Purpose: Hearing loss is a common problem worldwide, and there is an ever- increasing need for more audiologists to be trained. Unfortunately, audiology students cannot always get the clinical experience they need during training. Virtual reality involving computer-based simulation of real-life training experiences is one way of compensating for this. While there are several virtual audiometers available for student use, few of these include the vital case history component. This study sought to develop an interactive virtual patient that includes this component, and to objectively measure the effect of training with this software on student performance. Method: Development of the Patient Simulator Program (PSP) took place in two phases – Phase One involved development of audiometric information and a brief case history summary for 25 patient cases, and Phase Two involved development of comprehensive case histories for these and identification of triggering phrases and keywords for eliciting each piece of information from the virtual patient. Twelve first year audiology students were recruited from the University of Canterbury and divided into matched groups based on their pre-test scores. An alternating treatment design across groups was used to evaluate participants on their verbal and written accuracy, experience, confidence, and efficiency scores on case history tasks. Results: A significant difference was found in verbal accuracy scores between groups at the mid-way assessment point (following simulator training), but not for written accuracy. Differences between groups were not significant at all assessment points for efficiency and experience measures. Confidence gains were greater for the second group to train with the simulator than the first, while performance gains were greater for the first group. Conclusion: These findings support the evidence that simulation training can enhance student’s skills, and provide the first objective evidence for the benefits of training for case history tasks with an interactive virtual patient. While the effect size was small, these findings are a promising springboard for future research into this area. While the PSP is not adequate to replace real clinical encounters, it has potential as an adjunct to the current training program.

The term Virtual Patient (VP) refers to the use of virtual characters which embody patients in a virtual environment. They are implemented in computer simulations to create realistic clinical encounters. VPs have been used successfully in health education to promote and foster clinical communication skills. Additionally, computer simulations offer the advantage of being standardized, safe, repeatable, and do not require as much resources as role-play simulations which rely on actors. This thesis addresses the design and evaluation of a VP-based system aimed for clinical trainees, and uses the field of audiology as a case study. The system is designed to simulate real client encounters and allows students to practice using a standard set of procedures that they have to master in their profession. A wide range of VPs have been implemented for this purpose. The system was evaluated with audiology students, reinforcing the ecological validity of the research. The design of the system was guided by an iterative process of implementation, usability testing, and experiments focusing on students' learning outcomes. The Clinical Audiology Simulator (CAS) was evaluated during five experiments, assessing students learning gains following exposure to the CAS. Learning gains have been assessed through the use of role-play simulations and paper assessments. The procedures evaluated are clinical history taking, pure tone audiometry, and speech audiometry. A further experiment assessed the impact of additional formative feedback on students learning gains, using the pure tone audiometry procedure as an example. The results of these experiments suggest that the system has a great potential to foster students learning, with measurable gains in some of these procedures. They also indicate that feedback and its delivery take an important role in this process. This thesis elaborates how VP-based simulations can reinforce young clinicians' ability to learn procedural skills. I highlight some of the challenges a researcher faces in designing and evaluating such systems, focusing on the implementation of interaction scripts for the VPs, the assessment of learning gains and transfer of skills, and the evaluation of computer simulations as part of a curriculum. VPs have the potential to promote clinical trainees' learning of skills, and to provide students with more opportunities for safe practice in a field where beginning trainees often have few opportunities for actual hands on experience.

According to the Canadian Cancer Society, half of Ontario’s population will be diagnosed with cancer in their lifetime. Many patients being assessed for cancer however become overwhelmed when having to manage information overload, many appointments with different instructions and locations, and recommendations on how to improve their lifestyle. This causes much anxiety and uncertainty among patients. Some cancer assessment clinics offer some guidance in the form of paper-based patient navigators, which provide much reliable information to patients but are limited in terms of dynamic updates to appointments, opportunities for sharing knowledge between healthcare providers and patients, and of patients supporting each other. This thesis proposes a new web-based, mobile, and user-friendly virtual patient navigator application framework named Care Ami, which incorporates the information found in an existing paper-based navigator along with the new features such as remote updates to personal care paths and calendars, personalized navigation guidance, sharing of symptoms/medications information, and peer group support. Unlike existing solutions, Care Ami is configurable to support multiple types of diseases (e.g., lung cancer and breast cancer). This application is evaluated through testing and the usage of heuristic evaluation guidelines related to usability, and a comparison with related work highlights its many benefits.

