Experienced Based Codesign (EBCD) is a form of participatory action research that involves healthcare professionals and patients/members of the public working collaboratively to develop practical service improvements and patient care improvements in healthcare [18]. It is a multistage process that involves exploring and sharing subjective experiences (narrative-based approach) to enhance the skills and knowledge of healthcare professionals and organisations [19]. In this research project, the team adapted an EBCD process to provide a systematic way to identify and prioritise real-world problems experienced by SPP in a nursing preceptorship to inform the co design and co-production of a new preceptorship educational programme.
The EBCD process facilitated the involvement of all three members of the preceptorship relationship (SPP) in conjunction with Clinical Placement Coordinators (CPCs) (end-users; facilitators of the new educational programme), design experts, nursing experts, educational experts, and researchers at every stage of the design process from problem diagnosis to the design and development of this educational programme and its future implementation. The experiential knowledge SPP brings is essential to helping educators acknowledge multiple realities and meanings of nursing preceptorship relationships. It may also identify aspects of the professional relationship that are poorly understood. The codesign workshopsemployed a design thinking approach, a "human-centric" approach that involves the collaborative generation of ideas, defining and refining issues identified by the SPP. Resulting in iterated and generated solutions through brainstorming and prototype building [41].
Throughout the EBCD process, the researchers ensured authentic involvement from all members of the codesign team by implementing Knowles et al.'s framework [20] for authentic co-production. This involved providing a "space to talk", a "space to change", and a "space to talk" again, creating space for shared dialogue and decision making while offering a supportive and friendly environment throughout the project. The project ran for 16 months, commencing in January 2021. Due to Covid-19 government restrictions, the researchers hosted codesign workshops virtually; the codesign and co-production comprised the following steps (See Table 1).
Step 1: Recruitment of Co Designers
For the first phase of recruitment of the co design team, this study adopted a purposive sampling approach to choosing a cross-section of the population that represents "typical" members of a nursing preceptorship relationship (SPP). SPP were recruited to participate in one-to-one interviews and co design workshops. Students undertaking a Bachelor of Science (BSc) General nursing degree programme and qualified nurses who held the position of preceptors, were invited to participate via email through a gatekeeper (a senior administrator from the university programme office). Members of the public were recruited through several methods, including social media advertising posts, community advisement boards and word of mouth through the wider community.
For the second phase, representation was soughtfrom nursing experts, educational experts and technology-enhanced educational experts to collaborate with the SPP groups to inform the design and development of the educational programme in a series of co design workshops. These were chosen based on their expert knowledge in pedagogical design, universal design, storytelling, simulation, and virtual reality and they joined the team as the codesign process evolved. They were invited to participate via email directly by the lead researcher.
All interested participants received an information leaflet by email from the lead researcher describing the nature and purpose of the proposed project, how the project would operate and what level of involvement would be required, to ensure an informed decision about joining the project could be made. They were informed that participation was voluntary, with a right to withdraw from the project at any point without consequences. A two-week period between receipt of the email and obtaining written digital consent occurred. After receiving consent, a short video presentation outlining the practical organisation of the study, the proposed flow of the design workshops, and the goals, tasks, and roles was sent by the lead researcher by email to each co-designer prior to the first codesign workshop.
Twenty-six co-designers were recruited (listed in the acknowledgements section). A small sample size of approximately five participants were present per workshop , in line with expert opinion for effective EBCD workshops[43]. Table 2 outlines the diverse sample achieved and the participant demographics. Ethics approval for this study was granted by the University Human Research Ethics Committee.
Step 2: Capturing narrative experiences.
Narrative interviewing is a method employed to allow the participant to narrate their experience and have their stories captured [21]. Employing a narrative interview methodology using open-ended questions followed by questions based on the key themes identified in a recent scoping review [14], the researcher aimed to capture the experiences and perspectives of being involved in the interpersonal dynamics of a preceptorship relationship from students, preceptors, and patients (SPP). A key component of EBCD is to identify touchpoints, important moments with emotional tone, within an individual experience [22]. Touchpoints in this study denote personal or crucial memories that shape experiences of a nursing preceptorship relationship, where students, preceptors, and patients connect or disconnect.
