Collaborative Design of an Online Simulation Platform for

Unfolding Case Studies

cjni.net/journal/

By
William A. Matcham, PhD, RN, CCRN-K
Assistant Professor
Cleveland State University
Matcham.1@osu.edu

Cindra Holland, DNP, RN, RNC-OB, ACNS-BC

Assistant Professor
Wright State University
Cindra.holland@wright.edu

Matthew Davis, BS
Web Developer/Systems Administrator
Wright State University
Matthew.davis@wright.edu

Todd Pavlack, M.Ed

Manager, Distance Learning and Instructional Designer
Wright State University
todd.pavlack@wright.edu

Ann Bowling, PhD, RN, CPNP-PC, CNE

Assistant Professor
Wright State University
ann.bowling@wright.edu

Abstract
Technology is incorporated into all aspects of nursing education. This article explores the interdisciplinary process of
developing a novel software platform called the Nursing Innovation Lab (NIL). The NIL was created using an
adapted agile software design allowing conceptualization to implementation in less than twelve months. The NIL
was custom coded instead of using off-the-shelf software to ensure all feature specifications were met. The system
will host dynamic simulation-based learning experiences in an online environment that utilize unfolding case studies
to actively engage participants. A discussion of the project goals is followed by descriptions of each step used in the
conceptual design of the project and the software development process. The paper breaks down the project into
functional steps to help readers design their own projects. Functional testing and pilot testing results provide
guidance for software modification to meet the needs of nursing students. The NIL will provide a robust adaptable
platform to engage students in course content and support nursing student success.

Introduction
Active learning strategies are an effective way to engage students. One active learning strategy used in the
classroom to encourage critical thinking is the unfolding case study (Ulrich & Glendon, 2005). Unfolding case studies
involve patient-based scenarios where students process the information in a sequential manner to apply didactic
content and use problem solving skills in simulated clinical practice experiences (Glendon & Ulrich, 1997; Ulrich &
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Glendon, 2005). Simulation-based learning experiences, such as unfolding case studies, can also be conducted
through the use of online technology allowing the case to come to life in the classroom through the visual and audio
elements of the video scenarios.

Through a collaboration of nurses, instructional designers, digital artists and programmers, a novel software platform
called the Nursing Innovation Lab (NIL) was created to host dynamic simulation-based learning experiences in an
online environment. The online platform incorporates unfolding case studies in an effort to improve first year nursing
students success and retention. The software hosts a variety of learning objects that engage learners in a fun and
meaningful way. This paper will outline the interdisciplinary process of designing the software platform including a
discussion of benefits, challenges and rationale for design decisions.

Background
Active learning is an important aspect of the andragogical approach to effective teaching which engages adult
learners in the classroom. Students who are actively engaged in the classroom have improved retention of
knowledge (Knowles, Holton, & Swanson, 2015). Online simulation-based learning experiences represent actual
situations where students are able to enhance their knowledge, skills, and attitudes in an online environment
(Meakim et al., 2013). Online simulation-based learning experiences are techniques that can be used to actively
engage students in the classroom to promote understanding of content. Integrating technology-enhanced
experiences, such as the NIL into the active learning classroom allows students to interact with important content.
These strategies may help students evaluate, synthesize, and apply course content to problem-solving activities
they will encounter in professional practice.

When developing an online simulation-based experience, it is important to consider best practices. The
International Nursing Association for Clinical Simulation and Learning (INACSL) has published standards of best
practice. The first guidelines were released in 2011, the second version in 2013, and two additional standards were
added in 2015 (Sittner et al., 2015). These standards of best practice provide a foundation to ensure development
of high quality simulation experiences.

Instructional Design Features

Electronic simulations in the medical education field have been well documented in the literature (Issenberg,
Mcgaghie, Petrusa, Gordon, & Scalese, 2005; McGaghie, Issenberg, Petrusa, & Scalese, 2010). This project was
designed utilizing five instructional design features of effective simulations identified as best practices in the
literature for all disciplines (Cook et al., 2013). These features include: providing feedback, repetitive practice,
curriculum integration, a controlled environment, and individualized learning (Issenberg et al., 2005).

