or pull-down menu in SL can then be used to move the avatars (users) around the virtual space or island. The avatar can walk, travel or fly to travel around the island, and in order to go to different islands, the avatar can teleport with the use of a map in SL which allows the users to manipulate their avatars from one island to the other. Users are also capable of building objects through their avatars in SL and animate those objects by creating a scripting code. This code allows the user to build various things like a chair, and animate it so that the avatar can sit on it. Avatars in SL always come with a standard set of clothes, and if the user wishes for more, clothes can be made or bought from different vendors present in SL (Aebersold, Tschannen, Stephens, Anderson, & Lei 2012). The public, especially nurse educators in this context need to be aware that Second Life is a great alternative venue for simulated experiential learning (Skiba, 2009). This way, student-patient and interprofessional communication can be facilitated with the use of patient scenarios while students learn to provide the best form of patient care in a virtual setting. Second Life experiences have an impact on how students assessed their competence ( Peck & Miller, 2010) as well as the fact that students enjoyed Second Life and even requested additional experiences (Honey, Connor, Veltman, Bodily, & Diener, 2010). SL is a great alternative environment for nursing students and is widely used for various purposes such as role-playing, collaboration, and most importantly, real-time interaction between students and faculty that is different from the usual classroom setting (Skiba 2009). SL does not only provide the learner with a greater ability to be more involved in the scenario and to intimately immerse in the situation, but it also gives the learner the ability to simultaneously step back and get a broader view, less attached to the given virtual scenario thus, the reason why SL is educationally excellent in the role of supporting simulation, especially simulation that involves interaction among a number of participants (Aebersold, Tschannen, Stephens, Anderson, & Lei 2012).

2.2

Conceptual Framework The study focuses on the efficacy of virtual teaching as a new strategy that uses

virtual environment named Second Life to increase knowledge in clinical health care by the junior nursing students. The study applies concepts from the following theories: Sensory stimulation theory Traditional sensory stimulation theory has as its basic premise that effective learning occurs when the senses are stimulated (Laird, 1985). The majority of knowledge held by adults (75%) is learned through seeing, hearing is the next most effective (about 13%) and the other senses such as touch, smell and taste account for 12% of what we know. By stimulating the senses, especially the visual sense, learning can be enhanced. Student engagement and active learning are key concepts forming the basis of sound educational practices. The focus is now on student-centered learning rather than passive, teacher-centered instruction (Oermann, 2004).. Action Learning Learning theories and educational frameworks are the philosophical foundations that guide the selection of instructional strategies and learning activities. Andragogy (Knowles, 1980) and adult learning theory are commonly used as theoretical foundations for online course design both for nursing students and practicing nurses According to (McGill &Beaty 1995) action learning is the approach that links the world of learning with the world of action through a reflective process within small cooperative learning groups known as 'action learning sets'. Simulations created in virtual worlds provide an immersive environment in which students may experience common or risky problems and issues that are similar to those occurring in todays health care system (Mastrian, McGonigle, Mahan,

&Bixler, 2011). Second Life is an example of a virtual world where many people can interact within what is called a multiuser virtual environment (MUVE). A MUVE is described as an online, or virtual, environment that enables multiple simultaneous users to access virtual contexts where they can interact with digital artifacts, represent themselves through avatars, communicate with other participants, and take part in shared experiences that can be similar to those in real world contexts (Dieterle& Clarke, 2009). But although preparing the students is important so that they are ready to participate in the simulation, there was also a need to prepare lecturers to teach in a simulation context as this context is different from traditional classroom teaching. This is because in a lecture setting, the teacher is central, and a simulation allows a learner-focused approach (Jeffries, 2007). 2.3 Paradigm

Figure 1 Effects of Teaching Strategies to Senior Nursing Students Figure 1 shows the effects of teaching strategies to Senior Nursing Students and the relationship of the variables involved in the study. It was stated in the study that the researchers acted as a Virtual Educators/Teachers and were equipped with the use of second life website prepared by the researcher for the experimental. On the other hand, the adviser of the research team gave a Powerpoint Lecture Presentation for the controlled group. It can be noted that the teaching strategies used provided positive learning effects on the respondents and stimulated their cognitive ability. After increased learning occurred, the ability of the respondents to understand and retain knowledge about medical cases was tested using a post-test questionnaire.

2.4

Research Questions This study aims to determine if virtual teaching in Second Life enhances

students retention of knowledge in providing perioperative care to laparoscopic cholecystectomy patients. The following research questions will be explored in this study: 1. What is the state of the students knowledge retentiveness before providing the virtual teaching? 2. What are the factors that might affect the retentiveness of knowledge in students during virtual teaching? 3. What is the state of the students knowledge retentiveness after providing the virtual teaching? 4. Is there a significant difference on the level of knowledge retention before and after the intervention? 2.5 Hypotheses It was hypothesized that implementing the virtual case teaching would yield more likely to an outcome that would; (1) lessen nursing errors, (2) increase the students level of interest and (3) enhance the students memory retention in nursing education . 2.6 Operational Definition of Terms Avatar refers to the virtual body that would serve as the vehicle of the users of the software inside the second life Existing knowledge score (EKS) refers to the existing knowledge that the subjects have in regards to the topic that will be taught which is measured through the pretest Knowledge refers to the gained understanding of a given concept through exposure to an experience or situation that builds a body of information

Laparoscopic Cholecystectomy through a laparoscopic approach

- refers to the removal of the gallbladder

Learning evaluation score (LES) refers to the performance of the subjects of this study which aims to measure the level of learning acquired through the teaching method (either virtual or traditional) presented

Memory Retention refers to the level of understanding and appreciation of the topic of our subjects which is reflected on their memory span of the knowledge gained

Moving refers to the varieties of interactive methods present in the software which offers flexibility in terms of controlling the avatar Perioperative refers to the period extending from the time of hospitalization for surgery to the time of discharge. Second Life refers to the software designed for interactive purposes which aims to harness the powers of collective intelligence through virtual socialization in a realistic environment conducive for learning

Traditional teaching refers to the teaching method presented to the controlled group which consists of an outline presented in a chronological order identifying the disease process, nursing intervention and medical management of a given case.

