Feasibility of Augmented Reality in Clinical Simulations: Using Google Glass With Manikins

The use of smart glasses in nursing education: A scoping review

AIM

The aim of this scoping review was to give an overview of the usability and feasibility of smart glasses in nursing education. In addition, this study will highlight nursing students' experiences of using smart glasses in learning situations.

BACKGROUND

Healthcare is becoming increasingly complex and technological and so is nursing education. Technology enhanced learning aims to enhance the teaching-learning process through use of technology, for example through smart glasses.

DESIGN AND METHODS

A literature review using a scoping review methodology was conducted. Qualitative content analysis was performed to analyse data. 14 references were included in the analysis. References were found using the databases PubMed, SCOPUS and ERIC.

RESULTS

The analysis resulted in three categories; (1) Situations in which smart glasses have been used in nursing education, (2) Learning experiences from using smart glasses in nursing education, and (3) User experiences from using smart glasses in nursing education. Smart glasses were used in different learning situations and were in general positively evaluated by nursing students. Although, drawbacks of using smart glasses were noted which could negatively effect student learning.

CONCLUSIONS

Smart glasses have been used in a variety of learning situations in nursing education and enabled new learning situations. Students found smart glasses beneficial for their learning and smart glasses motivated and engaged students in the learning situation. Although, this was both user- and situation dependent. Technical issues could cause students to lose focus and there is need for technical support to facilitate the learning curve. By learning from others' experiences unnecessary drawbacks can be avoided.

Usability of Augmented Reality Technology in Situational Telementorship for Managing Clinical Scenarios: Quasi-Experimental Study

BACKGROUND

Telementorship provides a way to maintain the professional skills of isolated rural health care workers. The incorporation of augmented reality (AR) technology into telementoring systems could be used to mentor health care professionals remotely under different clinical situations.

OBJECTIVE

This study aims to evaluate the usability of AR technology in telementorship for managing clinical scenarios in a simulation laboratory.

METHODS

This study used a quasi-experimental design. Experienced health professionals and novice health practitioners were recruited for the roles of mentors and mentees, respectively, and then trained in the use of the AR setup. In the experiment, each mentee wearing an AR headset was asked to respond to 4 different clinical scenarios: acute coronary syndrome (ACS), acute myocardial infarction (AMI), pneumonia severe reaction to antibiotics (PSRA), and hypoglycemic emergency (HE). Their mentor used a laptop to provide remote guidance, following the treatment protocols developed for each scenario. Rating scales were used to measure the AR's usability, mentorship effectiveness, and mentees' self-confidence and skill performance.

RESULTS

A total of 4 mentors and 15 mentees participated in this study. Mentors and mentees were positive about using the AR technology, despite some technical issues and the time required to become familiar with the technology. The positive experience of telementorship was highlighted (mean 4.8, SD 0.414 for mentees and mean of 4.25, SD 0.5 for mentors on the 5-point Likert scale). Mentees' confidence in managing each of the 4 scenarios improved after telementoring (P=.001 for the ACS, AMI, and PSRA scenarios and P=.002 for the HE scenario). Mentees' individual skill performance rates ranged from 98% in the ACS scenario to 97% in the AMI, PSRA, and HE scenarios.

CONCLUSIONS

This study provides evidence about the usability of AR technology in telementorship for managing clinical scenarios. The findings suggest the potential for this technology to be used to support health workers in real-world clinical environments and point to new directions of research.

Just-in-Time, Just-in-Place Virtual Training in the Pediatric Emergency Department: A Novel Approach to Impact the Perfusion Exam

Background

Early identification of shock is vital in decreasing morbidity and mortality in the pediatric population. Although residents are taught the perfusion portion of the rapid cardiopulmonary assessment at our institution, they perform it at the bedside with 8.4% completing 1 part of the assessment and 9.7% verbalizing their findings. Newer technologies, including virtual reality (VR), offer immersive training to close this clinical gap.

Objective

To assess senior pediatric residents' performance of a perfusion exam and verbalization of their perfusion assessment following VR-based Just-in-Time/Just-in-Place (JITP) training compared to video-based JITP training. We hypothesized that JITP media training was feasible, and VR JITP was more effective than video-based training.

Methods

Residents were randomized to VR or video-based training during shifts in the emergency department. Clinical performance was assessed by review of a video-recorded patient encounter using a standardized assessment tool and by an in-person, two question shock assessment. Residents completed a survey assessing attitudes toward their intervention at the time of training.

Results

Eighty-five senior pediatric residents were enrolled; 84 completed training. Sixty-four (76%) residents had a patient encounter available for video review (VR 33; Video 31). Fourteen residents in the VR group (42.4%, 95% CI 25.5% to 60.8%) and 13 residents in the video group (41.9%, 95% CI 24.6% to 60.9%) completed a perfusion exam AND verbalized an assessment during their next clinical encounter (X2 p-value 1.00). Fifty-one of 64 residents (79.7%) completed the two-step shock assessment; 50 (98%) agreed with supervising physician's assessment. VR was rated more effective than reading, low-fidelity manikin, standardized patient encounters, traditional didactic teaching, and online learning. Video was rated more effective than online learning, traditional didactic teaching, and reading.

Conclusion

Novel video and VR JITP perfusion exam and assessment trainings are impactful and well-received by senior pediatric residents.

