Contextualising virtual interaction opportunities in the health sciences:

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1 Contextualising virtual interaction opportunities in the health sciences: Pharmacist and social work client counseling I. Stupans and L. Orwin dehub Report Series

2 dehub Innovation in distance education University of New England NSW 2351 Australia Worldwide web: First Edition National Library of Australia in Publication Data A catalogue record of this monograph series is available from the National Library of Australia ISSN: ISBN: Note from the editor: This research was not completed within the project timeframes and no evaluation of the project was conducted. In addition, the authors did not have time to fully respond to or address the reviewer s comments and suggestions; they may want to provide an updated report in the future. Nonetheless, this final project report had to be published as part of the deliverables under the DEHub Project conditions of grant. Series editor: Dr Rosalind James (Director DEHub) Edition copyeditor: Dr Miriam Verbeek Graphic Design: Jo Percy and Howard Randell 2

3 Copyright dehub, University of New England, 2013 With the exception of the Commonwealth Coat of Arms, all logos, any material owned by a third party, protected by a trademark or where otherwise noted, all material presented in this document is published under the terms of the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 Australia (CC BY- NC-SA 3.0 AU) License ( Excluded material owned by third parties may include, for example, design and layout, images or video that we have obtained under license from third parties, or where we link via URL to material on external, third-party sites. We have made all reasonable efforts to identify and label material owned by third parties. Under this license, you are free to share (to copy, distribute and transmit the work), to remix (to adapt the work) and build upon the work non-commercially, under the following conditions: You must attribute the dehub, University of New England, as the copyright holder of the work in compliance with our attribution policy outlined below. You use this work with the understanding that: Waiver Any of the above conditions can be waived if you get permission from the copyright holder. Public Domain Where the work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license. Other Rights In no way are any of the following rights affected by the license: Your fair dealing or fair use rights, or other applicable copyright exceptions and limitations; The author s moral rights; Rights other persons may have either in the work itself or in how the work is used, such as publicity or privacy rights. Notice For any reuse or distribution, you must make clear to others the license terms of this work. The best way to do this is with a link to the following web page: licenses/by-nc-sa/3.0/au/ To view a copy of the legal code for this license, visit au/legalcode or send a letter to: Creative Commons, 171 Second St, Suite 300, San Francisco, CA 94105, USA. 3

4 ATTRIBUTION POLICY Under the terms of this license, you are required to attribute the dehub, University of New England in a form specified by this policy. However, you may not attribute the dehub, University of New England in a way that would create an impression that the dehub, University of New England endorses you, your organisation, your work or your use of this work. Unmodified material Where you are distributing or using material as is and have not modified the material in any way, shape or form, you must attribute the dehub, University of New England by citing this publication in the following way: Source: Stupans, I. and Orwin, L. (2013) Contextualising virtual interaction opportunities in the health sciences: pharmacist and social work client counselling Final Report dehub Report Series 2013, Armidale NSW, Australia: University of New England,deh. Available from You must also include the following statement/acknowledgement: Support for the original work was provided by the Australian Government Department of Industry, Innovation, Science, Research and Tertiary Education (DIISRTE) through the dehub Project. Modified material Where you have modified, transformed or created derivative works based upon the dehub, University of New England material (such as, for example, creating graphs or charts or presentations based on data/text from this publication) you must attribute the dehub, University of New England by citing this publication in the following way: Based on material from Stupans, I. and Orwin, L. (2013) Contextualising virtual interaction opportunities in the health sciences: pharmacist and social work client counselling Final Report dehub Report Series 2013, Armidale NSW, Australia: University of New England, dehub. Available from You must also include the following statement/acknowledgement: Support for the original work was provided by the Australian Government Department of Industry, Innovation, Science, Research and Tertiary Education (DIISRTE) through the dehub Project

5 Acknowledgements Final Report June 2012 Report prepared by: Professor Ieva Stupans and Dr Lindy Orwin University of New England Project Team Members UNE: Professor Ieva Stupans Assoc Prof Myfanwy Maple Assoc Prof Linda Turner Mr Greg Cotterell Charles Sturt University: Heather Barton The contextualising virtual interaction opportunities in the health sciences: pharmacist and social work client counselling (Social Work and Pharmacy Interaction Contextualisation Experience SPICE) Project is grateful for the industry support from Armidale pharmacists and social workers who provided valuable feedback about the videos. The project team is also grateful to the University of Auckland and the New Zealand Virtual Worlds Grid for the provision of space in their OpenSim virtual world for use in the project. Second Life and Linden Lab are trademarks of Linden Research, Inc. OpenSim is an open source 3D virtual world platform. 5

6 List of acronyms CSU Charles Sturt University LMS Learning Management System e.g. Moodle SL Second Life (Virtual World) SPICE Social work and Pharmacy Interaction Contextualisation Experience (the contextualising virtual interaction opportunities in the health sciences: pharmacist and social work client counselling) SW Social Work UNE University of New England 6

7 Executive summary This grant created the opportunity that would not otherwise have been available for the health disciplines to collaboratively investigate the potential of virtual worlds as a learning environment to support off-campus students. Driving new practice in the online mode of the social work and pharmacy programs built staff capacity in the use of online technologies and digital pedagogies including scenario-based learning and role play. Role play provided an experiential method for developing counselling skills for social work and pharmacy. The use of machinima scenarios, created by using virtual worlds as the set and avatars as the actors, was a cost-effective method for developing realistic videos as a resource for offcampus students to access learning opportunities. Real time video conferencing provided these off-campus students with an opportunity to participate in live role play in an online mode. Theory driven praxis using virtual worlds and real time videoconferencing with Adobe Connect provided a recurring passage through a cyclical process of experiential learning allowing reflective practice and skill development. The next step will be to take the live role play into the virtual world using the lifelike context of the hospital and community settings created in 3D. Dissemination workshops led one of the pharmacy academics to begin investigating the use of the 3D coffee shop as a location to host debriefing sessions during industry placements. The participatory Action Research methodology provided a community of practice approach to research and implementation of the new pedagogies. The production process of the videos created a safe introduction to the potential of 3D virtual worlds without a daunting technical overhead for staff and students. Taking the familiar tool of real time videoconferencing and applying it to role play provided opportunities to apply theoretical counselling knowledge in practice. Talking about virtual worlds within UNE has led to a much closer relationship between Pharmacy and Social Work (located in different faculties), and a consequent investigation of other opportunities to work together. The whole project has enabled deeper thinking about how to deal with a program that is not traditionally taught in an off-campus mode, and the role that new and emerging technologies might play in providing effective learning experiences to remotely located students. The following tips for making and using machinima to create scenarios for teaching off-campus students may guide others when using this approach: 1. Seek input from practitioners in order that scenarios are authentic. 2. Develop scripts such that there are clear teachable moments. Some parts of the script should provide positive modelling but some parts should provide an opportunity for an inhibitory effect. 3. Encourage student reflection for action to develop their lifelong learning skills. 7

