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Exploring the Potential of Using Virtual Patient Cases: For Continuous Professional Development of Nurses Working in Primary Health Centres in Rwanda
Stockholm University, Faculty of Social Sciences, Department of Computer and Systems Sciences.ORCID iD: 0000-0002-2097-182X
2025 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Countries around the world have embraced continuous professional development (CPD) as a key learning strategy through which healthcare professionals maintain or acquire the skills, knowledge, and competencies needed to improve or sustain the quality of healthcare service delivery. Various approaches, such as face-to-face training, mentorship, and online learning, are currently employed to support the CPD of healthcare providers. This thesis, composed of five sub-studies, investigates the potential of virtual patient (VP) cases - an element of digital education - to improve the CPD of nurses in Rwanda's primary healthcare settings. The research is guided by five key questions. The first two studies explore the needs, facilitators, and barriers that could influence the implementation of virtual patient cases in these healthcare settings. The remaining three studies examine how virtual patient cases can enhance clinical reasoning, how nurses perceive the benefits of using VP cases as a CPD approach, and how they accept VP cases as a CPD approach.

The thesis used a quantitative and qualitative research design. The analysis of both qualitative and quantitative data from the exploratory phase reveals that healthcare managers and providers view CPD as a crucial strategy for enhancing healthcare service delivery. However, they also report barriers, such as insufficient electronic devices and unstable internet connectivity, which could hinder the effective implementation of VP cases as a CPD approach. During the intervention phase, 56 nurses engaged with four virtual patient cases - hypertension, depression, gastric cancer, and prostate cancer -as part of their CPD. The findings indicate that nurses who participated in this intervention demonstrated improved clinical reasoning skills in the cases they managed. Additionally, the study found that nurses generally accept VP cases as a viable CPD approach. Furthermore, it was shown that VP cases can complement learning by motivating nurses, providing a safe learning environment, and improving clinical reasoning through reflective practice and comparison with experts' responses to the scenarios presented in the VP cases. These findings, therefore, suggest the possibility of using VP cases as a CPD approach in primary healthcare settings, specifically in health centres in Rwanda and similar contexts. Future research could explore the impact of VP cases on patient outcomes and assess the feasibility of using them for CPD in settings beyond primary healthcare settings.

Abstract [sv]

Många länder runt om i världen har anammat kontinuerlig professionell utveckling (Continuous Professional Development, CPD) som en viktig inlärningsstrategi genom vilken vårdpersonal upprätthåller eller förvärvar de färdigheter, kunskaper och kompetenser som behövs för att förbättra eller upprätthålla kvaliteten på hälso- och sjukvård. Olika tillvägagångssätt, som t.ex. campusbaserade kurser, mentorskap och/eller onlinekurser, används för närvarande för att stödja vårdpersonalens CPD. Den här avhandlingen, som består av fem delstudier, undersöker potentialen hos virtuella patientfall – en del av digitalt lärande – för att förbättra CPD för sjuksköterskor i Rwandas primärvårdsmiljö. Forskningen styrdes av fem forskningsfrågor. De två första studierna undersökte behov, möjligheter och barriärer som kan påverka implementeringen av virtuella patientfall (VP) i dessa vårdmiljöer. De återstående tre studierna undersöker hur VP-fall kan förstärka kliniskt resonemang, hur sjuksköterskor uppfattar möjligheterna med att använda VP-fall som ett CPD-upplägg och deras acceptans av VP-fall för CPD.

 

Avhandlingen använder en forskningsdesign med olika metoder per delstudie, såväl kvantitativa som kvalitativa. Analys av data från de första studierna visar att chefer inom vården ser CPD som en avgörande strategi för att kontinuerligt förbättra sjukvården. Men de rapporterar också olika hinder, som t.ex. otillräcklig tillgång till datorer och instabil internetanslutning, vilket kan hindra ett effektivt genomförande av VP-fall som en CPD-metod. Under interventionsfasen använde 56 sjuksköterskor fyra olika virtuella patientfall – hypertoni, depression, magcancer och prostatacancer – för att se om och hur dessa kunde användas för CPD. Resultaten visar att sjuksköterskorna som deltog i denna studie visade förbättrad klinisk resonemangsförmåga för sådana fall. Dessutom fann studien att sjuksköterskor i allmänhet accepterar VP-fall som en möjlig CPD-metod. Vidare visade det sig att VP-fall kan komplettera lärandet genom att motivera sjuksköterskor, tillhandahålla en säker lärandemiljö och förbättra det kliniska resonemanget genom reflekterande praktik och jämförelse med experters kommentarer som presenteras i VP-fallen. Sammantaget visar resultaten en god möjlighet att använda VP-fall som en bra metod för CPD i primärvårdsmiljöer, särskilt på vårdcentraler i Rwanda och liknande sammanhang. Framtida forskning kan t.ex. undersöka kliniska effekter av VP-fall för CPD och bedöma möjligheten att använda dem för CPD i miljöer utanför primärvården.

