The University of Canberra uses holographic patients to augment nurse education. Dr. Jane Frost explains how using HoloPatient and HoloHuman has benefitted nursing students.
Technology enhanced learning has the potential to transform simulation in health education. Innovative applications such as HoloPatient and HoloHuman coupled with mixed reality headsets such as the Microsoft HoloLens are an innovative way to engage students and deliver content. The University of Canberra has embraced this technology with nursing students stating that “visualizing a scenario helps to create a longer lasting impression in the minds of a learner”.
Nursing schools across the globe have spent hundreds of thousands of dollars on simulation suites and high technology manikins. Simulation is not new to health care and there are already hundreds of products on the market and a multitude of techniques being employed. With clinical practice hours for undergraduate students at a premium there is currently a body of work that is promoting the idea that simulated learning can replace clinical practice hours. How to do this and in what form this should take has yet to be answered, however research in the US suggests that up to fifty percent of clinical training hours could be replaced by simulation (Hayden et al, 2014).
Over the last decade there has been a huge influx of both virtual reality and augmented reality platforms introduced into higher education particularly in the health space. Virtual reality (VR) is usually fully immersive and takes place in a computer-generated environment, whereas augmented reality (AR) is where digital elements are placed into the real world. Mixed reality (MR) exists on the technology continuum and has been defined by Milgram and Kishino (1994) as a subset of VR. MR merges both the real and virtual worlds. Microsoft HoloLens is a head mounted MR device.
At the University of Canberra work is underway using mixed reality headsets in the form of the Microsoft HoloLens to create new learning experiences for students. This technology has not been used to replace other simulation methods rather to augment existing approaches. Two specific application are gaining traction in the field, these are HoloHuman, an anatomy application and HoloPatient, an application that has been designed to show holographic standardized patients. HoloHuman and HoloPatient are applications developed by Pearson.
Imagine for a moment being able to view the organs inside a body with no cadaver required. This has been possible in VR platforms for some time but in a MR format the human anatomy can be viewed through holographic displays that can be projected at the bedside or on top of manikins or part task trainers (sections of a manikin used for skills development) the learner can still see the classroom environment and this allows more than one person to use the technology as they remain aware of each other in the space. In a recent nursing classroom, the HoloHuman application was used to enhance skills development in female catheterization.
Traditionally skills development is taught on manikins or part task trainers, using relatively low fidelity simulation. But in this class the learning was augmented with mixed reality. Students were given headsets to use in a group as they negotiated the task. HoloHuman allowed students to explore the body, to literally walk through the holographic image which was rotated to mimic the position of the manikin. As you move into the hologram the image slowly disappears to reveal the layers of the body in a cross-sectional view. Students could follow the route a catheter would take (or rather should take when placed correctly) through the body and observe the structures at either side of the urethra and bladder. It has also been used to explore the placement of intramuscular injections and to provide deeper learning and spatial understanding of structures in the body to reinforce the reasons for using for example, the deltoid muscle. This gives the students much more than a text book image, it allows students to visualize in 3D, to dissect the body and to enhance their knowledge and skills relating to specific tasks.
HoloPatient offers an aspect to simulation that has so far been difficult to create in other ways. As an early adopter of the technology, I have been using HoloPatient for several years.
HoloPatient is a holographic image of a patient that is displaying realistic symptoms of a condition/disease process. One of the difficulties of recognizing patient symptoms and deterioration is being able to identify signs and symptoms as they develop. A manikin can show deterioration on a monitor, or on auscultation, but not accurately portray the symptoms of breathlessness. Additionally, manikins cannot be easily positioned to show a realistic stance for someone who is breathless, for example the tripod position. An actor or standardized patient can sometimes give a rehearsed performance of symptoms, but this cannot usually be sustained.
HoloPatient is a 3D holographic image that can be used to allow students to visualize symptoms, to develop skills in visual assessment, and to promote critical thinking and clinical judgement. Patient safety is a key healthcare priority and early recognition of the deteriorating patient is paramount. Learning to notice deterioration and/or change is important and we should not be relying on solely on patient monitors as we often do in simulation with manikins to recognize this deterioration.