8 4. Use scenarios that have clear break points to provide the opportunity to generate scenario snippets ; these can also be used as teaching resources. 5. Script the avatars to demonstrate aspects of good practice such as hand washing in addition to participating in the key activities of a particular scenario. 6. Stimulate student discussion and reflection by using avatars that have a distinctive cultural background or physical impairment or disability. 7. Consider using professional voice actors for auditory clarity. 8. Note that for future virtual worlds projects, a minimum of two years funding,is necessary for the up-skilling of staff so that an action research cycle within the time frame of teaching delivery can occur. Four videos were made for use in the research and these are available from Professor Ieva Stupans at the University of New England [email protected]. 8

9 Table of Contents Acknowledgements... 5 List of acronyms used... 6 Executive Summary... 7 Table of Contents... 9 Tables and Figures Tables Figures Chapter Background & Context for the project Chapter Counselling in pharmacy and social work and the use of role play Chapter Methodology Phase 1 Video scenarios created in a 3D virtual world Phase 2. Real time video conferencing role play scenarios Phase 3. Role play in the virtual world of Second Life. (Future ) Chapter Narrative, data collection and analysis Phase 1 Videos (machinima) created in OpenSim and Second Life Implementation Phase 2 Role play using real time videoconferencing Pedagogical models for use of the videos Chapter Outcomes Tips for making and using machinima to create scenarios for teaching off-campus students

10 Products Dissemination Linkages The Future of 3D: Where to from here? Challenges of a short term, cross-institutional project References or Bibliography

11 Tables and Figures Tables Table 1: Medication counselling stages Table 2: Number of scenarios and titles Figures Figure 1: e-pedagogies (Conole, 2011, Slide 20) Figure 2: Students used this type of simple menu of role play events in Adobe Connect Figure 3: Action Learning Cycle diagram (MacIsaac, 1995) Figure 4: Sample of a script form Figure 5: Modified script form including teaching notes Figure 6: Sample video title slide Figure 7: Figure 8: New Zealand Virtual World Grid hospital entrance used in establishing shots Samples of scenes: Maternity Ward Nurse s Station (top left); Ward (centre left); Community pharmacy (bottom left); Pharmacist in the ward (top right); Nurse avatar (centre right); Pharmacist using the telephone behind the counter in the pharmacy (bottom right) Figure 9: Screen shot showing pharmacist avatar in the pharmacy Figure 10: Distribution of marks for counselling assessment in a pharmacy course. Students in the off campus mode had practiced prior to the examination using Adobe Connect tutorials and at the residential school. Students in the traditional mode had practiced in face to face tutorials Figure 11: Examples of annotated screens in a video Figure 12: Telehuman technology ( Beam me up Scotty: Life-size hologram-like telepods revolutionize videoconferencing, 2012)

12 Chapter 1 Background and context for the project Counselling skills are essential in many health professions. The focus of this study was on developing counselling skills in pharmacy and social work. Patient counselling is the term employed by pharmacists to describe verbal interactions with clients (Pharmaceutical Society of Australia, 2010). In social work, counselling describes the therapeutic approach which aims to increase clients sense of well-being and employs a range of techniques based on experiential relationship building (Australian Association of Social Workers, 2010, p. 9). To successfully engage with clients during student practicum and into their professional careers, pharmacy and social work students are required to develop core interpersonal skills during their student training. Pharmacy Skill development with respect to verbal communication, including patient and caregiver counselling, is vital for pharmacy students. There has been the recognition that pharmacists, as health-care professionals, have responsibilities for therapeutic selection and also, importantly, communication with doctors, and other health professionals, patients and caregivers. Verbal communication, including counselling is included in competencies outlined in the National Competency Standards Framework for Pharmacists in Australia (2010): Communication the ability to effectively communicate in English information, arguments and analyses. It encompasses the capacity to participate in sustained and complex oral transactions demonstrating flexible and adaptive techniques as well as the ability to generate written texts that clearly express complex relationships between ideas and purposes.(pharmaceutical Society of Australia, 2010, p. 4) Social Work Within the Code of Ethics document for social workers, communication and counselling skills are identified as key elements of the profession: Social work operates at the interface between people and their social, cultural and physical environments. Social work practice may include: engaging in interpersonal practice including casework, counselling, clinical intervention; work with individuals, families, partnerships, communities and groups; advocacy; community work; and social action to address both personal difficulties and systemic issues (Australian Association of Social Workers, 2010, p. 9) 12

