Virtually Nursing: Emerging Technologies in Nursing Education

Foronda, Cynthia L. PhD, RN, CNE, ANEF; Alfes, Celeste M. DNP, RN; Dev, Parvati PhD; Kleinheksel, A.J. PhD; Nelson, Douglas A. Jr BSE, BS; O'Donnell, John M. DRPH, RN, CRNA; Samosky, Joseph T. PhD

doi: 10.1097/NNE.0000000000000295
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Augmented reality and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective. The aim of this article is to present 6 newly emerged products and systems that may improve nursing education. Technologies may present opportunities to improve teaching efforts, better engage students, and transform nursing education.

Author Affiliations: Assistant Professor (Dr Foronda), Johns Hopkins School of Nursing, Baltimore, Maryland; Associate Professor (Dr Alfes), Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio; President (Dr Dev), Innovation in Learning, Inc, Los Altos Hills, California; Director of Instructional Design (Dr Kleinheksel), Shadow Health, Gainesville, Florida; and Doctoral Student, Simulation & Medical Technology Research and Development Center (Mr Nelson), Professor, School of Nursing (Dr O'Donnell), and Assistant Professor, Swanson School of Engineering (Dr Samosky), University of Pittsburgh, Pennsylvania.

vSim for Nursing was co-developed by Laerdal Medical and Wolters Kluwer Health and based on simulation scenarios written by the National League for Nursing. Cynthia Foronda is a paid consultant for Wolters Kluwer Health. She has served as a member of the CliniSpace Advisory Board. These arrangements have been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. The high-fidelity flight simulator described in this article was developed and funded by Jerry Gregoire of Redbird Flight Simulations and Joe Brown of Hartzell Propeller. Celeste M. Alfes acknowledges Dr Christopher Manacci as founder of the Dorothy Ebersbach Academic Center for Flight Nursing and the individual responsible for conceptualizing and co-directing the project. Dr Alfes does not have any financial disclosures or conflict of interest to report. Parvati Dev is co-founder and President of Innovation in Learning, Inc, developer of CliniSpace. A.J. Kleinheksel is the Director of Instructional Design for Shadow Health. The other authors declare no conflicts of interest.

Correspondence: Dr Foronda, Johns Hopkins School of Nursing, Room 414, 525 North Wolfe St, Baltimore, MD 21205-2110 (cforond1@Jhu.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.nurseeducatoronline.com).

Accepted for publication: May 30, 2016

Published ahead of print: July 21, 2016

Article Outline

Augmented reality (AR) and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective in improving student learning outcomes. Nurse educators may not be aware of the range of technologies that exist for use in the classroom, simulation center, and learner's home for independent study. The aim of this article is to describe several newly emerged technologies that have potential to advance nursing education at various levels from prelicensure to graduate studies.

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Background

Modern simulation can be traced back to Edwin Link who invented a “blue box” flight trainer prototype in the late 1920s that trained pilots after the onset of World War II.1,2 Since the introduction of these physical simulations, virtual worlds have been used to train military and first responder personnel how to respond to a range of disaster incidents.2,3 Virtual simulation also has been adopted into medical education to train physicians in various skills including bronchoscopy, colonoscopy, laparoscopy, and endoscopic procedures, as well as disaster triage.4

In nursing education, Benner and colleagues5 called for a “radical transformation” in nursing education. In light of the findings from the Carnegie National Nursing Education Study, Benner et al5 noted that nurses are undereducated for the demands of their practice. Simulation has been endorsed as 1 way to bridge the theory to practice gap. Virtual simulation has been used to teach communication, disaster, teamwork, and interviewing, among other skills.6-13 Research suggests that nursing students report positive experiences with the use of virtual worlds,12,14,15 and nurse faculty members also have expressed satisfaction with their implementation of virtual teaching methods.16 As the venues for simulation expand in the context of nursing education, this pedagogical approach seems to be increasing in scope and value.