Virtual Community refers to the a social network of media who interact through specific social media which aims to provide a realistic environmet Virtual teaching refers to the teaching method presented to the experimental group which consists of virtually constructed case scenarios that are commonly encountered in the actual ward setting which offers: 1) visualization of specific case scenarios, 2) facilitation of analytical thinking process and 3) promotion of interactive learning process.

CHAPTER 3: 3.1 Research Design The researchers in the study

RESEARCH METHODS

used

the

Randomized

Pretest-Posttest

Experimental Design which is composed of an experimental group and a control group. Random selection of samples will be done by the researchers in order to determine the participants for both the experimental and the control group. In this type of research design, the results from the pretest and posttest after the treatment was done will be compared. The control group will be given a pretest and posttest without receiving treatment and the experimental group will be given a pretest, treatment then, posttest (Burns & Groove 2009).The researchers will provide the experimental group with a strong treatment which is the visual teaching using Second Life. Using this design, the researchers will determine the effect of the treatment they will be providing the experimental group. O1 = observation or measurement prior to treatment O2 = observation or measurement after the treatment T = treatment Pretest Treatment Post-tests O1 O1 T

Experimental group Control group

The researchers will use this experimental design 3.2 Study Site The study will be conducted at the University of Sto. Tomas College of Nursing particularly at the St. Martin de Porres Building, Espana Manila. The proposed locations for the conduction of the study are the Nursing Auditorium and the ED Tech Laboratory which can cather the number of our respondents.

3.3

Selection of Subjects The total population of the incoming junior students for the academic year 2013-

2014 is 430. Out of this number of students our target population. The method used in obtaining the number of subject is fish-bowl method. Inclusion Criteria 1. Filipino citizen, able to read, write and understand. 2. Incoming nursing junior students without any OR Orientation or experience. 3. Has interest to participate and cooperate. 3.4 Data / Outcome Measures A questionnaire is a printed self-report form designed to elicit information through written or verbal responses of the subject. The information obtained from questionnaires is similar to that obtained by an interview, but the questions tend to have less depth (Burns and Grove, 2009). The questionnaire will be done covering the case that will be discussed. Furthermore, when making a questionnaire, knowledgeable persons should be able to check and review the grammatical errors and technical problems found in it. In addition, approximately 10-20 participants should answer the questionnaire to serve as a pilot test (Polit and Beck, 2009). The questionnaire that will be given will be composed of 25 items and will be used for the pre-test and post-test to be conducted. 3.5 Data Collection Procedure / Flowchart A letter of permission will be given to the Deans Office of the University of Santo Tomas. Once permission has been granted, two sectionsof the 4thyear students will be randomly selected and each will be chosen either to be the experimental or the control group. The exoerimental group will be taught using Virtual Teachig while the control group will be taught using the Traditional Classroom Teaching. The experimental group will be given a short course on how to manipulate the environment in Second Life. All the students and the teacher involved will be required to create their own accounts in Second Life.

Once accounts have been created, everybody involved in the study, will login to their accounts and the teacher will be starting to teach the students like having an actual ward class. After this ward class, the students will be given a posttest on what they have learned during the said activity. Meanwhile, after the control group has been taught using the traditional method of teaching, students will be given the same post test as what the experimental group has taken. Papers will then be checked and compared to see if the suggested Virtual Learning is effective in the Nursing Curriculum. 3.6 Ethical Consideration Informed consent will be given by the subjects without coercion and the subjects are not manifesting any criteria under vulnerable subjects. A criteria proposed by the researchers will be strictly followed. The consent form will contain all the essential information. Prospective participants will be given ample time to review the written document before signing it. The document will also be signed by the researchers and a copy will be retained by both parties(Polit& Beck 2009). Full disclosure of the research will be done by stating any risk-benefit ratio to the subjects by the researchers to allow subjects to defer decision whether to accept or refuse. The subjects when unavailable will not be forced to participate in the study and are free to withdraw their participation anytime intended. The data and results of the study will be kept confidential among the researchers and will not be divulged to any other person not involved in the study. The researchers will only obtain identifying information from participants when necessary (Polit& Beck 2009). All the pretest and posttest questionnaires that will be used in the study will be kept in a locked file.

Random sampling is used to choose subjects for the research thus, there will be equality and no bias posed among them regarding any demographic and academic profiles. Any results acquired from the study will not be tampered and will be accepted whether it does support or negate the hypothesis of the study. 3.7 Data Analysis In analyzing the data, the researchers will conduct a two-step approach consisting of both quantitative and qualitative methods of data gathering. In conducting the quantitative approach of the study, a two sample t-test will be used to determine the relationship of the two independent variables. This is being used in order to determine if new process or intervention is better than its current intervention through the significance level (Snedecor and Cochran 1898). Posttest results of the controlled group and experimental group would serve as the determinants of the significance of the two variables. On the qualitative analysis of the data, subjective perception of the subjects will be collected as well using questionnaires that would scale the subjects interest and willingness to learn. A likert-scale will be used in order to measure the level of approval of the subjects that will be evaluated on the respective teaching methods presented on each group. Lastly, the significance between the results of both the quantitative and qualitative data will be correlated as well. This is for the purpose of knowing whether the level of knowledge acquired in both groups is directly or indirectly related to the subjective level of the subjects perception regarding the effectiveness of the teaching method.