13 Off-campus students Prospective, mature aged students who seek career change often have mobility and financial constraints. Alternatives to traditional classroom-based teaching are their only option for retraining. In health disciplines, apart from nursing, non-classroom-based programs have not been widely available. At the University of New England (UNE) pharmacy and social work are offered in both internal and off-campus (external) modes. Charles Sturt University (CSU) delivers its pharmacy program at two campuses, with video conferencing of lectures and other presentations between the two locations. Social work at CSU is offered in both on- and offcampus modes with the added complexity of being offered on multiple campuses. Providing students with authentic, skills-based activities at off-campus locations has considerable inherent challenges, but with technology advances, some of the challenges of providing learning opportunities can be alleviated, thus providing on- and off-campus students with the same opportunities to practice their developing practical skills. This project addressed the substantial gap in understanding the educational approaches available to professionals, such as pharmacists and social workers, who need to develop significant expertise and skill in verbal counselling. There is little understanding of the optimal approaches to developing student expertise in this critical professional area. Successfully addressing this gap and disseminating optimal pedagogical approaches has the potential to: Improve off-campus student engagement in the program; Provide a model that can be adapted in other professional health-related disciplines teaching in on- and off-campus modes; Provide opportunity for cross-university assessment benchmarking; and Improve academic, industry partner and accrediting body understanding of how counselling skills can be taught off-campus in pharmacy and social work programs. It is important to acknowledge that, in Australia, programs such as pharmacy and social work are required to undergo professional accreditation. The possibilities for delivering programs such as pharmacy and social work in an off-campus mode are currently being vigorously debated; most often pharmacy and social work are taught only in on-campus mode (Elliott, McDowell, Marriott, Calandra, & Duncan, 2009, p. 7). This project The SPICE project focused on providing evidence-based practices in off-campus learning and using emerging technologies to support learning approaches that would significantly diversify capacity for off-campus education to those professional areas previously regarded as not being appropriate for off-campus delivery. The SPICE project was an innovative and future-focussed collaboration between two universities to develop resources and research. 13

14 The aim of this project was to develop a small suite of 3D virtual scenarios for pharmacy and social work students from UNE and CSU. Two different approaches were used. The first approach used recordings of avatars modelling various counselling practices to build students questioning repertoire and critical reflection skills. The second approach used an online interactive mode to enable students to practice counselling skills using role play with other students or academics using real time interactive video using, in this case, Adobe Connect to provide the online learning environment. Both approaches were evaluated to determine the usefulness and effectiveness of the 3D virtual world in teaching counselling skills to pharmacy and social work students. The ease of using 3D virtual scenarios for academic staff was also evaluated. The overarching purpose of this project was to develop and systematically evaluate the pedagogy of using virtual approaches to teach counselling skills to students studying in both onand off-campus modes in social work and pharmacy programs. Evaluation was at several levels. The first level evaluated student response to the learning opportunities (i.e. whether learning opportunities were easy to access, follow, and work through etc.). The second level evaluated students interaction and learning when using the resources and processes. Evaluation of the responses of academics and industry partners to the recordings and online interactions was also undertaken. Research questions The following research questions guided the Action Research process: Are videos of scenarios created in 3D virtual worlds effective for demonstrating counselling approaches to students in pharmacy and social work programs? Can virtual role plays using Adobe Connect provide opportunities for students to practice counselling approaches in a non-threatening safe environment? Can opportunities for students to reflect upon their own counselling performance be provided by reviewing the recordings made of their online interactions? Does the use of scenario-based videos created in virtual worlds and virtual role play improve counselling skills of students in pharmacy and social work programs? What pedagogy in the health sciences are academics implementing to make use of virtual approaches in teaching? 14

15 Chapter 2 Literature Review Current research about teaching in an off-campus mode, teaching of counselling skills, role plays and communities of practice, as well as the limited research in the use of 3D virtual scenarios in teaching informed our theoretical approach to the development and integration of video scenarios into curriculum, providing two different strategies to the use of virtual scenarios. E-pedagogy and e-learning The framework of e-pedagogies, shown in Figure 1, provides the theoretical basis for the approach taken in this project; Figure 1 highlights the features associated with situative, associative, constructivist and connectivist e-pedagogies. The videos and real time video conferencing, in which students are placed in simulated situations that closely resemble the reality of the work they are learning to perform, fall into, what has been described by Professor Gráinne Conole (2011), as a situative e-pedagogy in which knowing and learning are collaboratively constructed through participation in context. The use of video based scenarios and role play using real time videoconferencing software also meets many of the ten critical characteristics of authentic e-learning, as identified by Reeves, Herrington and Oliver (2002, p. 564). These electronically supported learning and teaching activities are authentic in that they have real-world relevance ; match as nearly as possible the real-world ; are ill-defined, requiring students to define the tasks and sub-tasks needed to complete the activity ; and are open to multiple interpretations. Viewing the videos and participating in the role plays provide the opportunity for students to examine the task from different perspectives and afford learners the opportunity to examine the problem from a variety of theoretical and practical perspectives. The activities are seamlessly integrated with assessment and allow competing solutions and diversity of outcome. 15

16 E-Pedagogies E-training Drill & practice Mobile learning Associative Focus on individual Learning through association and reinforcement Constructivist Building on prior knowledge Task-orientated Inquiry Learning Resource-based Experimental, Problem-based, Role play Mobile learning Situative Learning through social interaction Learning in context Connectivist Learning in a networked environment Reflective & dialogic learning, Personalised learning Thursday, 3 November 11 Figure 1: e-pedagogies (Conole, 2011, Slide 20) Counselling in pharmacy and social work and the use of role play Counselling in pharmacy For the pharmacy student, the goal of counselling is to achieve the safe and appropriate use of medicines and therapeutic devices. Relevant therapeutic discussions aim to promote adherence to the prescribed or recommended treatment regimen to optimise therapeutic outcomes and are, therefore, pivotal for competency. Patient counselling may range from simply stating the dosage of a drug as it is handed over to the client, through counter prescribing for common ailments, to giving advice with regard to lifestyle and health promotion issues clients will be equipped with the resources to use any medications more safely and effectively (Pilnick, 2003, p. 835). Key communication skills in the counselling process include building rapport, explaining, questioning and listening to pharmacy patients (Hargie, Morrow, & Woodman, 2000). The far right column of Table 1 (Wuliji & Airaksinen, 2005, p. 8) provides a guide to the level of quality medication counselling and identifies the types of practices that the programs at UNE and CSU are aiming to achieve. In terms of communication skills and, in particular, counselling skills, the need for scaffolding within Australian university pharmacy programs has been identified (Owen & Stupans, 2007). 16