Providing feedback is generally considered the most important feature of effective simulation-based education
(Cook et al., 2013). Given the target population (first year nursing students) for this project, the design incorporated
specific feedback throughout every step of the program. If the user correctly completed a step, positive feedback
was provided immediately in the form of a notification box. When an incorrect action was performed, feedback was
provided in the form of teachable moments that reinforced the correct path of action. Feedback, in the form of
debriefings, was also given to users after the simulation was completed to reinforce important concepts and
behaviors.

Users had the ability to repeat scenarios. Repetitive practice allowed for skill acquisition in a shorter amount of time
than learning via traditional methods (Issenberg et al., 2005). The unfolding case studies were delivered in a
controlled, online environment. This environment allowed learners to make errors regarding patient care without
negative consequences. This type of education allowed the learner and the instructor to focus on teachable
moments without distraction, and it allowed them to take advantage of valuable learning opportunities (Issenberg et
al., 2005).
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While this project utilized an individual, independent learning strategy, it was also designed to allow for flexibility
based on learner input. This feature made each user an active participant in their own learning instead of being a
passive bystander. The project allowed for complex tasks to be broken down into smaller steps for learners to
master at their own pace. Learners were able to take responsibility for their own educational progress which is an
important feature in educational simulations (Issenberg et al., 2005).

Learning Styles
Active learning strategies that incorporate various learning styles are vital to impacting student success (Andreou,
Papastavrou, & Merkouris, 2014; Michael, 2006). Students in nursing programs have many different learning styles.
Traditionally beginning nursing courses utilize a lecture format with minimal student interaction. Generational
differences exist that alter how learners engage with technology for communication, daily living and education. Older
learners tend to have less interest in online learning and find online technologies less user-friendly (Van Volkom,
Stapley, & Amaturo, 2014). Younger learners tend to be more technologically savvy, have increased familiarity with
daily technology and prefer multisensory methods of information presentation (Feiertag & Berge, 2008; Skiba &
Barton, 2006; Van Volkom et al., 2014).

The project was designed to engage students of varying generations with different learning styles including
kinesthetic (tactile), visual, and auditory (Doyle, 2011). The project utilized a learning styles conceptual framework
based on Kolbs work with student experiential learning (Kolb & Fry, 1974). The software engaged visual learners
with animations, video interviews and high resolution images. Audio learners benefited from realistic assessment
sounds (heart, lung ) and recorded voice interactions including a talking glossary of medical terminology.
Kinesthetic learners interacted with the software through the use of virtual skill performance, selection of answers to
questions and receiving immediate feedback (Kolb & Kolb, 2005). All students benefited from learning through
answering critical thinking questions and participating in activities that integrated content from prior coursework into
the unfolding case study at hand.

Software Design Methodology

Traditional software methodologies enforce a strict series of linear steps including requirements definition, software
design, implementation, testing, and deployment. The main purpose of traditional design is to visualize the entire
project before a single line of code is written. This is helpful for managing large, complex projects where the
business logic is well known in advance. Developers can focus on how to implement the logic rather than what logic
to implement.

Agile development methodologies take this concept of visualizing software before writing code, but utilize it cyclically
in rapid succession rather than in one long drawn out procedure. After each of these cycles, a prototype
incorporating some new set of features is produced for critique by the full project team, including software
developers and subject matter experts, and features or goals for the next cycle are decided. The process continues
until you arrive at a product that meets all of the subject matter experts needs or you hit the project deadline. This
modification of the traditional methodology allows the software development team to build the product that the
subject matter experts want iteratively, without knowing exactly what that final product looks like at the onset of the
project. An added benefit of these rapid cycles is ample opportunity to change course when undesirable elements of
the design are noticed. This helps to maximize the development teams efforts and reduce overall production time
(Pathak & Saha, 2013).