Augmented Reality Integration in Manikin-Based Simulations: Bringing Basic Science to the Critical Care Bedside with Limited Augmented Reality Resources

Immersive simulation and augmented reality (AR) are powerful educational tools in high-risk medical professions. Basic science AR, such as anatomic holograms, are gaining popularity. Many educators want to adopt AR and integrate basic science review in high-risk clinical decision-making but cannot afford it. In this project, we designed three AR integrated manikin-based simulations (ARI-MBS) by combining critical care scenarios with commercially available AR programs. Using a single headset and limited equipment, we technically integrated AR into MBS in a way that both students and faculty found rewarding. We present our design, so that others may replicate it.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01821-z.

Participant Perceptions of Augmented Reality Simulation for Cardiac Anesthesiology Training: A Prospective, Mixed-Methods Study

Background

Simulations are a critical component of anesthesia education, and ways to broaden their delivery and accessibility should be studied. The primary aim was to characterize anesthesiology resident, fellow, and faculty experience with augmented reality (AR) simulations. The secondary aim was to explore the feasibility of quantifying performance using integrated eye-tracking technology.

Methods

This was a prospective, mixed-methods study using qualitative thematic analysis of user feedback and quantitative analysis of gaze patterns. The study was conducted at a large academic medical center in Northern California. Participants included 7 anesthesiology residents, 6 cardiac anesthesiology fellows, and 5 cardiac anesthesiology attendings. Each subject participated in an AR simulation involving resuscitation of a patient with pericardial tamponade. Postsimulation interviews elicited user feedback, and eye-tracking data were analyzed for gaze duration and latency.

Results

Thematic analysis revealed 5 domains of user experience: global assessment, spectrum of immersion, comparative assessment, operational potential, and human-technology interface. Participants reported a positive learning experience and cited AR technology's portability, flexibility, and cost-efficiency as qualities that may expand access to simulation training. Exploratory analyses of gaze patterns suggested that trainees had increased gaze duration of vital signs and gaze latency of malignant arrythmias compared with attendings. Limitations of the study include lack of a control group and underpowered statistical analyses of gaze data.

Conclusions

This study suggests positive user perception of AR as a novel modality for medical simulation training. AR technology may increase exposure to simulation education and offer eye-tracking analyses of learner performance.

Prehospital Pediatric Emergency Training Using Augmented Reality Simulation: A Prospective, Mixed Methods Study

OBJECTIVE

Pediatric emergencies are high-stakes yet low-volume clinical encounters for emergency medical services (EMS) clinicians, necessitating innovative approaches to training. We sought to explore the acceptability, usability, and ergonomics of a novel augmented reality (AR) software for EMS crisis management training.

METHODS

This was a prospective, mixed-methods study employing qualitative and quantitative analyses. We enrolled emergency medical technicians (EMTs) and paramedics at a municipal fire service in Northern California. We ran the Chariot Augmented Reality Medical simulation software (Stanford Chariot Program, Stanford University, Stanford, CA) on the ML1 headset (Magic Leap, Inc., Plantation, FL), which enabled participants to view an AR image of a patient overlaid with real-world training objects. Participants completed a simulation of a pediatric hypoglycemia-induced seizure and cardiac arrest. Participants subsequently engaged in structured focus group interviews assessing acceptability, which we coded and thematically analyzed. We evaluated the usability of the AR system and ergonomics of the ML1 headset using previously validated scales, and we analyzed findings with descriptive statistics.

RESULTS

Twenty-two EMS clinicians participated. We categorized focus group interview statements into seven domains after an iterative thematic analysis: general appraisal, realism, learning efficacy, mixed reality feasibility, technology acceptance, software optimization, and alternate use cases. Participants valued the realism and the mixed reality functionality of the training simulation. They reported that AR could be effective for practicing pediatric clinical algorithms and task prioritization, building verbal communication skills, and promoting stress indoctrination. However, participants also noted challenges with integrating AR images with real-world objects, the learning curve required to adapt to the technology, and areas for software improvement. Participants favorably evaluated the ease of use of the technology and comfortability of wearing the hardware; however, most participants reported that they would need technical support.

CONCLUSION

Participants positively evaluated the acceptability, usability, and ergonomics of an AR simulator for pediatric emergency management training, and participants identified current technological limitations and areas for improvement. AR simulation may serve as an effective training adjunct for prehospital clinicians.

The HoloLens in medicine: A systematic review and taxonomy

The HoloLens (Microsoft Corp., Redmond, WA), a head-worn, optically see-through augmented reality (AR) display, is the main player in the recent boost in medical AR research. In this systematic review, we provide a comprehensive overview of the usage of the first-generation HoloLens within the medical domain, from its release in March 2016, until the year of 2021. We identified 217 relevant publications through a systematic search of the PubMed, Scopus, IEEE Xplore and SpringerLink databases. We propose a new taxonomy including use case, technical methodology for registration and tracking, data sources, visualization as well as validation and evaluation, and analyze the retrieved publications accordingly. We find that the bulk of research focuses on supporting physicians during interventions, where the HoloLens is promising for procedures usually performed without image guidance. However, the consensus is that accuracy and reliability are still too low to replace conventional guidance systems. Medical students are the second most common target group, where AR-enhanced medical simulators emerge as a promising technology. While concerns about human-computer interactions, usability and perception are frequently mentioned, hardly any concepts to overcome these issues have been proposed. Instead, registration and tracking lie at the core of most reviewed publications, nevertheless only few of them propose innovative concepts in this direction. Finally, we find that the validation of HoloLens applications suffers from a lack of standardized and rigorous evaluation protocols. We hope that this review can advance medical AR research by identifying gaps in the current literature, to pave the way for novel, innovative directions and translation into the medical routine.

