| Universitas Medica | Colombia | V. 60 | No. 3 | Julio-Septiembre | 2019 | ISSN 0041-9095 |

a  Correspondence: facevedo@javeriana.edu.co

How to cite: Acevedo Gamboa FE, Díaz Álvarez JC,Cajavilca Cepeda RA, Cobo Gómez JC. Instructionaldesign model applied to a virtual guide in clinicalsimulation. Univ. Med. 2019;60(3). http://doi.org/10.11144/Javeriana.umed60-3.mdis

DOI: https://doi.org/10.11144/Javeriana.umed60-3.mdis

Instructional Design Model Applied to aVirtual Guide in Clinical Simulation

Modelo de diseño instruccional aplicado a una guía virtual ensimulación clínica

Fanny Esperanza Acevedo GamboaPontificia Universidad Javeriana, Colombia

Juan Carlos Díaz ÁlvarezUniversidad Nacional de Colombia, Colombia

Rosa Alejandra Cajavilca CepedaPontificia Universidad Javeriana, Colombia

Juan Carlos Cobo GómezPontificia Universidad Javeriana, Colombia

Received: 29/11/2018 | Accepted: 25/02/2019

a

ABSTRACTIntroduction: The teaching experience of a group of teachers when teaching clinical procedures has been carried out through virtual guides prepared using instructional design models in which the pedagogical and technological pedagogical dimensions were taken into account. Objective: To create a virtual clinical simulation guide for nursing students to have autonomous learning of a clinical-care procedure, through the application of an instructional design model.Methods: To develop the guide it was necessary to apply the ADDIE (acronym for Analysis, Design, Development, Implementation and Evaluation) instructional design model, on which some qualitative and quantitative measurements were made.Results: Quantitative measurements made in 159 participants between 2015 and 2016 indicated an average score of 3.99 with a standard deviation of 0.86, which showed that the strategy used to teach the procedure with the virtual guide was effective. The qualitative evaluation assessed dimensions of satisfaction, realistic experience, confidence, motivation, technical skills and decision making, and it showed that teacher support was still required in the simulation area, which reduced the satisfaction of some participants. Likewise, one factor that was affected was communication, because the guide does not facilitate the development of this skill.Conclusion: The ADDIE instructional model is useful for developing virtual guidelines for clinical procedures, and in its final evaluation stage allows the implementation of qualitative and quantitative research value processes to verify its effectiveness.Keywordsinstructional design model; ADDIE model; nursing education; patient simulation; guide.

RESUMENIntroducción: La experiencia docente de un grupo de profesores en el proceso de enseñanza de procedimientos clínicos ha sido a través de guías

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virtuales elaboradas bajo modelos de diseño instruccional,en las que se tuvieron en cuenta la dimensión pedagógicay la tecnológica.Objetivo: Construir una guía virtual de simulaciónclínica para que los estudiantes de enfermería tenganun aprendizaje autónomo de un procedimiento clínico-asistencial, mediante la aplicación de un modelo de diseñoinstruccional.Métodos: La elaboración de la guía requirió aplicar elmodelo de diseño instruccional ADDIE (sigla en inglésque significa las etapas de análisis, diseño, desarrollo,implementación y evaluación), sobre el cual se ejecutaronalgunas mediciones tanto cualitativas como cuantitativas.Resultados: Las mediciones cuantitativas ejecutadas con159 participantes entre 2015 y 2016 señalaron unacalificación media de 3,99 con una desviación estándarde 0,86, lo que determinó que la estrategia utilizada parael aprendizaje del procedimiento con guía virtual fueefectiva. La medición cualitativa valoró dimensiones desatisfacción, experiencia realista, confianza, motivación,habilidades técnicas y toma de decisiones, y con ello seevidenció que el acompañamiento docente aún se requeríaen el área de simulación, lo que redujo la satisfacción dealgunos participantes. Igualmente, un factor que se afectófue la comunicación, porque la guía no facilita el desarrollode tal habilidad.Conclusión: Es útil el modelo de diseño instruccionalADDIE para la elaboración de guías virtuales deprocedimientos clínicos y en su etapa final de evaluaciónpermite implementar procesos valorativos investigativosde corte cualitativos y cuantitativos, para verificar suefectividad.Palabras clavemodelo de diseño instruccional; modelo ADDIE; educación enenfermería; simulación de paciente; guía.

