Evaluation of a virtual reality based interactive simulator with haptic feedback for learning NGT placement

Background The placement of a nasogastric tube is a blind process; the tube may be mistakenly inserted into other locations, leading to possible complications or fatal incidents. Effective education and training of nursing students to perform this procedure is essential. Purpose To investigate the application of the virtual reality based simulator with haptic feedback to nursing students for their learning around nasogastric tube placement. Methods A quasi-experimental non-equivalent group pre- and post-test study, in which the outcome measures of two classes of pre-registration nursing students were compared for their evidence of learning about the advanced NGT simulator (in addition to usual training) against the control group who only used mannequins for their usual education and training. Results There was a decrease, though remaining at a good level, in the technology acceptance rating within (p = .000) and between (p < .05) the simulator group than the control over time at post-test. Taking into consideration of some demographic differences at baseline between the two groups, analysis of results demonstrated that there was no predictor effect of those factors in relation to technology acceptance (F = .02, p = .922), but in scores for the test using multiple-choice questions (MCQ) about knowledge in nasogastric tube insertion (F = 23.4, p = .000). Both groups demonstrated significant increases in MCQ scores at post-test, with higher scores in the simulator group at both pre-test (p < .05) and post-test (p = .000). There was no significant difference in learning outcomes around competence in skills within the evaluation results between groups at post-test. Usability of the simulator system as rated by the simulator group was good. Conclusions Students did not reject the use of the new simulator for their learning about nasogastric tube placement. As an adjunct to conventional teaching and learning, the use of the simulator appears to be promising in enhancing the education and training of nursing students for development of the important clinical skill of safe nasogastric tube placement. Future studies are warranted, with the design inclusive of equivalent groups and a larger sample size to further the evidence in substantiating the use of this simulator for better learning outcomes

Simulation in Medical School Education: Review for Emergency Medicine

<p>Medical education is rapidly evolving. With the paradigm shift to small-group didactic sessions and focus on clinically oriented case-based scenarios, simulation training has provided educators a novel way to deliver medical education in the 21st century. The field continues to expand in scope and practice and is being incorporated into medical school clerkship education, and specifically in emergency medicine (EM). The use of medical simulation in graduate medical education is well documented. Our aim in this article is to perform a retrospective review of the current literature, studying simulation use in EM medical student clerkships. Studies have demonstrated the effectiveness of simulation in teaching basic science, clinical knowledge, procedural skills, teamwork, and communication skills. As simulation becomes increasingly prevalent in medical school curricula, more studies are needed to assess whether simulation training improves patient-related outcomes.</p

Simulation and Curriculum Integration: Does Simulation Improve Clinical Competence

Background: While simulation is a widely used pedagogy in nursing education, there is inconsistent evidence regarding its effectiveness in demonstrating positive learning outcomes. Therefore, further research is needed to establish the effectiveness of simulation in developing clinical competence, and the incorporation of this pedagogy into nursing curricula. Purpose: To explore how the integration of high-fidelity simulation into nursing curricula influences learning outcomes. More specifically, to examine differences in clinical competence as measured by the outcomes: knowledge, skills, critical thinking, and clinical judgment in nursing fundamental students taught using high-fidelity simulation versus traditional instructional methods. Design: A two-group time series experimental design was used to evaluate the impact of traditional or high fidelity simulation instructional methods on improving clinical competence at three time points. Findings: The results reveal significant improvements in knowledge, skills, and clinical judgment over time. However, instructional method did not have a significant effect on these learning outcomes. There was a significant interaction between time and instructional method on improving critical thinking, as both groups demonstrated significant improvements from pre to post intervention. The traditional group showed a significant decline in critical thinking ability 3 weeks post intervention, while the simulation group remained unchanged. Conclusions: The findings of this study support the inclusion of high-fidelity simulation into nursing curricula to facilitate improvements in clinical competence. This study provides evidence that high-fidelity simulation is a better approach than traditional instruction in developing critical thinking, and is analogous to traditional instruction in improving all other domains of clinical competence