Augmented Reality in Medical Education: A Mixed Methods Feasibility Study

BACKGROUND

Augmented reality (AR) is a novel technology with many applications in medical education. Perhaps one of the most beneficial potential applications is to enable better clinical access for students; however, there is limited research into this use. The purpose of this mixed-methods feasibility study was to evaluate the applicability and acceptability of AR in undergraduate and early postgraduate medical education.

METHODS

Single-group quasi-experimental study design was developed for critical care-themed simulation teaching delivered using Microsoft HoloLens (Microsoft Corporation, Redmond, Washington, United States). Post-test questionnaires were completed including a validated adapted immersive experience questionnaire (AIEQ) and an abridged intrinsic motivation inventory (AIMI). The AIMI focused on the domains of 'interest and enjoyment', and 'value and usefulness'. Following the teaching, focus group interviews with thematic analysis were conducted to evaluate participants' experiences with AR.

RESULTS

All 15 participants (100%) completed the AIEQ and AIMI. Co-located airway teaching (i.e., the demonstrator and participants were placed in the same AR environment) was reported as having a moderate level of user immersion (median 72) and a high level of user enjoyment and value (median 52). Thematic analysis revealed four key themes: visual conceptualization for learning, accessibility, varied immersion, and future application.  Conclusions: Remote simulation for the management of airways in critical care was found to be acceptable and afforded a high level of enjoyment and value. Similarly, this was reflected in the thematic analysis. However, immersion was rated variably in both AIEQ and thematic analysis. The challenges identified with the application of AR included technical infrastructure and patient consent. AR-enabled education benefits are relevant to a number of clinical teaching areas.

Augmented Reality in Supporting Healthcare and Nursing Independent Learning: Narrative Review

New advances in technology have brought challenges and opportunities for education and instructional methods. Compared with traditional education, the increased use of technology-enhanced blended learning in healthcare and nursing education requires students to take more responsibility for their learning. The use of advanced technology has resulted in independent learning skills becoming increasingly important. Many studies have reported a positive correlation between independent learning and success rates in an e-learning environment. This paper focuses on the potential contribution of augmented reality, which superimposes layers of virtual content on real physical objects. The paper initially presents a narrative literature review to identify augmented reality's strengths and challenges in facilitating independent learning and highlights several potential approaches for utilizing augmented reality in nursing education. However, it also reveals a lack of studies integrating augmented reality and independent learning theories such as self-regulated learning. The paper then addresses this gap by proposing a new learning approach to support independent learning.

Efficacy of virtual reality techniques in cardiopulmonary resuscitation training: protocol for a meta-analysis of randomised controlled trials and trial sequential analysis

INTRODUCTION

Cardiopulmonary resuscitation (CPR) is the most critical procedure in the rescue of patients with sudden cardiac death (SCD). The success rate of CPR remains far below expectations, which made CPR education identified as the top priority for SCD. CPR training using the virtual reality (VR) technique is a feasible training method, with a wider population and lower cost, but its efficacy remains controversial. Thus, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of the VR technique on CPR quality.

METHODS AND ANALYSIS

We will search PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases from inception to November 2021, to identify randomised controlled trials and the first period in randomised cross-over trials assessing the efficacy of VR techniques versus non-VR techniques for adult participants accepting adult CPR training. No language restrictions will be considered. Data synthesis will be performed using RevMan V.5.4 and Stata/MP V.16.0. Outcome measures will be present as relative risk with 95% CIs for dichotomous data and mean difference with 95% CIs for continuous data. The primary outcome will be the CPR quality defined as chest compression rate and depth. Secondary outcomes will be the overall performance of CPR. Heterogeneity will be assessed by the χ² test and I² statistic. Data will be synthesised by either fixed-effects or random-effects models according to the I² value. Trial sequential analysis and modified Jadad Scale will be used to control the risks of random errors and evaluate the evidence quality. Egger's regression test and funnel plots will be used to assess the publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The findings will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021281059.

AEducaAR, Anatomical Education in Augmented Reality: A Pilot Experience of an Innovative Educational Tool Combining AR Technology and 3D Printing

Gross anatomy knowledge is an essential element for medical students in their education, and nowadays, cadaver-based instruction represents the main instructional tool able to provide three-dimensional (3D) and topographical comprehensions. The aim of the study was to develop and test a prototype of an innovative tool for medical education in human anatomy based on the combination of augmented reality (AR) technology and a tangible 3D printed model that can be explored and manipulated by trainees, thus favoring a three-dimensional and topographical learning approach. After development of the tool, called AEducaAR (Anatomical Education with Augmented Reality), it was tested and evaluated by 62 second-year degree medical students attending the human anatomy course at the International School of Medicine and Surgery of the University of Bologna. Students were divided into two groups: AEducaAR-based learning ("AEducaAR group") was compared to standard learning using human anatomy atlas ("Control group"). Both groups performed an objective test and an anonymous questionnaire. In the objective test, the results showed no significant difference between the two learning methods; instead, in the questionnaire, students showed enthusiasm and interest for the new tool and highlighted its training potentiality in open-ended comments. Therefore, the presented AEducaAR tool, once implemented, may contribute to enhancing students' motivation for learning, increasing long-term memory retention and 3D comprehension of anatomical structures. Moreover, this new tool might help medical students to approach to innovative medical devices and technologies useful in their future careers.