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Method

The lead author chose 6 technologies to present in this article and reached out to representatives for a description of each technology. Therefore, this article does not constitute an endorsement of any of these products or systems; rather, the purpose is to disseminate knowledge about emerging technologies that may potentially fill a gap in nursing education. On the basis of the high variability of the technologies presented, costs range from large 1-time purchases to small licensing agreements. Some of the technologies described in this article are still in testing and refinement. The technologies were categorized into AR or virtual simulation.

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Augmented Reality

BodyExplorer

BodyExplorer is a simulator under development that combines virtual reality (VR) with physical reality (see Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A284).17 Combining digital and physical media is often called augmented reality. Augmented reality adds computer-generated imagery to everyday objects to provide additional information about the object or environment to a user. Virtual reality technologies support enhanced self-learning, automated tutoring, widespread deployment and accessibility, cognitive decision making, and communication through dialogues.

BodyExplorer uses a projector mounted above a patient simulator to provide “x-ray vision” views of anatomy, physiology, and clinical procedures.18 A physical model of a body is enhanced with a variety of sensors to measure and provide feedback to learners. Learners can explore anatomy and physiology by opening viewports on the surface of the patient simulator using an intuitive stylus-based interface. Once viewports are opened, learners can practice administration of simulated medications and visualize the internal physiological effects of their external actions on the simulated patient. A drug injection sensor system detects the identity of actual fluids injected into the simulated body and enables the simulator to respond automatically as a real patient would.19 For example, learners can give an intravenous cardiac drug and watch the patient's beating heart slow down while seeing the wave form changes of the electrocardiogram.

In addition to the benefits of VR, BodyExplorer's mixed virtual-physical approach supports team coordination in a physical space. The ability to assess, communicate, order, prepare, and administer medications incorporates cognitive, physical, tactile, and verbal interaction with clinical devices, the team, and the body. Developing both cognitive and psychomotor skills together is integral to mastery of clinical practice. This system is helpful to teach intravenous medication administration, teamwork, anatomy, physiology, pharmacology, and clinical procedures and is excellent for use in teaching intubation.

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Flight Simulator

To train acute care nurse practitioners in the art of flight nursing, the Frances Payne Bolton School of Nursing at Case Western Reserve University created a fully articulating, high-fidelity flight simulator. Red Bird Flight Simulation's patented simulation technology was adapted to the weight of a full-scale Sikorsky S76 medically configured helicopter that served in Hurricane Katrina (see Figure, Supplemental Digital Content 2, http://links.lww.com/NE/A285). The helicopter was mounted to a flight simulator platform that articulates with 11 degrees of pitch and roll. Fuselage windows were replaced with double-pane Lexan and coupled with a rear projection system to allow faculty to input any 2 coordinates to simultaneously display real-world views of any mission in the country. The visual technology is designed to “trick the brain” into feeling as though one is in an actual aircraft.

The Federal Aviation Administration approved interior is equipped with authentic medical equipment, aviation headsets, seat belts, radios, and air medical cot for the most realistic training of flight nurses, physicians, emergency medical, and ambulance personnel. Two GoPro cameras are mounted inside the fuselage allowing faculty to record and store data for posttraining debriefings, research analyses, presentations, and publications. This simulator allows acute care nurse practitioner students to gain experience and develop confidence using real flight equipment to medically manage a critically ill patient within the confines of an actual air medical helicopter. Faculty vary the simulated setting based on the season, terrain, weather, and location, including semipermissive environments requiring increased security considerations. Scenarios are tailored to specific patient conditions such as stroke, septic shock, myocardial infarction, multiple trauma, burns, and other complex medical and surgical conditions.

The flight simulator enhances student learning with a high degree of realism and has ensured standardization of training. Critical care transport simulations are shared with local community providers, national government flight teams, and the school's international academic exchange partners in Japan. Future possibilities for education and training include predeployment training, practice edification for civilian air medical crews, faculty research related to standardizing handoffs, and collaborative practice between nursing, medicine, and ancillary personnel.