Place, publisher, year, edition, pages
Stockholm: Department of Computer and Systems Sciences, Stockholm University , 2025. , p. 97
Series
Report Series / Department of Computer & Systems Sciences, ISSN 1101-8526 ; 25-001
Keywords [en]
Continuous professional development, clinical reasoning, nurses, primary healthcare settings, healthcare providers, virtual patient, virtual patient cases
Keywords [sv]
Kontinuerlig professionell utveckling, kliniskt resonemang, sjuksköterskor, primärvårdsmiljöer, vårdgivare, virtuella patientfall
National Category
Health Sciences
Research subject
Information Society
Identifiers
URN: urn:nbn:se:su:diva-236697ISBN: 978-91-8107-060-6 (print)ISBN: 978-91-8107-061-3 (electronic)OAI: oai:DiVA.org:su-236697DiVA, id: diva2:1920456
Public defence
2025-02-14, L70, NOD-huset, Borgarfjordsgatan 12 and online via Zoom, public link is available at the department website, Kista, 09:00 (English)
Opponent
Supervisors
Projects
Medical and Health Sciences, Health Sciences
Funder
Sida - Swedish International Development Cooperation Agency, 11277Available from: 2025-01-22 Created: 2024-12-11 Last updated: 2025-01-16Bibliographically approved
List of papers
1. Online learning for continuous professional development of healthcare workers: an exploratory study on perceptions of healthcare managers in Rwanda
Open this publication in new window or tab >>Online learning for continuous professional development of healthcare workers: an exploratory study on perceptions of healthcare managers in Rwanda
Show others...
2022 (English)In: BMC Medical Education, E-ISSN 1472-6920, Vol. 22, article id 851Article in journal (Refereed) Published
Abstract [en]

Due to outbreaks of new diseases, development of new treatment regimens and requirement of evidence-based practice, health professionals continuously need to acquire updated knowledge and skills. This type of learning is known as continuous professional development (CPD). The scarcity of skilled health care professionals in developing countries further increases the need of CPD. Traditionally, face-to-face approach has been preferred as the best mode of CPD. Currently, health professionals have started using online learning for continued professional growth in different parts of the world. Consequently, research studies from different settings are needed to investigate the significance of online learning for CPD. Therefore, the aim of this study was to investigate the importance and challenges attributed to online learning by the managers of health facilities in Rwanda. Moreover, the study aimed to identify the status of infrastructures that could support online CPD, and assess the perceived enhancement and barriers for implementing online CPD.

National Category
Information Systems
Research subject
Computer and Systems Sciences
Identifiers
urn:nbn:se:su:diva-213079 (URN)10.1186/s12909-022-03938-y (DOI)000895903600001 ()36482342 (PubMedID)2-s2.0-85143556617 (Scopus ID)
Available from: 2022-12-19 Created: 2022-12-19 Last updated: 2025-01-08Bibliographically approved
2. Online learning needs, facilitators, and barriers for continuous professional development among nurses, midwives, and physicians in Rwanda
Open this publication in new window or tab >>Online learning needs, facilitators, and barriers for continuous professional development among nurses, midwives, and physicians in Rwanda
Show others...
2023 (English)In: International Journal of Africa Nursing Sciences, E-ISSN 2214-1391, Vol. 18, article id 100574Article in journal (Refereed) Published
Abstract [en]

Background: Continuous professional development (CPD) is necessary for every healthcare professional, but it is even more important in developing countries. In addition to the traditional need for CPD to keep improving the quality of service delivery, in developing countries, some health professionals work in remote areas where they lack the experience of senior colleagues. In this regard, online CPD is among the strategies that can improve the quality of health care services delivery.