Introduction

In Colombia, nursing students face multiplerealities in human care, derived from nursingcare. They intervene the human body,manipulating tissues or organs and establishingsome type of action to provide health care. Theeffectiveness of the procedures will depend onthe training, which takes place in simulationcenters where they acquire a certain degreeof skill and dexterity; in addition, there theyunderstand the risks they face from deontologicaland teleological areas related to the procedure.In this regard, it is stated that: “The use ofsimulators should not only focus on practicingmanual procedures, but also generate a learningenvironment that includes the development of

other skills such as communication, reflection,critical thinking, decision-making and theconsideration of the patient as a complex humanbeing” (1).

Educational innovation with simulatorsfacilitates interactive learning based oninformation and communications technology(ICT), which combine informationtechnology, telecommunications, electronicmedia, interdisciplinary work with experts andthe creation of teaching materials, which shouldincorporate attractive technologies to facilitateteaching and, consequently, improve patient care(2).

The learning of nursing disciplinary contentsin virtual environments is an importantelement in the teaching and learningprocess (3). The technological resources usedillustrate nursing procedures realistically, whilefacilitating acceptance and effectiveness inlearning; therefore, e-learning uses multimediatechnologies and the Internet to promote andimprove its quality (4).

The scientific literature regarding theapplication of technologies in education showsthe term educational design or instructional designappears, in which the needs and the learningenvironment are analyzed, the training objectivesare defined and the more appropriate resourcesare chosen, taking into account the learningprocesses in which the contents are developedand the evaluation is designed (5).

To create the virtual guide, we used theADDIE instructional design model, which refersto a systematic process to create virtual learningenvironments, to recognize thematic contents,theories of learning, instructional strategies andthe technological medium that allows generatingrecreated environments in a mediated way, tosupport the knowledge-building processes (6). Inturn, the techno-instructional or techno-pedagogicaldesign concept, described by Coll (4), wastaken into account, which indicates that thepedagogical and technological dimensions mustbe taken into account, in order to identify thestrategies that facilitate the learning of contentsand the technological tools pertinent to thetraining process.

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The objective of the present teachingexperience was to build a clinical simulationvirtual guide so that nursing students canautonomously learn a clinical-care procedure,through the application of an instructional designmodel.

Background

Since 2008, a group of researchers identifiedhow nursing students learned clinical-careprocedures, including venipuncture.

In the clinical simulation center where thisresearch was carried out, teaching modeling wasused as a strategy: small work groups were formedto show them the steps of the procedure. Thisactivity required preparing the patient to obtainan informed consent, prepare the elements andtake steps to establish venous access. For thisreason, demonstrating the procedure took a longtime, and its effectiveness depended on thecognitive development of the trainee and onrepetition; in addition, the times and movementsused exceeded the estimates, which requiredcreating strategies to offer opportunities to learnby trial and error. As a result of this, a clinicalprocedural guide organized in a folder wascreated, showing the sequence of the steps andincorporating the possibility of developing skillswith simulators.

When creating the guide, a certain degreeof uncertainty was generated, since in order todesign it, teacher expertise was required, andnumerous steps were included. This situation ledthe students to rely on memory, which limitedreal learning. When the guide was put intooperation, checklists were applied to measureand confirm the learning, and over time theywere restructured based on the review of theliterature and on institutional protocols.

