Virtually Nursing: Emerging Technologies in Nursing Education.

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.

Enhancing medical device training with hybrid physical-virtual simulators: smart peripherals for virtual devices.

We introduce a novel platform for medical device training: hybrid physical-virtual simulators of medical devices, combining touchscreen-enabled virtual emulations of real devices with sensorized physical peripherals to enable tactile, hands-on interaction between the trainee, simulated device and standardized patients or mannequins. The system enables objective measurement and recording of trainee performance, including interactions with both the virtual device elements and the physical components, and can include metrics and feedback not available in the real device. The system also includes an integrated wireless signaling device for use with standardized patients. We present the implementation of an example system, a virtual defibrillator with sensorized paddles and wireless signaling of successful defibrillator operation.

PleurAlert: an augmented chest drainage system with electronic sensing, automated alerts and internet connectivity.

We have enhanced a common medical device, the chest tube drainage container, with electronic sensing of fluid volume, automated detection of critical alarm conditions and the ability to automatically send alert text messages to a nurse's cell phone. The PleurAlert system provides a simple touch-screen interface and can graphically display chest tube output over time. Our design augments a device whose basic function dates back 50 years by adding technology to automate and optimize a monitoring process that can be time consuming and inconvenient for nurses. The system may also enhance detection of emergency conditions and speed response time.

A novel automated drug simulant recognition system for naturalistic real-time medical simulation.

The ability for a medical simulator to automatically recognize and respond to a "drug" injected during a training exercise offers powerful capabilities for objective assessment and real-time interaction. To address some of the limitations of available mannequin drug recognition systems, we developed a novel sensing system that recognizes an IV-injected agent based on an inherent property of the fluid. Our system uses varying concentrations of saline to represent different drugs and identification is made via conductivity measurement. The system also determines the volume administered and the time over which the dose is injected. Simulant solutions in IV bags (e.g., simulated Hextend or crystalloids) can be identified even if the bag is placed at a distance from the body. The system may offer advantages for field training exercises, as no external components need to be attached to the syringe or IV bag.

BodyWindows: enhancing a mannequin with projective augmented reality for exploring anatomy, physiology and medical procedures.

Augmented reality offers the potential to radically extend and enhance the capabilities of physical medical simulators such as full-body mannequin trainers. We have developed a system that transforms the surface of a mannequin simulator into both a display screen and an input device. The BodyWindows system enables a user to open, size, and reposition multiple viewports onto the simulator body. We demonstrate a dynamic viewport that displays a beating heart. Similar viewports could be used to display real-time physiological responses to interventions the user applies to the mannequin, such as injection of a simulated drug. Viewport windows can be overlapping and show anatomy at different depths, creating the illusion of "cutting" multiple windows into the body to reveal structures at different depths from the surface. The developed low-cost interface employees an IR light pen and the Nintendo Wiimote. We also report experiments using the Microsoft Kinect computer vision sensor to provide a completely hand-gesture based interface.

The tool positioning tutor: a target-pose tracking and display system for learning correct placement of a medical device.

Safe and successful performance of medical procedures often requires the correct manual positioning of a tool. For example, during endotracheal intubation a laryngoscope is used to open a passage in the airway through which a breathing tube is inserted. During training it can be challenging for an experienced practitioner to effectively communicate to a novice the correct placement and orientation of a tool. We have implemented a real-time tracking and position display system to enhance learning correct laryngoscope placement. The system displays a 3D model of the laryngoscope. A clinical teacher can correctly position the laryngoscope to open the airway of a full-body simulator, then set this tool pose as the target position. The system displays to the learner the fixed, target pose and a real-time display of the current, "live" laryngoscope position. Positional error metrics are displayed as color-coded visual cues to guide the user toward successful targeting of the reference position. This technique provides quantitative assessment of the degree to which a learner has matched a specified "expert" position with a tool, and is potentially applicable to a wide variety of tools and procedures.

Real-time "x-ray vision" for healthcare simulation: an interactive projective overlay system to enhance intubation training and other procedural training.

We have developed a prototype of a real-time, interactive projective overlay (IPO) system that creates augmented reality display of a medical procedure directly on the surface of a full-body mannequin human simulator. These images approximate the appearance of both anatomic structures and instrument activity occurring within the body. The key innovation of the current work is sensing the position and motion of an actual device (such as an endotracheal tube) inserted into the mannequin and using the sensed position to control projected video images portraying the internal appearance of the same devices and relevant anatomic structures. The images are projected in correct registration onto the surface of the simulated body. As an initial practical prototype to test this technique we have developed a system permitting real-time visualization of the intra-airway position of an endotracheal tube during simulated intubation training.

Toward a comprehensive hybrid physical-virtual reality simulator of peripheral anesthesia with ultrasound and neurostimulator guidance.