Dean, Williams and Balnave (2017) suggest that the use of high technology manikins in simulation is leading to a lack of empathy in nurses. It is perhaps ironic to suggest MR technology maybe a solution that can be used to allow students the opportunity to really ‘see’ their patient rather than relying on monitors. Additionally, students described a benefit in the ability to explore the patient’s symptoms without having to negotiate personal space issues. Students also found that MR allowed them time to look and to think (without the need to respond) and to brainstorm possible causes of symptoms. Group discussion that arose also drew on peer learning strategies and allowed problem solving to occur organically.
HoloPatient gives a standardized image that is useful for consistent teaching and has potential in assessment, developed for a nursing audience the University of Canberra has also trialed this application in other disciplines such as pharmacy and occupational therapy with good results. Furthermore, the HoloPatient has additional benefits in teaching professional terminology regarding symptoms and deterioration.
It is important when embracing new technology that we understand what benefits the new technology is providing. Pedagogy before technology, I hear the cry. The above examples draw on active learning and experiential learning strategies and provide the activity or experience that is then discussed. Debrief is widely recognized as an important component part of simulation experiences and using the HoloLens is no different. These new applications need to be introduced in a considered way to secure their place in meaningful education. Perhaps in the next few years as headsets become cheaper and more accessible, they will be common place in the nursing classroom. This has not happened to date, but there is definite potential in using MR to create powerful learning moments.
Introducing new technology into curricula takes a vision and purpose, an advocate and access to and investment in the technology. It also takes more than a little time and a whole lot of patience. But the benefits are there. Research using augmented reality has shown that it increases motivation, engagement and increases learning (Zhu et al, 2014). MR as a more immersive platform has the potential to replicate and increase these benefits for learning.
HoloPatient and HoloHuman are useful resources that have promoted engagement with content in my classroom, and the head mounted devices are developing rapidly. Additionally, HoloLens 2 promises additional features and a larger range of vision as well as new opportunities to explore learning with the incorporation of eye tracking facilities.
We are not there yet. Future learners will use HoloLens technology, or its successor, and VR and MR will feature heavily in the simulation space and will no doubt become a staple element in simulation centres and curriculums. With the complexities of nursing and of healthcare in general it is unlikely that any one simulation technique or technology will provide all the answers.
Humanistic interaction and communication skills are fundamental for both physical and emotional wellness and as people we need to feel connected. Communication skills, compassion and empathy are an integral part of health care and require different approaches. Additionally, the manual dexterity associated with specific skills cannot yet be taught. However, as we negotiate ways of presenting content to our future learners who are technologically savvy, they will expect this type of simulation and we would be remiss not to utilise it.
About the Author
Dr Jane Frost, RN, NP, BSC (Hons), MSc NP, DNP, GCTE, SFHEA, is an Associate Professor in Nursing, and Program Director for Nursing Midwifery and Public Health at University of Canberra. Jane is a Senior Fellow of the Higher Education Academy. Jane is an experienced educator, endorsed Nurse Practitioner, and Nurse academic. In 2017, Jane was the first person in Australia to be conferred as a Doctor of Nurse Practitioner. Jane has had an extensive clinical career and is passionate about the role of the nurse in improving patient care. Jane enjoys teaching and employs innovative techniques to prepare students for the realities of clinical practice. She understands the importance of responding to individual patient needs and endeavours to develop the art of therapeutic communication in her students. Jane is considered a leader in using simulation to create authentic learning experiences.
Microsoft have announced the next version of the HoloLens called HoloLens 2. It is expected to be released into the market sometime in August 2019 or soon thereafter. For more information see the link www.microsoft.com/en-us/hololens/hardware# The HoloLens 2 has significant improvements including a wider (i.e. more than double) field of view, the devices are lighter, better balanced and more comfortable, and the method of interacting will use full hand articulation making hand gestures more natural and intuitive. In the future, the eye tracking and AI feature will enable apps to provide increased knowledge to the teacher and learner about the learning. Pearson apps will be compatible with HoloLens 2 before the product is released into the market.
Dean, S., Williams, C., & Balnaves, M. (2017). Living dolls and nurses without empathy. Journal of Advanced Nursing, 73(4), 757-759.
Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation.
Milgram, P. and Kishino, F., 1994. A taxonomy of mixed reality visual displays. IEICE TRANSACTIONS on Information and Systems, 77(12), pp.1321-1329.
Zhu, E., Hadadgar, A., Masiello, I., & Zary, N. (2014). Augmented reality in healthcare education: an integrative review. PeerJ, 2, e469.
Originally published in Issue 3, 2019 of MT Magazine.