Between 2012 and 2014, a quantitative,observational and evaluative research wasconducted in the classroom with 175 nursingstudents. The objective was to compare theeffectiveness of two didactic strategies throughthe clinical simulation: teaching modeling andprocedural guide for the autonomous learning of

venipuncture. A checklist was used to comparesamples with random variables obtained in fiveacademic periods; at the same time, we soughtto evaluate the difference established in thevariances of the tests applied by analyzingdata with Fisher’s F test. The results showedthat in some academic periods, the teachingmodeling strategy produced better learningresults. In other academic periods, the strategythat showed the best results was the proceduralguide for autonomous learning. When comparingthe results, we concluded that there was nosignificant statistical difference in both strategies,which favored the learning of venipuncture (7).

At that time, studies on learning wereencouraged, using clinical simulation with thethematic axes “perception of nursing studentsabout the use of clinical simulation as a learningstrategy” and “adherence of students to theprocedural guides in clinical simulation.”

The studies showed that the clinicalsimulation allows to repeat the procedureaccording to the students’ needs, and helpsthem to gain confidence from the analysis oftheir mistakes. Practicing with an inanimateobject allowed the transfer of knowledge to realsituations with which theory and practice couldbe connected (8). Likewise, becoming familiarwith a clinical environment develops criticalthinking in decision making. In this regard,Gamboa et al. state that “students considerthat clinical simulation is a useful strategy intransferability to face the challenges of realclinical practice through safe and controlled toolsand scenarios” (9).

At the time, it was suggested to increaseteaching support in simulated practices (9),because with the guides it was not possible tostudy and practice, due to limitations in timeand in opportunities to repeat and learn from themistakes (10).

The studies confirmed that there was a lowadherence to the guides, in terms of studentattendance and their commitment to practicethem in the clinical simulation center (11); thislow adherence is related to time management,work reasons and academic load. The mainrecommendation was: “the guides must be

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available in the University virtual platform, sothat students can study them before arriving atthe simulation center to practice them” (12).This allowed us to look for a model to builda virtual guide to substantiate both teachermodeling and autonomous learning, which wasachieved by applying an instructional designmodel and the concept of techno-instructional ortechno-pedagogical design.

Method

The ADDIE instructional design model refersto five moments when creating virtual learningenvironments: analysis, design, development,implementation and evaluation.

The analysis identifies the students, thecontents and the environment that thetraining needs poses. The design defines thepedagogical approach and content organizationand sequence. The development incorporatesthe creation of learning materials based onthe contents set out in the design phase. Theimplementation refers to the execution andimplementation of the teaching material with thestudents. The evaluation has two moments: inthe first, the stages of the ADDIE process areevaluated, and in the second, specific tests areused to analyze the results of the training with thestudents (6).

The concept of techno-instructional ortechno-pedagogical design described by Coll (4)points out that the pedagogical and technologicaldimensions must be taken into account. Inthe pedagogical dimension it is necessary toidentify the recipients with their characteristics,as well as the objectives or skills of the virtualtraining; with this, it is possible to determinethe “content development and implementation,activity planning, with guidelines and suggestionson the use of the technological tools in thedevelopment of the activities and the preparationof a plan to evaluate the processes and theresults.” The technological dimension involves“the selection of technological tools apropriateto the training process to be carried out,analyzing its possibilities and limitations, such

as the virtual platform, software applications,multimedia resources.”

Application of the ADDIE instructionaldesign model and the concept of techno-instructional design

Analysis

To create the venipuncture virtual guide, thepedagogical dimension was analyzed, identifyingthe students that were the object of thetraining process, which in this case correspondedto nursing students who would be taughtthe contents of the selected procedure. Thisclinical-care procedure is frequently carriedout in hospital care practices. Initially, theparticipation of students of the Basic Caresubject was considered, who were beginning todevelop technical skills during their first practice.However, the guide was designed for studentsof different semesters who face the healthcareprocedure on a daily basis.

The thematic content was defined as anursing care activity from the functional healthpatterns included in the diagnoses of the NorthAmerican Nursing Diagnosis Association (13), inpatterns such as Activity Exercise, Eliminationand Nutritional Metabolic. This allowed us toconceptually support nursing care.