Integration of Extended Reality and a High-Fidelity Simulator in Team-Based Simulations for Emergency Scenarios

Wearable devices such as smart glasses are considered promising assistive tools for information exchange in healthcare settings. We aimed to evaluate the usability and feasibility of smart glasses for team-based simulations constructed using a high-fidelity simulator. Two scenarios of patients with arrhythmia were developed to establish a procedure for interprofessional interactions via smart glasses using 15-h simulation training. Three to four participants formed a team and played the roles of remote supporter or bed-side trainee with smart glasses. Usability, attitudes towards the interprofessional health care team and learning satisfaction were assessed. Using a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree), 31 participants reported that the smart glasses were easy to use (3.61 ± 0.95), that they felt confident during use (3.90 ± 0.87), and that that responded positively to long-term use (3.26 ± 0.89) and low levels of physical discomfort (1.96 ± 1.06). The learning satisfaction was high (4.65 ± 0.55), and most (84%) participants found the experience favorable. Key challenges included an unstable internet connection, poor resolution and display, and physical discomfort while using the smart glasses with accessories. We determined the feasibility and acceptability of smart glasses for interprofessional interactions within a team-based simulation. Participants responded favorably toward a smart glass-based simulation learning environment that would be applicable in clinical settings.

The Effectiveness of Using Augmented Reality for Training in the Medical Professions: A Meta Analysis (Preprint)

Background

Augmented reality (AR) is an interactive technology that uses persuasive digital data and real-world surroundings to expand the user's reality, wherein objects are produced by various computer applications. It constitutes a novel advancement in medical care, education, and training.

Objective

The aim of this work was to assess how effective AR is in training medical students when compared to other educational methods in terms of skills, knowledge, confidence, performance time, and satisfaction.

Methods

We performed a meta-analysis on the effectiveness of AR in medical training that was constructed by using the Cochrane methodology. A web-based literature search was performed by using the Cochrane Library, Web of Science, PubMed, and Embase databases to find studies that recorded the effect of AR in medical training up to April 2021. The quality of the selected studies was assessed by following the Cochrane criteria for risk of bias evaluations.

Results

In total, 13 studies with a total of 654 participants were included in the meta-analysis. The findings showed that using AR in training can improve participants' performance time (I²=99.9%; P<.001), confidence (I²=97.7%; P=.02), and satisfaction (I²=99.8%; P=.006) more than what occurs under control conditions. Further, AR did not have any effect on the participants’ knowledge (I²=99.4%; P=.90) and skills (I²=97.5%; P=.10). The meta-regression plot shows that there has been an increase in the number of articles discussing AR over the years and that there is no publication bias in the studies used for the meta-analysis.

Conclusions

The findings of this work suggest that AR can effectively improve performance time, satisfaction, and confidence in medical training but is not very effective in areas such as knowledge and skill. Therefore, more AR technologies should be implemented in the field of medical training and education. However, to confirm these findings, more meticulous research with more participants is needed.

The use of virtual reality and augmented reality to enhance cardio-pulmonary resuscitation: a scoping review

BACKGROUND AND OBJECTIVE

Virtual reality (VR) and augmented reality (AR) have been proposed as novel methods to enhance cardio-pulmonary resuscitation (CPR) performance and increase engagement with CPR training. A scoping review was conducted to map the global evolution of these new approaches to CPR training, to assess their efficacy and determine future directions to meet gaps in current knowledge.

METHODS

A standardised five-stage scoping methodology was used to (1) identify the research question, (2) identify relevant studies, (3) select the studies, (4) chart the data and (5) summarise the findings. The Kirkpatrick model levels of evidence were used to chart and assess the efficacy of each intervention reported. A multi-pronged search term strategy was used to search the Web of Science, PubMed, CINAHL and EMBASE databases up to June 2020.

RESULTS

A total of 42 articles were included in this review. The first relevant paper identified was published in 2009 and based on VR, from 2014 onwards there was a large increase in the volume of work being published regarding VR and AR uses in CPR training. This review reports Kirkpatrick level one to three evidence for the use of VR/AR-CPR. Inconsistencies in the specific language, keywords used and methodologies are highlighted.

CONCLUSION

VR and AR technologies have shown great potential in the area of CPR, and there is continuing evidence of new novel applications and concepts. As VR/AR research into CPR reaches an inflection point, it is key to bring collaboration and consistency to the wider research community, to enable the growth of the area and ease of access to the wider medical community.

Can anxiety in undergraduate students in a high-fidelity clinical simulation be predicted? A randomized, sham-controlled, blinded trial

INTRODUCTION

High-fidelity clinical simulation has implied a revolution in health science training. Despite its benefits, some drawbacks could hinder the learning process, especially the anxiety produced during such scenarios.

