Participants’ flow chart and characteristics
The participant flow chart of completers (n=27) and non-completers (n=22) is presented in Figure 4.
<Insert Figure 4 about here>
Figure 4. Flow chart of the completers and non-completers
Legend *: The student-researcher and most of the participants kept in touch via e-mail during the research period. Reminders were sent to participants to invite them to complete the VP simulation. During asynchronous e-mail communications, some participants indicated the reasons for not completing the study.
Most of the completers held a bachelor’s degree. They had been working as nurses for an average of 18 years. Eighteen nurses (66.67%) had experience as HIV nurses. Eight nurses (30%) had previous MI training. Majority of participants (25/27, 93%) reported being confident in their computer skills.
From these 27 completers, five nurses took part in the qualitative component: two men and three women. They worked with different clienteles, including people living with HIV (PLHIV). Four nurses were trained in MI. Additional completers and non-completers’ characteristics are presented in Table 3.
<Insert Table 3 about here>
All participants’ recruitment strategies
Participants were recruited in person (28/49, 57.14%), i.e. by being informed by a colleague or by the student-researcher; by e-mails sent by the Quebec order of nurses (11/49, 20%) and the HIV mentoring program (10/49, 20%).
Quantitative findings of completers
The detailed quantitative findings are presented in the additional files: the simulation design elements (Additional file 7), the global system quality and technology acceptance (Additional file 8), the role of the simulation (Additional file 9), and the learning objectives achievement (Additional file 10). Highlights are presented in each subsection.
Simulation design elements
A great majority (93%) of participants watched the video content and 78% read the corresponding text on the context of the simulation. Most of the participants (89%) felt that, to understand this context, it was key to have access to both text and video.
All participants agreed that the labels constructively supported their learning. Some 96% found that these cues were key to qualifying the content of the nurse-patient dialogue. All participants agreed that quizzes made them reflect on their nursing practice and they saw themselves in the quiz answers.
Almost all participants (96%) agreed that the feedback was provided in a timely manner (i.e. as the consultation progressed). All participants agreed that the feedback allowed them to make connections between the simulated situations and the theoretical elements of MI.
A majority of participants agreed with the simulation’s fidelity: the patient’s story (96%), the HIV-positive man’s appearance (96%), the nurse-patient interactions (93%), and the nurse’s office (85%) were all perceived as authentic.
Global system quality and technology acceptance
The mean score was rated a 3.65 (±0.48) for the service quality construct among participants who used the VP simulation support services (11/27). The interface design quality (3.54 ±0.55) was the second construct with the highest score of the global system quality dimension, followed by system quality (3.51±0.54) and by information quality (3.49±0.50).
Participants had a good intention to use (3.53±0.60) the VP simulation. Nurses perceived enjoyment (3.47±0.57) and an ease of use (3.42±0.67) with the simulation. The lowest mean score of the technology acceptance dimension was the perceived usefulness (3.35±0.71), which is, above all, highly acceptable.
The role of simulation in supporting nurses’ professional practice
The items with the highest scores were: simulation led nurses to reflect on their practice in general, not just with PLHIV (3.58±0.58); the content will lead nurses to improve their communication skills with clienteles other than PLHIV (3.50±0.51), the health of PLHIV (3.50±0.51), and the quality of therapeutic relationships with PLHIV (3.50±0.51).
Achievement of learning objectives
Scores on the achievement of objectives ranged from 3.35 to 3.58, indicating a favourable assessment by participants. These two learning objectives had the highest scores: identification of traps within nursing interventions that can shut down communication with the patient (3.58±0.50), and those that can optimize openness to the patient’s experience (3.54±0.51).
Four main themes are presented: 1) Motivations to engage in the simulation-based research; 2) Learning in a realistic, immersive, and non-judgmental environment; 3) Perceived utility of the simulation; and, 4) Perceived difficulty in engaging in the simulation-based research.