Semi-structured in-depth interviews were carried out individually with each participant and independently of the group they belonged to (i.e., SP or P) as recommended [19], via teleconferencing, video call or telephone. Each interview lasted between 1-1.5hr. The interview was divided into two parts; the first used a series of open-ended questions exploring their individual experiences and he second part used a series of questions based on key themes from the literature. Participants were provided with the open-ended questions before the interview via email, e.g., "have there been any key moments that you feel have shaped your experiences of being involved in a nursing preceptorship, either positively or negatively"? They were informed that there would be further questions based on major themes from the literature, including the themes of First Impressions (of an occasion of preceptorship), of Workplace Incivility (if experienced) and the theme of Feedback (their experience and or observations). A typical question posed was "Have you ever observed a nurse giving student feedback? How did you feel at the time"? The researchers withheld the second set of questions until they had finished the open-ended questions as they did not want to influence the participants' responses to the earlier questions (See supplemental information 1 for a complete list of questions and key themes).
Step 3: Thematic Analysis
Thematic analysis is a method for identifying, analysing, organising, describing, and reporting themes within a data set. A dualistic inductive and deductive thematic analysis technique using Braun and Clarke's six-phase framework was applied [23].
Each semi-structured interview (n=15) was transcribed verbatim by a transcription software package (www.happyscribe.com). The lead author immersed himself in the data through repeated listening and reading of the audio transcripts. Data was manually colour coded; semantic codes (explicitly expressed meaning) generated themes from the data. An inductive thematic analysis (bottom-up approach) was carried out on the data gathered from the open-ended questions regarding SPP touchpoints to conceptualise both positive and negative themes that influence nursing preceptorship relationships without fitting them into pre-existing themes from the literature or the researchers' analytic preconceptions. Using supporting quotations, themes were categorised into major positive and negative "touchpoints". The prevalence of a theme was counted in terms of the number of speakers who articulated the theme.
Secondly, a deductive thematic analysis applying a top-down approach to identify key topics the SPP wished to include in the new educational programme was carried out. Similarly, a deductive thematic analysis of the data gathered from the second set of questions based on key concepts from the literature to identify participants' experiences of these themes was carried out.
Combining these approaches allowed the development of patterns from the unknown parts of a nursing preceptorship that may fall outside the predictive themes of deductive reasoning. However, the lead author noted that when carrying out the interviews, many of the "touchpoints" iterated by SPP spoke to themes previously identified in the literature suggesting universal themes and experiences are prevalent. Similarly, the lead author reflected on his previous experiences as a preceptor and student nurse, recognising similar concepts and experiences in the clinical environment. Data was then lifted from its original context and deidentified for each group of the SPP.
Step 4: SPP individual group codesign workshops.
During this phase, the lead researcher met with each SPP group online, where participants took part in design activities utilising a virtual collaborative whiteboard (Padlet). Before the workshop, the findings from step 3 were sent by email or post to allow sufficient time for participants to review and digest the data gathered prior to the codesign workshop. The workshop began with an "icebreaker exercise" to help the group get to know one another and develop a safe environment for creativity and design thinking mindset [40]. The lead researcher then read aloud the group's touchpoints
The group discussed, organised, and reorganised the touchpoints until a consensus was reached on two critical positive and negative. ones. The most suitable qualitative quotes representing these were chosen encapsulating an accurate account of the group's experiences in a meaningful and valuable way (See Supplemental Information 2). Two members of each cohort agreed to audio record verbatim the original touchpoints identified in the individual interviews. These are known as trigger videos in EBCD, and their aim is to effectively communicate the SPP experiences for the group co design workshops in the next phase. The original audio recordings were not used to maintain the confidentiality of each member's stories.
Secondly, each group presented, discussed, and reached a consensus on two key educational topics and pedagogical approaches for the programme, e.g., feedback and building inclusive relationships using simulation role play. The workshop finished by summarising the key themes to be brought forward to the next round of the codesign process, and one member of each cohort was elected to represent the SPP at the next codesign workshop.
The patient group did not wish to have a group workshop; therefore, the lead researcher adapted and encouraged participation by emailing or posting the thematic analysis results from the one-to-one interviews and spoke with each person individually over the phone. The lead researcher then combined all their ideas and populated their chosen outcomes. These were then emailed or posted to all patients for further review and the opportunity to comment. All group members responded positively with the selected touchpoints and key educational topics/suggested teaching approaches for the new educational programme.