OBJECTIVES

The aim of the present work is to develop a predictive model capable of determining which students will present high levels of anxiety.

DESIGN

We performed a randomized, sham-controlled, blinded trial in which students were randomly assigned to four scenarios and played one of two possible roles.

METHODS

Before and after the simulation we assessed the anxiety level along with physiological and analytical parameters. The main analyzed outcome was an increase of ≥25% in anxiety compared with baseline.

RESULTS

The type of scenario or the role played had no effect on anxiety. The predictive model presented an Area Under the Receiver Operating Characteristics of 0.798 (95% CI: 0.69-0.90; p < 0.001), with age and systolic blood pressure being protective factors against anxiety.

CONCLUSIONS

Our results showed that the anxiety level developed during simulation could be predicted. The application of this predictive model when associated to appropriate techniques to deal with increased anxiety levels could improve the learning process of medical students during simulations.

Augmented Reality Technology as a Teaching Strategy for Learning Pediatric Asthma Management: Mixed Methods Study

Background

Asthma is a major chronic disease affecting 8.6% of children in the United States.

Objective

The purpose of this research was to assess the use of clinical simulation scenarios using augmented reality technology to evaluate learning outcomes for nurse practitioner students studying pediatric asthma management.

Methods

A mixed-methods pilot study was conducted with 2 cohorts of graduate pediatric nurse practitioner students (N=21), with each cohort participating for 2 semesters.

Results

Significant improvements in pediatric asthma test scores (P<.001) of student learning were found in both cohorts at posttest in both semesters. Student satisfaction with the augmented reality technology was found to be high. The focus group discussions revealed that the simulation was realistic and helpful for a flipped classroom approach.

Conclusions

The study results suggest augmented reality simulation to be valuable in teaching pediatric asthma management content in graduate nursing education.

Virtual and Augmented Realities in Nursing Education: State of the Science

The use of simulation in nursing education is an integrated part of the curriculum and has demonstrated the benefit for learning in nursing students at all levels. The next stage in simulation-based learning will utilize the wide variety of new technologies that are currently available, including virtual and augmented reality. The use of these new technologies brings with it a need for standard definitions, evaluation of its impact on learning, and new opportunities for research. Efforts are underway to standardized definitions and publish early findings on research using these new technologies. There are many opportunities available for nursing educators to create a new era of simulation-based learning methodologies by incorporating virtual and augmented realities in their curriculum. The state of the science is showing promising outcomes and commercial products are maturing.The utilization of these new technologies should be approached in the same way as other learning methodologies as many new ideas and ways of learning are emerging in this area. It will be critical for nursing educators and faculty to determine the optimal ways to utilize them.

Learning With Virtual Reality in Nursing Education: Qualitative Interview Study Among Nursing Students Using the Unified Theory of Acceptance and Use of Technology Model

Background

Digital games–based learning is a method of using digital games to impart knowledge. Virtual reality (VR) programs are a practical application of this method. Due to demographic changes, the nursing profession will become increasingly important. These VR applications can be of use in training nurses for future professional challenges they may encounter. The continuous development of VR applications enables trainees to encounter simulated real life effectively and to experience increasingly concrete situations. This can be of great importance in nursing education, since 3-dimensionality enables a better visualization of many fields of activity and can prevent potential future errors. In addition to this learning effect, VR applications also bring an element of fun to learning.

Objective

The aim of this qualitative research effort is to observe the degree of acceptance of VR applications by nursing students in Germany. Various factors, including social influences, performance expectations, and effort expectations, are taken into consideration.

Methods

With a qualitative cohort study, the acceptance of nursing students towards VR applications in anatomy teaching was determined. The 12 participants were first asked to fill out a quantitative questionnaire on their sociodemographic characteristics and the extent to which they valued and liked using technology. The participants were then allowed to test the VR application themselves and were finally asked about their experience in a qualitative interview. For the collection of data and the analysis of results, the unified theory of acceptance and use of technology was used in this study.

Results

Overall, the study shows that the interviewed persons rated the VR application quite positively. The greatest influence in this was the personal attitude towards technology; the higher this affinity is, the more useful the VR application appears. Social influences can also increase the participant’s own acceptance if peers have a positive attitude towards such applications. The study shows that the trainees' motivation to learn was increased by using VR. We believe this is because each trainee could learn individually and the VR application was perceived as an enjoyable activity. Nevertheless, the cost factor of implementing VR applications in nursing training is currently still an obstacle, as not every institution has such financial capacities.

Conclusions

The extent to which the use of VR applications in the training of nursing staff is justified depends on the degree of personal acceptance. The collected results give good practice-oriented insight into the attitude of trainees towards VR. Many of the interviewed persons saw benefits in the use of VR technologies. As VR applications are constantly developing, it is necessary to conduct further studies on VR applications in nursing education and to include other possible disciplines in which these applications can be helpful.

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Augmented Reality Learning Environment for Basic Life Support and Defibrillation Training: Usability Study

Background

Basic life support (BLS) is crucial in the emergency response system, as sudden cardiac arrest is still a major cause of death worldwide. Unfortunately, only a minority of victims receive cardiopulmonary resuscitation (CPR) from bystanders. In this context, training could be helpful to save more lives, and technology-enhanced BLS simulation is one possible solution.

