In their formative process, health professionals acquire different procedural skills by level and discipline. One of the main issues in teaching procedural tasks is that instruction is based on the master-apprentice model [1
] (Wigton, 1992. The master executes an action and the apprentice imitates the procedure under the informed and critical supervision of the trainer. This model is known as “see one, do one, teach one” [2
There are multiple issues with this teaching model. First of all, there are ethical issues with exposing patients to procedures executed by individuals with no experience (novices) [4
]. Second of all, there are limitations in the amount of procedures and attempts that the apprentice can execute under direct supervision due to the alternative cost of having an expert dedicated to that instance. Lastly, there are limitations in the quantity and quality of the educational feedback that the instructor can give to the trainee, making it hard to determine if a trainee has reached the learning objectives expected by a patient without direct supervision [5
During the last 15 years, and to solve these issues, the use of simulation has been proposed as an alternative to improve the learning and teaching experience in health professionals [6
]. Thus, multiple institutions have implemented successful training programs based on simulation [6
]. A study published by the Journal of Nursing Regulation in 2014 provides substantial evidence that up to 50% of simulation can effectively substitute traditional clinical experience in all prelicensure core nursing courses [9
One of the key procedural techniques for nursing students to learn during their undergraduate studies is how to install peripheral intravenous accesses [10
]. Complications derived from an incorrect execution of this procedure in real patients include bleeding, extravasation, hematomas, or infections [11
]. Even though there is consensus on the need for training and for the use of simulation as means for instruction, there are practical issues in the existing simulation devices currently available. As Carlson et al. indicate: “Few objective metrics exist to quantify differences between providers of various skill levels” (p. 1) [14
Conceptually, the benefit of using an objective metrics device that is autonomous is twofold: it allows repetitions without the need for a physically present instructor, and it provides a reliable form of feedback that is independent from the number of attempts or students considered in the learning session.
In order for the device to be usable and intuitive and to fulfill the expectations of learners and instructors, a user-centered design approach becomes key. User centered design involves widely User Experience (UX). Unlike market research, user research involves three main components: (1) meeting an important user need (“Usefulness”); (2) being usable (“Usability”); and (3) evoking positive emotions through look and feel (“Desirability”)” [15
]. When a product is designed successfully with the different end-users in mind, the possibilities of embracing a new technology increase [16
]. As Miranda asserts, the human interface must be accounted for when designing solutions for real people. Through the active involvement of the users, stakeholders, and key informants we are able to embrace the human complexities of our innovation challenges [17
Considering that the costs in simulation are very variable and not always more affordable than traditional clinical placements [18
], adoption of equipment becomes relevant. Literature states that resources available to provide education are finite; therefore, for the implementation of innovations in health education to be successful, they must be submitted to previous economic evaluations [19
]. People-centered innovation shies away from a purely economic model [20
] and looks to what makes the user experience memorable. This could be key to not only the adoption of a new device, but also to embodying immersive and sensory characteristics that are key to a significant educational experience.
A considerable body of academic work has been dedicated to studying the educational effect of simulation [21
]. Nonetheless, most studies on simulation in nursing education have not adopted learning-centered research designs and explanations [22
] or learning theory at large [23
]. All complex and human psychological processes (higher psychological processes), such as learning itself are embedded into history and culture, but also structured through basic bodily processes (lower psychological processes). Learning does not occur in the brain alone, but all across the body and it involves the student as a whole. For simulation-based nursing education, this means that we have to consider all integrated dimensions of the conscious experience: the psychomotor, the cognitive, the emotional and all bodily systems in general. Additionally, learning is co-constructed by interaction with an “other”. This other is not necessarily a human person, but rather, something acting as a human person. Physical objects can also act as socializing agents for development under a socio constructivist framework [24
]. Simulation devices operate as a collaborating other and thus devices should be designed to be interactive, emotionally supportive and feedback-giving (as collaborating with humans is). This sort of integral approach to learning becomes key when trying to change the perception of an uninvolved student to that of an active apprentice in control of their own training. A participatory approach could benefit students by making them emotional owners of their own learning process [25
]. It could also benefit faculty staff by providing student feedback directly and engaging them as a partner in teaching and learning [26
]. The main purpose of this study is to describe the process undertaken for the design and development of an intravenous peripheral access simulation device and shed a light on the participative design, anthro-design for health and educational principles of creating new technologies that resonate with the final users. In this article we aim to address the following research question: How are user-centered design tactics deployed when creating a new educational device that resonates with the educator and the trainee? What are the main strategies to follow?