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Microsoft HoloLens

Microsoft HoloLens is a “mixed reality” device that is worn on one's head (see Figure, Supplemental Digital Content 3, http://links.lww.com/NE/A286). The untethered, see-through holographic computer allows one to view high-definition holograms within his or her learning space.20 In a video spotlight showcasing Microsoft HoloLens, images of the human body including the various inner layers are shown 3-dimensionally. For example, the layers of muscles and bones can be viewed at various levels to facilitate mastery of anatomy and physiology. Such technology could replace the need for cadavers as well as facilitate understanding of the human body in its true 3-dimensional form, surpassing traditional teaching methods. Although this system offers broad use outside nursing education, Microsoft has already partnered with a university to use the holographic computing system for educational purposes within the health sciences.21 This technology would be excellent in teaching anatomy, physiology, and pathophysiology and could be used with multiple disciplines.

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Virtual Simulation Technologies

CliniSpace by Innovation in Learning, Inc

CliniSpace is a 3-dimensional representation of a health care setting on a computer screen. The “world” is a clinical space, such as an acute care unit, an office, a clinic, or a patient's home. CliniSpace is a Web-based, multiuser system, meaning that multiple students log in on their personal laptops from about any location. Students choose their “avatar” or character, such as a nurse, physician, or administrator, and they meet in the virtual acute care unit (see Figure, Supplemental Digital Content 4, http://links.lww.com/NE/A287). Through the use of a headset with a microphone, they are heard by others in the clinical space and participate in a real-time conversation, while working with the patient and surrounding equipment. The conversational interaction between remotely logged-in users gives a sense of immersion and presence.

The virtual patient in the room is computer controlled or is controlled by one of the participants. Each virtual patient has a physiological model that includes vital signs, physical appearance, and behavior. Physiology variables are observed; for example, physiologic values may be evident on the monitor or in the hematology report. Other variables are changed based on the learner's interventions. For example, administering intravenous fluids would cause a replenishment in blood volume, and the blood pressure would respond.

Learners click on items in the environment to read vital signs, listen to heart and breath sounds, conduct a physical assessment, review the electronic medical record, or give medications. All actions are tracked and used for feedback. Working in the virtual environment allows learners to experience a realistic work situation, explore information and action options, and receive feedback from the environment and virtual patient as they work. If the simulation includes other learners, together they can practice collaboration, team interaction, leadership, and resolving problems. This environment offers opportunity to unite multiple professions to practice skills of conflict resolution or interprofessional communication. This technology is useful for teaching assessment, documentation, use of an electronic health record, pharmacology, decision making, prioritization, and communication.

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Digital Clinical Experience

Shadow Health created the Digital Clinical Experience (DCE) building on academic research at a consortium of nursing, medical, and allied health schools. The DCE is a suite of Web-based, asynchronous virtual patient simulations designed for the practice and assessment of clinical reasoning skills within the nursing process, with modules for graduate and prelicensure and graduate nursing programs.

The DCE virtual environments are home to autonomous 3-dimensional virtual patients with realistic speech and animation, each capable of recognizing and responding to more than 100 000 questions (see Figure, Supplemental Digital Content 5, http://links.lww.com/NE/A288). This technology provides students the freedom to form their own questions to ask while they conduct a patient interview and identify opportunities for empathy and patient education and to organize their physical examination of the virtual patient. The DCE virtual patients have deep patient narratives and diverse sociocultural backgrounds, spanning pediatric, young adult, adult, and older adult patients, and can be accessed from any home, classroom, or laboratory setting with Internet access. In each simulation, students are guided through a prebrief with a virtual preceptor, conduct a patient interview and physical assessment, document findings, organize and interpret findings to develop diagnoses and/or care plans, intervene if appropriate (eg, administering medication), and engage in interprofessional communication. Each DCE simulation concludes with a structured self-reflection activity and a debrief with immediate and detailed feedback, which provides a review of a model performance for self-directed remediation.