Objective

The aim of this study is to assess the feasibility and acceptability of our augmented reality (AR) prototype as a tool for BLS training.

Methods

Holo-BLSD is an AR self-instruction training system, in which a standard CPR manikin is “augmented” with an interactive virtual environment that reproduces realistic scenarios. Learners can use natural gestures, body movements, and spoken commands to perform their tasks, with virtual 3D objects anchored to the manikin and the environment. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the feasibility and acceptability of the proposed tool (5-point Likert scale; 1=Strongly Disagree, 5=Strongly Agree).

Results

The system was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04).

Conclusions

We found the Holo-BLSD system to be a feasible and acceptable tool for AR BLS training.

Augmented reality in medical education: a systematic review

INTRODUCTION

The field of augmented reality (AR) is rapidly growing with many new potential applications in medical education. This systematic review investigated the current state of augmented reality applications (ARAs) and developed an analytical model to guide future research in assessing ARAs as teaching tools in medical education.

METHODS

A literature search was conducted using PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar. This review followed PRISMA guidelines and included publications from January 1, 2000 to June 18, 2018. Inclusion criteria were experimental studies evaluating ARAs implemented in healthcare education published in English. Our review evaluated study quality and determined whether studies assessed ARA validity using criteria established by the GRADE Working Group and Gallagher et al., respectively. These findings were used to formulate an analytical model to assess the readiness of ARAs for implementation in medical education.

RESULTS

We identified 100,807 articles in the initial literature search; 36 met inclusion criteria for final review and were categorized into three categories: Surgery (23), Anatomy (9), and Other (4). The overall quality of the studies was poor and no ARA was tested for all five stages of validity. Our analytical model evaluates the importance of research quality, application content, outcomes, and feasibility of an ARA to gauge its readiness for implementation.

CONCLUSION

While AR technology is growing at a rapid rate, the current quality and breadth of AR research in medical training is insufficient to recommend the adoption into educational curricula. We hope our analytical model will help standardize AR assessment methods and define the role of AR technology in medical education.

Augmented Reality in Medicine: Systematic and Bibliographic Review

Background

Augmented reality (AR) is a technology that integrates digital information into the user’s real-world environment. It offers a new approach for treatments and education in medicine. AR aids in surgery planning and patient treatment and helps explain complex medical situations to patients and their relatives.

Objective

This systematic and bibliographic review offers an overview of the development of apps in AR with a medical use case from March 2012 to June 2017. This work can aid as a guide to the literature and categorizes the publications in the field of AR research.

Methods

From March 2012 to June 2017, a total of 1309 publications from PubMed and Scopus databases were manually analyzed and categorized based on a predefined taxonomy. Of the total, 340 duplicates were removed and 631 publications were excluded due to incorrect classification or unavailable technical data. The remaining 338 publications were original research studies on AR. An assessment of the maturity of the projects was conducted on these publications by using the technology readiness level. To provide a comprehensive process of inclusion and exclusion, the authors adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Results

The results showed an increasing trend in the number of publications on AR in medicine. There were no relevant clinical trials on the effect of AR in medicine. Domains that used display technologies seemed to be researched more than other medical fields. The technology readiness level showed that AR technology is following a rough bell curve from levels 4 to 7. Current AR technology is more often applied to treatment scenarios than training scenarios.

Conclusions

This work discusses the applicability and future development of augmented- and mixed-reality technologies such as wearable computers and AR devices. It offers an overview of current technology and a base for researchers interested in developing AR apps in medicine. The field of AR is well researched, and there is a positive trend in its application, but its use is still in the early stages in the field of medicine and it is not widely adopted in clinical practice. Clinical studies proving the effectiveness of applied AR technologies are still lacking.

Augmented Reality in Emergency Medicine: A Scoping Review

BACKGROUND

Augmented reality is increasingly being investigated for its applications to medical specialties as well as in medical training. Currently, there is little information about its applicability to training and care delivery in the context of emergency medicine.

OBJECTIVE

The objective of this article is to review current literature related to augmented reality applicable to emergency medicine and its training.

METHODS

Through a scoping review utilizing Scopus, MEDLINE, and Embase databases for article searches, we identified articles involving augmented reality that directly involved emergency medicine or was in an area of education or clinical care that could be potentially applied to emergency medicine.

RESULTS

A total of 24 articles were reviewed in detail and were categorized into three groups: user-environment interface, telemedicine and prehospital care, and education and training.

CONCLUSIONS

Through analysis of the current literature across fields, we were able to demonstrate that augmented reality has utility and feasibility in clinical care delivery in patient care settings, in operating rooms and inpatient settings, and in education and training of emergency care providers. Additionally, we found that the use of augmented reality for care delivery over distances is feasible, suggesting a role in telehealth. Our results from the review of the literature in emergency medicine and other specialties reveal that further research into the uses of augmented reality will have a substantial role in changing how emergency medicine as a specialty will deliver care and provide education and training.

Use of Smartphone-Based Head-Mounted Display Devices to View a Three-Dimensional Dissection Model in a Virtual Reality Environment: Pilot Questionnaire Study

BACKGROUND

Virtual reality (VR) technology has started to gain attention as a form of surgical support in medical settings. Likewise, the widespread use of smartphones has resulted in the development of various medical applications; for example, Google Cardboard, which can be used to build simple head-mounted displays (HMDs). However, because of the absence of observed and reported outcomes of the use of three-dimensional (3D) organ models in relevant environments, we have yet to determine the effects of or issues with the use of such VR technology.

