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Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills Azizeh K. Sowan ∗ Department of Health Restoration & Care Systems Management, School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
a r t i c l e
i n f o
a b s t r a c t
Article history:
Purpose: Streaming videos (SVs) are commonly used multimedia applications in clinical
Received in revised form
health education. However, there are several negative aspects related to the production and
31 March 2014
delivery of SVs. Only a few published studies have included sufficient descriptions of the
Accepted 15 April 2014
videos and the production process and design innovations. This paper describes the pro-
Keywords:
students at a public university in Jordan and focuses on the ethical and cultural issues in
Multimedia
producing this type of learning resource.
duction of innovative SVs for medication administration skills for undergraduate nursing
Streaming videos
Method: The curriculum development committee approved the modification of educational
Video production
techniques for medication administration procedures to include SVs within an interactive
Medication administration
web-based learning environment. The production process of the videos adhered to estab-
Nursing education
lished principles for “protecting patients’ rights when filming and recording” and included: preproduction, production and postproduction phases. Medication administration skills were videotaped in a skills laboratory where they are usually taught to students and also in a hospital setting with real patients. The lab videos included critical points and Do’s and Don’ts and the hospital videos fostered real-world practices. The range of time of the videos was reasonable to eliminate technical difficulty in access. Results: Eight SVs were produced that covered different types of the medication administration skills. The production of SVs required the collaborative efforts of experts in IT, multimedia, nursing and informatics educators, and nursing care providers. Results showed that the videos were well-perceived by students, and the instructors who taught the course. Conclusions: The process of producing the videos in this project can be used as a valuable framework for schools considering utilizing multimedia applications in teaching. © 2014 Elsevier Ireland Ltd. All rights reserved.
Abbreviations: SVs, streaming videos; IV, intravenous; IRB, Institute Review Board. Correspondence to: Department of Health Restoration & Care Systems Management, School of Nursing, University of Texas Health Science Center at San Antonio, Suite 2.628, 7703 Floyd Curl Drive – MC 7975, San Antonio, TX 78229-3900, USA. Tel.: +1 210 567 5799; fax: +1 210 567 1719. E-mail addresses: [email protected], [email protected] ∗
http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004 1386-5056/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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1.
Introduction
Multimedia applications are being more heavily utilized for clinical courses in health education. Multimedia refers to “computer-based systems that use associative linkages to allow users to navigate and retrieve information stored in a combination of text, sounds, graphics, video, and other media” [1]. Given recent advancements in telecommunications and High-speed bandwidth Internet, streaming videos (digital videos streamed on the web) have become the most commonly used multimedia application to support clinical health education and to role-model practices. Learning benefits using streaming videos (SVs) are evident in areas such as achievement, technical skills, satisfaction, and selfconfidence [2–9]. This strategy also offers flexible learning by allowing students to revisit sections of procedures they did not grasp the first time and it empowers students with a self-paced learning and control over the learning process. Despite these benefits, there are several negative aspects that can be encountered related to the production and delivery processes of SVs. These include poor quality of videos, poor instructional design, cost, technical problems and low levels of student and faculty interaction, all of which result in unsatisfying learning experiences. For example, while the majority of dentistry students perceived SVs as an effective substitute for in-class demonstrations and rated the video quality as excellent [10], the majority of students in an asynchronous video streaming pharmacy class were unsatisfied about the learning experience and preferred a mixed-mode of teaching [11]. In a systematic review of 53 studies published from 2002 to 2011 on SVs, Kay found mixed results about the effect of SVs on students’ attitudes, behaviors and performance. According to Kay, insufficient description of the SVs was the main methodological concern and “technical problems” in the delivery process was the main challenge for not using SVs [12]. Although there has been an increase in the use of SVs in health education, studies with sufficient description of the videos and the production process are few [13,14]. In addition, the majority of studies have used SVs to demonstrate ideal practices and few are available where innovation in the video production was used, such as comparing normal and abnormal musculoskeletal examination findings [11] and demonstrating errors in the cavity preparation and restoration examination [10]. This paper describes the production process of high-quality and well-produced SVs for medication administration fundamental skills aimed at undergraduate nursing students at a public university in Jordan. The final videos illustrated the ideal performance of medication administration in the skill laboratory as demonstrated by the instructors who were teaching the course, and also included a demonstration of the procedures by registered nurses for real patients in hospital settings. The latter helped students differentiate between the ideal “lab-based” practice and real-world practice, an exercise that will help facilitate practice transition for the nursing students. This report also focuses on the ethical and cultural issues in producing this type of learning resource for educational purposes.
1.1.
Background and planning
In almost all schools of nursing, Fundamentals of Nursing Skills is the first clinical course offered for the undergraduate nursing students in the first year of the program. Students usually encounter their first clinical skills training in a laboratory-based environment to prepare them for the subsequent hospital-based rotations. Fundamental skills include maintaining a safe environment (hand washing, infection control, surgical dressing, vital signs); personal cleansing and dressing (changing linens on an occupied bed, disposal of linens, assisting individuals with bathing); medication administration, intravenous (IV) therapy and parenteral nutrition; urinary catheterization; administration of oxygen therapy; and enteral feedings such as placement and maintaining of a nasogastric tube. In addition to the psychomotor skills, the course also focuses on patient–provider communication, critical thinking and problem solving, and documentation of care. At the School of Nursing where these SVs were produced, the fundamentals of nursing skills course is usually taught by 15 baccalaureate and master-prepared nursing clinical instructors using demonstration and practice techniques on non-interactive mannequins to groups of 8–12 students in each lab session, for a total number of 130–150 students. The disadvantages of this method of teaching include: a limited lab time for students to practice the procedures after the demonstration, which also affects applying skills such as critical thinking, problem solving and documentation of the procedures; the unavailability of other learning resources for skill demonstration; a lack of consistency in skill demonstration between the instructors; not considering the different learning styles of the students; missing equipment from the lab for the demonstration purposes; and difficulty transition to real-patient setting. Therefore, SVs were introduced as supplementary learning experiences to maximize student learning. The researcher who was an expert in coordinating the fundamentals course and in informatics recognized the need for integrating information technology and multimedia innovations to transform the teaching/learning experience of the fundamentals of nursing course. The project was approved by the curriculum development committee and the faculty involved in teaching and coordinating the course. An executive committee was formed that was responsible for addressing the value and feasibility of integrating SVs into the course and the process of producing, disseminating and evaluating the application, as well as selecting procedures for the SVs pilot based on the available funding. Procedures suggested as the most challenging for students were medication administration, surgical dressings, and urinary catheterization. Since we intended to videotape the procedures in the lab and in a hospital with real patients, we excluded urinary catheterization for cultural issues, because in a conservative society such as Jordan it is extremely unlikely that we could obtain a patient consent on such a procedure for educational purposes. Based on the available funds and since medication safety is a priority [15], we selected the medication administration procedures. The medication administration skills included eight skills for administering oral, nasal, ocular, ophthalmic, IV, intramuscular, intradermal and subcutaneous medications.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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2.
