3.3.- TEORÍAS DEL LIDERAZGO

The VP application uses an animated patient within an interactive computer programme to simulate a pharmacy consultation. The patient, ‘Henry Gentle’, has been newly started on

− Is it significantly different from current theories of classroom, workplace or lifelong learning?

− Does it account for the mobility of learners?

− Does it cover both formal and informal learning?

− Does it theorise learning as a constructive and social process?

− Does it analyse learning as a personal and situated activity mediated by technology?

12

rivaroxaban, a NOAC, for AF and he presents to his community pharmacy with his new prescription. The user takes on the role of the pharmacist to interact with the patient. The case progresses with the intention of providing a realistic representation of a NOAC

consultation. The VP aims are to teach pharmacists how to counsel patients on NOACs for AF, to improve their own knowledge and ability and to contribute to their professional

development. The development of the VP was previously reported (Richardson et al. 2018) and the design of the application is discussed below.

The technology

Broadly speaking, the VPs that are developed at Keele School of Pharmacy are designed around a clinical decision pathway with integrated visual effects. A virtual character responds to the user’s decisions, with personalised user feedback at the conclusion of the case to enhance clinical decision making and counselling skills. This VP consists of computer- generated, animated, VP videos that depending on the decision made, trigger a relevant animation. The systems use Hypertext Mark-up Language (HTML), cascading style sheets (CSS) and JavaScript resource accessing video renders that allow the VPs to work on smartphones, tablets, and desktop devices (Figure 1.4 and Figure 1.5). This is in line with a previous research recommendation for VPs using more sophisticated graphics and animations (Jabbur-Lopes et al. 2012).

13

Figure 1.4 The VP interface accessed from a laptop running Google Chrome

Figure 1.5 The VP interface from a smart mobile phone

The VP is accessed via a purpose-built website that can be used on an electronic device connected to the internet, the interface adapts to screen size of the device being used. The VP team at Keele University stated that the chosen technology had benefits based on the

14

potential for incorporating aspects not achievable in reality. These characteristics are supported by other studies that discussed the advantages of VPs (Bracegirdle and Chapman 2010, Tan et al. 2010, Douglass et al. 2013).

The avatar

Each avatar, or visual character, for each VP application, is carefully constructed to a specific design. Characteristics that can be tailored to create a unique character include facial features, age, gender, expressions, hair, clothes, and ethnicity. For some VP cases, patient

characteristics will impact the case outcome and they need to be carefully considered.

In this case, Henry Gentle is described as a 67-year-old man and this was in keeping with the visual appearance of the avatar, his age and ethnicity are not specific to the outcome of the case but reflect common demographics of patients with AF. The VP’s verbal responses are audio-recordings utilising the skills of a voice actor. The chosen voice actor is usually a close a match to the avatar’s characteristics; Henry’s voice actor was a similar age and ethnicity to him.

Application development

Every VP application is individually designed for a particular purpose and client and application details are precise; this can include elements such as the patient characteristics and script to the type and nature of feedback. Five proposed phases for VP development were loosely adopted during the development of this VP (Guise, Chambers, Conradi, et al. 2012). Phase one involved explicitly defining learning outcomes; phase two concerned concepts and designs; phase three technical design aspects and; phases four and five a cycle of evaluation and improvement (Guise, Chambers, Conradi, et al. 2012). The technology-orientated VP development team at Keele University led a three-way approach where the development

15

team, client, and a steering group informed VP development as part of the development process.

Development of the VP first involved the concept of the VP being discussed with the development team who developed a prototype using a basic script with stationary and

incomplete characters. Following the modification and approval of this, a functional prototype was developed to test the script and scenario further. After approval of this, a fully functional version was developed.

Learning outcomes

The VP team requested the client to outline the VP’s indented learning outcomes, this was to ‘learn how to counsel a new patient on rivaroxaban’ (Figure 1.6). There was a further list of topics required to be covered in the scenario to ensure an application was created that included particular elements, a named example being, specific drug information such as, how to take the medication. The learning outcome and topic list helped with the development of the scenario script to meet the specific requirements of the client. The script was developed by the design team in conjunction with the client so that the application met both the client’s expectations and the technological abilities of the software. This was particularly important when the client suggested ideas that were not possible or were difficult to achieve technically. The learning outcomes and topic list were rewritten a number of times during development to facilitate this.

16

Figure 1.6 The VP application introduction as presented to the user

Decision tree and script

Once the scenario had intended learning outcomes, a decision tree of the script was developed. This simplified the case, detailing it from start to finish, helping to establish key points and decisions. Each question and/or action was carefully incorporated into the decision tree, with considerations for how individual elements could impact the case pathways moving forward within the application and also how decisions affect user feedback. The decision tree had approximately 40 questions and 90 elements that were highlighted as ‘good’ and ‘bad’ decisions relevant to the intended learning outcome. Each decision was categorised as more or less favourable compared to the optimum case pathway. The optimum pathway through the case was developed first before the addition of alternative routes, this is in keeping with the usual method for developing a decision tree (Guise, Chambers, Conradi, et al. 2012). The decision tree also highlighted the points within the case when additional information became available to the user, for example, access to the patient’s medication record. The decision tree evolved throughout development until feedback in the development process suggested that the case pathways were ready for use; this process was an iterative development process led

17

by the expertise of the development team and steering group. No specific verification processes were used and this could have introduced bias from the developers in to the decision tree. Although this is a limitation of the development process this evaluation has taken place outside of the original development team and so any limitations identified can be reported to the developments; further specific considerations for bias within the decision tree may be required but is outside the scope of this evaluation.

Question design

The type of questioning within the VP case was also considered in some detail. VPs, generally, use either multiple choice questions or free text questioning. The former allows the user to select the most appropriate option from a list of a few, this appeared to be a commonly adopted approach and it was the method used in this VP (Pereira and Cavaco 2014, Moule et al. 2015, Zlotos et al. 2016). The later design appeared to be less common; it was used in the work by Stevens et al. (2006). A third questioning design makes use of both methods: the user types a keyword and a selection of related questions appear. This has been used in the medicines use review (MUR) work by Keele School of Pharmacy (Keele School of Pharmacy 2017) and the work by Bracegirdle and Chapman (2010).

This VP used multiple-choice questioning and although this can be less flexible for users it made the case technologically easier to develop. Additionally, multiple-choice questioning is recognised to be suited to narrative VPs with andrological influences of reflection-based learning through practice (Bearman et al. 2001), such as in this VP where users are encouraged to reflect on their performance.

User feedback

User feedback can vary depending on the design and purpose of the particular VP (Guise, Chambers, Conradi, et al. 2012). Examples include verbal or written feedback and some

18

systems give comprehensive feedback whereas others intentionally limit it for educational purposes (Zary et al. 2006). VP programmes can also grade the user’s attempt or incorporate a pass/fail system as the design requires (Douglass et al. 2013, Taglieri et al. 2017).

Actions within this specific VP scenario triggered positive and negative feedback and at the end of the case personalised feedback was collated. Henry verbally delivered this feedback to the user, giving the impression that the patient was talking to the user, as the pharmacist, detailing what they did well and what could be improved (Figure 1.7 and Figure 1.8). Feedback was instantaneous after case completion which was intended to contribute to usability. The VP did not incorporate a user assessment such as a test because this was not in keeping with the exploratory and reflective purpose of the VP.

Figure 1.7 Feedback at the end of the application, Henry verbally provides feedback alongside subtitles

19

Figure 1.8 Downloadable and printable feedback at the end of the application