OBJECTIVE

The aim of this paper was to study the issues that arise while observing a 3D model of an organ that is created based on an actual surgical case through the use of a smartphone-based simple HMD. Upon completion, we evaluated and gathered feedback on the performance and usability of the simple observation environment we had created.

METHODS

We downloaded our data to a smartphone (Galaxy S6; Samsung, Seoul, Korea) and created a simple HMD system using Google Cardboard (Google). A total of 17 medical students performed 2 experiments: an observation conducted by a single observer and another one carried out by multiple observers using a simple HMD. Afterward, they assessed the results by responding to a questionnaire survey.

RESULTS

We received a largely favorable response in the evaluation of the dissection model, but also a low score because of visually induced motion sickness and eye fatigue. In an introspective report on simultaneous observations made by multiple observers, positive opinions indicated clear image quality and shared understanding, but displeasure caused by visually induced motion sickness, eye fatigue, and hardware problems was also expressed.

CONCLUSIONS

We established a simple system that enables multiple persons to observe a 3D model. Although the observation conducted by multiple observers was successful, problems likely arose because of poor smartphone performance. Therefore, smartphone performance improvement may be a key factor in establishing a low-cost and user-friendly 3D observation environment.

Assessment of Google Glass for Photographic Documentation in Veterinary Forensic Pathology: Usability Study

Background

Google Glass is a head-mounted device designed in the shape of a pair of eyeglasses equipped with a 5.0-megapixel integrated camera and capable of taking pictures with simple voice commands.

Objective

The objective of our study was to determine whether Google Glass is fit for veterinary forensic pathology purposes.

Methods

A total of 44 forensic necropsies of 2 different species (22 dogs and 22 cats) were performed by 2 pathologists; each pathologist conducted 11 necropsies of each species and, for each photographic acquisition, the images were taken with a Google Glass device and a Nikon D3200 digital single-lens reflex (DSLR) camera. The pictures were collected, divided into 3 groups (based on the external appearance of the animal, organs, and anatomical details), and evaluated by 5 forensic pathologists using a 5-point score system. The parameters assessed were overall color settings, region of interest, sharpness, and brightness. To evaluate the difference in mean duration between necropsies conduced with Google Glass and DSLR camera and to assess the battery consumption of the devices, an additional number of 16 necropsies were performed by the 2 pathologists. In these cases, Google Glass was used for photographic reports in 8 cases (4 dogs and 4 cats) and a Nikon D3200 reflex camera in the other 8 cases. Statistical evaluations were performed to assess the differences in ratings between the quality of the images taken with both devices.

Results

The images taken with Google Glass received significantly lower ratings than those acquired with reflex camera for all 4 assessed parameters (P<.001). In particular, for the pictures of Groups A and B taken with Google Glass, the sum of frequency of ratings 5 (very good) and 4 (good) was between 50% and 77% for all 4 assessed parameters. The lowest ratings were observed for the pictures of Group C, with a sum of frequency of ratings 5 and 4 of 21.1% (342/1602) for region of interest, 26% (421/1602) for sharpness, 35.5% (575/1602) for overall color settings, and 61.4% (995/1602) for brightness. Furthermore, we found a significant reduction in the mean execution time for necropsy conduced with the Google Glass with respect to the reflex group (P<.001). However, Google Glass drained the battery very quickly.

Conclusions

These findings suggest that Google Glass is usable in veterinary forensic pathology. In particular, the image quality of Groups A and B seemed adequate for forensic photographic documentation purposes, although the quality was lower than that with the reflex camera. However, in this step of development, the high frequency of poor ratings observed for the pictures of Group C suggest that the device is not suitable for taking pictures of small anatomical details or close-ups of the injuries.

Using Google Glass in Surgical Settings: Systematic Review

Background

In recent years, wearable devices have become increasingly attractive and the health care industry has been especially drawn to Google Glass because of its ability to serve as a head-mounted wearable device. The use of Google Glass in surgical settings is of particular interest due to the hands-free device potential to streamline workflow and maintain sterile conditions in an operating room environment.

Objective

The aim is to conduct a systematic evaluation of the literature on the feasibility and acceptability of using Google Glass in surgical settings and to assess the potential benefits and limitations of its application.

Methods

The literature was searched for articles published between January 2013 and May 2017. The search included the following databases: PubMed MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO (EBSCO), and IEEE Xplore. Two reviewers independently screened titles and abstracts and assessed full-text articles. Original research articles that evaluated the feasibility, usability, or acceptability of using Google Glass in surgical settings were included. This review was completed following the Preferred Reporting Results of Systematic Reviews and Meta-Analyses guidelines.