Method – videos’ production process
2.1.
Human rights
After the project was approved by the appropriate committees and stakeholders at the School of Nursing, we obtained the approval of the Institute Review Boards (IRBs) of the University and the hospital where the procedures were videotaped. Instructors in the lab videos and patients and staff nurses in the hospital videos were consented for their participation. A major ethical risk of using videos in clinical settings is the invasion of patient privacy and confidentiality of the caregiver–patient communication. Therefore, the consent forms and the production and distribution processes of the videos adhered to the rules and principles for “Protecting Patients’ Rights when Filming and Recording” defined by (a) the Joint Commission’s Standard RI.01.03.03, EP 7 [16]; (b) The Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164 [17]; and (c) the “British General Medical Council” who developed comprehensive guidelines for “Making and Using Visual and Audio Recordings of Patients” [18]. In addition to the voluntary participation and the right for withdrawal, the consent forms highlighted the exact purposes of the recording, and described the videotaping procedure, duration of the videotaping, who would be allowed to see the videos, the circumstances in which they would be seen, whether copies will be made, and the arrangements for storage. At the end of each recording, the demonstrating instructors and staff nurses and patients were asked if they want to withdraw their consent to the use of the recording. Additionally, they were given the chance to see the recording in the final form. The university ethics committee would not allow the recording of female patients, instructors or nurses or the faces of the participating groups for cultural considerations, even when males participated in the procedures. In some communities in the Jordanian culture, female patients require their husbands or male legal guardians to sign on behalf of or with them for medical treatment and research participation. Therefore, when the facial features were captured during the filming we obscured them in the final product of the recordings and only adult male patients, registered nurses and instructors were recorded to overcome any social or cultural dilemmas. Furthermore, participants in the videos were asked to remove nametags, which could have identified them on the video. All materials posted on walls (e.g., instructions, brochures, certificates) that could possibly identify the hospital were removed as requested by the IRB because our purpose was not to market the hospital. To further minimize participant risks, the recorded procedures in the hospitals were part of the patients’ care plans and physicians’ approvals for recording were obtained. The consent form also stated that every patient will be recorded only once, even if technical problems occurred during the recording or production phases and even if that patient will receive the same recorded procedure again by the medical staff, in order to decrease any psychological discomfort that may result
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from videotaping. Patients were selected for the recording if they were competent, could make informed decisions to participate, had fairly stable medical conditions as indicated by the medical care team, and could not be considered to be vulnerable. To ensure voluntary participation, patients were approached to participate by the research team and not by the care providers.
2.2.
Production of lab and hospital videos
The production of the lab videos followed three essential steps (Fig. 1): preproduction (planning), production (filming), and postproduction (editing), [19]. The main activities in the preproduction phase included initial scriptwriting and piloting of the procedures. The course manual and textbook were reviewed for the initial scriptwriting (content areas for each procedure). Scriptwriting outlined the main steps for each procedure and eliminated unnecessary steps. Additionally, a decision was made to what information the videos should include and what information could be presented by other means. To facilitate easy download of the videos, the core contents for each video were limited to: the title of the procedure, the main purpose, equipment used, patient assessment required, and demonstration of the steps. Other information such as detailed purposes, important notes when administering any medication, variations in practice, precautions to be followed before administering any medication, and extra equipment that may be required for some procedures were presented elsewhere in the interactive web-based course. At the end of this information in the web-course, SVs were presented in each module. The process of scriptwriting took many rounds of revisions with the multimedia specialists in order to decrease the wording while maintaining the narration and key content of the videos. The effects and text that would be introduced on the screen while displaying the videos, and the critical points (steps that if omitted or wrongly performed by students will cause them to fail the procedure) were also delineated in this stage. The videographer visited the school labs to decide on the appropriate place and background for shooting (filming), placement of the recording equipment, and the extra equipment needed for shooting (e.g., extra lights). Three clinical nursing instructors, each with 3–5 years of experience in teaching the course, were selected to pilot the demonstration of the procedures with the multimedia specialists from the video producing company and the researcher. It was noted that many pieces of equipment were missing from the school labs, such as a patient record on which to document the procedures, some IV solutions, IV labels, and different sizes of syringes and needles. Missing equipment had to be replaced in order to enhance the quality of teaching. The production phase involved the actual recording of the videos in the nursing clinical laboratory, after setting up the labs with the necessary equipment. A clear “blue” background with the appropriate lighting was used for the recording to decrease visual distraction. Two cameras were used to record multiple perspectives of the same scene. Close-up scenes were recorded in all videos. During the recording of any given procedure, each step was recorded separately in that the researcher read the step in the sequence presented in the scriptwriting and the demonstrating instructor performed that step.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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Fig. 1 – Process of producing the laboratory videos.