17 Level of information Medication information transfer Basic, brienf, non-individualised Medication information exchange Detailed individualised Medication education Comprehensive group or individualised Medication counselling Detailed discussion and guidance Spontaneous or planned Most often spontaneous in response to the medication prescription Spontaneous or planned Planned Planned Objective of process Essential information related to taking prescribe medication as directed (monologue) Provider responds to and askes questions related to prescribed medication (dialogue) Collaborative learning experience and process regarding prescribed medication (conversation) Guidence that assists in fulfilling needs in managing medical condition and prescribed medication (discussion) Product to patient Focus is on safe and proper use of drug product Answers and solicits questions about the drug product. Adapts information to the individual, increases knowledge regarding proper and safe use of medication for specific condition Increases knowledge regarding proper and safe use of medication for specific condition Enhances problem solving skills and assists with proper management of medical condition and effective use of medication Nature of relationship Passive individual receives instruction given by the health care provider Questions and answers are actively exchanged between patient and provider Interactive learning about the implication of the medication is shared between patient and provider Interactive and collaborative discussion and learning between patient and provider Table 1: Medication counselling stages (Wuliji & Airaksinen, 2005, p. 8) It has been suggested that learning opportunities such as role plays, scenarios, group assignments, oral presentations and case studies are included in pharmacy curricula to scaffold counselling (Owen & Stupans, 2007). On-campus students have opportunities to engage in small group faceto-face discussions and also role plays. The challenge for lecturers is to provide these powerful learning opportunities to students who are studying in an off-campus mode by using online tools to access course materials within a Learning Management System (LMS). Role plays, specifically simulated pharmacist-patient interactions between students and tutors/ actors, are central to many initiatives described in the pharmacy education literature related to counselling (Marja-Leena, Paavo, Nina, & Pekka, 2008; Planas & Er, 2008; Rickles, Tieu, Myers, Galal, & Chung, 2009). The role plays not only provide students with opportunities to improve 17

18 their abilities to counsel patients about appropriate medication use but can also be used for summative assessment. This form of assessment is perceived by students to be authentic and aligns teaching and assessment with their future professional contexts (Mueller, 2008). Students further value role plays as a form of assessment at university because they are keenly aware that it is also used in the professional board registration examinations in Australia (Rao & Stupans, 2011). Counselling in social work Role play provides opportunities to develop skills in managing emotional reactivity when working with complex client presentations (Grant, 2006). It has been shown to enhance active-listening skills, social problem-solving skills and demonstration of emotional empathy in the area of hostage negotiation (Hasselt et al., 2005). Role play for developing counselling skills and understanding Traditionally, role plays are used for teaching the application of counselling theory (Stupans, Owen, Ryan, Woulfe, & McKauge, 2010). In role plays the student is cast as the professional and the role of the client is often played by an academic, another student or sometimes an actor, with the second academic observing the interactions to gauge student performance (Rao & Stupans, 2011). Role play exercises can be very time intensive and costly activities, particularly with large class sizes. Such activities rely on students and academics being together at the same physical location, which presents additional challenges for programs taught in off-campus mode. The challenge arises in providing off-campus pharmacy and social work students with appropriate opportunities to engage in role play to develop these vital counselling skills. Virtual Worlds and Role Play Greenridge and Daire (2005, p. 1) proposed that virtual worlds could provide unlimited opportunities for the presentation of scenarios, clinical environments, multi-cultural populations, client demographics and client disorders (as cited in Walker, 2009). Walker (2009) identified the issue that students using virtual worlds for skill development in a counselling course do not want the technological or learning curve challenges to overwhelm the course content (p. 10). The use of a virtual world was also an issue for students with low levels of computer literacy (p. 10) and with older computers and slow Internet connections (pp ). Forewarned of the potential technical challenges for participation related to using a virtual world directly, the research team at UNE decided to look at alternative methods that still capitalised on the strength of virtual worlds to provide a realistic, lifelike context for role play. Cognisant of the prospect of students in remote, rural locations with slow connections and older computers struggling to connect and losing valuable class time solving technical issues, the opportunity to make videos of scenarios became the basis of the first phase of the research. Such videos would minimise the technical problems while simultaneously providing: stimulus for discussing counselling skills; opportunities for creating alternative scripts; and reflection on standards. 18

19 The process of creating videos in virtual worlds is called machinima, a term derived by blending machine and cinema. Machinima provides a relatively low cost method of creating videos compared with using human actors and physical sites (Middleton & Mather, 2008). There is a high degree of flexibility for creating scenarios that can cater to local contexts, type of hospital or community pharmacy, and demographics, languages and ethnicities; in this way, a diverse range of contexts can be created. Videos can also be viewed asynchronously so that students would not have to be present at the same time to make use of the pre-recorded scenarios. The role of videos in the teaching-learning process. Bandura s social learning theory (Zinkiewicz, Hammond, & Trapp, 2003, p. 51) describes three roles that videos might play: The Modelling Effect occurs when a person almost directly duplicates an action she or he has seen someone else perform. The Eliciting Effect occurs when a person performs an action similar but different to the model s. The Inhibitory Effect occurs when a person refrains from an action after seeing someone disadvantaged by engaging in that action. Another technology that could cater for student role play is real time videoconferencing. By using this kind of software, students can be virtually present using their web cam and speaking to each other, thus allowing role play between geographically dispersed students. Although lacking the visual cues that immersive environment of a virtual world provides, it is possible to see the other members of the role play via video and speak to them in real time. Recordings can be made of the role play and discussion of the event can be conducted synchronously at the time of the event or later using tools such as a discussion forum or even another real time videoconference. The research used Adobe Connect for this purpose. Tuesday 28 February 2-4 Tuesday 13 March 2-4 Tuesday 27 March recording 2-4 Tuesday 3 April 2-4 Tuesday 8 May 2-4 Tuesday 22 May 2-4 EXAM TUESDAY 5th June Figure 2: Tuesday tutorial date and time 19