Objetivos: Descrever todo o processo de implantação dos laboratórios de prática de simulação farmacêutica e desenvolver e avaliar um simulador virtual de seguimento farmacoterapêutico adaptando o software SIACC. Métodos: Para a implantação dos laboratórios de prática foi realizado o planejamento da área física, incluindo o fluxo de atividades, identificados os materiais e equipamentos necessários a realização das práticas, os procedimentos que ali serão realizados, bem como a validação dos mesmos, por meio de desenvolvimento, avaliação de realização e correção de desenvolvido. Em relação ao simulador, a metodologia do estudo foi realizada em quatro fases: Fase de planejamento: a adaptação do SIACC para o ensino da prática farmacêutica; Fase de uso do simulador; Desempenho dos usuários; Fase de avaliação do simulador que foi realizada utilizando dois instrumentos de avaliação: ISO 9126 e as Dez Regras de Ouro para avaliação de software. A avaliação foi qualitativa e quantitativa. Na avaliação qualitativa, utilizou-se a Técnica do Grupo Nominal. Resultados: No que se refere a implantação dos laboratórios de prática de simulação, o estudo descreveu todas as etapas da implantação dos laboratórios de prática para a formação do profissional farmacêutico. A avaliação do software com base na ISO 9126 mostrou que não houve diferença estatísticas (p < 0,05) das dimensões avaliadas por dois grupos diferentes: estudantes e especialistas. Também não houve diferença estatística (p < 0,05) das dimensões avaliadas em relação a três grupos: os que não utilizam a informática na educação, os que utilizam apenas para fazer apresentação e os que utilizam mais de um recurso computacional na educação. Na avaliação com base nas Dez Regras de Ouro, apenas dois dos dez itens avaliados tiverem a média < 4 (média máxima: 5,0). Os resultados da avaliação qualitativa corroboraram com a avaliação quantitativa. Conclusões: Estes são os resultados da investigação destinada a desenvolver modelos para a aplicação de métodos de aprendizagem ativos usando novas tecnologias que se destina a ser implementado inicialmente na Escola de Farmácia da UFRGS. / Objectives: The aim was to describe the entire implantation process of the simulation practice laboratories and to develop and evaluate a virtual simulator for pharmacotherapeutic follow-up by adapting IASCC software. Methods: In order to set up the laboratories, the planning of the physical area was carried out to include the flow of activities and the materials and the equipment needed were identified. Also, the procedures that would be done were validated through development and evaluation of achievement and then correction was proposed. In relation to simulator, the methodological development study was conducted in four phases: Planning phase: the adaptation of SIACC for pharmaceutical practice teaching; A second phase using the simulator; and a third consisting of grading the performance of users; and finally, the evaluation of software using two instruments: ISO 9126 and the Ten Golden Rules. The assessment was qualitative and quantitative. In qualitative evaluation, was used the Nominal Group Technique. Results: Regarding the implantation of the simulation practice laboratories, the study described all steps needed to set up laboratories for the training of pharmacists. The evaluation based on the ISO 9126 showed that there was no statistical difference (p < 0.05) between the factors evaluated by two different groups: students and experts in this field. Also, there was no statistical difference (p < 0.05) among the factors evaluated by three groups: those who do not use information technology in education, those who use it only to make presentations and those who use more than one IT resource in education. In the evaluation based on the Ten Golden Rules, only two of the ten items evaluated had an average < 4.0 (maximum average: 5.0). The results of the qualitative evaluation corroborate the quantitative assessment. Conclusions: These are the results of the authors’ research aimed to develop models for the application of active learning methods using new technology to be initially implemented at UFRGS School of Pharmacy.

