Ⅰ. Introduction
According to the Organization for Economic Co-operation and Development (OECD) Education 2030 Project, future education should focus on developing “student agency” [1]. A project-based learning technique allows students to automomously gain knowledge and skills using problem-finding processes [2]. Therefore, project-based learning is a preferable method for future student-centeered nursing education. In particular, professionals need a higher social awareness of new diseases to better address unmet medical needs. This can enable a higher quality of medical services, ultimately leading to higher satisfaction with those services [3][4]. Therefore, nursing student education is essential for the improving medical services.
As part of design thinking, service design is a human-centered systematic process used to create services and solve problems with a facilitator through a 4D service design (SD) process [5][6][7]. In recent medical practice, design thinking has been used to solve problems and help better understand patient experiences [8][9]. Therefore, applying SD to nursing education introduces new teaching and learning techniques that enhance students’ creative thinking and empathy [10].
Due According to societal changes and demands for new education paradigms, the need for online-based learning continues to rise in university-level education [11]. Leveraging this online resource requires effective communication between instructors and students, smaller student-centered classes, and facilitators equipped with professional knowledge and communication skills [12]. Instructors benefit from being process experts to facilitating online project-based learning based on effective SD methodology. Therefore, this study aimed to provide facilitation guidelines according to each SD process for instructors in order to promote nursing service improvement education for nursing students.
Ⅱ. Methods
1. Implementing online team projects for PEN-SD
This study was conducted in four session, two weeks each, targeting 72 fourth-grade nursing students. Each of the four sessions included three teams of 6 to 7 students for a total of 18-19 students pre session. Three nursing professors who attended regular conferences led and facilitated the teams. This study aimed to identify patients’ needs and improve nursing services by creating SD methodology strategies and enhancing overall patient experience. The problem-solving methodology, PEN-SD applied the SD approach where “P” refers to patients and all nursing service users, including nurses and medical personnel. The PEN-SD study was conducted online due to COVID-19 pandemic restrictions.
Ethical review and approval were waived because this study aimed to share facilitation tips for the PEN-SD process. The study adhered to the principles of the Declaration of Helsinki. Each participant provided written consent, acknowledged that they could not be identified through the study, and all identifying information was anonymized.
The 4D process steps and guidelines are described in subsequent sections. Specific guidelines and guided questions based on the SD process are also described.
2. Process #0: Orientation and team building
The orientation and team building stage outlined the project’s overall purpose and operation and conducted a team-building session. A video recording of the SD process, implementation method, and explanation of tools was uploaded onto a learning management system (LMS) as pre-learning material. For team building, the students introduced themselves, created team names and established ground rules. They also set up a team meeting schedule, and assigned roles. In addition to regular conferences, student teams frequently interacted online. The professors communicated with their teams through chats, calls, and video conferences to project implementation.
Additionally, participants were informed of their progress at each stage of the project. Results were presented using PowerPoint slides or videos to be discussed over the Zoom platform for video conferencing. Other students were encouraged to ask questions and receive feedback during presentations to promote interactive learning, as reflected in the learning outcomes. Participants were also informed that the evaluation would include team and peer evaluations focusing on the processes and results of the PEN-SD team projects using the professors’ evaluation rubric.
At this stage, students were curious about using the SD tool and interacting with the professors and students in the online learning process. Some teams maintained a neutral attitude due to poor communication between team members, while others actively exchanged opinions during the team-building process. The guidelines for successfully implement Process #0 were as follows.
First, establish a team-building environment. Here, organiaing team share various opinions, and real-time question-and-answer (Q&A) sessions aer held through an online community site that engages professors and students. Second, facilitates the formation off consensus and trust building between team members by guiding them to wards mutually agreed ground rules. Third, agenda item selection should be encouraged early on. Meetings should be review by rotating moderators and reporters separate from the team leader. Fourth, real-time online meetings are planned once or twice a week in advance and Q&A sessions are held. Finally, we explain the detailed manuals for using the SD tool, and present examples. The guide questions for Process #0 were as follows.
Does the professor offer contextual questions and feedback to promote student participation?