The learning spaces in which we workedwere three: a) the classroom, b) technologicalmeans and c) the clinical simulation center.In the classroom, we developed the thematiccontent that justified, from the conceptualpoint of view, the realization of venipuncture.The technological means used were computers,tablets or smartphones to study the virtual guide,which allowed reinforcing the concepts learnedin the classroom and preparing the simulatedpractice. At the clinical simulation center, thestudent practiced each step of the procedurerepeatedly on task trainers in parts.

The analysis of the technological dimensioncomprised the thematic review of the contentstaught in the classroom, which allowedgenerating the information architecture (14)

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based on the classification, content structuring,definition of general concepts, identification ofequipment, procedure processes and verification,as can be seen in Figure 1. In each of theseitems we defined the scope and the learningobjectives on what the student “should know,”coupled with the possible interaction with whatthe student “should do,” within the frameworkof the acquired skills. In the content matrix forthe development of the virtual learning object(VLO), a list was made with the description ofeach topic, based on the students’ multiple skills.Figure 2 shows the initial content matrix.

Figure 1Information Architecture: “Guide for VenipunctureProcedures,” first version.

Figure 2Content matrix for the development of the VLOproposed by the Centro Ático design team (2012).

Design

From the pedagogical dimension, the designincluded elements from the behavioral andconstructivist approaches, because knowledgeand skills framed in observable and measurablelearning objectives were taken into account(15), and the possibility of controlling ownlearning, mediated by the interaction with thetechnological resource included in the guide wasincreased (16).

The learning objectives consisted of:a) administering intravenous solutions, b)achieving permeable access routes, and c) takingsamples for laboratory tests. The structure wasbuilt with a script that contained generalities,equipment and procedure. In the generalitiesdimension, aspects such as the definitionof venipuncture, anatomy of vascular access,indications, contraindications, and aspectsrelated to biosafety were taken into account.In the equipment dimension, an inventoryof resources was carried out, among whichwere venous catheters, venoclysis equipmentand syringes. In the procedure dimension, theliterature was reviewed to find the scientificevidence in venous catheterization, to adjust theexisting checklists, which contained the stepsthat were incorporated and supplemented for theprocedure.

From the technological dimension, the designtook into account the elements of theconstructivist model, providing the studentwith the relevance of “building” his/her ownknowledge, through the experience with theinteraction of the learning contents. Thislearning environment leads to the creation ofcognitive schemes through the assimilation ofconcepts and an approach to processes (15).

When defining the learning objectives,selecting the thematic concepts and creating thelist of the equipment and the processes set outin the previous “Analysis” stage, methodologicalstrategies were established within the frameworkof the creation of a constructivist learningenvironment leading to the understanding of thecontents and the verification of the processes.

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Graphic and interactive representations of thevenipuncture procedure were created to promotethe approach to significant experiences in thecontext of the clinical simulation center; thisallowed to build knowledge in a collaborativeway through applicable digital media andtechnological formats. In this way, with thecontent matrix (Figure 2) all the thematic axeswere listed and the dynamics of interaction forthe students were identified; each item wasdefined with multimedia elements (17), and aninventory of graphic and audiovisual resourceswas generated, among others (Figure 3).

Figure 3Navigation map [interaction scheme]

Likewise, a scheme was created that definedthe interconnection of the thematic contents,relating concepts and procedures, which offeredthe students the possibility of deciding thesequence of information, deepening, rhythm oflearning, and a relation with the contents.

Next, the navigation levels were outlined,configured by hierarchy of the informationanalyzed in the previous stage. In this sense,a multimedia container or web application wasdesigned that connected the digital thematiccontents and the students’ learning experience.Graphic interaction elements were used, suchas hyperlinks and user interface (UI) design(18); this latter is the relationship of the graphicappearance of the software (web application)with the user (student) interaction. Suchinterface was designed with a usability approach,so that it allowed to achieve the learningobjectives in an imperceptible way; in otherwords, the nursing students found theoreticalconcepts and didactic exercises to understandthe contents and in some cases obtain feedback,which led to a comprehensible and intuitive userexperience.