The Use of Virtual Reality Simulations in Nursing Education, and Patient Safety

Nursing education puts theory into practice. Patient safety is indispensable in nursing education. During clinical practice, nursing students make medication errors and have difficulty deciding on what interventions to perform in unusual situations and communicating with patients or other healthcare professionals. All these problems put patient safety at risk. However, “First, do no harm” is a fundamental human right and an ethical principle, which nurses should always consider when they perform interventions. Nursing students can help develop a culture of patient safety through experience in line with their knowledge, skills, and affective goals. Clinical settings can be equipped with real-life laboratories, mannequins, etc. Virtual reality simulations show nursing students what it is like to be in a real-world clinical setting and what problems and risks they may encounter there, and thus, helps them develop skills, build confidence, and prepare for clinical practice. This section addressed the effect of virtual reality simulations on skill development and patient safety in nursing education

Immersive Virtual Reality as an Effective Alternative to Traditional Clinical Nursing Education: An Integrative Review

Immersive Virtual Reality as an Effective Alternative to Traditional Clinical Nursing Education: An Integrative Review  Abstract  Aim: To assess the usefulness of immersive virtual reality as an effective alternative to traditional face-to-face clinical education for undergraduate nursing students.  Background:  The Covid-19 pandemic impacted nursing education to a point where change is needed in traditional curricula to meet program outcomes. Virtual Reality (VR) based simulations introduce students to clinical situations in a safe environment and therefore became an effective solution during the pandemic to enhance student learning. Due to the lack of research, regulatory bodies are hesitant to accept VR clinical hours in place of traditional hours. Design: Integrative review.  Data Sources: CINAHL Plus, Ovid Nursing Collection, MEDLINE (Ebsco), and Scopus databases, keywords, and inclusion/exclusion criteria were searched. Fourteen studies were selected for inclusion. Review Methods: Studies were appraised using the Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP). Thematic analysis was used to generate emerging and recurrent themes with similar concepts.   Results: Five main themes were identified during thematic analysis: ‘improving student engagement/satisfaction’, ‘improving knowledge/skill acquisition’, ‘complementing traditional teaching/learning methods’, ‘improving clinical reasoning’, ‘barriers to implementation’. Conclusion: VR enhances learning, improves student engagement, increases knowledge retention and skill acquisition, complements other teaching methods, and augments clinical reasoning. However, further research is needed about the use of VR as an alternative to traditional nursing clinical education. Challenges of implementing this technology include cost and equipment training

3D technologies to support teaching and learning in health care education – scoping review

This scoping review aimed to describe the use of three-dimensional (3D) technology to support teaching and learning in health care education and the outcomes related to 3D technology from the perspective of teaching and learning. The study identified 31 articles that met the inclusion criteria. The results are presented in four categories: 3D environment, 3D image, 3D holograms and 3D print. There were multiple pedagogical contexts, including the teaching of anatomy. All categories were connected to positive learning outcomes and outcomes that supported learning, e.g. satisfaction. Positive learning outcomes were related to skills, knowledge, students’ perceptions and emotions. These findings describe multiple uses of 3D technology, which can have a positive effect on student learning in health care education.</p