Objetivos: Descrever todo o processo de implantação dos laboratórios de prática de simulação farmacêutica e desenvolver e avaliar um simulador virtual de seguimento farmacoterapêutico adaptando o software SIACC. Métodos: Para a implantação dos laboratórios de prática foi realizado o planejamento da área física, incluindo o fluxo de atividades, identificados os materiais e equipamentos necessários a realização das práticas, os procedimentos que ali serão realizados, bem como a validação dos mesmos, por meio de desenvolvimento, avaliação de realização e correção de desenvolvido. Em relação ao simulador, a metodologia do estudo foi realizada em quatro fases: Fase de planejamento: a adaptação do SIACC para o ensino da prática farmacêutica; Fase de uso do simulador; Desempenho dos usuários; Fase de avaliação do simulador que foi realizada utilizando dois instrumentos de avaliação: ISO 9126 e as Dez Regras de Ouro para avaliação de software. A avaliação foi qualitativa e quantitativa. Na avaliação qualitativa, utilizou-se a Técnica do Grupo Nominal. Resultados: No que se refere a implantação dos laboratórios de prática de simulação, o estudo descreveu todas as etapas da implantação dos laboratórios de prática para a formação do profissional farmacêutico. A avaliação do software com base na ISO 9126 mostrou que não houve diferença estatísticas (p < 0,05) das dimensões avaliadas por dois grupos diferentes: estudantes e especialistas. Também não houve diferença estatística (p < 0,05) das dimensões avaliadas em relação a três grupos: os que não utilizam a informática na educação, os que utilizam apenas para fazer apresentação e os que utilizam mais de um recurso computacional na educação. Na avaliação com base nas Dez Regras de Ouro, apenas dois dos dez itens avaliados tiverem a média < 4 (média máxima: 5,0). Os resultados da avaliação qualitativa corroboraram com a avaliação quantitativa. Conclusões: Estes são os resultados da investigação destinada a desenvolver modelos para a aplicação de métodos de aprendizagem ativos usando novas tecnologias que se destina a ser implementado inicialmente na Escola de Farmácia da UFRGS. / Objectives: The aim was to describe the entire implantation process of the simulation practice laboratories and to develop and evaluate a virtual simulator for pharmacotherapeutic follow-up by adapting IASCC software. Methods: In order to set up the laboratories, the planning of the physical area was carried out to include the flow of activities and the materials and the equipment needed were identified. Also, the procedures that would be done were validated through development and evaluation of achievement and then correction was proposed. In relation to simulator, the methodological development study was conducted in four phases: Planning phase: the adaptation of SIACC for pharmaceutical practice teaching; A second phase using the simulator; and a third consisting of grading the performance of users; and finally, the evaluation of software using two instruments: ISO 9126 and the Ten Golden Rules. The assessment was qualitative and quantitative. In qualitative evaluation, was used the Nominal Group Technique. Results: Regarding the implantation of the simulation practice laboratories, the study described all steps needed to set up laboratories for the training of pharmacists. The evaluation based on the ISO 9126 showed that there was no statistical difference (p < 0.05) between the factors evaluated by two different groups: students and experts in this field. Also, there was no statistical difference (p < 0.05) among the factors evaluated by three groups: those who do not use information technology in education, those who use it only to make presentations and those who use more than one IT resource in education. In the evaluation based on the Ten Golden Rules, only two of the ten items evaluated had an average < 4.0 (maximum average: 5.0). The results of the qualitative evaluation corroborate the quantitative assessment. Conclusions: These are the results of the authors’ research aimed to develop models for the application of active learning methods using new technology to be initially implemented at UFRGS School of Pharmacy.

Objetivos: Descrever todo o processo de implantação dos laboratórios de prática de simulação farmacêutica e desenvolver e avaliar um simulador virtual de seguimento farmacoterapêutico adaptando o software SIACC. Métodos: Para a implantação dos laboratórios de prática foi realizado o planejamento da área física, incluindo o fluxo de atividades, identificados os materiais e equipamentos necessários a realização das práticas, os procedimentos que ali serão realizados, bem como a validação dos mesmos, por meio de desenvolvimento, avaliação de realização e correção de desenvolvido. Em relação ao simulador, a metodologia do estudo foi realizada em quatro fases: Fase de planejamento: a adaptação do SIACC para o ensino da prática farmacêutica; Fase de uso do simulador; Desempenho dos usuários; Fase de avaliação do simulador que foi realizada utilizando dois instrumentos de avaliação: ISO 9126 e as Dez Regras de Ouro para avaliação de software. A avaliação foi qualitativa e quantitativa. Na avaliação qualitativa, utilizou-se a Técnica do Grupo Nominal. Resultados: No que se refere a implantação dos laboratórios de prática de simulação, o estudo descreveu todas as etapas da implantação dos laboratórios de prática para a formação do profissional farmacêutico. A avaliação do software com base na ISO 9126 mostrou que não houve diferença estatísticas (p < 0,05) das dimensões avaliadas por dois grupos diferentes: estudantes e especialistas. Também não houve diferença estatística (p < 0,05) das dimensões avaliadas em relação a três grupos: os que não utilizam a informática na educação, os que utilizam apenas para fazer apresentação e os que utilizam mais de um recurso computacional na educação. Na avaliação com base nas Dez Regras de Ouro, apenas dois dos dez itens avaliados tiverem a média < 4 (média máxima: 5,0). Os resultados da avaliação qualitativa corroboraram com a avaliação quantitativa. Conclusões: Estes são os resultados da investigação destinada a desenvolver modelos para a aplicação de métodos de aprendizagem ativos usando novas tecnologias que se destina a ser implementado inicialmente na Escola de Farmácia da UFRGS. / Objectives: The aim was to describe the entire implantation process of the simulation practice laboratories and to develop and evaluate a virtual simulator for pharmacotherapeutic follow-up by adapting IASCC software. Methods: In order to set up the laboratories, the planning of the physical area was carried out to include the flow of activities and the materials and the equipment needed were identified. Also, the procedures that would be done were validated through development and evaluation of achievement and then correction was proposed. In relation to simulator, the methodological development study was conducted in four phases: Planning phase: the adaptation of SIACC for pharmaceutical practice teaching; A second phase using the simulator; and a third consisting of grading the performance of users; and finally, the evaluation of software using two instruments: ISO 9126 and the Ten Golden Rules. The assessment was qualitative and quantitative. In qualitative evaluation, was used the Nominal Group Technique. Results: Regarding the implantation of the simulation practice laboratories, the study described all steps needed to set up laboratories for the training of pharmacists. The evaluation based on the ISO 9126 showed that there was no statistical difference (p < 0.05) between the factors evaluated by two different groups: students and experts in this field. Also, there was no statistical difference (p < 0.05) among the factors evaluated by three groups: those who do not use information technology in education, those who use it only to make presentations and those who use more than one IT resource in education. In the evaluation based on the Ten Golden Rules, only two of the ten items evaluated had an average < 4.0 (maximum average: 5.0). The results of the qualitative evaluation corroborate the quantitative assessment. Conclusions: These are the results of the authors’ research aimed to develop models for the application of active learning methods using new technology to be initially implemented at UFRGS School of Pharmacy.