The principle investigator participated in the entire production phase to guide the multimedia experts to the important angles for each procedure for best demonstration. After production (postproduction) and before adding the voiceover, the researcher reviewed the accuracy and sequence of all steps in the procedures and the quality of the videos for editing purposes. The initial scriptwriting was further edited in the postproduction phase. This process proved to be the most time-consuming in order for the voiceover dialog to match the actual length of every step performed in the lab videos. The researcher highlighted the important words and steps in the script that needed to be stressed by the narrator who added the voiceover. The video producing company edited the videos using Adobe® Premiere® Pro CS6 video editing software and voiceover sound was recorded in a multimedia support room using the Pro Tools 10® software. A professional native English-speaking documentary narrator recorded the voiceover, illustrating the correct pronunciation of terms and eliminating variations in pronunciations from the Arabic-speaking instructors. Then, effects, text and critical points were added to the videos. The researcher edited the videos again for a final check. The main problems identified during the production of the video were related to the voiceover or added-text that did not correctly match the timing of the video segments, as well as the omission of some critical points. The video company fixed these issues, and display screens focusing on critical points and “Don’ts” for each procedure were inserted into the video. All instructors in the course were asked for their feedback on content organization, production quality and potential impact before the final digital video was converted into web-streaming files. Instructors were very pleased about the video quality. Their comments mostly focused on the technical aspects required to view the videos and the exact
process of integrating the SVs and the web-course into the teaching process. In the final stage of the process, an expert IT technician converted the videos into streaming formats using HTML code. The final videos consisted of 12–17 min of a stepby-step visual and auditory demonstration of the selected procedures. Recording the hospital videos consumed less time and effort than the lab videos. Since the main aim was to capture real nursing care provided to patients (as opposed to the “ideal” laboratory procedures), no environmental control for the hospital setting was necessary before videotaping. In the postproduction phase, all hospital videos were reviewed for quality. The editing process was limited to decreasing the background distraction and noise and obscuring the facial features of the nurses and patients in some videos. Similar to the lab procedures, these videos were converted to web-streaming formats.
3. Summary of the implementation and evaluation of SVs Since the main goal of this paper was to describe the production process of SVs, detailed information about the implementation and evaluation processes will be presented elsewhere. In summary, the videos were streamed on an interactive web-based course designed using Blackboard learning management systemTM (Release 7). The course included a separate module for each of the eight medication administration skills, and discussion board questions. One of the questions asked students to evaluate the nurse-patient communication and the assessment of the patient condition before, during and immediately after the procedure in the hospital recordings, and also to comment on the unintentional, inappropriate
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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practices performed by nurses. The virtual course was used as an adjunct to the traditional lab demonstration. Evaluation of the course included (1) student satisfaction with the virtual course and SVs using a 30-items questionnaire of 5-point scale of agreement and open-ended questions regarding advantages and disadvantages of SVs; (2) eight self-efficacy questionnaires, one for each nursing procedure; and (3) student performance in the medication administration skills examination. Data were also collected on student demographics, course accessibility, and skills improved by SVs as compared to the lab demonstration. Out of the 120 students who were enrolled in the course, 102 provided complete responses to the questionnaires. Overall, students were satisfied with the online course (3.9 + 0.56). The item that received the highest rank in the satisfaction questionnaire was “Hospital videos were very valuable to understand the procedures” (4.23 + 0.9). Students also reported high self-efficacy for administering all types of medications. The overall mean self-efficacy for the eight medication administration skills out of a 5-point Likert-type scale was 4.38 (0.42). Additionally, students achieved significantly higher scores in the skill test of the medication administration exam compared to the grades of the previous cohort of students who were taught the skills using the lab demonstration only (p < .05). Almost 75% of students provided positive comments to the qualitative questions about the SVs and the virtual course. According to students, lab videos were extremely useful to prepare students for the upcoming laboratory sessions, decrease their anxiety, improve performance in the exam, understand the procedure as a “whole”, and to standardize the expectations during the exam, (60%, 62). The hospital videos were also reported as a very valuable learning resource by 72% of students (n = 73) to reinforce the learning process, appropriately assess and communicate with the patient, facilitate transition to hospital practice, and provide a meaningful learning experience. Negative comments were mainly related to technical difficulty to access the course and download the videos from home (30%, 30). However, these students managed to access the videos using the campus computers. Half of the students reported that they could understand 51–75% of the entire procedures by themselves without the need for further explanation from their instructors, and almost 40% (n = 41) of the students viewed the virtual course as a sufficient substitute for the lab demonstration. Furthermore, up to 90% of the students strongly agreed that SVs made the following skills much more clear and understandable compared to the laboratory sessions: identifying injections’ sites, maintaining sterility, documenting the procedures, handling, assembly and usage of equipment, and the critical points in each procedure. The majority of students also captured the “unintentional mistakes” and inappropriate performance by nurses in the hospital videos. These included providing insufficient description about the procedure to the patient, breach of sterility and rubbing the site after a heparin subcutaneous injection. The 15 instructors in the course also reported their experience using a questionnaire. From the instructors’ perspectives, the use of the virtual course and videos provided sufficient time to supervise student performance in the lab,
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reduced training variability and standardized the demonstration process among instructors, helped provide rich learning experience for students, and was used as a source for students who missed classes. The instructors valued the hospital recordings and used them as sources to stimulate critical thinking and problem solving during the lab discussion.
4.
Discussion
With the modern increase of investment in educational technology, academic institutes need to prepare students for the informatics skills of multimedia literacy. The Institute of Medicine’s “The Future of Nursing” report focused on education transformation to maximize the learning experience and meet today’s complex healthcare demands [20]. Today, students are categorized as the net generation – technologically savvy, requiring flexible methods of teaching, immersed in the web 2.0 social networking applications such as YouTubeTM , Facebook and MySpace, preferring pictures and videos over lengthy demonstrations, heavily engaged in gaming and internet surfing, expecting immediate feedback, and demanding instructions that are fun, interactive and non-linear. Due to the pressure exerted by advances in technology, faculty shortages and student demand for flexible learning, the momentum of educational technology growth is likely to continue to increase in the future. In this project we designed SVs as a pilot to supplement the skill-lab demonstration of medication administration skills to enhance the learning process and free up some of the lab time for critical thinking and problem solving applications. The hospital videos demonstrated real-life practices. The lab videos provided standardized performance to help students in the skill examination, and offered accessible resources for students to view the steps in the procedures as a “whole”, rather than separate interrupted steps as used to be demonstrated in the lab. In this project, we had no intention to compare between the two sources of videos, but rather used them as valuable resources to serve different learning purposes. The data supported the usefulness of the two types of videos on students learning. For examples, the majority of students (almost 90%) strongly agreed that the two types of SVs, in comparison to the traditional laboratory demonstration, enhanced their understanding and performance of the documentation process, identification of injections’ sites, maintaining sterility, and equipment handling, assembly and usage. In particular, the lab videos helped students identify the critical points in each procedure, which are safety-related considerations and skills related to sterility, rights of the medication administration, appropriate injection sites, the Do’s and Don’ts while giving medications to patients. This infers that clinical safety in education can be enhanced using welldesigned SVs. Additionally, the hospital recordings allowed students to explore factors that may affect the ideal nursing practice (e.g., workplace interruption, patient conditions), appropriate communication with the patient, and individualized patient care, and to better understand nursing practice in real-patient settings. After viewing the hospital recordings, the majority of students believed that they would be ready for hospital practice. The two recordings also provided