There was a close relationship betweenthe user interface (UI) design and the userexperience (UX) design. The UX design tries to

model the experience to use the product, whichin this case is the web application; this involvedknowing and analyzing the user: who he/she is,why and in what conditions he/she will use theapplication. “The objective of the interactiondesign is to create products that allow the userto reach his/her objectives in the best possibleway” (19).

For the graphic pattern or interface design(Figure 4), we proposed the treatment of astylized and schematic image, a photographicquality with optimal lighting and detail amongits elements, together with the palette of freshcolors, concerning the clinical environment. Inthis way active or sensitive zones were created onthe images that display information, to establisha virtual relationship between the elements andthe practices.

Figure 4Design of the graphic interface of the Guide forVenipuncture Procedures

Development

Once we had the pedagogical approach and thedesign of the content structure, we proceeded todevelop the materials. We took into account thetextual explanation of each conceptual section,represented graphically and reviewed through arapid and simple test, called Verification of theProcess. The texts were written based on thecontents of the guide, where each concept wasdescribed, which was supported by theoreticalreferences explaining the scientific knowledge fornursing care in the execution of the procedure.The graphic representation took into account aresource inventory, according to the sequence

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of the thematic contents. In terms of processverification, interactivity was incorporated intothe guide through games that linked videos, self-assessment tests and case selection.

The development of the technologicaldimension took into account that each thematicitem would be represented by a digital product,framed in a graphic pattern applied to allthe elements of the project (Figure 5). Thetheoretical bases were represented by aninteractive content supported with illustrations,photographs and videos. The learning processeswere verified as didactic activities and, in somecases, playful, where the student solved situationsof case studies. Likewise, the clinical procedureswere registered under an audiovisual productionand post-production deployment.

Figure 5Audiovisual presentation of the Guide forVenipuncture Procedures

To develop the web application and thecomplementary digital content, we started witha production design, in which we consideredthe resource inventory defined in the designphase and the schedule based on productiontimes. With a design team and audiovisual mediaexperts, we proceeded to create the graphsfor the user interface based on the script,the identification of the scenes for the visualrecord, and the venipuncture procedures. Theweb application was developed in Action Script3.0 language, which allows to create complexinteractivity, control of audiovisual reproductionand visualization of digital contents (20).

Additionally, we used an illustration, drawingand photography software to create three

illustrations for the item Anatomy of vascularaccesses: the human body and the vein and arterycirculation system. From the graphic record,we selected 25 photographs of the venoclysisequipment and scenes from the physical spaceat the Clinical Simulation Center, made with ahigh-end camera and spot lighting. We recorded12 audiovisual contents that consisted of 3moments of venipuncture: preparation, purgeand procedures. In addition, we recorded theuse of biosecurity barriers, hand hygiene andwaste disposal, among others. This audiovisualrecord was made with professors executing theprocesses. The narration was later recorded inan audio studio. The audiovisual equipmentwere high-end cameras that incorporate lightsfor filming and television. This recording tookapproximately 20 hours. In the post-production,the audio was edited and synchronized.After finishing the graphic and audiovisualelements, content was incorporated into theweb application under planned programmingparameters (Figure 6).

Figure 6Presentation of the Guide for VenipunctureProcedures

Implementation

Starting with the pedagogical dimension inthe implementation phase, the students wereallowed to review the didactic material inthe Learning Manager System (LMS) virtualplatform, in which they studied the thematiccontents and consulted the videos that showedthe modeling of the procedure; at the sametime, when interacting, the learned process

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was verified. Next, the students attended theClinical Simulation Center to practice with thetechnological support media, among which werecomputers, tablets, puncture materials and tasktrainers in parts.