Project Design
The project concept developed from a vision by faculty teaching beginning nursing students in two consecutive
courses. Students struggled with transferring knowledge from didactic content to clinical practice. In addition,
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students had difficulty with application of concepts and critical thinking in clinical scenarios. The goal of this project
was to develop a software platform that would enable students to make choices about patient scenarios through the
use of unfolding case studies. The project was reviewed for human subjects protection by the institutional review
board before being tested and implementation with students.

Custom Platform vs. Off-The-Shelf Product

There are a few commercially available products that provide the functionality needed to build interactive case
studies. A majority of these products are limited in terms of adaptive content delivery, accessibility, scalability, and
data reporting. Many off-the-shelf platforms are not cost effective for a limited program budget. Based on these
considerations and the availability of personnel with technical expertise, the team decided to design a custom
platform. Development of the custom solution allowed the subject matter experts and instructional designers to
ensure that the final product incorporated best-practices of pedagogy and functional design. The result was a
platform capable of delivering rich multimedia content and videos in an interactive case study format where an end-
user can dictate their own path through the scenario. Critical thinking questions were dispersed between video
vignettes to allow students to reflect on important concepts and practice problem-solving skills while applying course
content. Additional modules allowed for formative assessment, feedback and remediation. The platform was
adaptable for use with any style of educational case study.

Storyboarding
The initial concept for each case study was developed by content experts using a storyboard framework in
PowerPoint. Multiple features were combined into a concept map that demonstrated the relationships between
major points. The storyboards were reviewed in a team meeting and an integrated scenario flow diagram was
created on a large white-board. To facilitate production, the scenario was divided into a task list and assigned to
appropriate team members. Before production could begin, detailed actor scripts were drafted and reviewed.

Scripting of Content
The scenario was designed to stimulate critical thinking and application of course content. The script was adapted
from paper-based case studies validated in an introductory nursing course. Content experts adapted the scripts for
the actors to guide their depiction of nursing scenarios to facilitate the students learning. The script was composed
to realistically represent the actor that was chosen for the role (elderly man with hearing problems, etc.).

The script was then divided into small scenes to accommodate actor memorization and facilitate video recording of
the vignettes. It is also important to match the actor with the script to achieve the desired outcome. Many times a
student is recruited to play the role of an older person which is unrealistic, because there is not enough fidelity to
immerse the students in the learning activity.

Video Production
Production of each video vignette required capturing scripted scenes from multiple angles to provide enough footage
to produce smooth transitions and close-up detail for use in post production to make a polished final cut.
Professional grade cameras were used to record the scenes. The technical requirements for video recording these
vignettes included any camera capable of recording in 1920x1080p resolution at 30 frames per second. Any style of
camera could be used; for example, most common cell phones possess cameras with enough resolution and
processing power to produce useable video segments.

Sound was a vital part of the project. A studio quality microphone was essential to capture high quality audio from
the actors. Other high quality audio samples, such as breath sounds, were sourced from websites that allow free
use such as the National Library of Medicine and Centers for Disease Control and Prevention (Centers for Disease
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Control and Prevention, Office of the Associate Director for Communications, & Division of Public Affairs, 2016; U.S.
National Library of Medicine, National Institutes of Health, & U.S. Department of Health and Human Services, 2014).
Adobe Premiere software was used for editing and post-production of sound and video; however, any non-linear
editing program could be used (e.g. Final Cut Pro, Sony Vegas, etc.). Edited videos were enhanced with animation
and compositing graphics by a motion graphic artist.

Animated effects
Motion graphics were created with the video compositing software Adobe After Effects , however any standard video
compositing software could have been used. The completed animations were processed by Adobe Premiere
software for final export and compression. Finalized videos were exported as H.264 MP4 files compressed to 3.0
Mbps for streaming delivery over HTML5 compliant web browsers. Once videos were finalized, additional platform
features such as the talking glossary and reporting were designed.