Motivations to engage in the simulation-based research
Participants identified several reasons for taking part in the simulation-based research. First, the simulation offered accreditation and was free of charge, which were appealing incentives. Second, nurses reported that their interest and curiosity had been stirred by the learning modality, which was perceived as innovative, stimulating, and interactive, and by the way MI could be transposed into technology:
I was curious to see this new training modality because I have already followed MI training, and sometimes we’d practice with a coworker. I was curious to see how far we could get with the simulation. (Female nurse-manager)
Nurses perceived that the simulation could be applicable and coherent in their own practice with different clienteles (e.g. youth, people with hepatitis C), and, more broadly, to a variety of contexts:
[The simulation] was addressing the issue of adherence to HIV treatment and I felt that [the topic] fit in well with my practice. (Male assistant head nurse)
I thought [the simulation] was something that was interesting and not just about HIV [...] it was something that could be transferred to other areas of activity. (Female school nurse)
Finally, the desire to learn new knowledge or strengthen existing knowledge about MI and HIV were factors motivating nurses’ participation.
I found it important to do this training to learn things about HIV but also about motivational interviewing, which we do daily, enormously, at our office. (Female school nurse)
Learning in a realistic, immersive, and non-judgmental environment
Two nurses who were experienced in providing HIV care reported the VP’s story to be an uncommon one for non-adherence, but felt that it was nonetheless credible and realistic. What they felt to be most important was the nurse-patient interaction, which allowed to immerse themselves in the simulation:
Maybe this is because I’ve done a lot of work around the issue of taking antiretroviral treatment, so I found the [VP’s] situation ... maybe less typical... At the same time, I realized that it was not necessarily very important. Eventually, you forget about the situation, you know, because [the learning activity] is more about how to react to interactions with the patient [...] I was more focused on what he was saying than the image. I think it’s a really strong point of [the learning activity] that we got really into it. (Female nurse-researcher)
One nurse’s first impression was the VP’s resemblance to a puppet, which lead him to wonder about the seriousness of the learning activity. The patient’s appearance could have caused this participant to lose interest in the learning experience, but eventually this image of the VP gave way to a more human and realistic impression:
At first, I thought [the VP] looked like a puppet [...] I kind of wondered if [the simulation] was for real. I don’t really want to question its seriousness… Beyond the caricature, I could see the patient asking himself questions; he was squinting a little. Human beings do that. They’re not puppets [...] And as I went along doing the interview, I saw there was communication between the nurse and the patient. And [my impression] faded away. (Male nurse case-manager)
Two participants compared the simulation to physical presence-based group learning, where MI must be practiced through role-playing with a coworker. The simulation was seen as an advantageous way to reproduce a real interaction with a VP, reducing the discomfort and bias of practicing with someone, and fostering the learning progress:
In classic training activities, we practice with a coworker. I find that quite biased because we’ve both just learned the theory; we try to apply it; the other person has just learned the same thing so, in the end, well, we help each other only a little bit. But here, we were faced with a virtual character who is very realistic. I find it even more real than with, shall we say, another trainee. But for people who are shy in groups, [the simulation] is really very accessible and allows them to progress. (Male assistant head nurse)
Compared to group training activities, the simulation provides freedom while targeting individual learning and performance:
I think that doing it one by one, well, alone, allows something that is not necessarily possible in a group training activity. It’s even more in-tune with what you would actually do. There is no judgment. There are no right or wrong answers. [The simulation] allows you to answer more freely. (Female nurse-researcher)
Finally, this participant summed up her experience: “I feel like I got real practice.” (Female school nurse).
Perceived utility of the virtual patient simulation
We identified three sub-themes as part of this theme: developing reflective learning and transferring it to practice, being present and revisiting relational skills, and acquiring and consolidating motivational interviewing knowledge and skills.