20 Chapter 3 Methodology Action Research was used as an iterative approach, allowing for the testing of the videos as each was made followed by modification based on feedback. Action Learning is a cyclic process of planning, action, observation and reflection that leads to revisions of the plan as illustrated in Figure 3. Reflect Plan CYCLE 1 Observe Action Reflect CYCLE 2 Observe Revised Plan Action Figure 3: Action Learning Cycle diagram (MacIsaac, 1995). The geographically dispersed members of the research team met virtually using Adobe Connect and Skype to discuss research plans, provide feedbackand modify plans. Between meetings the team communicated using and shared Google docs. Data collection methods Data collection methods consisted of: Staff interviews and discussion; Student feedback after viewing the videos as a concept; Student surveys after using the videos in their classes; and Informal feedback from practitioners. 20

21 Phase 1. Video scenarios created in a 3D virtual world The following sequence of activity was repeated for four cycles to create two pharmacy and two social work videos: 1. Planning meeting online using Skype. 2. Creating scenario scripts asynchronously; including multiple versions of the same scenario with different counselling behaviours and patient outcomes. 3. Sharing and editing scripts by the research team asynchronously; feedback via Approving the final script by the Principal Investigator. 5. Recording of sound track by professional voice actors. 6. Creating sets in Second Life or OpenSim. 7. Creating avatar actors, costumes, props and animations. 8. Creating still images for title slides and credits using Microsoft PowerPoint saved as jpg files. 9. Filming the scenes of the scenario using a virtual world as the set and avatars as the actors. 10. Post-production editing and creation of a video for use with students. 11. Using the videos in class. 12. Collecting survey data. 13. Repeating. Phase 2. Real time video conferencing role play scenarios Because all students are not able to access the virtual world, real time video conferencing was trialled as an alternative to taking students in-world to conduct role plays. Adobe Connect was used so that no special training was required for staff or students as it was already in use for other activities. The high quality voice communication, possible using Adobe Connect but not easily achieved in a virtual world, supports verbal interactions which are necessary in counselling. 21

22 The following sequence of activities was repeated four times to create two pharmacy and two social work videos: 1. Planning meeting online using Skype. 2. Creating scenario scripts asynchronously; including multiple versions of the same scenario with different counselling behaviours and patient outcomes. 3. Sharing and editing scripts by the research team asynchronously; feedback via from team members and industry representatives who checked scripts for accuracy. 4. Approving the final script by the Principal Investigator. 5. Recording the interaction of students who used Adobe Connect in their class role play. 6. Discussing the activity. 7. Collecting survey data. 8. Repeating the cycle for each scenario. Phase 3. Role play in the virtual world of Second Life. (Future ) 1. Train staff to use Second Life to allow informed decision making. 2. Plan meeting in Second Life, Adobe Connect or Skype to create scenarios. 3. Create additional buildings in the Health Precinct in Second Life with the capacity for a range of scenarios including community pharmacy, hospital wards, hospital pharmacy, waiting room, nurses station, counselling room, office and coffee shop. 4. Continued practice by staff using role plays planned for the students. 5. Refinement of the role play scenarios. 22

23 6. Make clothing for role play characters including doctors and nurses hospital scrubs, pharmacy and social work professional attire, pharmacy coats, patients hospital pyjamas, and suitable clothing for family members and hospital visitors available. 7. Customise the Health Precinct with details for the scenarios. 8. Train students in the use of Second Life. 9. Additional use of the 3D role play spaces, especially the coffee shop, to include debriefing students while they are on industry placements in Trimester Role play with on campus students in Second Life. Record these as samples. 11. Discussion in Second Life, asynchronous web based forums in the Moodle LMS or in Adobe Connect. 12. Collect survey data. 13. Repeat from Step 8 including off campus students who have technology capable of participating. As the Action Learning cycles through more iterations, feedback from staff and students will cause modifications of the process and scenarios. Publication of findings will assist dissemination. 23

24 Chapter 4 Narrative, data collection and analysis The Social work and Pharmacy Interaction Contextualisation Experience project began with the vision of a two-stage process. The first stage was to create videos in a virtual world (machinima) and use these as resources to stimulate discussion about the counselling behaviours modelled by the actors. These videos were intended to show various behaviours that, upon reflection and discussion by students, would provide teachable moments in relation to the standards and practices of counselling. They would also serve to acquaint students with the virtual world and avatar capabilities so that students would be prepared to enter the virtual world as avatars in the second phase of the project. It was intended that students would do real time role plays as avatars using the sets created for the videos as a lifelike context for their activities, thus adding more realism to their counselling role play practice. However, after studying the literature and discussions with staff and students, the decision was made to use real time video conferencing for the second phase because it was likely that not enough students would have access to equipment to meet the hardware and Internet bandwidth requirements necessary for using the virtual world. It was also determined in the planning meetings that staff skills in virtual worlds were still too basic or non-existent for them to be able to manage groups of avatars. This was compounded by some staff absences and changeover during the project. Staff intend to explore more of the avatar based role plays and develop their skills during the second semester of 2012 and re-evaluate the value of the avatar-based role play when they have more experience to make informed decisions. The first hands-on training sessions have now been conducted and the sets from the videos are providing the basis for the Health Precinct in Second Life. The New Zealand Virtual Worlds Grid has also provided a trial space in their OpenSim environment. The real time video conferencing software, Adobe Connect, was used for student role plays to practice and develop counselling skills. Recordings were made of the sessions for play back, reflection and discussion. There is potential for the use of the recordings in various ways including as assessment, for discussion and for students personal reflection. Phase 1 Videos (machinima) created in OpenSim and Second Life The collaborators began the project with online group planning meetings to discuss the creation of appropriate scripts for the first videos. The ideas for appropriate scenarios and contexts were ed among group members for feedback. A script template was developed to capture the scenarios as dialogue and action in readiness for the set creation and avatar actor costuming prior to filming. The initial format included the following headings. Context Statement: Optional statement read aloud by a narrator at the beginning of a scenario to set the scene. Actors: The name and description of characters listed at the start of the script and then the names used throughout the script. 24