Talking Glossary
A talking glossary was developed for use in the software. Lists of words that either captured essential concepts or
were hard for students to understand were chosen from each scenario. Each word was included in the glossary with
a standard phonetic spelling, dictionary definition and audio file (.wav) that voiced the correct pronunciation. Unlike
most online talking glossaries, these words also had a descriptive paragraph linking their importance to the practice
of nursing. This assisted students with application of the vocabulary to professional practice. Although developed
with all students in mind, this feature has been especially helpful for students who are not native English speakers.
The glossary can be easily updated and expanded through the database interface.

Reporting Features
As users proceeded through the online simulation experience, data was collected about their navigational decisions
and question responses. Data elements collected included which scenario node the user entered, how long each
node was viewed, question responses, and other important events. Data was exported from the database in a
simple comma separated variable (.csv) file, allowing for further manipulation and analysis using standard analysis
software. The reporting feature was designed using an agile process that allowed for quick modifications as
researcher data needs changed based on new observations of user patterns and behaviors.

Software Design Process

This software platform was developed utilizing an agile software development model rather than a traditional, rigid
software development process. Given the short development timeframe, available personnel, and dynamic design,
an agile approach to software design was chosen over a more traditional, predictive method which is slow, costly
and does not easily adapt to changing software specifications.

At the onset of the project, basic functionality was outlined with an expectation that additional features would be
added as the project advanced through the steps of the agile development cycle. The software platform began with
a basic prototype using an adapted SCRUM-like pattern to add features incrementally to build the software around
the case study scenarios (Schwaber, 1997). Short programming steps ranging from one to two weeks were used to
develop modules that were rapidly critiqued by the team to provide guidance and structure for the next step (see
figure 1). The results of this process were the completion of the core software functionality from conceptualization of
the project to implementation in the classroom in less than 12 months. Feedback from each iteration of the
development cycle informed the team about the need for additional features not originally included in the design.

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 Figure 1. Steps in the NIL Development Cycle using an Adapted SCRUM-like Process Model

Technical/Engineering Specifications
The projects nonfunctional requirements focused on maximizing accessibility and scalability by reducing client-side
computational overhead and bandwidth use as much as possible. The platform was developed using PHP version
5.6 and deployed on a standard virtual Linux-Apache-MySQL-PHP (LAMP) stack. The instance used for this project
was deployed with limited resources; however, the platform can accommodate thousands of concurrent connections
with no performance impact. Pages were delivered in standard HTML, CSS, and JavaScript that can be rendered in
any modern browser. The video content used in the platform was delivered in H.264 MPEG-4, using a standard
HTML5 video element.

End User Requirements

The project was designed to be used on a wide range of hardware to allow for maximum access. The end user
requirements included a computer capable of displaying a minimum resolution of 12801024 pixels and an internet
connection capable of a 3.5 Mbps download rate and a 512 Kbps upload rate. The online simulation experience will
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run on all current modern web browsers without any special plugins or extra software required. The decision to not
require additional software was important, as third party plugins such as Flash and Java routinely have to be
updated due to security vulnerabilities. Some of these plugins are also in the process of being phased out of active
web development projects.

Mobile platform support is not available at this time due to limitations of the underlying software stack(s). For
instance, the simulation depended on auto playing video in the browser, a feature intentionally not supported by iOS
in order to protect end-users from data overage charges. As soon as these foundational features are available on
mobile platforms, the online simulation experiences can be accessed on these devices with little additional
development effort.

Functional Testing and Pilot Implementation Results

Functional testing on the online simulation experience was completed by six volunteers from multiple disciplines
(nursing, psychology and engineering). Functionality was tested by having volunteers navigate the simulation and
make decisions without prompting. Major themes identified in the functional testing results included: spelling and
grammar errors, lack of audio on one term in the talking glossary, and a few broken hyperlinks. Feedback from the
functional testing was used to implement appropriate changes prior to release of the pilot program.