Developing reflective learning and transferring it to practice
All the nurses mentioned the simulation’s capacity to promote mistake-based learning through quizzes and feedback loops:
It was fun because it’s like action/reaction. It was immediately obvious if you asked the question wrong, you could see the effect. I found it interesting because if you took a wrong action, you could get back on track. That way, we could understand why it was a mistake. (Female nurse-manager)
This participant, who did the entire virtual simulation twice, reported a progression of his learning, building on the mistakes he had made:
The first time, I made a lot of mistakes because I told myself that I was going to go with my knowledge and experience. The second time, I did it with my new knowledge. It gives you parallel vantage point onto yourself, onto your own beliefs. (Male nurse case-manager)
The simulation thus allowed participants to reflect and take a critical look at themselves and their practice, becoming aware of past mistakes and the impact of their interventions on their relationship and interactions with patients:
You’re never neutral in a MI. Yes, you’re the care provider, but you’re a person. It can set certain limits or can even make you get stuck in it. [The simulation] makes you aware of who you are through all this. (Male nurse case-manager).
Look, if patients don’t react or aren’t motivated, well, maybe it’s because I too am playing a part as the care provider: maybe I am not addressing them in the right way, maybe I am not considering them in their entirety, according to their beliefs and values. (Female nurse-manager)
The interactivity inherent to the simulation supports this reflexive process, which in turn can lead to transferring learning to real practice, and thus improve it:
When you’re one-on-one [with a young person], sometimes you’ll answer off the cuff because you’re in a hurry. If you’ve practiced [the situation] in simulation, you’re going to know that whatever you said was not so great, you know, you’re going to question yourself. So, you’re going to be more careful when a similar situation occurs in reality [...] I’m going to try saying it differently to help the person get a little further. It makes you better. (Female school nurse)
This participant questioned his past interventions, in which he hastily presumed the cause of non-adherence (e.g. relapse, substance abuse) when interacting with his clientele. After participating in the simulation, this nurse stated his intention of changing his way of intervening so that he better understands the patient’s situation, before drawing conclusions:
Do I go too fast sometimes? Telling myself that, well, he didn’t take it [his treatment], that he must have relapsed, always jumping to my conclusions first. Don’t I miss things sometimes, too? I was thinking that maybe now I will be more careful and try to understand the patient’s reasons and stop just saying ‘Ah, well, he didn’t take it.’ (Male assistant head nurse)
Being present and revisiting relational skills
The simulation helped to underscore the importance of listening to patients. This meant being present, available during the consultation and living in the “here and now”:
It helps nurses understand or realize that it’s important to listen, to be there in the here and now. More and more, we have our electronic medical records, we write in the record and don’t even look at the patient. We no longer take the time to actually look at the patient because we are so busy on our computer... It’s really worth it to sit down and look at the patient and just be present with them. (Female nurse-manager)
The simulation had a positive influence on revisiting ways of communicating and asking patients the right questions to support them in reflecting and identifying their own solutions:
I’d say it’s more in the way the questions are asked. It’s really focused on open-ended questions, and solutions that come from the patient. We [nurses] may have solutions, but they have to come from them [the patients], and that’s when they are most effective [...] How can we ask questions that bring out the best in the patient? (Male nurse case-manager)
The simulation alerted the nurses and raised their awareness of how they relate to patients, creating optimal conditions for successful relational practice and mobilizing communication skills that allow patients to express themselves and, especially, to find their own solutions.
Acquiring and consolidating motivational interviewing knowledge and skills
One participant with no prior MI training considered the simulation to be an effective and efficient way to achieve intensive learning:
I’d read a little about MI, but I’d never done any training. I didn’t expect to learn so much in such a short time. (Female nurse-researcher)
Moreover, for another participant, who had received training in MI and who does not practice directly with patients, the key lays in putting theoretical elements into action with the VP. Consequently, the simulation-facilitated practice helped reinforce her knowledge and feelings of competence in applying MI:
I had already had some MI training. [The simulation] reassured me a bit that, actually, I was competent and that I would have been good, face-to-face, with a patient. So, it just confirmed this for me. Because there’s always a doubt about MI being this huge thing. But in the end, you know, we just lack practice. And I found that the platform meant that I was able to strengthen my nursing practice and my past theoretical learning, since I don’t see patients every day. (Female nurse-manager)
For the other three participants who had previous MI training, the simulation helped them better understand the theory and refresh their knowledge, as well as learn how to better apply it. Simulation as a learning modality thus seemed to benefit nurses with various levels of MI training and knowledge.