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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sufficient time for the instructors to supervise the performance of the individual students, apply critical thinking and problem solving exercises, and teach students the appropriate documentation process. Also the videos facilitated consistency in skill demonstration among instructors. Our experience supported the need for innovation in education in lab-based clinical courses and the use of two types of videos, one to reflect the ideal performance and the other to illustrate a real-life nursing practice. This can be applied to schools of health with lab-based clinical courses with a focus on patient-related interventions. Although some schools of nursing are moving toward finding clinical settings for the fundamentals of nursing course in addition to the lab teaching, with the high competition on clinical sites, the use of SVs to supplement the lab demonstration can be an excellent alternative. Having 40% of the students who believed that the virtual course and SVs can be a sufficient substitute for the lab demo is an important finding that can help schools of nursing and health with faculty shortage adopt this method of teaching. On the other hand, the production effort and cost of such videos is not to be underestimated. For example, the cost of producing our videos was US $11,000.00, excluding faculty, instructors and nurses’ participation time. It is critical to note that we followed the production framework to produce our videos (preproduction, production, and postproduction), worked hard on the details and extensively edited and tested the videos. Although this project was led by an informatics specialist who has an extensive experience in technology in education, the interdisciplinary collaboration between the instructors who taught the course, faculty members from school committees, healthcare providers, multimedia experts, IT experts, and Blackboard administrators and instructional designers was a key to the project success. Unlike many studies in SVs, which have been limited to the demonstration of ideal procedures [14], in this project we integrated innovative ways to maximize the learning experience. These include the integration of the critical points and Do’s and Don’ts in the laboratory videos and the recording of the hospital videos. In the future, it would be valuable to examine if the hospital videos actually facilitated transition to hospital settings and how the utilization of SVs in education can help in the faculty shortage witnessed by many schools of nursing. For a higher success rate and utilization of SVs, schools need to create culturally sensitive resources and high quality videos with innovative design features. Additionally, schools need to consider the main limitation of using SVs, which is difficulty in access and download. In this project, we carefully outlined the scriptwriting and decided on the information that should be included in the videos and limited the final videos to 12–17 min each. However, almost one third of the students faced difficulty in home access and download. Despite the distributed instructions on the technical requirements to view the videos, it seems that some students selected home access for convenience. With the limited technology infrastructure in Jordan, especially in rural areas where majority of our students reside, we made CD packages with the SVs available for these students and facilitated their use of the campus resources. Although many nursing skills textbooks are supplemented with digital videos that can be streamed on web-enhanced
Summary points What was already known on the topic • Streaming videos (SVs) are commonly used multimedia applications in clinical health education. • There are several negative aspects related to the production and delivery of SVs. • Only few studies have included sufficient description of the videos and the production process. • Majority of studies on streaming videos demonstrated the ideal-practice, innovation in the design process is lacking. What this study added to our knowledge • The production process of educational videos should be culturally sensitive and adhere to the principles of human rights when filming and recording. • The production of SVs requires collaborative efforts of experts in IT, multimedia, nursing and informatics educators and nursing care providers. • High-quality videos should go through many rounds of revisions in the production phase to meet the usability principles and course objectives. • A systematic approach of preproduction, production and postproduction is fundamental for video production.
courses, these resources are not valuable teaching options for students in Jordan because of the differences in the equipment, communication styles with the patient, and sequences of the steps compared to the skill-manual used by the students. It would, however, be very interesting to evaluate the utilization of the market or textbook videos by different biomedical schools and the usefulness of using such resources as supplementary materials.
5.
Conclusions
The process of producing the videos in this project can be used as a valuable framework for schools considering utilizing multimedia applications in teaching.
Author contributions Dr. Azizeh Sowan, the corresponding author, designed the study, chaired the school committees, obtained the fund, and executed the entire project plan (wrote the scripts for the videos, edited the videos in all phases of the project, coordinated the pilot test and attended all the recording sessions and participated in the postproduction phase). She also wrote this manuscript.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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Competing interest The author of this study disclose that she has no financial or personal relationships with any individuals mentioned in the study, the companies of the learning management system and multimedia, or the hospitals where some of the videos were recorded. The author also has no personal relationships within the Hashemite University (the setting of the study) that may have the chance to introduce bias in describing the process of producing the streaming videos or the results of the study.
Acknowledgements • The corresponding author, Azizeh Sowan, was working at the Hashemite University, School of Nursing in Jordan when this study was conducted. • This study was funded by Abdul Hameed Shoman Fund for Supporting Scientific Research, Amman-Jordan. • We would like to acknowledge professor Cheryl Lehman from the University of Texas Health Science Center at San Antonio for editing this paper.
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[7] R. Modica, J. Thundiyil, C. Chou, et al., Teaching musculoskeletal physical diagnosis using a web-based tutorial and pathophysiology-focused cases, Med Educ. Online 14 (13) (2009) (serial online). [8] A. Sowan, L. Jenkins, Designing, delivering and evaluating a distance learning nursing course responsive to students’ needs, Int. J. Med. Inform. 82 (2013) 553–564. [9] P. Vivekananda-Schmidt, M. Lewis, A. Hassell, et al., Cluster randomized controlled trial of the impact of a computer-assisted learning package on the learning of musculoskeletal examination skills by undergraduate medical students, Arthritis Rheum. 53 (5) (2005) 764–771. [10] K. Boberick, Creating a web-enhanced interactive preclinic technique manual: case report and student response, J. Dent. Educ. 68 (2004) 1245–1257. [11] M. Moridani, Asynchronous video streaming vs. synchronous videoconferencing for teaching a pharmacogenetic pharmacotherapy course, Am. J. Pharm. Educ. 71 (1) (2007), Article 16. [12] R. Kay, Exploring the use of video podcasts in education: a comprehensive review of the literature, Comput. Hum. Behav. 28 (2012) 820–831. [13] G. Cannon, M. Kelly, C. Lyng, et al., The production and deployment of an on-line videolearning bank in a skills training environment, AISHE J. 1 (2009) 3.1–3.11. [14] M.A. Corbally, Considering video production: lessons learned from the production of a blood pressure measurement video, Nurs. Educ. Pract. 5 (2005) 375–379. [15] The Institute of Medicine, Preventing Medication Errors: Quality Chasm Series, The National Academies Press, 2006, Available at: http://www.nap.edu/catalog/11623.html (accessed 08.01.13). [16] The Joint Commission Accreditation Program – Hospitals, 2009, Available at: http://www.canainc.org/compendium/ pdfs/D%201.%20JC%20Standards%202010.pdf (accessed 07.11.13). [17] US Department of Health and Human Services Office for Civil Rights, Standards for Privacy of Individually Identifiable Health Information (45 CFR Parts 160 and 164), 2003, Available at: http://www.nacua.org/documents/ HIPAAPrivacy 101002.pdf (accessed 04.05.13). [18] General Medical Council, Making and Using Visual and Audio Recordings of Patients, 2013, Available at: http://www.gmcuk.org/static/documents/content/Making and using visual and audio ecordings of patients 8 May 2013.pdf (accessed 03.09.13). [19] S.V. Mahadevan, M.A. Gisondi, S.S. Sovndal, et al., Emergency department orientation utilizing web-based streaming video, Acad. Emerg. Med. 11 (8) (2004) 848–852. [20] The Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, 2011, Available at: http://www.nap.edu/download.php?record id=12956 (accessed 30.05.13).
