Growing number of learners at medical schools and teaching hospitals are training through computer-generated simulations thanks to VR and its cousin, augmented reality (AR). These sophisticated tools allow learners to plunge safely into life-or-death scenarios, peel away layers of human anatomy, walk through a virtual heart, and more. As technologies from the gaming industry improve and costs decline, leaders in academic medicine are increasingly exploring the place of such simulations in medical education.
Early adopters note the varied benefits of AR and VR, including the opportunity for real-life experiences without real-life consequences.
Let us start by explaining what each one actually means
Virtual reality is an entirely computer-generated view of a world — that is, purely virtual. Everything the user sees is manufactured but as close to experiencing it in real life as you can get.
Augmented reality, by contrast, superimposes computer-generated images and sounds onto the real world. In medicine, this includes simulated internal organs overlaid on a real manikin.
It bridges the gap between role-playing and high-fidelity simulation.”
Virtual Reality vs Augmented Reality:
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Who are the Early adopters of these technologies and what areas have they identified for these technologies?
Children’s Hospital Los Angeles (CHLA): Handling emergency situations
Stanford University School of Medicine: Use of VR for training in its Neurosurgical Simulation and Virtual Reality Center. There, a platform called Surgical Theater fuses several types of brain scans from a real patient to achieve greater specificity and verisimilitude.
Mayo Clinic: Instructors use AR for various purposes at Multidisciplinary Simulation Center, to teach students how to interpret ultrasound imaging. As students look at a standard ultrasound view, AR adds images of underlying tissues, bone structures, blood vessels, muscles, and nerves for a deeper understanding of the ultrasound visualization.
UC Irvine School of Medicine: Faculty recently launched an AR pilot project for fourth-year students and emergency medicine residents. There, a computer app superimposes a hologram of a patient over a manikin to produce a much more lifelike and responsive simulation
What the early adopters are saying about their experience using these technologies?
“The beauty of this is really that you can appreciate in three dimensions what the structures look like.”
Gary Steinberg, MD, PhD
Stanford Medical School
“You don’t get that feeling of adrenaline through a written test,” says White. “You get it through experiencing it, and I think this is as close to experiencing it in real life as you can get.”
Todd Chang, MD, MAcM,
Director of research and scholarship at CHLA
“Wearing my technologist hat, this is an incredibly exciting time. … But my physician side is a little more cautious in thinking that we shouldn’t jump headfirst into every new technology that comes out.”
Warren Wiechmann, MD
Associate Dean of Clinical Science Education and Educational Technology
University of California Irvine School of Medicine
So who is winning the race VR or AR?
Let us start by saying that this is definitely not a race but an opportunity in our future that needs to be taken seriously by all the stakeholders involved, including the learners and patients.
As prices fall, the capabilities of the technology grow, and developers create new teaching modules, a trend toward greater use of virtual and augmented reality in teaching and training seems almost guaranteed.
One of the most exciting developments in virtual reality has been its rapid entry into medical education and healthcare. Researchers, doctors, and nurse educators are discovering innovative ways to leverage immersive technologies and transform both healthcare teaching and practice.
Financial as well as regulatory restrictions has burdened the nursing education, as a result of which, providing adequate training has become a challenging task for the nursing educators. Not only the patients, but the practitioners and the devices used are at a risk of harm and malfunction if the quality of training is not up to the mark.
Simulation-based training has been used and shown to be an effective tool in the fields other than medicine as the virtual reality provides a range of learning and training enhancing aspects.
Various problems challenge the expected level of skill proficiency of nursing students who practice clinical skills with patient manikin simulators, and inside simulated learning environments labs. These challenges include, but are not limited to,
limited availability of nurse faculty to provide instruction and repetitive practice needed for nursing student’s opportunities to practice outside nursing laboratories regular hours of operations.
The capability of nurse faculty to address individual learning needs of nursing students during each practice session
Instructional and evaluation variability among nurse faculty.