We are developing a simulator of peripheral nerve block utilizing a mixed-reality approach: the combination of a physical model, an MRI-derived virtual model, mechatronics and spatial tracking. Our design uses tangible (physical) interfaces to simulate surface anatomy, haptic feedback during needle insertion, mechatronic display of muscle twitch corresponding to the specific nerve stimulated, and visual and haptic feedback for the injection syringe. The twitch response is calculated incorporating the sensed output of a real neurostimulator. The virtual model is isomorphic with the physical model and is derived from segmented MRI data. This model provides the subsurface anatomy and, combined with electromagnetic tracking of a sham ultrasound probe and a standard nerve block needle, supports simulated ultrasound display and measurement of needle location and proximity to nerves and vessels. The needle tracking and virtual model also support objective performance metrics of needle targeting technique.

Critical thinking skills in nursing students: comparison of simulation-based performance with metrics.

AIM: This paper is a report of an examination of the relationship between metrics of critical thinking skills and performance in simulated clinical scenarios. BACKGROUND: Paper and pencil assessments are commonly used to assess critical thinking but may not reflect simulated performance. METHODS: In 2007, a convenience sample of 36 nursing students participated in measurement of critical thinking skills and simulation-based performance using videotaped vignettes, high-fidelity human simulation, the California Critical Thinking Disposition Inventory and California Critical Thinking Skills Test. Simulation-based performance was rated as 'meeting' or 'not meeting' overall expectations. Test scores were categorized as strong, average, or weak. RESULTS: Most (75.0%) students did not meet overall performance expectations using videotaped vignettes or high-fidelity human simulation; most difficulty related to problem recognition and reporting findings to the physician. There was no difference between overall performance based on method of assessment (P = 0.277). More students met subcategory expectations for initiating nursing interventions (P ≤ 0.001) using high-fidelity human simulation. The relationship between videotaped vignette performance and critical thinking disposition or skills scores was not statistically significant, except for problem recognition and overall critical thinking skills scores (Cramer's V = 0.444, P = 0.029). There was a statistically significant relationship between overall high-fidelity human simulation performance and overall critical thinking disposition scores (Cramer's V = 0.413, P = 0.047). CONCLUSION: Students' performance reflected difficulty meeting expectations in simulated clinical scenarios. High-fidelity human simulation performance appeared to approximate scores on metrics of critical thinking best. Further research is needed to determine if simulation-based performance correlates with critical thinking skills in the clinical setting.

Impact of simulation-based learning on medication error rates in critically ill patients.

PURPOSE: To compare medication administration error rates before and after the provision of educational sessions using either traditional didactic lecture or simulation-based training. METHODS: A single-center, parallel, controlled, prospective study conducted in adult coronary critical care (CCU) and medical intensive care units (MICU). Twenty-four nurses were observed administering medications. Documentation included drug name, dose, route, time and technique during observation and active medication orders in the patient's chart. A direct observation method was completed at baseline and repeated twice after the interventions. Data obtained during observation were analyzed for medication administration error rates. Interventions were two types of educational sessions with content developed from baseline medication administration error data: simulation-based training for CCU nurses and a didactic lecture for MICU nurses. Quizzes completed before and after the interventions were used to assess knowledge. RESULTS: A total of 880 doses (402 CCU, 478 MICU) were observed. After the simulation-based educational intervention in the CCU, medication administration error rates decreased from 30.8 to 4.0% (p < 0.001) in the initial post-intervention observation and were sustained in the final post-intervention observation (30.8 to 6.2%; p < 0.001). The error rate in the MICU after the didactic lecture intervention was not significantly different from the baseline and increased in the final post-intervention observation from 20.8 to 36.7% (p = 0.002). Mean quiz scores were significantly improved after education sessions in both ICUs. CONCLUSIONS: Simulation-based learning provides a significant advantage to patient care through the reduction of medication administration errors compared to lecture style education.

Spatially-localized correlation of dGEMRIC-measured GAG distribution and mechanical stiffness in the human tibial plateau.

The concentration of glycosaminoglycan (GAG) in articular cartilage is known to be an important determinant of tissue mechanical properties based on numerous studies relating bulk GAG and mechanical properties. To date limited information exists regarding the relationship between GAG and mechanical properties on a spatially-localized basis in intact samples of native tissue. This relation can now be explored by using delayed gadolinium-enhanced MRI of cartilage (dGEMRIC--a recently available non-destructive magnetic resonance imaging method for measuring glycosaminoglycan concentration) combined with non-destructive mechanical indentation testing. In this study, three tibial plateaus from patients undergoing total knee arthroplasty were imaged by dGEMRIC. At 33-44 test locations for each tibial plateau, the load response to focal indentation was measured as an index of cartilage stiffness. Overall, a high correlation was found between the dGEMRIC index (T(1Gd)) and local stiffness (Pearson correlation coefficients r = 0.90, 0.64, 0.81; p < 0.0001) when the GAG at each test location was averaged over a depth of tissue comparable to that affected by the indentation. When GAG was averaged over larger depths, the correlations were generally lower. In addition, the correlations improved when the central and peripheral (submeniscal) areas of the tibial plateau were analyzed separately, suggesting that a factor other than GAG concentration is also contributing to indentation stiffness. The results demonstrate the importance of MRI in yielding spatial localization of GAG concentration in the evaluation of cartilage mechanical properties when heterogeneous samples are involved and suggest the possibility that the evaluation of mechanical properties may be improved further by adding other MRI parameters sensitive to the collagen component of cartilage.