Step 5: SPP joint codesign workshop
The multi-group collaborative design workshop was held virtually with a representative from each SPP cohort present. Each SPP's touchpoints were introduced using audio clips. Participants expressed that this design exercise was beneficial in increasing awareness and understanding of each SPP perspective, particularly aspects of the patient experience invisible to students and preceptors, for example, how a patient can feel if there is tension between a student and preceptor. Next, the lead researcher presented a table summarising the educational topics and pedagogical approaches suggested by each group. Participants discussed several issues with the current preceptorship education programmes, including the lack of focus on practical skills such as teaching methods and feedback skills to be an effective preceptor. Preceptors emphasised that current preceptorship programmes focus primarily on regulatory guidelines and documentation associated with preceptorship. A critical insight from the group discussion was that similar themes arose from all three groups for inclusion in the new programme. These themes included: building inclusive relationships, psychological safety, and feedback. Similarly, active pedagogical approaches that placed the learner at the centre of their learning were suggested by all three groups; examples included online interactive learning resources and role-play simulations.
It was collectively agreed that the new educational programme would adopt an active blended learning approach consisting of a series of online reusable learning objects (RLOs), face to face role-plays and a state-of-the-art virtual reality storytelling experience (Table 2). Two pilot studies previously led by the lead researcher influenced the blended learning programme, having identified that students felt prepared to engage in face-to-face simulation following exposure to RLOs [24]. In addition, his experience of VR storytelling offered the unique ability to provide an immersive storytelling learning experience to supplement learning [25]. A constructivist approach was applied to the new educational programme, believing that active learners in their learning journey create new knowledge from experiences. [26], with Kolb's [27] experiential learning theory principles also guiding the programme's design. In addition, the principles of Universal Design for Learning (UDL), an inclusive approach, were embedded in the programme to ensure that the programme offered all learners, including those with disabilities or required accommodations, providing equal opportunities to learn [28; 42]. Table 4 outlines Kolb's Experiential Learning Theory & UDL principles strategies for the Nursing Preceptorship Programme.
Step 6: Specialists Codesign Workshop
To validate and further develop the programme several nursing, educational, psychological and design specialists were recruited to examine and discuss the project's outcomes to date. An overview of the project, including suggested educational topics and pedagogical approaches, was presented at a virtual workshop, followed by audio presentations of SPP touchpoints. The specialist group discussed and agreed on the proposed outline for the new educational programme, agreeing it would meet its intended outcome to create an authentic learner-centred educational programme for developing interpersonal and communication skills amongst trainee preceptors.
Finally, to improve the effectiveness and uptake of the new educational programme, the expert group suggested that the programme should also be underpinned by behavioural change theory. Identifying the behavioural barriers and enablers to facilitating positive interpersonal relationships would strengthen the likelihood that the new educational programme would act as a catalyst to change practices among established preceptors. Members of the expert group worked with the lead researcher to achieve this. Table 5 outlines the combined approach of behavioural change theory and EBCD and Kurt Lewin's Model of Change Principles and how they were applied to the new educational programme to promote change in preceptorship practice.To conclude the workshop, experts agreed to continue peer-reviewing the new educational content as it was designed and created.
Step 7: Presentation of an outline of the new programme.
Upon completion of the first stage of codesign workshops, all participants and codesign team members were invited to a presentation of the outline of the new educational programme, offering further opportunities to provide input and feedback. An overview of the suggested timeline for the development of the programme was presented, and a collective agreement was made that the lead researcher would send the codesign team bi-monthly updates on the status of the project.
Step 8: Part1: Codesign of RLOs
RLOs are defined as "a digital resource that can be reused to facilitate learning" [30]. It was collectively agreed that a series of RLOs would be created to promote flexible and autonomous learning online to support a proposed half-day face to face simulation. Six RLOs were developed, each addressing a specified learning objective. The six-month process involved the codesign team following a participatory approach based on the ASPIRE framework (Aims, Storyboarding, Population, Implementation, Release, and Evaluation) [31].
Aims: Firstly, the team outlined and agreed on the learning outcomes of each RLO unit, mapping them back to the overall programme outcomes to ensure the RLOs were focused and met the acquired learning objectives of the programme.