VR Technology can address all the above mentioned challenges and enhance the ability of faculty to sometimes quantifiably evaluate, student-learning performance. Augmented Reality (AR) and simulation are technology interventions modalities that can be integrated into nursing curriculum to help nursing student achieve and improve clinical skill proficiency.
Advantages of AR /VR application for Nursing Education
There are many advantages to using virtual reality in nurse training. Nurses can build familiarity with technology in a controlled environment, and learn by “doing,” rather than “seeing.”
Simulation helps develop competences for professional practice. Students who have the opportunity to develop clinical practices in a simulated environment report an increase in confidence, as they were able to transfer significantly the knowledge learned in the classroom to the simulated environment. Studies have reported improvements in the areas of critical thinking, confidence and/or knowledge/skills after participating in the simulation.
Simulation provides a rich learning opportunity for students to integrate theory with practice while making real-time clinical decisions in an environment that poses no risk to patients. HFS is one such example that provides students with a safe environment to learn and make mistakes without compromising patient safety.
Simulation can standardize clinical experiences in an environment with often unequal clinical learning opportunities. The use of High-Fidelity Simulation (HFS) in health care education has emerged as a possible solution to address limited clinical experiences.. Research studies have shown HFS to be beneficial in acquiring new knowledge in many clinical areas, including Medical-surgical, advanced cardiac life support, and acute myocardial infarction treatment.
Human patient simulation-based clinical nursing education has the potential to promote transformative learning and lead to a metamorphosis of students’ preconceived meaning schemes. It allows students to engage in social interactions and enhance their psychomotor skills in a patient safe environment, which helps most students relax and increases their confidence in performing clinical skills during a simulated clinical experience.
Current Implementation of AR/VR in nursing and medical education
The INACSL meeting is a leading forum for nursing simulation aficionados, researchers, and vendors providing the ideal environment to gain and disseminate current, state-of-the-art knowledge in the areas of skills/simulation operations and applications in an evidenced-based venue.
The Hayden Vanguard Lectureship recognizes innovation in Nursing Simulation. Bundle of Rays focuses on “clinical skills and health-based training” utilizing virtual reality to teach anatomy and physiology, combined with simulation technology to link imaging to patient assessment. Designed by nurses, these training programs focus on patient safety, quality assessment skills and escalation of clinical deterioration. All of this is done in small class sizes at dynamic venues, conceptualizing the future of healthcare education.
Showcasing Augmented Reality (AR) in real-time, Brad shared how he could pick up a digital beating heart on his desk, bringing digital animation into a real background. Combining these technologies allows educators to have multi-user sessions across mediums to teach countless learners at the same time, even if they are located at different locations around the world. Brad shared that through his startup Bundle of Rays, to provide education for multiple learners at the same time even though they are spread across a wide geographic region.
2. Another excellent example of implementation of VR in Nursing education is A VR game that allows nursing students to practice urinary catheter insertion — what Kardong-Edgren (Suzan Kardong-Edgren, a professor at the School of Nursing and Health Science at Robert Morris University in Pennsylvania) called “a perfect marriage of nursing skills and software development”. Nursing students wearing Oculus Rift headgear and interactive gloves, called haptics, practice cleaning their hands and inserting a catheter into a patient’s bladder. In a study published in the March 2018 issue of Clinical Simulation in Nursing, Ellertson, Kardong-Edgren and Ann Butt of College of Nursing at University of Utah, report that the VR-trained students had the same pass rate as students who practiced the traditional way, on manikins, and that the VR students said they enjoyed the learning experience more.
A nursing student practicing catheterization procedures with a VR game developed by Boise State University and Robert Morris University. (Photo: Boise State University)
Catheterization was a good candidate for VR training, because it is a procedure that is difficult to learn and dangerous to patients if done incorrectly
Normally, nursing students have to practice urinary catheterization 30 to 50 times before they can do it on human beings. Many universities, however, don’t have enough medical simulation facilities and students are often not interested in repeating the same procedure over and over, Ellertson said.