The online simulation experience was pilot tested with 79 nursing students in an active learning classroom during an
hour long session. Due to a delay in the review of human subjects protection application, implementation of the full
research plan consisting of a pre/post test and surveys could not be implemented. Formative feedback was
collected during the session. Feedback about the software platform was very positive. The students liked the
interactive nature of the online simulation experience, were engaged during class and felt the experience was a
good review of important course concepts. Some students commented that the nurse actor in the case study
modeled professional behavior that would benefit their future practice. The feedback was used to inform revisions
for production of a final version for full research implementation.

Future Plans
Initially two scenarios and an introduction were developed and implemented on the electronic platform. More
scenarios have been storyboarded and scripted for future implementation. Future scenarios will utilize cutting edge
technology including an innovative process to create 3D images by digitizing data from the Visible Human Project
sponsored by the National Library of Medicine (U.S. National Library of Medicine et al., 2014). Virtual 3D organs will
be reconstructed from slices of a human cadaver for realistic interactive modeling of pathophysiology concepts.
Additionally images will be supplemented from the Centers for Disease Control and Prevention Public Health Image
Library (PHIL), both of which are free of charge (Centers for Disease Control and Prevention et al., 2016).

The next step for this application is to conduct the full research protocol with a new cohort of first-year nursing
students. Once the data has been collected to inform modifications to the software, it could be implemented in
different disciplines. The versatile software platform can host content adapted to any specialization and be
implemented in an active learning classroom, with online courses or as a stand-alone educational product.

Conclusion
This paper discussed the development of an interactive online simulation experience software platform for use in
educational settings. The team used agile software design methodology to produce a functional product within
twelve months of initial conceptualization. The novel software platform provides functionality not found in
commercially available off-the-shelf products. The online simulation platform and scenarios were designed to use
standard HTML 5 features allowing for maximum distribution without platform or software restrictions. Initial

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implementation with nursing students produced positive feedback and enhanced understanding of course content.
The platform was developed for easy updating and expansion for future implementation of additional scenarios. This
technology has potential to improve student engagement through active learning in the classroom and online.

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Biographical Statements of Authors

William A. Matcham, PhD, RN, CCRN-K

William is an Assistant Professor at Cleveland State University. Dr. Matcham, has a diverse background in nursing,
technology and genetics. His research explores how technology can enhance or improve nursing practice to
improve patient outcomes and facilitate nursing student transition to professional practice.

Cindra Holland, DNP, RN, RNC-OB, ACNS-BC

Cinder is an Assistant Professor at Wright State University. Dr. Hollands expertise includes effective teaching
strategies, and adult health nursing including a specialty in obstetrics. Her passion is to implement evidenced-based
strategies to promote professional development of nurses and future nurses along their practice journey.

Matthew Davis, BS

Matthew is a software engineer working in the Center for Teaching and Learning at Wright State University. His
work focuses on the implementation and development of innovative solutions to enhance online education. Mr.
Davis has a B.Sc. in Computer Engineering from Wright State University (2014).

Todd Pavlack, M.Ed.

Todd is the Manager of Distance Education at Wright State University. He has over 14 years of experience
supporting teaching and learning through the use of innovative technology. Mr. Pavlack focuses his expertise on the
areas of instructional design and using technology to support teaching and learning.

Dr. Ann M. Bowling

Ann is an Assistant Professor at Wright State University in Dayton, Ohio. She completed her doctoral studies at
Case Western Reserve University in Cleveland, Ohio. She is certified as a primary care pediatric nurse practitioner
and nurse educator. Her research focus is on using simulation enhance nursing competency.

Acknowledgement of funding
Funding for this project was provided by the Wright State University Office of the Provost through the 2015 Teaching
Innovation Grants for Student Engagement and Alternative Delivery.
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