Perceived difficulty in engaging in the simulation-based research
We asked participants in the focus group to reflect on the difficulties they experienced in completing the study, or those they heard their coworkers mention. Technical difficulties were noted as one of the main potential explanations of some participants’ withdrawal, either because of the complexity of creating an account, the delay between the characters’ words and movements, or the system’s slowness. Individual perseverance became important in this context:
I’m not saying the work flow was slow... but maybe that’s why some people didn’t finish the training activity. I’m not saying it was repetitive, but maybe if they feel it was too slow... When the patient talks, he moves his arms around, and sometimes there was a little delay. This was maybe a feeling I had, since I was persistent at first. (Female nurse-manager)
One participant did not like the simulation’s lack of progress indicators, which she felt might also have discouraged others. Individual and time-related elements were another hypothesis for some participants’ withdrawal:
Perhaps a lack of time or a drop in motivation along the way. When I start something, I like to finish it. So maybe it’s question of personality, too. (Female school nurse)
Integration of quantitative and qualitative findings into mixed method interpretations
Four mixed method interpretation findings describe how the VP simulation quality and element designs contributed to nurses’ learning experience (see the joint display in Additional file 3 for further detail).
Influence of the simulation’s fidelity on nurses’ impression of getting a real practice and of having an immersive learning experience
While various simulation design elements were assessed quantitatively as being realistic, the qualitative results provide insight into how fidelity contributed to nurses’ immersion in their learning experience, among other gains. The quantitative and qualitative results are therefore complementary. Participants were able to overcome the VP’s appearance and become immersed in the scenario to focus on the nurse-patient interactions. They also felt the simulation gave them an opportunity for real practice.
Simulation’s perceived flexibility, efficacy, and control over one’s learning led to a positive learning experience
As described in Additional file 8, global system quality and technology acceptance were rated with high scores. VP simulation offers flexibility for when and where learning occurs, it gives users control over their learning, and it was generally perceived as more effective than other types of training. These aspects all positively influenced participants’ learning experience. The qualitative findings supported the quantitative results. All participants in the focus group appreciated being able to use the simulation during or outside of work hours and even from home. The flexibility of the learning modality allowed them to consult the simulation more than once. Compared to face-to-face training that requires trainees to practice with a colleague, the simulation gave them practice with the VP that was both more realistic and less intimidating. This modality therefore allows users to express a sincere response, without fear of making a mistake in front of a group. Simulation also facilitates the evaluation of individual knowledge and performance, rather than collective ones.
Taping self-awareness and reflection in relational practice
The quantitative results indicate that the high scores in favour of the role of simulation, quizzes, and feedback prompted the participants to reflect on their nursing practice, make connections between theory and practice, learn from mistakes, and raise their awareness of elements that can facilitate or hinder therapeutic relationships with patients. The qualitative results also enriched the quantitative results when nurses gave concrete examples of their own communication styles that had been less effective in the past (e.g. leading the consultation, making recommendations to the patient without asking permission, jumping to conclusions too quickly) and that could be improved. The nurses said that practicing with the VP and getting synchronous feedback that mirrors their actual practice would help them avoid replicating ineffective patterns. The simulation therefore contributed to educating and raising awareness of self, as nurse, and of others (i.e. patients), and underscored the importance of nurses’ presence, open-mindedness, availability, and good listening.
Acquiring new knowledge and building self-confidence
By assessing the role of simulation in supporting nursing practice, participants reported having learned something new. They also expressed having built self-confidence. Indeed, they felt capable of applying communication skills and of facing similar situations with PLHIV and other clienteles in the future. The qualitative results reinforce these findings, reflecting the simulation’s influence on nurses feeling better prepared and equipped to apply MI with their clienteles, to consolidate their practice, and thus to reinforce their sense of confidence and competence.