This case study is a contribution to research for the development of partial task simulators for nursing education. The results of our development process could shed a light on new ways to involve educators and students to create devices that resonate with them making learning significant and effective. During our fieldwork done in California, Boston, and Santiago de Chile, educators and students would complain about the lack of robustness of existing technologies in simulation. Furthermore, they perceived that simulators currently lack a satisfying user-experience that considers the point of view of the educator and the trainee. While doing the benchmark, we realized that simulation devices in this area had not been very innovative in incorporating technologies that could improve these gaps in the experience (UX). Through the use of an anthro-design methodology, we were able conduct a research and development (R&D) process to create an alternative device that we perceive to be more founded on the needs, habits and motivations of students and teachers. The device delivers successfully value to the users by being intuitive, matching their expectations on the experience (resonates with their expectations), and allowing autonomous peripheral venous access training (without the presence of an on-site instructor).
In the first phase of the process, the design principles were derived from theoretical knowledge and discussion with experts. Some preconceptions about the way students learn were challenged, and some of the original design principles were reinforced and validated, others were discarded. The empirical knowledge gained from one cycle was immediately implemented in the next one. This iterative and reflexive attitude is crucial in order to integrate such different sources of knowledge (educational theory, medical expertise, teachers’ practical knowledge, and students’ subjective experience). Ultimately, a great number of participants (about 135) and in depth data were needed to produce a final prototype that reflected all of the requirements identified in the research process. From the incorporation of a blood pump to the design of the interface, almost every major design decision was motivated by users’ participation. Overall, these results add to the growing interest in nurse education to adopt a more learning-centered approach [22
]. Additionally, these results also add to the recent interest in nurse education to generate design principles to guide the development of simulation-based educational strategies [46
]. In the following section, we will systematize the design tactics we inductively learnt during this research and development process.
Design Tactics for Future Developments That Resonate with Educators and Students
The proposed methodology facilitated insight into the design process behind the development of a simulator that incorporates the point of view of educators and students to achieve multivocality [37
]. Figure 7
exemplifies some of the important user centered design tactics that we identified throughout this study in order to achieve a simulation device that resonates with the end users. It is relevant to notice that these can be put in practice in the development of any simulation device that implies the use of hardware and software. Considering that, in simulation, learning is co-constructed by the interaction with the device, the focus is to achieve a successful interactive experience between a simulator and the individuals. Through these design tactics, we propose that other research and development processes can increase their odds in achieving that goal. The design tactics identified are the following:
Start with ethnographic research: Start talking to your users in their field: Anthro Design works wonders because it involves going in the field and understanding their day-to-day activities. In turn, this means that future simulation designers and practitioners would benefit from learning the basics of qualitative research and some of the fundamental tools (and theoretical foundations of those tools), such as observation, semi structured interviews and field notes.
Involve users in every stage of the process: Co-creating instead of convincing. Involve the user from the beginning and empower them to tell you about their ideas. People want to be heard. Additionally, we found that “snowball sampling” is key to testing with diverse institutions and individuals. When your participants are your allies, they can lead you to more participants.
Develop iterative prototypes: Start with cheap prototypes like mockups before investing in packaging a full technology. Prototyping several times to receive continuous feedback can be cheaper than developing and getting to the users with something that does not resonate with them. Forecast and plan for incremental development cycles and not just one field research and not just one development stage. It may seem expensive and time consuming to address it that way, but it is much cheaper than producing a final product that will not appeal to user or will not have a meaningful impact
Transform feedback into concrete requirements: Exercise translating qualitative information into design requirements. Sometimes it will not be too obvious, mostly because users do not think in terms of requirements (they think in terms of experience). However, creating requirements from data is a skill that can be developed over time.
Be open to modifications and changes: Do not impose your solutions. Perhaps one of the more challenging aspects of adopting an ethnographic approach is to suspend your previous judgments when entering the field. Under an anthro-design methodology it is equally important not to grow infatuated with your current ideas. Be open to learning and making mistakes. Do not start the process with a solution and do not rush to one once you get a little data. Trust the process and maintain an open mind.
Ultimately, all of these tactics point to a single strategy: Be people-driven, not only technology-driven. Devices should follow users’ guidelines, not the other way around. This also means that both “rational” (cold aspects of cognition), as well as “emotional/motivational” (hot aspects of cognition), should be considered. Simulation devices are not bound to the ideal learning scenario, but rather, to the human and complex scenarios of real-life teaching and learning.
Altermatt, Fernando, Constanza Miranda, Benjamín Garnham, and Sanz-Guerrero Jorge. Medical Simulator for the Simulation of Puncture Operations. WO/2017/113022, issued 2017.
Altermatt, Fernando, Constanza Miranda, Benjamín Garnham, and Sanz-Guerrero Jorge. A medical simulator for the procedures associated with punctures for the simulation and training of interventions and punctures. It involves a phantom, an intervention device and a system for processing the communication and data between the phantom, the sensors, and detection means for the detection related to a group of membrane simulation and a base (translated). INAPI 59089. Granted in April 2020.