Aim: Thus, this study assessed the needs, facilitators, and barriers of using online learning for continuous professional development among nurses, midwives, and physicians in Rwanda.

Design: The study used a cross-sectional study design and a survey to collect quantitative data from physicians, nurses, and midwives on their views about online learning for continuous professional development needs, facilitators, and barriers.

Method: The study used proportionate stratified random sampling strategy to collect quantitative data from 261 participants from 51 health institutions. The major analysis used was descriptive statistics in terms of describing the responses of participants in percentages and frequencies.

Results: The findings indicate that 97.3% of participants consider the importance of CPD, 71.6% prefer blended approach for CPD, and 86.5% use smartphones. About the internet status, 28.0% of participants reported to have fast and stable internet, 57.1% to have fast but not stable internet, and 14.2% reported to have not fast and stable internet.

Conclusion: Nurses, midwives, and physicians perceive online learning as a good source of continuing professional development, but its implementation must depend on improved internet access, compatible technology with smartphones, or increasing the availability of computers and tablets at health institutions.

Keywords
Continuous professional development, Online learning, Sub-Saharan Africa region, Nurses, Midwives, Physicians
National Category
Other Computer and Information Science
Research subject
Computer and Systems Sciences
Identifiers
urn:nbn:se:su:diva-223513 (URN)10.1016/j.ijans.2023.100574 (DOI)2-s2.0-85159267265 (Scopus ID)
Available from: 2023-10-31 Created: 2023-10-31 Last updated: 2025-01-08Bibliographically approved
3. Enhancing clinical reasoning for management of non-communicable diseases: virtual patient cases as a learning strategy for nurses in primary healthcare centers: a pre-post study design
Open this publication in new window or tab >>Enhancing clinical reasoning for management of non-communicable diseases: virtual patient cases as a learning strategy for nurses in primary healthcare centers: a pre-post study design
2024 (English)In: BMC Medical Education, E-ISSN 1472-6920, Vol. 24, article id 441Article in journal (Refereed) Published
Abstract [en]

Background In Rwanda, nurses manage all primary care at health centres, and therefore are their clinical reasoning skills important. In this study, a web-based software that allows the creation of virtual patient cases (VP cases) has been used for studying the possibility of using VP cases for the continuous professional development of nurses in primary health care in Rwanda. Previous studies in pre-service education have linked VP cases with the enhancement of clinical reasoning, a critical competence for nurses. This study investigated the feasibility of continuous professional development through VP cases to further train in-service nurses in clinical reasoning.

Method The study used a pre-post test design. Initially, seventy-six participants completed a questionnaire as part of the pre-test phase, subsequently invited to engage with all four VP cases, and finally responded to the post-test questionnaire evaluating clinical reasoning skills. Fifty-six participants successfully completed the entire study process and were considered in the analysis. The primary outcomes of this study were evaluated using a paired t-test for the statistical analysis.

Results The results show that the mean score of clinical reasoning increased significantly from the pre-test to the post-test for all four illness areas (p < 0.001). The study findings showed no statistically significant difference in participants’ scores based on demographic factors, including whether they worked in urban or rural areas. 

Conclusion and recommendation Utilizing VP cases appears to significantly enhance the continuous professional development of nurses, fostering a deliberate learning process that enables them to reflect on how they manage cases and, in turn, refine their clinical reasoning skills. This study strongly recommends incorporating VP cases in the continuous professional development of nurses at the primary health level (health centers). This is especially pertinent in a context where nurses are required to perform diagnostic processes similar to those employed by physicians.

Keywords
Virtual patient cases, Virtual case system, Continuous professional development, Nurses, Health care providers, Primary health care, Assessment, Clinical reasoning, Pre-posttest
National Category
Nursing Learning
Identifiers
urn:nbn:se:su:diva-228956 (URN)10.1186/s12909-024-05440-z (DOI)001207202300001 ()38654323 (PubMedID)2-s2.0-85191042768 (Scopus ID)
Available from: 2024-05-14 Created: 2024-05-14 Last updated: 2025-01-08Bibliographically approved
4. Acceptance of virtual patients as a continuous professional development approach among practicing nurses in primary health care settings in a low-income country: a quasi-experimental posttest setup design
Open this publication in new window or tab >>Acceptance of virtual patients as a continuous professional development approach among practicing nurses in primary health care settings in a low-income country: a quasi-experimental posttest setup design
2024 (English)In: BMC Nursing, E-ISSN 1472-6955, Vol. 23, article id 332Article in journal (Refereed) Published
Abstract [en]

Background Virtual patients are an educational technological approach used in healthcare education. Its distinctive features have rendered virtual patient technology appealing for the training of medical and healthcare students, particularly in the enhancement of clinical reasoning. Virtual patients are less often applied for continuous professional development for practicing healthcare providers, and there is a scarcity of studies exploring this possibility. This study aimed to assess the acceptability of nurses for using virtual patients as a continuous professional development approach.

