Research Design
A mixed-methods approach was used during the three-phase study, combining both quantitative and qualitative techniques and instruments. Phase 1 is characterized by the designing of a Palliative Care Stay Room (Intervention), Phase 2 corresponds to its testing, and Phase 3 its evaluation. Participatory Action Research (PAR) using the Design Thinking (DT) approach and adopting the Public Engagement in Responsible Research and Innovation (PE-RRI) strategy was the methodology adopted for this study.
Justification of research methodology
PAR is comprehended as progressive research, consisting of cyclical steps: i) planning, ii) action, iii) observation, and iv) results, involving the participants since the beginning. It is considered the preferred methodology in educational science that, in a practical way, develops and tests measurable solutions to a specific problem and context. We choose this method as it is focused on generating change, promoting knowledge and applicable results, and reflecting systematically on the action and the problem studied (19). In addition, we used Design Thinking methodology as it works on human-centred problem solving, enhancing creativity and innovation of final products (solutions/interventions). This methodological procedure also uses cyclical steps described as: i) empathy, ii) definition, iii) ideation, iv) prototyping, and v) testing. In education, Design Thinking was first applied in design schools where students from different faculties and disciplines integrated interdisciplinary projects, working together to find disruptive solutions (20). As part of the PE-RRI strategy we involved the subjects of the study in the research team, as involvement increases the quality and validation of the research findings and promotes the enhancement of knowledge between researchers and beneficiaries (21). Two students (taking degrees in nursing and education) were integrated from the beginning in research design, together with five researchers (four experts in Palliative Care and one statistician), three university professors (from education, communication, and public administration), and one expert in Design Thinking.
Participants
For the phase 1 of this study (Palliative Care Stay Room Design), researchers, university professors and students of the UniversityName were invited by email to design the palliative care stay room. These people were from different areas and they were already involved in the EnPositive-PAL project, in which they had already collaborated on two studies: one focused on the perception of university students of palliative care (4) and the other, which aimed to find an innovative strategy among the university community to promote palliative care (2).
For the phase 2 and 3 (Palliative Care Stay Room Test and Evaluation), undergraduate students of Universityname taking clinical and non-clinical degrees, up to 23 years old, able to understand the Spanish language, were invited by social media and the university newsletter to sign up for a gamified experience called Stay Room, advertised as follows: “Dare to stay in the room –Come and play on caring for vulnerable people and their environment with a maximum duration of 60 min”.
Study context
This study was carried out at the UNIVERISTYNAME in Spain. UNIVERSITYNAME is a Christian-inspired non-profit institution with teaching, research, and healthcare resources. The University has seven different campuses in Spain, 16 schools, 38 undergraduate degrees with about 8,705 undergraduate students from 109 nationalities. The Universityname 2021-2025 strategy adopted sustainable development, care for people (where we can find Palliative Medicine), and the environment as the keystones of the university projects.
Procedures
Phase 1 – Designing the Palliative Care Stay Room
Six people designed the Palliative Care Stay Room [four experts in Palliative Care (CR), Communication (BG), Design Thinking (SH), Pedagogy (SR) and two students taking Nursing (DL) and Pedagogy (BV) degrees]. Described as similar to an Escape Room – a game in which players discover clues, solve puzzles and carry out tasks inside a room, with the aim of escaping as quickly as possible to move on to the next phase – the aim of our game was not to escape from the room but to challenge players to stay to experience, explore and resolve enigmas together with the game master (who leads the game – a young patient). The design was co-created during six work sessions made during one month. Literature on gamification, communication and palliative care, clinical case studies, brainstorming, brainwriting, visual thinking and storytelling were resources used as a methodological basis to design the Palliative Care Stay Room. The Phase 1 design was built in three steps: 1) Theme and storyline, 2) Game ground-rules, and 3) Practical issues. Table I summarizes which aspects were discussed in each step, and the supplement material of this paper includes the full script of the game.
(Insert Table 2 here)
Phase 2 – Testing the Palliative Care Stay Room
A week before the start of the Palliative Care Stay Room, four students were invited to test the game to detect any flaws. Their feedback was essential to improving the logistics and procedures and to facilitating harmony between the game and the learning experience itself. On the day and time scheduled, each group of students went to the Medical Simulation Centre of Universityname and were received by a researcher who ensured that the consent form was properly filled out. A brief explanation of the game was given in Room 1 (Reception) without mentioning that it was an experience related to Palliative Care. In total, there were five prepared Rooms, and the aim was that undergraduate students could find messages and solve enigmas based on the story of Ricardo, a fictitious patient and the master of the game, who audio-guided them through the circuit. The goal was to meet Ricardo’s needs and fill his life with life (#LlenadeVidaTuVida, the hashtag used for the game).