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills Azizeh K. Sowan ∗ Department of Health Restoration & Care Systems Management, School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
a r t i c l e
i n f o
a b s t r a c t
Article history:
Purpose: Streaming videos (SVs) are commonly used multimedia applications in clinical
Received in revised form
health education. However, there are several negative aspects related to the production and
31 March 2014
delivery of SVs. Only a few published studies have included sufficient descriptions of the
Accepted 15 April 2014
videos and the production process and design innovations. This paper describes the pro-
Keywords:
students at a public university in Jordan and focuses on the ethical and cultural issues in
Multimedia
producing this type of learning resource.
duction of innovative SVs for medication administration skills for undergraduate nursing
Streaming videos
Method: The curriculum development committee approved the modification of educational
Video production
techniques for medication administration procedures to include SVs within an interactive
Medication administration
web-based learning environment. The production process of the videos adhered to estab-
Nursing education
lished principles for “protecting patients’ rights when filming and recording” and included: preproduction, production and postproduction phases. Medication administration skills were videotaped in a skills laboratory where they are usually taught to students and also in a hospital setting with real patients. The lab videos included critical points and Do’s and Don’ts and the hospital videos fostered real-world practices. The range of time of the videos was reasonable to eliminate technical difficulty in access. Results: Eight SVs were produced that covered different types of the medication administration skills. The production of SVs required the collaborative efforts of experts in IT, multimedia, nursing and informatics educators, and nursing care providers. Results showed that the videos were well-perceived by students, and the instructors who taught the course. Conclusions: The process of producing the videos in this project can be used as a valuable framework for schools considering utilizing multimedia applications in teaching. © 2014 Elsevier Ireland Ltd. All rights reserved.
Abbreviations: SVs, streaming videos; IV, intravenous; IRB, Institute Review Board. Correspondence to: Department of Health Restoration & Care Systems Management, School of Nursing, University of Texas Health Science Center at San Antonio, Suite 2.628, 7703 Floyd Curl Drive – MC 7975, San Antonio, TX 78229-3900, USA. Tel.: +1 210 567 5799; fax: +1 210 567 1719. E-mail addresses: [email protected], [email protected] ∗
http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004 1386-5056/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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1.
Introduction
Multimedia applications are being more heavily utilized for clinical courses in health education. Multimedia refers to “computer-based systems that use associative linkages to allow users to navigate and retrieve information stored in a combination of text, sounds, graphics, video, and other media” [1]. Given recent advancements in telecommunications and High-speed bandwidth Internet, streaming videos (digital videos streamed on the web) have become the most commonly used multimedia application to support clinical health education and to role-model practices. Learning benefits using streaming videos (SVs) are evident in areas such as achievement, technical skills, satisfaction, and selfconfidence [2–9]. This strategy also offers flexible learning by allowing students to revisit sections of procedures they did not grasp the first time and it empowers students with a self-paced learning and control over the learning process. Despite these benefits, there are several negative aspects that can be encountered related to the production and delivery processes of SVs. These include poor quality of videos, poor instructional design, cost, technical problems and low levels of student and faculty interaction, all of which result in unsatisfying learning experiences. For example, while the majority of dentistry students perceived SVs as an effective substitute for in-class demonstrations and rated the video quality as excellent [10], the majority of students in an asynchronous video streaming pharmacy class were unsatisfied about the learning experience and preferred a mixed-mode of teaching [11]. In a systematic review of 53 studies published from 2002 to 2011 on SVs, Kay found mixed results about the effect of SVs on students’ attitudes, behaviors and performance. According to Kay, insufficient description of the SVs was the main methodological concern and “technical problems” in the delivery process was the main challenge for not using SVs [12]. Although there has been an increase in the use of SVs in health education, studies with sufficient description of the videos and the production process are few [13,14]. In addition, the majority of studies have used SVs to demonstrate ideal practices and few are available where innovation in the video production was used, such as comparing normal and abnormal musculoskeletal examination findings [11] and demonstrating errors in the cavity preparation and restoration examination [10]. This paper describes the production process of high-quality and well-produced SVs for medication administration fundamental skills aimed at undergraduate nursing students at a public university in Jordan. The final videos illustrated the ideal performance of medication administration in the skill laboratory as demonstrated by the instructors who were teaching the course, and also included a demonstration of the procedures by registered nurses for real patients in hospital settings. The latter helped students differentiate between the ideal “lab-based” practice and real-world practice, an exercise that will help facilitate practice transition for the nursing students. This report also focuses on the ethical and cultural issues in producing this type of learning resource for educational purposes.
1.1.