As part of the learning self-verification, thestudents —after giving an informed consent—were filmed in the execution of the procedure,to contrast the executed steps in the audiovisualmaterial, compared with the steps proposed inthe virtual guide, in order to determine criticaland control points to build learning, correctmistakes and seek excellence and clinical safety.

Teacher support from the feedback wascontinued after the learning self-verification.There, both, teacher and student, reviewed thesteps to identify mistakes and adjust the process.

From the technological dimension, theimplementation allowed to administer thecontents, to put into practice the training actionwith the participation of the students, and tomonitor the learning process.

The web application was hosted in aUniversity network environment under LDAP(Lightweight Directory Access Protocol), whichmeans that only the students and professorsof the School of Nursing were allowed access.In turn, this information is provided throughthe LMS platform, based on the licensesadministered by the University for students whotake courses of the clinical component.

Evaluation

The evaluation phase corresponds to thepresentation of results that allowed to verify thelearning of the guide using virtual mediation.From the pedagogical dimension, the verificationchecklists and the perception of the studentswere analyzed.

A classroom research related to theapplication of checklists to verify learning had asunit of observation 159 participants distributedin four academic periods between 2015 and 2016.Table 2 shows the distribution of the primarystatistics by academic period.

Table 2Distribution by academic period

Source: Own preparation.

The average score of the virtual guide was3.99, which represents a negative asymmetry,because the mode was higher than the median,due to the influence of the concentration of highgrades in the data distribution. Regarding thestatistical range (maximum and minimum), thestatistical range average was 3.75, for the 159students evaluated.

Between 2015 and 2016, nursing studentsconducted a research called: Perception of NursingStudents of the Pontificia Universidad Javerianaabout the Use of the Virtual Guide for VenipunctureProcedures as a Learning Strategy. This researchassessed the following dimensions: satisfaction,realistic clinical experiences, confidence-motivation, technical skills and decision-making(21). The dimension Realistic clinical experiencesobtained the highest score, due to the connectionbetween technical and practical knowledge andthat it allowed to develop skills in the executionof several clinical procedures. On the other hand,the satisfaction dimension obtained the lowestscore, due to factors such as teaching support,time management and availability of materials inthe simulation center. The results show a goodperception of the students on learning basedon the virtual guide; they consider it practical,because it favors autonomy and strengthensthe theoretical component. Communication waspresented as a negative aspect, because the guidelacks this component to develop this skill.

Studying with the virtual guide satisfies andstimulates learning needs, because it motivatesautonomy, is easy to understand, incorporates

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steps similar to the real procedure, and containsimages and explanatory videos. Teacher supportwas considered an important aspect, becauseit favors the development of operational skills,creates confidence to attend clinical practiceand complements the material studied in theclassroom.

Regarding the technological dimension, inthe evaluation phase there were problems tovisualize the virtual guide, because the browsersused by the students should have an updatedFlash application. At the time of using thevirtual guide in 2010, Apple banned Flash iniPhones and iPads, and the web applicationcreated in the Action Script 3.0 language usedFlash Player, Addobe Systems (19). This ledto subsequent virtual guide building projectsto identify the most popular browsers amongstudents in new websites. Google Chrome is oneof the favorites, for its stability; likewise, “Googledesignated HTML5 as the preferred Rich Mediaoption in its Chrome browser through FlashPlayer” (20), which implies reading new websitesin Hypertext Markup Language (HTML5),another programming language adaptable tomobile devices. These two languages haveallowed to create multimedia material withsimilar interactions.

Discussion

The application of the instructional designmodel (ADDIE) in the construction of avirtual guide has showed satisfactory results.Analyzing, designing, developing, implementingand evaluating activities require time anddedication, in addition to having clear objectivesthat must be developed to achieve a betterlearning.

In 2008, the United Nations Educational,Scientific and Cultural Organization (UNESCO)created the information and communicationstechnology (ICT) competency standards forteachers, which were assumed by Colombia in2013. A pentagon of skills was identified relatedto: a) teaching, b) research, c) communication,d) management and e) technology; the latter

is defined as the ability to “select and usea variety of technological tools in a relevant,responsible and efficient manner, understandingthe principles that govern them, the way tocombine them and the licenses that protectthem” (22). The skills are expressed in degreesof complexity that correspond to exploration,integration and innovation.