25 Script: The words said by actors and any non-verbal communication, e.g. sighing, laughing, nodding and looking down. Action: The actions taken by actors e.g. sitting up, holding a chart and passing a booklet. Shot list: The actual shots suggested by the author including wide angle establishing shots. Shot number: The numbers added during filming to enable the list of shot clips to be identified as they relate to the script. Often several shots are associated with a single spoken element of the script, e.g. the speaker may have a close-up shot, then there may be a cut away to a nodding head of the listener followed to a wide-angle shot of the scene. Shot lengths average four to six seconds so several shots are needed for a long section of speech. The completed script with shot list is given to the video editor to do the post production work assembling all the clips, synchronising the lip movements to the audio, adding titles and credits, and adding sound effects and background music. Shot number Actor Script Action Shot list and effects Figure 4: Sample of a script form. On reflection, an additional column was added that identified the teaching points and intended learning related to a particular scene. Shot number Actor Script Action Shot list and effects. Annotations and pictures to be inserted. Teaching point or intended learning. Figure 5: Modified script form including teaching notes. Recording audio with professional voice actors Storyboards Storyboards were created including the shots required for each script. A range of back shots and angles of various scenes were planned to provide the video editor with a range of options for manipulating the footage into a coherent video. 25

26 Post-production The video clips, audio files, credits and title images were sent to the video editor at UNE for post-production using Final Cut Pro on an Apple Mac computer. Previewing and staff feedback during post production After the production of each scenario, staff in the respective areas of pharmacy and social work viewed the videos and provided feedback. This included comments on the accuracy of the scenes, the quality of the voice, the flow of the vision and the fidelity of the overall scenario to the script. Slight adjustments were made taking on board the feedback wherever possible. At times, the virtual world environment of Second Life limited the fidelity of movement and the quality of animations. Video Production Process Four videos were produced modelling various counselling practices to build students questioning repertoire and critical reflection skills. These videos used a technique called machinima, a process for animated filmmaking within a real-time virtual 3-D environment instead of using traditional human actors and physical sets. Scenario Community pharmacy including interdisciplinary collaboration. Area Pharmacy In hospital medication counselling about Warfarin. Pharmacy In hospital counselling scenario - patient has a badly broken leg and stranded animals at home with no one to care for them. Social Work In hospital counselling scenario adter the still birth of the first child of a young couple. Social Work Table 2: Number of scenarios and titles. The digital sets were created in two virtual world platforms: OpenSim and Second Life. A street scene for the community pharmacy and a hospital ward were created in 3D to be used as the sets to allow for various counselling opportunities to be filmed. The actors were avatars dressed as patients, nursing staff, social workers and pharmacists, as required. Animations and props were used to create lifelike interaction between the avatars in accordance with the script. Titles and credits for the videos were created using Microsoft PowerPoint slides saved as image files and inserted into the video in the post-production stage. The videos were edited by the multimedia staff at UNE. Copyright free music was used for background music. 26

27 Figure 6: Sample video title slide. The hospital in the medical precinct on the Auckland node of the New Zealand Virtual World (OpenSim) Grid provided appropriate establishing shots for the hospital videos. Figure 7: New Zealand Virtual World Grid hospital entrance used in establishing shots. The rest of the action was filmed in Second Life using mostly props and animations purchased from the marketplace and a pharmacy building produced by the University of South Australia OpenSim project. Challenges were faced in using the OpenSim environment as intended in the original proposal. As an open source, free software platform that emulates the commercial Second Life platform closely, OpenSim was technically capable of providing all the resources needed. However, Second Life has a thriving web based marketplace and a large population of content creators making the purchase of props, animations and avatar costumes fast and extraordinarily cheap, often free or just a few cents. Since OpenSim has a much smaller, scattered user base, assets are much harder to find and customisation makes the building both slower and dramatically more costly. With contractor rates ranging from $50 to $120 per hour, an item that could be purchased readymade for a few cents in Second Life would have cost a few hundred dollars to make from scratch using contract builders, scripters and animators. 27

28 Figure 8: Samples of scenes: Maternity Ward Nurse s Station (top left); Ward (centre left); Community pharmacy (bottom left); Pharmacist in the ward (top right); Nurse avatar (centre right); Pharmacist using the telephone behind the counter in the pharmacy (bottom right). The scenarios are being incorporated into the university s LMS to model practice and provide students with discussion triggers. Students may choose to watch these at times convenient to them and then participate in asynchronous discussions and/or post personal reflections. Initial evaluation of the approach with the first fully produced scenario video has been undertaken through student survey. Results from the survey (n=52 students) indicated that 46 per cent did not feel as if they were watching communication of real people in Second Life, perhaps reflecting the proportion of our students who are mature age. Our findings are in contrast to literature which suggests that the learners in the Net Generation don t 28

29 differentiate between the real and virtual world or simply sees the virtual world as an extension of the real world (Frand, 2000). Of greater importance is the fact that 90 per cent of students believed that the scenario was enriching their learning. Many of the free text comments were similar to these quotes: seeing the dialogue made it easier to envisage a real patient and pharmacist ; initiated discussion with others about the communication and interaction between the pharmacist and patient and we discussed what we thought of the scenario and how we would feel in a similar situation. Improvements were also suggested. These included several comments regarding the need for an opportunity to discuss more afterwards or interact more with it. We are currently working to complete several more scenarios. Figure 9: Screen shot showing pharmacist avatar in the pharmacy. Implementation Student feedback based on first viewing impressions The first video was shown to students to gain reaction to the medium. The students commented on the strengths of the videos for providing examples with only one student stating a preference to use human actors for role play videos. As intended, many found points that triggered discussion about the behaviours of the staff in the pharmacy that ranged from comments about staff standing too far away from the client to speaking too openly about private medical information. Staff feedback related to in-class use Staff suggested that the scenarios could have multiple versions so this was added to the two socialwork scripts with an introduction to the video followed by two different outcomes; one positive and one negative. Each provided different discussion points. 29