Background and planning
In almost all schools of nursing, Fundamentals of Nursing Skills is the first clinical course offered for the undergraduate nursing students in the first year of the program. Students usually encounter their first clinical skills training in a laboratory-based environment to prepare them for the subsequent hospital-based rotations. Fundamental skills include maintaining a safe environment (hand washing, infection control, surgical dressing, vital signs); personal cleansing and dressing (changing linens on an occupied bed, disposal of linens, assisting individuals with bathing); medication administration, intravenous (IV) therapy and parenteral nutrition; urinary catheterization; administration of oxygen therapy; and enteral feedings such as placement and maintaining of a nasogastric tube. In addition to the psychomotor skills, the course also focuses on patient–provider communication, critical thinking and problem solving, and documentation of care. At the School of Nursing where these SVs were produced, the fundamentals of nursing skills course is usually taught by 15 baccalaureate and master-prepared nursing clinical instructors using demonstration and practice techniques on non-interactive mannequins to groups of 8–12 students in each lab session, for a total number of 130–150 students. The disadvantages of this method of teaching include: a limited lab time for students to practice the procedures after the demonstration, which also affects applying skills such as critical thinking, problem solving and documentation of the procedures; the unavailability of other learning resources for skill demonstration; a lack of consistency in skill demonstration between the instructors; not considering the different learning styles of the students; missing equipment from the lab for the demonstration purposes; and difficulty transition to real-patient setting. Therefore, SVs were introduced as supplementary learning experiences to maximize student learning. The researcher who was an expert in coordinating the fundamentals course and in informatics recognized the need for integrating information technology and multimedia innovations to transform the teaching/learning experience of the fundamentals of nursing course. The project was approved by the curriculum development committee and the faculty involved in teaching and coordinating the course. An executive committee was formed that was responsible for addressing the value and feasibility of integrating SVs into the course and the process of producing, disseminating and evaluating the application, as well as selecting procedures for the SVs pilot based on the available funding. Procedures suggested as the most challenging for students were medication administration, surgical dressings, and urinary catheterization. Since we intended to videotape the procedures in the lab and in a hospital with real patients, we excluded urinary catheterization for cultural issues, because in a conservative society such as Jordan it is extremely unlikely that we could obtain a patient consent on such a procedure for educational purposes. Based on the available funds and since medication safety is a priority [15], we selected the medication administration procedures. The medication administration skills included eight skills for administering oral, nasal, ocular, ophthalmic, IV, intramuscular, intradermal and subcutaneous medications.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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2.
Method – videos’ production process
2.1.
Human rights
After the project was approved by the appropriate committees and stakeholders at the School of Nursing, we obtained the approval of the Institute Review Boards (IRBs) of the University and the hospital where the procedures were videotaped. Instructors in the lab videos and patients and staff nurses in the hospital videos were consented for their participation. A major ethical risk of using videos in clinical settings is the invasion of patient privacy and confidentiality of the caregiver–patient communication. Therefore, the consent forms and the production and distribution processes of the videos adhered to the rules and principles for “Protecting Patients’ Rights when Filming and Recording” defined by (a) the Joint Commission’s Standard RI.01.03.03, EP 7 [16]; (b) The Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164 [17]; and (c) the “British General Medical Council” who developed comprehensive guidelines for “Making and Using Visual and Audio Recordings of Patients” [18]. In addition to the voluntary participation and the right for withdrawal, the consent forms highlighted the exact purposes of the recording, and described the videotaping procedure, duration of the videotaping, who would be allowed to see the videos, the circumstances in which they would be seen, whether copies will be made, and the arrangements for storage. At the end of each recording, the demonstrating instructors and staff nurses and patients were asked if they want to withdraw their consent to the use of the recording. Additionally, they were given the chance to see the recording in the final form. The university ethics committee would not allow the recording of female patients, instructors or nurses or the faces of the participating groups for cultural considerations, even when males participated in the procedures. In some communities in the Jordanian culture, female patients require their husbands or male legal guardians to sign on behalf of or with them for medical treatment and research participation. Therefore, when the facial features were captured during the filming we obscured them in the final product of the recordings and only adult male patients, registered nurses and instructors were recorded to overcome any social or cultural dilemmas. Furthermore, participants in the videos were asked to remove nametags, which could have identified them on the video. All materials posted on walls (e.g., instructions, brochures, certificates) that could possibly identify the hospital were removed as requested by the IRB because our purpose was not to market the hospital. To further minimize participant risks, the recorded procedures in the hospitals were part of the patients’ care plans and physicians’ approvals for recording were obtained. The consent form also stated that every patient will be recorded only once, even if technical problems occurred during the recording or production phases and even if that patient will receive the same recorded procedure again by the medical staff, in order to decrease any psychological discomfort that may result
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from videotaping. Patients were selected for the recording if they were competent, could make informed decisions to participate, had fairly stable medical conditions as indicated by the medical care team, and could not be considered to be vulnerable. To ensure voluntary participation, patients were approached to participate by the research team and not by the care providers.
2.2.
Production of lab and hospital videos
The production of the lab videos followed three essential steps (Fig. 1): preproduction (planning), production (filming), and postproduction (editing), [19]. The main activities in the preproduction phase included initial scriptwriting and piloting of the procedures. The course manual and textbook were reviewed for the initial scriptwriting (content areas for each procedure). Scriptwriting outlined the main steps for each procedure and eliminated unnecessary steps. Additionally, a decision was made to what information the videos should include and what information could be presented by other means. To facilitate easy download of the videos, the core contents for each video were limited to: the title of the procedure, the main purpose, equipment used, patient assessment required, and demonstration of the steps. Other information such as detailed purposes, important notes when administering any medication, variations in practice, precautions to be followed before administering any medication, and extra equipment that may be required for some procedures were presented elsewhere in the interactive web-based course. At the end of this information in the web-course, SVs were presented in each module. The process of scriptwriting took many rounds of revisions with the multimedia specialists in order to decrease the wording while maintaining the narration and key content of the videos. The effects and text that would be introduced on the screen while displaying the videos, and the critical points (steps that if omitted or wrongly performed by students will cause them to fail the procedure) were also delineated in this stage. The videographer visited the school labs to decide on the appropriate place and background for shooting (filming), placement of the recording equipment, and the extra equipment needed for shooting (e.g., extra lights). Three clinical nursing instructors, each with 3–5 years of experience in teaching the course, were selected to pilot the demonstration of the procedures with the multimedia specialists from the video producing company and the researcher. It was noted that many pieces of equipment were missing from the school labs, such as a patient record on which to document the procedures, some IV solutions, IV labels, and different sizes of syringes and needles. Missing equipment had to be replaced in order to enhance the quality of teaching. The production phase involved the actual recording of the videos in the nursing clinical laboratory, after setting up the labs with the necessary equipment. A clear “blue” background with the appropriate lighting was used for the recording to decrease visual distraction. Two cameras were used to record multiple perspectives of the same scene. Close-up scenes were recorded in all videos. During the recording of any given procedure, each step was recorded separately in that the researcher read the step in the sequence presented in the scriptwriting and the demonstrating instructor performed that step.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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Fig. 1 – Process of producing the laboratory videos.