The exploration level is generated when theteacher approaches the knowledge that allowshim to conceptually elaborate the idea. Thesecond level of integration is characterized by thefact that appropriate knowledge allows solvingproblems in specific contexts. This is followed bythe innovation level, where there is an emphasison creating, going beyond what has been learnedand imagining novel explanations or significantactions (23).

These elements proposed by UNESCOcorrespond to ADDIE model stages, wherethe teachers identified the environment, raisingthe training needs. That exploratory levelhelped to establish the pedagogical approach tosequentially organize those harmonic contentswith the instructional process with which itwas intended to support a significant andautonomous learning; therefore, the use of anICT could promote and stimulate a higher-levelcomplex thought in the students.

Góngora and Martínez (5) point out thatpreparing professionals capable of using toolsto efficiently create good-quality didacticallycoherent training materials requires trainingthe learning designer, a role defined ineducational software development teams. Theseauthors conclude that learning models basedon constructivist theories are adequate formodern educational contexts, as they offer betteropportunities to design training actions and todevelop professional skills. According to this,in order to creatively impact the teaching-learning process, ICTs should be used in linewith overcoming challenges in the environmentswhere the knowledge-based society has beenestablished.

Robinson and Dearmon (24) consider thatlearning design requires some stages with definedtasks and results. For example, in the analysis

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stage, the task will be to assess the needs,identify the problem and analyze the tasksin order to establish a student profile. Atthe design stage, the process will consist ofspecifying how to learn after identifying theobjectives, developing the topics and establishingan instructional plan, which requires establishingmeasurable objectives, specifying a prototype anddefining the instructional strategy. Regarding thedevelopment stage, it is necessary to establishthe process for the authorization and productionof the material; therefore, at this stage thework is carried out with the producers, andscripts, organizational charts and work plansare developed; practical exercises are establishedand learning environments are created, becausethe instruction can be in a computationalsystem that includes feedback, measurementand collaborative learning instruments. Theimplementation stage is the process of installingthe project within the educational context,where the teacher receives a pilot training toverify the student’s comments and generateevaluation data. Finally, in the evaluationstage, where the instruction is adapted, timerecords are needed, interpretation of evaluationresults, and the recommendations obtained areparameterized.

The experience of applying the ADDIEinstructional model to the creation of avirtual guide involved conceptualizing each ofits stages. The implementation, for example,required executing what had been programmedin a didactically constructed format so thatthe learning was pleasant, and the evaluationrequired several moments to determine theresults of the training action with the students.Therefore, the perception for the managementof the guide was assessed and favorability wasfound to develop autonomy and theoreticalapprehension. Apparently, the virtual guidestimulates learning and satisfies the students,because they find answers to their questionsand the operational skill is strengthened. TheADDIE model has proven to be a usefulinstructional model for preparing traditionalteaching materials, as there is an important

intention to use this model in electronics andgenerate materials for online teaching (25).

Frota et al. (3) conducted a study onthe construction of a technological educationto teach peripheral venipuncture to nursingstudents, based on virtual learning environments.They concluded that the use of new ICTsfacilitates instruction, as long as an interactivedistance perspective is used and time is spentlearning with new experiences. Technologicalresources illustrate nursing procedures, whichmakes it easier for students to easily acceptinstruction; therefore, learning is more effective.Videos, hyperlinks, images and hypertext wereused in the research to present information,which improved learning, because the conceptswere structurally associated. The results alsoshowed that the participants considered positiveto use virtual learning environments, since thesecreate new possibilities to keep information andcommunication channels open. In turn, thestudy showed that the guide did not supportany learning process regarding communicationbetween the student and the patient, sincethe intention was the significant learning of aclinical-care procedure.