This thesis explores the support of learning through reflection, in the context of medical students and practitioners, working through a series of simulated consultations involving the diagnosis and management of chronic illness. A model of the medical consultative process was defined, on which a web-based patient simulation was developed. This simulation can be accessed over the Internet using commonly available web-browsers. It enables users to interact with a virtual patient by taking a history, examining the patient, requesting and reviewing investigations, and choosing appropriate management strategies. The virtual patient can be reviewed over a number of consultations, and the patient outcome is dependant on the management strategy selected by the user. A second model was also developed, that adds a layer of reflection over the consultative process. While interacting with the virtual patient users are asked to formulate and test their hypotheses. Simple tools are included to encourage users to record their observations and thoughts for further learning, as well as providing links to web-based library resources. At the end of each consultation, users are asked to review their actions and indicate whether they think their actions were critical, relevant, or not relevant to the diagnosis and management of the patient in light of their current knowledge. Users also have the opportunity to compare their activity to their peers or an expert in the case under study. Three formal cycles of evaluation were undertaken during the design and development of the software. A number of clinicians were involved in the initial design to ensure there was an appropriate structure that matched clinical practice. Formative evaluation was conducted to review the usability of the application, and based on user feedback a number of changes were made to the user interface and structure of the application. A third, end user, evaluation was undertaken using a single case concerning the diagnosis and management of hypertriglyceridaemia in the context of Type 1B Glycogen Storage Disease. This evaluation involved ten medical students, five general practitioners and two specialists. The evaluation involved observation using a simplified think-aloud, as well as administration of a questionnaire. Users were engaged by the simulation, and were able to use the application with only a short period of training. Usability issues still exist with respect to the processing of natural language input, especially when asking questions of the virtual patient. Until such time that natural language recognition is able to provide satisfactory performance, alternative, list-based, methods of interaction will be required. Evaluation involving medical students, general practitioners, and specialist medical practitioners demonstrated that reflection can be supported and encouraged by providing appropriate tools, as well as by judiciously interrupting the consultative process and providing time for reflection to take place. Reflection could have been further enhanced if users had been educated on reflection as a learning modality prior to using SIMPRAC. Further work is also required to improve the simulation environment, improve the interfaces for supporting reflection, and further define the benefits of using this approach for medical education and professional development with respect to learning outcomes and behavioural change.