The principle investigator participated in the entire production phase to guide the multimedia experts to the important angles for each procedure for best demonstration. After production (postproduction) and before adding the voiceover, the researcher reviewed the accuracy and sequence of all steps in the procedures and the quality of the videos for editing purposes. The initial scriptwriting was further edited in the postproduction phase. This process proved to be the most time-consuming in order for the voiceover dialog to match the actual length of every step performed in the lab videos. The researcher highlighted the important words and steps in the script that needed to be stressed by the narrator who added the voiceover. The video producing company edited the videos using Adobe® Premiere® Pro CS6 video editing software and voiceover sound was recorded in a multimedia support room using the Pro Tools 10® software. A professional native English-speaking documentary narrator recorded the voiceover, illustrating the correct pronunciation of terms and eliminating variations in pronunciations from the Arabic-speaking instructors. Then, effects, text and critical points were added to the videos. The researcher edited the videos again for a final check. The main problems identified during the production of the video were related to the voiceover or added-text that did not correctly match the timing of the video segments, as well as the omission of some critical points. The video company fixed these issues, and display screens focusing on critical points and “Don’ts” for each procedure were inserted into the video. All instructors in the course were asked for their feedback on content organization, production quality and potential impact before the final digital video was converted into web-streaming files. Instructors were very pleased about the video quality. Their comments mostly focused on the technical aspects required to view the videos and the exact
process of integrating the SVs and the web-course into the teaching process. In the final stage of the process, an expert IT technician converted the videos into streaming formats using HTML code. The final videos consisted of 12–17 min of a stepby-step visual and auditory demonstration of the selected procedures. Recording the hospital videos consumed less time and effort than the lab videos. Since the main aim was to capture real nursing care provided to patients (as opposed to the “ideal” laboratory procedures), no environmental control for the hospital setting was necessary before videotaping. In the postproduction phase, all hospital videos were reviewed for quality. The editing process was limited to decreasing the background distraction and noise and obscuring the facial features of the nurses and patients in some videos. Similar to the lab procedures, these videos were converted to web-streaming formats.
3. Summary of the implementation and evaluation of SVs Since the main goal of this paper was to describe the production process of SVs, detailed information about the implementation and evaluation processes will be presented elsewhere. In summary, the videos were streamed on an interactive web-based course designed using Blackboard learning management systemTM (Release 7). The course included a separate module for each of the eight medication administration skills, and discussion board questions. One of the questions asked students to evaluate the nurse-patient communication and the assessment of the patient condition before, during and immediately after the procedure in the hospital recordings, and also to comment on the unintentional, inappropriate
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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practices performed by nurses. The virtual course was used as an adjunct to the traditional lab demonstration. Evaluation of the course included (1) student satisfaction with the virtual course and SVs using a 30-items questionnaire of 5-point scale of agreement and open-ended questions regarding advantages and disadvantages of SVs; (2) eight self-efficacy questionnaires, one for each nursing procedure; and (3) student performance in the medication administration skills examination. Data were also collected on student demographics, course accessibility, and skills improved by SVs as compared to the lab demonstration. Out of the 120 students who were enrolled in the course, 102 provided complete responses to the questionnaires. Overall, students were satisfied with the online course (3.9 + 0.56). The item that received the highest rank in the satisfaction questionnaire was “Hospital videos were very valuable to understand the procedures” (4.23 + 0.9). Students also reported high self-efficacy for administering all types of medications. The overall mean self-efficacy for the eight medication administration skills out of a 5-point Likert-type scale was 4.38 (0.42). Additionally, students achieved significantly higher scores in the skill test of the medication administration exam compared to the grades of the previous cohort of students who were taught the skills using the lab demonstration only (p < .05). Almost 75% of students provided positive comments to the qualitative questions about the SVs and the virtual course. According to students, lab videos were extremely useful to prepare students for the upcoming laboratory sessions, decrease their anxiety, improve performance in the exam, understand the procedure as a “whole”, and to standardize the expectations during the exam, (60%, 62). The hospital videos were also reported as a very valuable learning resource by 72% of students (n = 73) to reinforce the learning process, appropriately assess and communicate with the patient, facilitate transition to hospital practice, and provide a meaningful learning experience. Negative comments were mainly related to technical difficulty to access the course and download the videos from home (30%, 30). However, these students managed to access the videos using the campus computers. Half of the students reported that they could understand 51–75% of the entire procedures by themselves without the need for further explanation from their instructors, and almost 40% (n = 41) of the students viewed the virtual course as a sufficient substitute for the lab demonstration. Furthermore, up to 90% of the students strongly agreed that SVs made the following skills much more clear and understandable compared to the laboratory sessions: identifying injections’ sites, maintaining sterility, documenting the procedures, handling, assembly and usage of equipment, and the critical points in each procedure. The majority of students also captured the “unintentional mistakes” and inappropriate performance by nurses in the hospital videos. These included providing insufficient description about the procedure to the patient, breach of sterility and rubbing the site after a heparin subcutaneous injection. The 15 instructors in the course also reported their experience using a questionnaire. From the instructors’ perspectives, the use of the virtual course and videos provided sufficient time to supervise student performance in the lab,
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reduced training variability and standardized the demonstration process among instructors, helped provide rich learning experience for students, and was used as a source for students who missed classes. The instructors valued the hospital recordings and used them as sources to stimulate critical thinking and problem solving during the lab discussion.
4.
