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Augmented Reality in Nursing Education

By Karyn Madden and Cassie Carstensen

Article taken from : Kai Tiaki Nursing New Zealand vol 25 no 5 - June 2019

Interest in the use of augmented reality (AR) in education and training has been growing around the world in recent years. AR involves the use of three-dimensional models – in the form of holograms – to aid students’ learning. The first documented use of AR in education was in the 1960s in aviation (though its roots date back to the 19th century, with the development of 360-degree panoramic art murals).

More recently, it has received increased attention across a number of disciplines (e.g. aviation, medicine, social sciences and computer science). In July 2018, six staff from the Southern Institute of Technology (SIT) in Invercargill travelled to Canberra University in Australia to train in the use of the AR “Hololens”– a form of simulation technology. This group comprised the head of the nursing school, four nurse educators and an SIT information technology specialist.

SIT then bought four Hololens headsets and supporting programmes, and introduced them into its foundation to nursing, enrolled nursing, Bachelor of Nursing, and postgraduate nursing curriculums at SIT in September 2018. These programmes involve a total of 350 students.

The Hololens technology was developed by Microsoft, and the associated applications by the British company, Pearson Education.

In the classroom, the technology allows an educator to project a hologram – e.g. of a sick patient or of the human skeleton – which is “seen” by a student wearing a headset. The students can walk right around the hologram, to observe and assess the “patient” from all angles. They can also interact with and manipulate the hologram by air-tapping options that are projected in front of them, and by using hand movements and voice. The technology is described as “mixed reality”, which means students are not completely immersed in the holographic experience – they can both see the hologram, and also see each other and the classroom around them.

One of the Hololens applications being used at SIT is “Holopatient”, which is designed to help students practise and develop assessment and clinical judgement skills, in a “safe” clinical environment (ie where patients are not at risk). Within the Holopatient application are 10 different patient scenarios (including heart failure, anaphylaxis, stroke, asthma, myocardial infarction and trauma), each accompanied by a life-size hologram of a patient with that condition.

As well as being able to observe and interact with the life-size hologram, the student is hearing critical assessment data through the speaker in the headset. For example, this could involve data about the patient’s breathing, and include elements such as rate, pattern, audibility, symmetry and mode. The students can also “see” projected data of the patient’s vital signs.

Within each scenario are multiple holographic video clips, showing how the patient’s scenario or condition is changing. The Holopatient videos and holograms are created from filming live actors playing the participants.

In the classroom, the application is paused between each video, to allow the class to talk about what they are seeing. At SIT, classes using Hololens are in small groups of six. Students take turns using the four headsets – those students without a headset can see the same visuals on a video screen.

Pearson’s Education has also developed a facilitator guide – in the form of a hardcopy book – for each scenario and each video clip within it. The guide is used by the educator to help promote learners’ clinical reasoning and critical thinking by integrating questioning into the cases presented through the AR technology. These questions flow throughout the activity and challenge the learner to apply and integrate previous knowledge.

Four phases

This type of questioning complements the clinical judgement model used at SIT, titled Thinking like a nurse – A clinical judgement model in nursing. This model consists of four phases. First, what do the students “notice”, which focuses on observing, recognising deviations from expected patterns and seeking information. The second phase, “interpret”, is about students making sense of the data and beginning to formulate priorities to maintain patient safety. The third component, “respond”, looks at how students are responding to their prioritised care plan. In this phase, the aim is for students to respond in a calm, confident manner, using clear communication and well-planned interventions. The final phase, “evaluation”, promotes self-analysis of the interventions and a commitment to improve.

The interweaving of the questions within the Holopatient applications promotes student engagement, facilitates realism without putting patient safety at risk and allows students to pause and reflect throughout the scenario. A debriefing session is held at the end of each scenario to ensure students feel comfortable about what they have been seeing and doing.

Human anatomy

A second Hololens application, Holohuman, which is also used at SIT, allows students to explore three-dimensional human anatomy. It complements and enhances classroom teaching of anatomy and physiology. The application opens with a projection of the full human skeleton, and students can then direct their own learning by focusing on one part of the skeleton and then layering on nerves, blood, muscle and organs.

Holohuman is used at SIT in conjunction with science papers. Students learning about a particular body system in class can then reinforce that with exploration of three-dimensional holographic models.

Education researchers say that nursing students are looking for greater understanding and insight into the care they will be delivering. Nursing theorist Patricia Benner says that for the nurse to progress from novice to expert, they must be able to articulate the knowledge and ethos embedded in their practice. Students must also learn to do this as they progress through their degree programme. Hololens encourages the transformation of knowledge that occurs as students begin to develop clinical judgement.

Nursing educators are often challenged to find innovative ways to engage with students who have differing learning styles and needs. The digital stories provided by Hololens enhance students’ learning about patient safety and person-centred care, while meeting a diverse array of student learning styles. Equally, within the applications of Hololens, students have the ability to take charge of their education and reflect on their learning.

Preliminary feedback from SIT students indicates they are appreciating the realism of the Hololens technology, are finding it new and exciting and want to use it more. SIT educators have observed the technology enhances students’ assessment skills. Due diligence and best educational practice require that SIT do further research and seek further student feedback to ensure students are receiving maximum benefit from this technology. It should complement, rather than replace, other types of simulation and other teaching methods.

More Headsets

SIT plans to buy another four Hololens headsets, so more of its nursing students can take advantage of this cutting-edge technology. The educators initially had concerns the headsets might cause head- aches or migraines in some students, but so far this has been unfounded.

Use of holographic scenarios provides a safe and non-threatening environment for students to practise and refine their assessment skills. The integration of Hololens and other types of simulation into SIT’s nursing curriculums has helped educators bridge the theory-practice gap and offers new methods of teaching nursing education in the 21st century.

This article was reviewed by Jolanda Lemów, a senior academic staff member in the Centre for Health and Social Practice at the Waikato Institute of Technology (Wintec), and by the Kai Tiaki Nursing New Zealand co-editors.

Karyn Madden, BN, MN, Dip Adult Ed, and Cassie Carstensen, BN, MN, Dip Adult Ed, are nurse educators at the Southern Institute of Technology, Invercargill.

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