Storyboarding: Each RLO was then storyboarded in PowerPoint using a purpose-built instructional design framework created by the lead researcher. Once storyboarded, each RLO unit was peer-reviewed by all codesign team members using the learning object review instrument (LORI) [32], reviewing the overall design, usability, motivation, learning goal alignment, and quality of the content before production began. During this phase, the group agreed on the sequence and structure of the RLOs, how the information would be presented, including SPP touchpoints, multimedia content and images and how learners would be provided with opportunities for self-testing and reflection to achieve the desired learning outcomes.
Population: During this phase, the content for the RLOs was created, including videos, images, voiceovers, and infographic slides. An educational technologist (A.B.) populated all media on an online platform, Articulate 360 (https://articulate.com)). The codesign team members were provided with links for further peer-review, focusing on the representation of the content to ensure it was effective. All co-designers had one final opportunity for comment before the final product was completed. Release and evaluation will be discussed in the coming sections.
Step 8: Part 2:Co Design of Role Play Simulations
Simulation role play will allow learners to practice the theoretical and practical information provided in the RLOs. It facilitates the practice of interpersonal and communication skills in a realistic yet safe learning environment [33]. The lead researcher and an academic with a specialist background in simulation-based education and patient safety led the design of the role-play simulations, which was iteratively peer-reviewed by the remaining co-designers. Applying the International Nursing Association for Clinical Simulation and Learning (INACSL) framework [34], the codesign team considered design criteria such as creating a simulation experience that can achieve measurable objectives, is participant-centred and incorporates a level of fidelity that creates a perception of realism to the simulated scenario. The INACSL framework also guided the inclusion of a structured pre-brief session and a structured debrief session following the role plays. The final outputs were two role-play scenarios simulating fundamental interpersonal interactions in a nursing preceptorship requiring dynamic and practical interpersonal and communication skills. All co-designers had one final opportunity for comment before the final product was completed.
Step 8: Part 3: Codesign of Immersive Virtual Reality Storytelling Experience
In addition to the RLOs and role-play simulations produced, it was decided to develop a new state of the art immersive storytelling experience. This pedagogy combines the emerging world of VR technology with the art form of classical storytelling. During the VR storytelling experience, the learner embodies the role of the patient, feeling the same sensation toward a virtual body within an immersive virtual environment as the biological body in the real world would experience [35]. This will permit trainee preceptors to step into a patient's shoes, experiencing the interpersonal dynamics of a preceptorship relationship from the patient perspective, creating a meaningful and memorable learning experience. It is planned that trainee preceptors will engage with this experience as part of their face-to-face learning, followed by a structured debrief session.
The lead researcher and a member of the codesign team with a specialist background in storytelling and film production led the design of the VR simulation in collaboration with a VR production company [36]. It was also iteratively peer-reviewed by the remaining co-designers applying the INASCL framework [34] (see Table 1).
Narratives collected from the interviews with patients set the foundations for the narrative of the VR storytelling experience. Using critical touchpoints from the narratives and the three-act structure to storytelling (Introduction; rising action; falling action (conclusion)) to structure the storyline, a short 10 mins VR storytelling was scripted, storyboarded and peer-reviewed. Using a state of the art 360 VR camera, the simulation was filmed in a simulated hospital ward environment using actors. All co-designers had one final opportunity for comment before the final product was completed.
Step 9: Celebratory Event
The final step involved a celebratory event, all co-designers (as well as family and friends) were invited to an informal celebration and launch of the new preceptorship education and training programme. The final product was available for all to experience. The lead researcher gave a short talk summarising the project, how it is hoped it will impact nursing education and plans for future research projects investigating the impact of the educational programme on nurses' interpersonal and communication skills. and thanked everyone involved in the project. Co designers expressed they felt they had a meaningful involvement throughout the co design and co production process and were grateful for the opportunity to be involved in the project, particularly the patient co designers who felt it was important their voice was heard and included in the new educational programme.
Step 10: Pilot Study
This blended learning programme will be piloted across several general nursing hospitals in Ireland that run preceptorship programmes in late 2022. Following implementation, the researchers will seek feedback from preceptees to establish possible areas for improvement and the perceived impact on learners' future practice regarding their interpersonal and communication skills and their role as a preceptor.