Faculty can integrate the DCE virtual patient simulations in their curricula as formative assessments throughout their course, as prerequisites for entry to laboratory sessions, or as summative assessments. The DCE is particularly useful in the instruction of physical assessment, communication, and clinical reasoning skills and the nursing process.

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vSim for Nursing

A collaboration between Laerdal, Wolters Kluwer Health, and the National League for Nursing resulted in the creation of vSim for Nursing. This Web-based, single-user product allows for students to practice cognitive nursing skills in a virtual environment (see Figure, Supplemental Digital Content 6, http://links.lww.com/NE/A289). A variety of adult, medical-surgical simulations are available with recent additions of maternity, pediatric, gerontology, fundamentals, and pharmacology scenarios depending on the package purchased. Features include an objective pretest and posttest, a simulation performance score with immediate feedback, and a timeline of student actions.22

The electronic health record is a strong feature for learners to be exposed to how patient data are organized as well as how to seek information. Learners are given opportunity to assess the patient, view orders, give medications, and apply nursing interventions. The patient responds based on interventions allowing learners to evaluate and learn from their mistakes. The simulation performance feedback displays correct interventions in green and inaccurate interventions in red. Learners view actions they performed well and those that require improvement. This virtual simulation allows students to learn independently, from the convenience of home, and provides opportunity to remediate and repeat the simulation until performance is mastered. The technology may be used to enhance lecture, as a case study or an assignment, to augment clinical practice, or for formative assessment. vSim for Nursing is valuable to teach assessment, prioritization, clinical reasoning, pharmacology, and other nursing actions.

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Discussion

The systems discussed in this article present novel and practical approaches to enhance nursing education using technology. Augmented reality and virtual simulation may provide a solution to meet the needs of nursing programs that are facing issues of faculty shortages, scarcity of clinical placements for students, and limited onsite laboratory space and for alternate clinical experiences. Furthermore, use of these technologies provides a means of offering more application-based learning and integration of visual imagery that exceeds conventional teaching methods. It is plausible that these systems may contribute to shortening the learning curve, decreasing practice time, and improving learning outcomes. The realism and depth of understanding enabled by these technologies provide great promise in making learning more engaging and meaningful.

These technologies provide promise to improve and transform nursing education as called on by the Carnegie Report.5 Technologies may prove a valuable resource for nursing faculty who are developing competency-based curriculum or struggling to model and assess concepts such as clinical reasoning. Students benefit from the ability to engage in deliberate practice and receive immediate feedback.

Augmented reality provides valuable opportunities as well. It enables learners to view the human body in a new way—1 layer at a time. The high quality 3-dimensional visuals facilitate proportional understanding of anatomy and physiology, transcending the 2-dimensional norm, leading to a more thorough appreciation of the body. Comparative research is warranted examining the retention of learning using AR versus the standard methods.

Simulation started in aviation—a high-pressure, life or death industry. Given the importance of patient safety, it is fitting that nursing education build on teaching techniques from high-reliability organizations. Virtual simulation in health care presents learners the opportunity to practice and apply their knowledge in a safe learning space. Learners are able to enact similar cognitive skills as found in the clinical setting without posing risks to patients. Furthermore, virtual simulation enables learners to practice low-incidence, high-risk events that they may not encounter in their clinical practicum.

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Conclusions

With the expansion and advancement of AR and virtual simulation, nursing education is being transformed. Advances in emerging technologies offer nurse educators a variety of current and future teaching applications from simulating disasters to flying in a helicopter. The technologies described in this article are not comprehensive, but they serve to inform educators and administrators of some of the options to consider when planning to adopt new simulation technology. We encourage educators to study these pedagogical innovations to optimize the education of future health providers. With improved nursing education, improved patient outcomes will follow.

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Keywords:

augmented reality; nursing education; simulation; technology; virtual simulation; virtual reality

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