“The underlying goal of the training is going to remain the same, but the shift is that we want students to practice more,” said Ellertson, who led a team of eight software developers to design, test, and then improve the VR game.
Kardong-Edgren and her team of researchers tested 20 nursing school students, who had practiced urinary catheterization on manikins. Lab assistants taught the students how to synchronize and calibrate the VR gear to their own movements, and then asked the students to perform the procedure. After an initial 15-minute orientation, students were instructed to use as little or as much of the remaining hour allotted to practice catheter insertion.
In the virtual world, the student goes from one corner of the room to another to find a tray where the sterile package lies. Then they need to wash their hands, don clean gloves, pick up the catheter package, and bring it to the patient. After cleaning the patient’s bottom, they need to correctly open the package, and insert the sterile catheter. To emphasize the importance of proper sterile technique, a green cloud of small falling particles appears on the screen if students did not wear their gloves properly.
The possibilities for using virtual reality in nursing are endless.
Medical professionals will be monitoring the student’s practice on computers, where they can see the student’s vision on the left and real-time video of them on the right. (Photo: Boise State University)
Two weeks later, the students who underwent VR training for that hour did the same procedure on manikins. Professors compared their performance with that of nursing students who had only worked with manikins. Results showed that the VR-trained students not only had the same pass rate as the manikin-only group, but they also rated the VR training experience as “fun, engaging,” and they noted that it made them “lose track of time.”
A Novel Multiplayer Screen-Based Simulation Experience for African Learners Improved Confidence in Management of Postpartum Hemorrhage.
Postpartum hemorrhage affects approximately thirteen million women every year and remains a leading cause of maternal mortality in Asia and Africa. Mannequin-based simulation is the most common way for practicing care of critical patients but has its challenges when it comes to global health in developing countries.
A novel multiplayer screen-based simulation is developed in virtual world to practice team coordination with PPH cases. It was hypothesized that such a screen-based simulation may enhance the learner’s confidence and ability to manage critical PPH cases. The same was implemented in Mulago, Uganda.
Screen-shot of 3DiTeams—postpartum hemorrhage—multiplayer screen-based simulation. Each character is controlled by a unique individual using a computer, mouse, and voice-over-IP headset.
Study Design : pre- and a post-intervention survey.
Sample size : 48 interprofessional subjects
One of 9, 1 Hour simulation sessions in PPH software
The subjects were tested on 15 self-assessment question, before and after the intervention. And was designed to probe the areas of learning as defined by Bloom and Krathwohl: affective, cognitive, and psychomotor.
The confidence scores in each category of Bloom’s Taxonomy : affective, cognitive and psychomotor as well as combined score of all three increased significantly following the simulation experience.
The study provides a preliminary evidence that multiplayer screen-based simulation represents a scalable, distributable form of learning. The same can be used effectively in global health education and training.
Award Winning AR Training and Simulation
Virtual Reality Airway Learning Lab, a program that uses cutting edge virtual reality technology in clinical education.
It was honored to win the Best in Show award at the annual International Meeting for Simulation in Healthcare in 2018 in partnership with Adtalem Global Education (NYSE: ATGE), a leading global education provider. (Dr Eric B Bauman and Dr Nick Slamon)
Acadicus simplifies and democratizes the educational learning curve associated with VR training, allowing for cost effective scenario creation by faculty and instructional staff. Stakeholders are able to create authentic environments that may not otherwise be available to students… this helps solve the bricks-and-mortar, time-and-place challenges associated with traditional simulation laboratories.
The 3D recording feature within the Acadicus environment is a powerful way for faculty and staff to create and capture their own instructional content. The multi-user feature allows for remote learners to collaborate in real-time in authentic spaces that promote environmental fidelity in ways that encourage the suspension of disbelief and promote psychological fidelity.
Applied as part of a layered learning approach, Acadicus promotes learner engagement and creates sticky learning experiences that often rival or exceed real-life learning experiences, effectively driving learners toward curriculum objectives and outcomes.”
Introduction to various airway instruments and how they’re used.
Overview of steps and technique in airway management
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