Discussion
With the modern increase of investment in educational technology, academic institutes need to prepare students for the informatics skills of multimedia literacy. The Institute of Medicine’s “The Future of Nursing” report focused on education transformation to maximize the learning experience and meet today’s complex healthcare demands [20]. Today, students are categorized as the net generation – technologically savvy, requiring flexible methods of teaching, immersed in the web 2.0 social networking applications such as YouTubeTM , Facebook and MySpace, preferring pictures and videos over lengthy demonstrations, heavily engaged in gaming and internet surfing, expecting immediate feedback, and demanding instructions that are fun, interactive and non-linear. Due to the pressure exerted by advances in technology, faculty shortages and student demand for flexible learning, the momentum of educational technology growth is likely to continue to increase in the future. In this project we designed SVs as a pilot to supplement the skill-lab demonstration of medication administration skills to enhance the learning process and free up some of the lab time for critical thinking and problem solving applications. The hospital videos demonstrated real-life practices. The lab videos provided standardized performance to help students in the skill examination, and offered accessible resources for students to view the steps in the procedures as a “whole”, rather than separate interrupted steps as used to be demonstrated in the lab. In this project, we had no intention to compare between the two sources of videos, but rather used them as valuable resources to serve different learning purposes. The data supported the usefulness of the two types of videos on students learning. For examples, the majority of students (almost 90%) strongly agreed that the two types of SVs, in comparison to the traditional laboratory demonstration, enhanced their understanding and performance of the documentation process, identification of injections’ sites, maintaining sterility, and equipment handling, assembly and usage. In particular, the lab videos helped students identify the critical points in each procedure, which are safety-related considerations and skills related to sterility, rights of the medication administration, appropriate injection sites, the Do’s and Don’ts while giving medications to patients. This infers that clinical safety in education can be enhanced using welldesigned SVs. Additionally, the hospital recordings allowed students to explore factors that may affect the ideal nursing practice (e.g., workplace interruption, patient conditions), appropriate communication with the patient, and individualized patient care, and to better understand nursing practice in real-patient settings. After viewing the hospital recordings, the majority of students believed that they would be ready for hospital practice. The two recordings also provided
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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sufficient time for the instructors to supervise the performance of the individual students, apply critical thinking and problem solving exercises, and teach students the appropriate documentation process. Also the videos facilitated consistency in skill demonstration among instructors. Our experience supported the need for innovation in education in lab-based clinical courses and the use of two types of videos, one to reflect the ideal performance and the other to illustrate a real-life nursing practice. This can be applied to schools of health with lab-based clinical courses with a focus on patient-related interventions. Although some schools of nursing are moving toward finding clinical settings for the fundamentals of nursing course in addition to the lab teaching, with the high competition on clinical sites, the use of SVs to supplement the lab demonstration can be an excellent alternative. Having 40% of the students who believed that the virtual course and SVs can be a sufficient substitute for the lab demo is an important finding that can help schools of nursing and health with faculty shortage adopt this method of teaching. On the other hand, the production effort and cost of such videos is not to be underestimated. For example, the cost of producing our videos was US $11,000.00, excluding faculty, instructors and nurses’ participation time. It is critical to note that we followed the production framework to produce our videos (preproduction, production, and postproduction), worked hard on the details and extensively edited and tested the videos. Although this project was led by an informatics specialist who has an extensive experience in technology in education, the interdisciplinary collaboration between the instructors who taught the course, faculty members from school committees, healthcare providers, multimedia experts, IT experts, and Blackboard administrators and instructional designers was a key to the project success. Unlike many studies in SVs, which have been limited to the demonstration of ideal procedures [14], in this project we integrated innovative ways to maximize the learning experience. These include the integration of the critical points and Do’s and Don’ts in the laboratory videos and the recording of the hospital videos. In the future, it would be valuable to examine if the hospital videos actually facilitated transition to hospital settings and how the utilization of SVs in education can help in the faculty shortage witnessed by many schools of nursing. For a higher success rate and utilization of SVs, schools need to create culturally sensitive resources and high quality videos with innovative design features. Additionally, schools need to consider the main limitation of using SVs, which is difficulty in access and download. In this project, we carefully outlined the scriptwriting and decided on the information that should be included in the videos and limited the final videos to 12–17 min each. However, almost one third of the students faced difficulty in home access and download. Despite the distributed instructions on the technical requirements to view the videos, it seems that some students selected home access for convenience. With the limited technology infrastructure in Jordan, especially in rural areas where majority of our students reside, we made CD packages with the SVs available for these students and facilitated their use of the campus resources. Although many nursing skills textbooks are supplemented with digital videos that can be streamed on web-enhanced
Summary points What was already known on the topic • Streaming videos (SVs) are commonly used multimedia applications in clinical health education. • There are several negative aspects related to the production and delivery of SVs. • Only few studies have included sufficient description of the videos and the production process. • Majority of studies on streaming videos demonstrated the ideal-practice, innovation in the design process is lacking. What this study added to our knowledge • The production process of educational videos should be culturally sensitive and adhere to the principles of human rights when filming and recording. • The production of SVs requires collaborative efforts of experts in IT, multimedia, nursing and informatics educators and nursing care providers. • High-quality videos should go through many rounds of revisions in the production phase to meet the usability principles and course objectives. • A systematic approach of preproduction, production and postproduction is fundamental for video production.
courses, these resources are not valuable teaching options for students in Jordan because of the differences in the equipment, communication styles with the patient, and sequences of the steps compared to the skill-manual used by the students. It would, however, be very interesting to evaluate the utilization of the market or textbook videos by different biomedical schools and the usefulness of using such resources as supplementary materials.
5.
Conclusions
The process of producing the videos in this project can be used as a valuable framework for schools considering utilizing multimedia applications in teaching.
Author contributions Dr. Azizeh Sowan, the corresponding author, designed the study, chaired the school committees, obtained the fund, and executed the entire project plan (wrote the scripts for the videos, edited the videos in all phases of the project, coordinated the pilot test and attended all the recording sessions and participated in the postproduction phase). She also wrote this manuscript.
Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
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Competing interest The author of this study disclose that she has no financial or personal relationships with any individuals mentioned in the study, the companies of the learning management system and multimedia, or the hospitals where some of the videos were recorded. The author also has no personal relationships within the Hashemite University (the setting of the study) that may have the chance to introduce bias in describing the process of producing the streaming videos or the results of the study.
Acknowledgements • The corresponding author, Azizeh Sowan, was working at the Hashemite University, School of Nursing in Jordan when this study was conducted. • This study was funded by Abdul Hameed Shoman Fund for Supporting Scientific Research, Amman-Jordan. • We would like to acknowledge professor Cheryl Lehman from the University of Texas Health Science Center at San Antonio for editing this paper.
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Please cite this article in press as: A.K. Sowan, Multimedia applications in nursing curriculum: The process of producing streaming videos for medication administration skills, Int. J. Med. Inform. (2014), http://dx.doi.org/10.1016/j.ijmedinf.2014.04.004