30 Student in-class use Initial evaluation of the approach with the first fully-produced scenario video has been undertaken. Students were recruited in face-to-face classes at the intensive schools for offcampus students or in traditional face-to-face classes for on-campus students. Students were provided with ipads TM displaying the video and were then encouraged to discuss the scenario is small groups of two to three students. Every student who participated completed a paperbased survey, which were collated manually. Phase 2 Role play using real time videoconferencing Adobe Connect Pro is being used to provide virtual tutorials in which students can acquire and practice counselling skills in the same role playing exercises typically used in traditional classrooms. Adobe Connect synchronously provides online access to a shared screen, and text and voice discussions. Students and staff can connect in real time, allowing natural conversations. This means that some students can participate in role plays, and teaching staff of provide and other students can provide feedback. In 2011, second-year off-campus UNE pharmacy students participated in 13 online tutorials facilitated through Adobe Connect. Within these tutorials, each student participated in three role play exercises. The intensive school period did not include formal counselling opportunities. Students in the traditional mode had either one or two opportunities each to practice counselling during the semester. The students studying in the traditional mode were also encouraged to undertake role play with each other outside formal teaching sessions. Assessment of students counselling skills was also undertaken in an Adobe Connect session. Preliminary evaluation of Adobe Connect has been undertaken through review of student marks for the counselling assessment (results displayed in Figure 10). Students studying in the online mode do not appear to be disadvantaged by having minimal access to face-to-face tutorials for practicing their counselling skills as opposed to those undertaking regular face-toface counselling role play exercises. Students were not randomised to study mode and, hence, limitations of non-experimental studies, such as pre-existing differences between students in each study mode, may have contributed to the findings. Some minor issues remain to be resolved, including scheduling of sessions for students who have chosen to study flexibly at times which suit them. However, the value of Adobe Connect synchronous discussions is attested by unsolicited comments in unit feedback such as, The use of new learning media was a great asset... worked very well and provided greater access for the distance students and by requests from these same off-campus students to set up student-led sessions for other subjects in which they were enrolled to permit online discussions to collaboratively problem solve and support one and other. 30

31 marks Counselling Distance Counselling Traditional Figure 10: Distribution of marks for counselling assessment in a pharmacy course. Prior to the examination, students in the off-campus mode had practiced by completing Adobe Connect tutorials and using Adobe Connect at the residential school. Students in the traditional mode had practiced in face-to-face tutorials Pedagogical models for use of the videos Members of the research collaboration collected ideas for different ways of integrating the videos into the on- and off-campus programs including ideas of how to use the videos during intensive on-campus events for the off-campus students. Opportunities to use the videos include: The videos could be viewed in-class as a stimulus for synchronous discussion by on-campus students; The videos could be viewed by off-campus students followed by an asynchronous discussion using the discussion forum tool within the Moodle LMS; The videos could be viewed by both on campus and off campus students followed by a joint asynchronous discussion using the discussion forum tool within the Moodle LMS The videos could be viewed by the off-campus students prior to a synchronous discussion in Adobe Connect that may or may not include on-campus students. Short snippets of the videos could be cut from the longer videos and used as stimulus material in a discussion forum addressing specific points. This could be used by both on-s and off-campus classes. Questions such as these could be used: 31

32 - What could be done differently? - What questions should the pharmacist ask next and why? What considerations should the social worker activate now? - Can you describe an appropriate continuation for this counselling session? Snippets could be used to stimulate brainstorming. Snippets or stills could be used to highlight theory in lectures; for example, the theory behind Warfarin dosing. Opportunities for communication with other health professionals related to each case could be identified by the students. 32

33 Chapter 5 Outcomes The project achieved the following outcomes: (i) A suite of four videos of 3D virtual scenarios demonstrating a variety of counselling approaches and skills for pharmacy and social work students; (ii) Evidence concerning the effectiveness of real time video conferencing to teachd counselling skills; (iii) Insights into innovative approaches to teaching off-campus students using 3D virtual world in teaching counselling skills; (iv) Formation of a community of practice of academics using 3D virtual teaching in health and allied fields. Identification of technical issues or concerns and solving these will be critical to the development and continued use of the 3D virtual worlds. Recent publications have described issues around counselling and have discussed the implementation of a 3D virtual learning environment, with students undertaking counselling exercises in Second Life in an online Human Services counselling program (Walker, 2009). Recognising issues faced by students with potentially poor Internet connections and graphics cards with limited capability, and the program costs associated with use of Second Life, the project team adopted an approach which shows excellent potential. With respect to the work presented in this paper regarding Adobe Connect and virtual scenarios on video, preliminary evaluation indicates effective implementation into the range of learning opportunities provided for pharmacy students who are learning off-campus; these approaches have addressed students interactions with the content, with their teacher and with other students. The project team have collected the following insights into innovative approaches for teaching off-campus students. Tips for making and using machinima to create scenarios for teaching off-campus students 1. Consider seeking input from practitioners in order that scenarios are authentic. 2. Scripts need to be developed such that there are clear teachable moments. Some parts of the script should provide positive modelling but some parts should provide an opportunity for an inhibitory effect. 33

34 3. Reflective practice is the key to the development of lifelong learning, therefore scripting to encourage student reflection for action also needs to be considered. 4. Scenarios which have clear break points provide the opportunity to generate scenario snippets which can also be used as teaching resources. 5. The avatars can be scripted to demonstrate aspects of good practice, such as hand washing, in addition to participating in the key activities in a particular scenario. 6. Avatars can be constructed such that they appear to have a distinctive cultural background or physical impairment or disability. Consider whether use of such an avatar may provide greater opportunity for student discussion and reflection. 7. Consider using professional voice actors for auditory clarity. 8. For future virtual worlds projects, a longer period of funding (minimum of two years), not necessarily more money, is necessary for the up-skilling of staff so that an action research cycle within the time frame of teaching delivery can occur. Products Scenarios Videos and Photo Gallery Four scenario videos are available. Please Professor Ieva Stupans [email protected] for further information. Dissemination Dissemination activities occurred throughout the project, including formal and informal sharing through meetings, conferences, publications and presentations. Regular updates to members of the Australian Virtual Worlds Working Group, another DEHub funded project, kept the nearly 150 members up to date with the project through virtual meetings in second Life and minutes on the wiki. Peer reviewed journal articles Peer reviewed conference papers were presented at the ASCILITE 2011 (B. Gregory et al., 2011) and HERDSA 2012 (Stupans & Orwin, In press) conferences and another is in progress for ASCILITE 2012 (S. Gregory et al., In press). Presentations were also given at the international, online Best Practices in Virtual Worlds Conference 2012 in Second Life. The trans-disciplinary nature of the project ensured that dissemination occurred across a number of audiences including health education, higher education, distance education and educational technology, specifically virtual worlds. Dissemination also occurred through a face-to-face seminar and hands-on workshop at the University of New England in May