The aim of this study was to examine the effectiveness of different types of feedback on learning pure-tone audiometry using a simulator. Participants were 51 undergraduate students in the Department of Communication Disorders. Participants were randomly allocated to one of two groups whilst undertaking pure-tone audiometry training with the Clinical Audiology Simulator (CAS). One group received summative feedback during the learning task while the second group received formative feedback. Probes were administered to examine participants’ knowledge of pure-tone audiometry following training. In addition, a subjective workload analysis was used to measure perceived cognitive load during training and assessment. Between-groups analysis was conducted to establish the effect of feedback on learning and cognitive load. Data regarding how much time each student spent training on the simulator was also collected, and a regression analysis was conducted to evaluate the relationship between time and learning. Formative feedback was found to have a large positive effect on learning in comparison to summative feedback. Cognitive load was perceived as being higher for students receiving formative feedback during training compared to those receiving summative feedback. In subsequent assessment, the formative feedback group reported a lower cognitive load than the summative feedback group. No relationship was observed between time spent training on the simulator and probes outcome. The formative feedback training mode of the CAS proved to be effective in supporting learning and cognitive load in novice students. The findings suggest that the type of feedback employed when using simulators affects learning outcomes for users.

This thesis explores the support of learning through reflection, in the context of medical students and practitioners, working through a series of simulated consultations involving the diagnosis and management of chronic illness. A model of the medical consultative process was defined, on which a web-based patient simulation was developed. This simulation can be accessed over the Internet using commonly available web-browsers. It enables users to interact with a virtual patient by taking a history, examining the patient, requesting and reviewing investigations, and choosing appropriate management strategies. The virtual patient can be reviewed over a number of consultations, and the patient outcome is dependant on the management strategy selected by the user. A second model was also developed, that adds a layer of reflection over the consultative process. While interacting with the virtual patient users are asked to formulate and test their hypotheses. Simple tools are included to encourage users to record their observations and thoughts for further learning, as well as providing links to web-based library resources. At the end of each consultation, users are asked to review their actions and indicate whether they think their actions were critical, relevant, or not relevant to the diagnosis and management of the patient in light of their current knowledge. Users also have the opportunity to compare their activity to their peers or an expert in the case under study. Three formal cycles of evaluation were undertaken during the design and development of the software. A number of clinicians were involved in the initial design to ensure there was an appropriate structure that matched clinical practice. Formative evaluation was conducted to review the usability of the application, and based on user feedback a number of changes were made to the user interface and structure of the application. A third, end user, evaluation was undertaken using a single case concerning the diagnosis and management of hypertriglyceridaemia in the context of Type 1B Glycogen Storage Disease. This evaluation involved ten medical students, five general practitioners and two specialists. The evaluation involved observation using a simplified think-aloud, as well as administration of a questionnaire. Users were engaged by the simulation, and were able to use the application with only a short period of training. Usability issues still exist with respect to the processing of natural language input, especially when asking questions of the virtual patient. Until such time that natural language recognition is able to provide satisfactory performance, alternative, list-based, methods of interaction will be required. Evaluation involving medical students, general practitioners, and specialist medical practitioners demonstrated that reflection can be supported and encouraged by providing appropriate tools, as well as by judiciously interrupting the consultative process and providing time for reflection to take place. Reflection could have been further enhanced if users had been educated on reflection as a learning modality prior to using SIMPRAC. Further work is also required to improve the simulation environment, improve the interfaces for supporting reflection, and further define the benefits of using this approach for medical education and professional development with respect to learning outcomes and behavioural change.

Indiana University-Purdue University Indianapolis (IUPUI) / Immigrants are at elevated risk for not having their diabetes treatment appropriately intensified, likely resulting in poorly-controlled diabetes and increased morbidity and mortality. Immigrant status is a powerful sociodemographic cue, yet its influence on providers’ diabetes treatment decisions is unknown. The study objective was to determine the effect of patient immigrant status on providers’ decisions to (1) take no action, (2) add an oral hypoglycemic agent (OHA), (3) add/switch to insulin, or (4) refer the patient to an endocrinologist. Participants were 140 medical students/professionals (‘providers’). Providers viewed profiles (videos + vignettes) for virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group (‘nomothetic’) and individual (‘idiographic’) levels. Nomothetic results indicated providers were less likely to refer foreign-born patients to endocrinology than U.S.-born patients (p=0.03). No differences were detected for the other three treatment likelihood ratings. Idiographic results indicated that about half of provider decisions were influenced by patient immigrant status (i.e., Cohen’s d≥0.50) across all four treatment decisions. Effect size data show an almost even split between higher treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add an OHA, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). This study found that providers are less likely to refer foreign-born patients to endocrinology, potentially leading to therapeutic inertia. In addition, half of individual-level provider decisions were meaningfully influenced by patient immigrant status. However, traditional group-level analyses mask these important individual-level differences. These systematic differences in treatment based on non-relevant factors could lead to unintended adverse outcomes for the foreign-born population.