Is there immediate communication and feedback based on team learning dynamics between the professor and students and student peers on the team?
Are potential issues and conflicts anticipated during team learning, and are effective solutions provided?
3. Process #1: Discover
The discover stage is where a project begins. It helps students gather ideas and inspiration to identify patient needs. The students produced topics appropriate for service design in the nursing field. Due to the COVID-19 pandemic, clinical practicum opportunities were unavailable. Therefore, the students used earlier clinical practicum experiences as case studies or utilized online videos of patient experiences to generate relevant topics. Once completed, they selected final topics based on their influence and feasibility. Online interviews <Figure 1>, roleplay, and telephonic interviews were conducted instead of on-site observations, shadowing, or on-site interviews. A stakeholder map was drawn to visualize the connections between various stakeholders related to the service. In addition, desk research has identified and explored relevant literature, benchmarking, and related trends.
Students found it difficult to select topics and were sometimes not confident in them. Notably, considerable time was spent empathizing with their subjects, and the students were curious about the number of interviewees and the scope of their desk research. Specifically, they had difficulty incorporating and drawing insights from the data obtained during contextual and empathetic observations and interviews. The guidelines for successfully implementing Process #1 can be divided into several sections.
When selecting a project topic, a specific service experience is targeted by identifying difficulties in the services experienced by the patients. Next, students should set project goals in advance but without specific solutions. Consensus among team members must be achieved based on a decision grid that considers feasibility and influence of the goals. Finally, the status analysis is conducted on objective data, goals, and directions in the project statement. The guide questions for topic selection in Process 1 are as follows:
Were the patients challenges with ther services identified?
What are the undisclosed needs of the patients?
Does my team have sufficient reasons and motivation to continue the project?
In empathizing section, we explain the observation and interview methods that enable teams to empathize with patients from their perspectives. Next, we observed the emotions, thoughts, behaviors, environments, and contexts of the patient’s experience. A list of empathetic questions was composed to elicit more detail on challenges experienced and their causes. Finally, after observations and interviews, we conclude and reflect on potentially undiscovered needs and real problems. The guide questions for empathizing in Process #1 are as follows.
Next, observe emotions, thoughts, behaviors, environments, and contexts of the patient experience and establish a list of empathetic questions to elicit more detailed inconveniences and their causes. Last, conclude and reflect on potentially undiscovered needs and real problems after observations and interviews. The guide questions for empathizing in process #1 are as follows.
Were the contents described from the patient’s perspective rather than the service provider`s?
How do you create a checklist and questions that resonate with observations and interviews?
For the Desk Research section, we conclude and reflect on the status analysis and solutions. Research of relevant literature and journals to find benchmarking examples related to the team’s project is conducted while facilitating continuous research throughout the project. The guide questions for desk research in process #1 are as follows:
What did I discover, and what insights did I gain through desk research?
Where and how can I gather more information or ideas for my team project?
4. Process #2: Define
The define stage identifies the patients’ pain points, needs, and problems with their root causes, including obvious problems obtained from the discover stage data. To this end, the students conducted persona modeling <Figure 2> by creating a persona representing the patients’ patterns. They also visualized the nursing service user experience through a Patient Journey Map (PJM) <Figure 3> that described the patients’ experience over time. How Might We (HMW) questions identify the patients’ core needs to meet the service goal of improving patient experiences, as described in this stage.
At this stage, students had difficulties identifying pain points and needs through persona modeling, setting PJM stages, describing touchpoints, and representing patients’ emotions and behaviors.
Next, we monitored whether the persona modeling described a detailed scenario related to the team project and whether pain points and needs were correctly identified. The guidelines to successfully carry out Process #2 include making connections to real problems by revealing pain points based on the patient’s behaviors and emotions using the PJM. Subsequently, the patients’ language and emotions were fully expressed from ‘patients perspective when drafting the PJM. The guide question for this section was, “were the patient’s emotions and pain points explicitly described, in order, in the PJM?”