Results

Of the 520 records obtained, 31 met all predefined criteria and were included in this review. Google Glass was used in various surgical specialties. Most studies were in the United States (23/31, 74%) and all were conducted in hospital settings: 29 in adult hospitals (29/31, 94%) and two in children’s hospitals (2/31, 7%). Sample sizes of participants who wore Google Glass ranged from 1 to 40. Of the 31 studies, 25 (81%) were conducted under real-time conditions or actual clinical care settings, whereas the other six (19%) were conducted under simulated environment. Twenty-six studies were pilot or feasibility studies (84%), three were case studies (10%), and two were randomized controlled trials (6%). The majority of studies examined the potential use of Google Glass as an intraoperative intervention (27/31, 87%), whereas others observed its potential use in preoperative (4/31, 13%) and postoperative settings (5/31, 16%). Google Glass was utilized as a videography and photography device (21/31, 68%), a vital sign monitor (6/31, 19%), a surgical navigation display (5/31, 16%), and as a videoconferencing tool to communicate with remote surgeons intraoperatively (5/31, 16%). Most studies reported moderate or high acceptability of using Google Glass in surgical settings. The main reported limitations of using Google Glass utilization were short battery life (8/31, 26%) and difficulty with hands-free features (5/31, 16%).

Conclusions

There are promising feasibility and usability data of using Google Glass in surgical settings with particular benefits for surgical education and training. Despite existing technical limitations, Google Glass was generally well received and several studies in surgical settings acknowledged its potential for training, consultation, patient monitoring, and audiovisual recording.

Using Google Glass in Nonsurgical Medical Settings: Systematic Review

Background

Wearable technologies provide users hands-free access to computer functions and are becoming increasingly popular on both the consumer market and in various industries. The medical industry has pioneered research and implementation of head-mounted wearable devices, such as Google Glass. Most of this research has focused on surgical interventions; however, other medical fields have begun to explore the potential of this technology to support both patients and clinicians.

Objective

Our aim was to systematically evaluate the feasibility, usability, and acceptability of using Google Glass in nonsurgical medical settings and to determine the benefits, limitations, and future directions of its application.

Methods

This review covers literature published between January 2013 and May 2017. Searches included PubMed MEDLINE, Embase, INSPEC (Ebsco), Cochrane Central Register of Controlled Trials (CENTRAL), IEEE Explore, Web of Science, Scopus, and Compendex. The search strategy sought all articles on Google Glass. Two reviewers independently screened titles and abstracts, assessed full-text articles, and extracted data from articles that met all predefined criteria. Any disagreements were resolved by discussion or consultation by the senior author. Included studies were original research articles that evaluated the feasibility, usability, or acceptability of Google Glass in nonsurgical medical settings. The preferred reporting results of systematic reviews and meta-analyses (PRISMA) guidelines were followed for reporting of results.

Results

Of the 852 records examined, 51 met all predefined criteria, including patient-centered (n=21) and clinician-centered studies (n=30). Patient-centered studies explored the utility of Google Glass in supporting patients with motor impairments (n=8), visual impairments (n=5), developmental and psychiatric disorders (n=2), weight management concerns (n=3), allergies (n=1), or other health concerns (n=2). Clinician-centered studies explored the utility of Google Glass in student training (n=9), disaster relief (n=4), diagnostics (n=2), nursing (n=1), autopsy and postmortem examination (n=1), wound care (n=1), behavioral sciences (n=1), and various medical subspecialties, including, cardiology (n=3), radiology (n=3), neurology (n=1), anesthesiology (n=1), pulmonology (n=1), toxicology (n=1), and dermatology (n=1). Most of the studies were conducted in the United States (40/51, 78%), did not report specific age information for participants (38/51, 75%), had sample size <30 participants (29/51, 57%), and were pilot or feasibility studies (31/51, 61%). Most patient-centered studies (19/21, 90%) demonstrated feasibility with high satisfaction and acceptability among participants, despite a few technical challenges with the device. A number of clinician-centered studies (11/30, 37%) reported low to moderate satisfaction among participants, with the most promising results being in the area of student training. Studies varied in sample size, approach for implementation of Google Glass, and outcomes assessment.

Conclusions

The use of Google Glass in nonsurgical medical settings varied. More promising results regarding the feasibility, usability, and acceptability of using Google Glass were seen in patient-centered studies and student training settings. Further research evaluating the efficacy and cost-effectiveness of Google Glass as an intervention to improve important clinical outcomes is warranted.

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.

Objective

The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.

Methods

We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.

Results

Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.

Conclusions

AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

DJINNI: A Novel Technology Supported Exposure Therapy Paradigm for SAD Combining Virtual Reality and Augmented Reality

The present paper explores the benefits and the capabilities of various emerging state-of-the-art interactive 3D and Internet of Things technologies and investigates how these technologies can be exploited to develop a more effective technology supported exposure therapy solution for social anxiety disorder. "DJINNI" is a conceptual design of an in vivo augmented reality (AR) exposure therapy mobile support system that exploits several capturing technologies and integrates the patient's state and situation by vision-based, audio-based, and physiology-based analysis as well as by indoor/outdoor localization techniques. DJINNI also comprises an innovative virtual reality exposure therapy system that is adaptive and customizable to the demands of the in vivo experience and therapeutic progress. DJINNI follows a gamification approach where rewards and achievements are utilized to motivate the patient to progress in her/his treatment. The current paper reviews the state of the art of technologies needed for such a solution and recommends how these technologies could be integrated in the development of an individually tailored and yet feasible and effective AR/virtual reality-based exposure therapy. Finally, the paper outlines how DJINNI could be part of classical cognitive behavioral treatment and how to validate such a setup.