Phase 3 – Evaluating the Palliative Care Stay Room
When students registered themselves through a link or QR code, they automatically received the following information: “1. Welcome! Gather a group of four Universityname students and assign a group name. 2. Select a day and time to play. 3. Agree to fill out a survey on empathy before and after the game. 4. Share your experience. 5. This game is free of charge and the participants will receive an Amazon voucher worth €10”. The participants were also informed that they needed to contribute their impressions of the learning experience in a 10´ videotaped debriefing at the end of the game.
The registration on the Google form recorded the consent of the participants. Before starting the Stay Room, students filled out the Cognitive and Affective Empathy Test – Spanish version (TECA: Test de Empatía Cognitiva y Afectiva) (López-Pérez, B.; et al., 2008), a global measure of empathy containing 33 items. This self-report measure presents a four-factor structure: i) Perspective Adoption (PA), referring to the intellectual or imaginative capacity to step into somebody else’s shoes (8 items); ii) Emotional Understanding (EU), related to the capacity to recognize and understand the emotional states, intentions and impressions of others (9 items); iii) Empathic Stress (ES) or the ability to share other the negative emotions of others (8 items); and iv) Empathic Joy (EJ), which refers to the ability to share the positive emotions of others. The same scale was sent to the participants by email 48 hours after the game ended. The researchers registered the field notes using direct observation, seeing the interaction of the participants during the game through surveillance cameras and one-way mirrors. In the last Room the participants were invited to leave their reflections in writing. A meeting to share the experience (brief videotape debriefing) was also promoted in each group of participants, and a short online satisfaction survey was given to participants to ascertain the acceptability of the Stay Room, identifying potentials and areas for improvement (Figure 1).
(Insert Figure 1 here)
Analysis
Quantitative data analysis
In a preliminary way, the reliability of the factor measurements was evaluated by calculating TECA Cronbach statistics, where Alpha values of 0.6 for PA, 0.7 for EU, 0.7 for ES, and 0.7 for EJ were obtained. In general, the skewness and kurtosis values had absolute values lower than the two units (Lloret-Segura, et al., 2014), except for three items of the EJ dimension (2, 4 and 19) and for one item of PA (25). Given this problem of normality of the data, the scores of the dimensions were calculated by estimating a SEM model through the robust two-stage method (SAS, 2013), before and after the intervention. For the subsequent analyses, the difference between the scores of the different dimensions of empathy after the intervention minus the previous values was taken as the response variable to the calculation; this difference was called gain. Initially, the gain was evaluated for the factors of age and sex through uncorrected t-tests. This variable was then evaluated under an analysis of covariance model, in which the gain was presented as a function of the scores of each of the respective scores before the intervention and the factors of sex and age group. For the age group, the respondents were classified into two groups: younger than 20 years, and equal to or older than 20 years. The covariance model was evaluated for the normal distribution of residuals using the Shapiro-Wilk test. The software used was SAS 9.4.
Qualitative data analysis
The Palliative Care Stay Room was analysed using the materials produced in the game, the experience of the participants, direct observation, and field notes. In Design Thinking, the analysis of the results happens systematically (Walker et al., 2019). All materials resulting from the action (e.g., post-its, drawings, diagrams) were organised into idea blocks and discussed directly within the research group. This phase of direct analysis and synthesis aimed, in a constant and participatory way, to analyse what was being felt in each group of participants. Subsequently, an affinity analysis of the materials (a predictive analysis technique that aims to build correlations between data and interpret them based on their occurrence among participants), was carried out. From here, preliminary categories and themes were found. The transcriptions of seven participant group debriefings (n=24 students), field notes of the research group and direct observation records were inductively and independently analysed by three independent experts in PC, qualitative analysis, and ethnography (AC, AS, CR). A descriptive analysis was made based on three questions: 1. Has the stay room promoted positive attitudes in students? 2. What were the main take home participants' messages? 3. How did participants evaluate the game? Constant conversations and discussions on the findings were made to reach a final agreement. The final analysis was discussed with other people of the research group (BG, SH, SR, GR) experts in public management, narrative journalism, linguistic, design thinking and medicine, noting differences, and with one student of pedagogy (B), part of the research team since the beginning of the study.