Some mistakes were made in the design ofthe guide, which were promptly corrected. Forexample, the use of images and trademarksbelonging to various economic sectors, asituation that generated learning in this aspectand required a structural redesign, to avoidcopyright problems. The implementation of theguide required significant financial support, giventhat this type of projects require technologicalelements with limited availability; in addition,trying to demonstrate that virtual education is asimportant as classroom and traditional educationgenerates a cognitive dissonance in the universitydirectors whose structural vision is centered onthe administration and optimization of resources.

In our experience the evaluation was veryinteresting, because it required a permanentassessment by cohorts and academic periods; inaddition, we made a qualitative and quantitativeassessment of the perception of the use of thissystem, pointing out that in the programmingphase the teacher plays the prominent role,

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and in the practice phase the student plays theprominent role. Dillard et al. (26) state thatthere are no standard methods to assess clinicalsimulation; therefore, it is important to havestrategies to evaluate tasks, establish nursingroles and strengthen clinical judgment.

When comparing this experience with somestudies, we found that the students’ perceptionis positive in the acquisition of skills, inthe participants’ knowledge and attitudes; thisimproves the overall vision of the health problemand it is prioritized, especially when learningis combined with the simulated scenarios withwhich clinical-care procedures are practiced.This was demonstrated by Juguera Rodríguez etal. (27) in a clinical simulation study as a trainingtool.

In another study, Niño et al. (28) foundthat more than 90% of the students recognizedthat with clinical simulation significant learningis achieved and skills are strengthened, whichmakes them feel confident. Therefore, thecreation of simulation guides helps to increaseskills in a systematic way. In this regard, Curl etal. (29) reported that simulation should be part ofthe nursing curriculum from the first semesters,to better train students in care practices.

The ADDIE instructional model allows tocreate virtual guides of clinical-care proceduresapplying constructivist theory. This theory isvery appropriate in modern educational contexts,because it offers better opportunities to designtraining actions and, with this, establish someprofessional skills. In this regard, Góngora andMartínez (5) have pointed out that the studentsuse their knowledge better in changing and newsituations if teaching is based on models thatapply and solve problems, and learning designis a timely and optimal guidance to meet theeducational needs. Likewise, these authors haveidentified that taking advantage of ICTs is crucialfor teachers to use creative tools in teaching andlearning processes, which is very relevant in thedevelopment of the knowledge-based society.

It is clear that part of the developmentof a virtual guide requires incorporatingan instructional design model, whose maincharacteristic is behaviorism, since the contents

are rigorously selected and made available to thestudent using didactics and VLOs for interaction;meanwhile, its presentation has graphics andsound, and it is incorporated into multimedia.The purpose of these resources it that the studenthas a programmed and systematic contact withcontents and learning proposals that take himfrom simple to complex.

Luzardo, cited in Londoño (30), statesthat instructional design models used invirtuality, built with cognitive, behavioral andconstructivist learning approaches, are thosethat best adapt to these learning environments,especially because they behave as open systemsthat exchange information with the environmentwhere they are used. However, the constructivistinstructional design incorporated in virtualeducation is not easy to develop, because “itmust offer the student the possibility to choosedifferent paths to reach knowledge” (30).

The teacher support process requiresidentifying the learning needs and exercisinga responsible pedagogical practice with whichinterest, enthusiasm and motivation aretransmitted, based on effective communication.On the other hand, autonomous learning isestablished when the student reflects criticallyon a process or procedure with which he/shechooses the best action based on knowledge.Thus, teaching support and autonomous learningare complementary processes that influence theparticipant’ satisfaction, which is even increasedwhen both are executed harmonically in anacademic environment, especially in clinicalsimulation to learn assistance processes.

Conclusion

The results of the present teaching experienceindicate that learning using a virtualguide provides a great opportunity togenerate knowledge; however, its constructionunquestionably requires an application methodthat in this case was the ADDIE model, whichshowed its relevance and favorability.

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