35 The videos were shown, feedback gained and the interim findings were disseminated to local industry partners and professional pharmacy advisory body members during their formal meetings in September 2011 and June 2012, and at informal monthly meetings throughout the year. Linkages The project has been a collaboration between the health disciplines of pharmacy and social work through their common need for the development of counselling skills by students. Including the industry accreditation body and local professionals creates a strong linkage between the project, the courses and the potential future workplaces of the students. Community of Practice The community of practice that currently includes UNE, CSU, James Cook University (JCU) and the University of South Australia (UniSA) is expanding to a broader health group with linkages with a project collaborator and UNE social work staff member who has moved to Algoma University, Northern Ontario, Canada. It is expected that as universities access the existing videos under the Creative Commons Licence, many more universities will join in the professional discussions and trials of the materials. There will be opportunities for presentations and discussion in the meeting areas of the Health Precinct in Second Life. Beyond the participating institutions, contact was also made with other international groups which are also exploring the potential of 3D virtual worlds for use in healthcare education. These include: International Community of Practice (icop) of Nursing, Midwifery, Healthcare educators and Learning Technologists called the HealthEd-iCop-VW Second Life Healthcare List listinfo/healthcare Other Health education programs Discussions have already taken place to include this method of making scenario-based videos into the inter-professionalism program by constructing an interdisciplinary Health Education Precinct on an island in Second Life. UNE-based technical staff have the necessary skills and an island has been acquired. Staff from Pharmacy have also had initial Second Life orientation and hands-on training. Staff are approaching other institutions with a view to finding Film and T V students who may be able to make more scenario-based videos as part of their courses. 35

36 The Future of 3D: Where to from here? 1 year Further exploration of Second Life using a rented space with a view to purchasing an island if interest is sustained and further research indicates that these methods yield improved outcomes and a better student experience. Training of staff in Pharmacy and Social Work with appropriate support from internal IT staff and members of the Community of Practice. Establishment of the Health Education Precinct in Second Life using the existing buildings created for the first videos. This includes a four-bed hospital ward, a nurses station and a community pharmacy. Increased fidelity of ever more lifelike avatars with more realistic animation to create even more accurate productions. New scripts with input from a wider range of industry collaborators and academic colleagues providing scenarios from their work experience. Addition of annotations on some of the videos inspired by Chodos, Naeimi and Stroulia (2009, p. 18) and demonstrated in Figure 11. Figure 11: Examples of annotated screens in a video. 36

37 3 years Continue to work in collaboration with other faculties and institutions to develop the capacity of staff and students to use 3D virtual world and their successors. Exploration of bots, programmed artificial intelligence robotic patients that students can interact with in their own time using natural language (Newby & Jin, 2011)1614?solrsort=score%20desc</url></related-urls></ urls><research-notes>software is available at: edu.au/virtualpatient/private/uploads/ Usernames and passwords can be requested from Cite></EndNote>. 5 year New technologies under development support a variety of exciting futures for 3D environments to support off campus learners. These include alternative virtual world technologies such as: Kitley, that uses Facebook identity to link into a web based launcher for an OpenSim virtual world that is hosted in the cloud; CloudParty that uses Facebook identity to link into a web based virtual world similar to but different from Second Life and OpenSim; Unity 3D which is a game engine that is being used to create virtual worlds accessed via the web browser 37

38 Holograms Promising research at Human Media Lab in the Telehuman Project, a holographic projection technology below in Figure12: Telehuman technology ( Beam me up Scotty: Life-size hologramlike telepods revolutionize videoconferencing, 2012). Figure 12: Telehuman technology ( Beam me up Scotty: Life-size hologram-like telepods revolutionize videoconferencing, 2012). Challenges of a short term, cross-institutional project Staff Although the one-year project made great steps forward, there were challenges along the way; they impacted on timelines and outcomes but did not stifle the enthusiasm or the determination of the project leader. At the beginning of the project, the planned research staff member became unavailable to work on the project and the start was delayed by five months while recruiting a replacement. During the project, two of the staff members in one of the partner universities left their positions. Another staff member took study leave and her replacement had to be brought up to speed quickly. A sudden illness took the project leader out for two blocks of time. These are the day-to-day challenges of working in a dynamic university environment. Longer-term projects are somewhat easier to manage as there is time to cope with these challenges without dire impact on the project outcomes. Technology and Training There is always a period of orientation and skill development needed when new technologies are implemented in a university environment. Training of staff, set up of software, hardware and firewall access take time in higher education institutions. Fortunately, at UNE, access to Second Life is available on the university network; this is not always the case in institutions and gaining access to Second Life on campus through the university firewall has taken significant time and, in some cases, has not been allowed (Albion & McKeown, 2010). Student access for remotely located off-campus students, however, was not so easy to ensure. Access to capable hardware and high bandwidth Internet access with appropriate download volume capacity could not be guaranteed in the available timeframe. This meant that the use 38

39 of avatars for role play by students was replaced with real time video conferencing using Adobe Connect. This allows for an additional point of comparison between technologies for virtual role play in the future and also gives staff time to improve their skill levels in the 3D virtual world. Gathering student access data at the beginning of courses will also allow decision to be made about which technologies students will be able to access during the course. 39

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