Method The study used a quasi-experimental posttest setup design. The study was conducted in ten primary healthcare settings in Rwanda. Among 76 nurses who consented to participate in the study, 56 completed the intervention and responded to the study questionnaire. Following a one-week program of continuous professional development on four non-communicable diseases, the study used a self-administered questionnaire based on the Technology Acceptance Model 3 to collect data. Descriptive analysis served as the primary method for analyzing participants’ responses. The study also used a correlation test to assess the relationship of variables.

Results Across all items in the questionnaire, the median response tended towards either agree or strongly agree, with only a minority number of participants expressing strong disagreement, disagreement, or neutrality. The results indicated a significant positive correlation between perceived usefulness and behavior intention (p < 0.001).

Conclusion The findings indicate an acceptability and behavioral intention of adopting virtual patients as an alternative continuous professional development approach among nurses working at health centers in Rwanda or other locations with similar contexts.

Keywords
Virtual patient, Healthcare education, Continuous professional development, Continuing nursing education, Nurses, Primary healthcare settings, Low-income countries
National Category
Nursing Pedagogy
Identifiers
urn:nbn:se:su:diva-232395 (URN)10.1186/s12912-024-02000-0 (DOI)001227182200003 ()38755655 (PubMedID)2-s2.0-85193502854 (Scopus ID)
Available from: 2024-08-16 Created: 2024-08-16 Last updated: 2025-01-08Bibliographically approved
5. Exploring the Benefits of Virtual Patient Cases During Continuous Professional Development (CPD) of Registered Nurses: A Qualitative Study in Primary Healthcare Settings in Rwanda
Open this publication in new window or tab >>Exploring the Benefits of Virtual Patient Cases During Continuous Professional Development (CPD) of Registered Nurses: A Qualitative Study in Primary Healthcare Settings in Rwanda
(English)In: Article, review/survey (Other academic) Submitted
Abstract [en]

Background: Virtual Patients (VPs) are interactive computer simulations replicating real-life clinical scenarios. While primarily utilized in training healthcare students, VPs have also shown potential in improving the clinical reasoning skills of in-service healthcare providers like nurses in primary healthcare settings. However, there is limited research on the benefits of VP cases during continuous professional development (CPD).

Aim: This study aimed to explore the perceptions of registered nurses regarding the possible benefits of VP cases for CPD in primary healthcare settings, specifically at health centers in Rwanda. 

Methods: The study employed a qualitative interpretive description design. The study used a simple random sampling to select fifteen nurses from six different health centers. The sample was purposively selected from a group of nurses who had previously participated in a study using four virtual patient cases as continuous professional development exercises over a one-week period. The participants took part in individual in-depth and focus group interviews. The study employed inductive thematic analysis as its chosen method of analysis. 

Results: The results indicate that the nurses perceived pedagogical and professional benefits of using VP cases for CPD, which are categorized into three themes: 1. Perceived benefits of virtual patient cases as a pedagogical method in continuous professional development, and 2. Perceived professional benefits of virtual patient cases in continuous professional development. The results also revealed a miscellaneous third theme identifying 3. potential challenges for using VP cases for CPD. 

Conclusion: VP cases seem to be beneficial for the CPD of practicing nurses. The participants in this study acknowledge that engaging with VP cases allowed them to learn by reflecting on their daily practice, self-assessing when comparing their decisions with those of experts in VP cases, and preparing them for uncommon cases. They also reported that VP cases are user-friendly, motivate learning, and provide a safe learning environment and are thus useful for CPD. 

Keywords
Continuous professional development, nurses, primary healthcare settings, healthcare providers, virtual patient, virtual patient cases
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:su:diva-237588 (URN)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2025-01-08 Created: 2025-01-08 Last updated: 2025-01-08

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