5. Process #3: Develop
In the develop stage, team members search for, generate, and verify solutions to the identified problems. The students used several conceptualization techniques to identify various solutions. These included brainstorming, brain-writing, lotus blossom technique, stepping-stone method, and SCAMPER (Substitute, Combine, Adapt/Assimilate, Modify/Magnify/Minify, Put to another use, Eliminate, Reverse/Rearrange). After analyzing and evaluating the ideas, the students designed a prototype of the chosen alternative service concept.
The students found it difficult to develop their initial broad topics and questions while brainstorming, analyzing, evaluating, incorporating various ideas, and implementing their prototypes. The guidelines for successfully conducting Process #3 include supplying various idea generation tools and skills. These enable students to analyze, evaluate, and select solutions from ideas and explain useful brainstorming principles and online methods in detail. The guide questions for Process #3 were as follows:
Am I accepting team member’ suggestions without criticism?
Do we have sufficient brainstorming processes to develop solutions and achieve the project goal?
6. Process #4: Deliver
The deliver stage identifies solutions or prototypes to produce outcomes based on feedback from the subjects, stakeholders, and experts. Students visualized the service concept through storyboards to produce solutions as services. In addition, prototypes made through videos, papers, LEGO, or roleplays were verified and modified based on feedback. Each team shared its processes and results through presentations during the conference.
The students were undecided regarding who should verify their prototype, what should be checked during verification, and what questions should be added. They were also curious about how their prototypes should be implemented. The guidelines for successfully conducting Process #4 include building storyboards or scenarios to propose solutions, monitoring proposed solutions to identify the patient’s pain points and needs properly, and modifying them based on patient feedback. The guide questions for desk research in Process #4 are as follows:
Can prototyping visualization be implemented in the nursing field?
Was the solution modified and corrected by reflecting on feedback to solve the patient’s problems?
Ⅲ. Results
The students developed practical and creative themes to solve patient-centered issues by completing a PEN-SD course according to the suggested guidelines <Table 1>. Using the facilitation tips and guide questions presented in this study, the PEN-SD process was deemed successful based on the students’ responses. Testimonials received after the PEN-SD team project included: “Thanks to the team members, we were able to discover various creative ideas, and by working together, we were able to fill the gap;” “I was able to empathize with the patient and think a lot about their needs;” “The process of solving clinical problems and enhancing services by applying SD was very novel, and through trial and error, we were able to reach the final goal.”
Ⅳ. Discussion
Modern health-profession education should reflect digital transformation and technology trends in higher education. An outcome-based approach must be implemented to promote student creativity and convergence competencies. Using PEN-SD in this study, the online project-based learning method showed its potential as a powerful learning tool. It enabled students to effectively develop collaboration, empathy, and creative problem-solving skills using LMS and Zoom meetings for active learning. A critical factor in the success of the PEN-SD learning project was the professors’ preparation and effort as facilitators, despite the implementation of full-scale online learning. The facilitation tips suggested in this study will help students by providing immediate and applicable feedback on challenges at each stage.
Offering digital collaboration tools and support for user education in each PEN-SD process is essential to stimulate more advanced online project-based learning. Digital collaboration tools can boost project learning efficiency. These tools accelerate progress through rapid communication within the team, mutually checking work assignments and progress, and reducing unnecessary or repetitive tasks. Furthermore, the digitalization of online team project learning processes and outcomes are expected to serve as a starting point for the formation of a digital nursing education platform by recycling, sharing, transforming, and recreating processes and outcomes. Online learning environments also provide advantages such as real-time information sharing and interaction, visualization of learning processes and outcomes, and adopting paperless practices. However, this environment has limitations. These include insufficient offline activities to strengthen teamwork, field observations for patient empathy, and a lack of shadowing and interviewing opportunities. This study also presented guidelines for instructors of project class operations to improve nursing services for prospective nursing students. Therefore, there is a limitation in that it is not connected to the actual improvement of clinical nursing services.
Ⅴ. Conclusions
The suggested guidelines can help instructors effectively lead a PEN-SD process. PEN-SD can be a powerful method for online learning and team projects in health-profession education. This study recommends utilizing a blended team project method that incorporates online and face-to-face learning advantages. Based on the results of this study, many health profession educators can benefit from the PEN-SD method by generating a healthcare workforce that can provide patient-centered health services.