A simulação como recurso pedagógico no ensino médico

Background: The use of simulation in medical education ensures improved learning and an increase in experience without the risk of real events. The absence of previous training in the execution of technical procedures may involve risks to the patient, inseparable from the technique in question. Thus, medical education is decisive in preventing medical errors, and simulation has a critical role in this field. Different approaches, such as mixed-realism scenarios, high-fidelity mannequins, and virtual reality, are used in simulation as resources for medical education. Simulation can be used to train technical and non-technical skills such as team endeavor, team communication, and clinician-patient communication. The latter, which includes the disclosure of an adverse event to a patient, contributes to the increase in the clinician's confidence. Although the recognition of simulation as a fundamental resource in medical education has been increasing in the last years, there is a lack of implemented courses, as part of pre- and post-graduate medical training, and quantitative evaluation of the impact of these courses in residency and, at ultimately, in patient care improvement. Objectives: To increase anesthesiology training's efficacy and safety by including simulation training as a mandatory component of Anesthesiology Residency. To accomplish this primary objective, the work was divided into three aims: 1) to train and evaluate, through the construction of an evaluation instrument divided into two-parts: the participation in a clinical episode that triggered an adverse event in a simulation scenario in an Operating Room context and the dissemination of the same adverse event, in a hybrid simulation scenario; 2) to design a skill training program, in a simulation environment according to the programmatic contents included in the Portuguese Residency in Anesthesiology including technical and non-technical skills; 3) to implement and evaluate the program through the construction and validation of self-assessment questionnaires answered by the residents before and after each simulation module. Results: The comprehensive methodology involving mixed-realism simulation engaged 42 Anesthesiology residents in an adverse event and its disclosure to the patient. It allowed practicing to a range of patients’ answers through the different stages of a grief response. The instruments to assess the performance and the anesthesiology residents' disclosure practice showed excellent interrater reliability and high internal consistency (p<0.05). Three-hundred and forty individuals attended the competencies training program for Portuguese Anesthesiology residents, designed according to the programmatic contents defined by the Portuguese Board of Anesthesiology: 76 from the first year, 89 from the second, 82 from the third, and 93 from the fourth and last year. For the evaluation of this program, self-assessment questionnaires to be applied before and after each simulation module were designed, and the internal consistency was tested, indicating a high internal consistency of all questionnaires. Students assessed the importance attributed to several main technical concepts in Anesthesiology, and their training and experience before and after each simulation course. The results were statistically significant in almost all comparisons (p<0.05). Likewise, these questionnaires also included questions regarding non-technical skills such as need for help, making mistakes, self-efficacy over time, need for support, communication, and team attitude. Over time, the need for support and the number of mistakes increased from the residents' perspective (p<0.001). However, the students assumed that, through the residency, there was an improvement in the communication skills since they easily expressed their opinion, even if they disagreed with the consultant anesthesiologist. Unanimity is highlighted regarding the importance of non-behavioral competencies for clinical practice excellence, identified by 4th-year residents at the end of training with simulation. Finally, the residents rated all the programmatic contents addressed during the simulation modules as highly important. The last year's topics were the ones with numerically higher importance attributed by the trainees. Conclusions: The evaluation instrument divided into two parts demonstrated solid psychometric properties to evaluate the performance of communication to the patient of the occurrence of an adverse effect. The mixed concept of reality-simulation allowed residents to be involved in an adverse event and train their communication before direct contact with a patient. The construction of a simulation program according to the Anesthesiology Residency's pedagogical contents improves training in this area without putting patients at risk. It has repercussions on recognizing the error, enriching the value of self-confidence and the fundamental role of behavioral skills.In the end, this study showed that simulation also has repercussions on the identification of gaps that must be overcome before the residents become independent, culminating in improved patient safety. Together, the results obtained emphasize the positive impact of simulation as a learning instrument of the Medical Residency in Anesthesiology.Introdução: O uso da simulação no ensino médico assegura uma melhoria na aprendizagem e um acréscimo de experiência, sem o risco dos eventos reais. A ausência de treino prévio na execução de procedimentos técnicos pode associar risco para o doente, indissociável da técnica em questão. Assim, a educação e o treino em segurança são decisivos para a prevenção do erro médico. Neste contexto, a simulação tem um papel determinante. Diferentes abordagens, como cenários híbridos realidade-simulação, manequins de altafidelidade e realidade virtual são usadas em simulação enquanto recurso de ensino médico. A simulação pode ser utilizada na aquisição de competências técnicas e competências não técnicas, como o trabalho de equipa, a comunicação em equipa e a comunicação médicodoente. A relação médico-doente pode também ser desenvolvida pelo treino de situações como a comunicação de um evento adverso a um doente ou familiar. Embora o reconhecimento da simulação como instrumento fundamental na educação médica tenha aumentado nos últimos anos, falta ainda a sua integração na formação médica pré e pós-graduada, tal como a avaliação quantitativa dessa integração no desempenho dos médicos internos e, em última instância, na melhoria assistencial do doente. Objetivos: Aumentar a eficácia e a segurança da formação em Anestesiologia através da inclusão do treino em simulação como componente obrigatória do programa de formação específica desta especialidade. Para atingir esse objetivo principal, o trabalho foi dividido em três objetivos secundários: 1) Treinar e avaliar, através da construção de um instrumento de avaliação dividido em duas partes: a participação num episódio clínico que desencadeou um efeito adverso num cenário de simulação em contexto de bloco operatório e a divulgação do mesmo evento adverso, num cenário híbrido de simulação; 2) desenhar um programa de formação de competências, em ambiente de simulação, de acordo com os conteúdos programáticos incluídos no Internato de Anestesiologia, incluindo competências técnicas e não técnicas; 3) implementar e avaliar o programa através da construção e validação de questionários de autoavaliação respondidos pelos internos antes e depois de cada curso de simulação. Resultados: A metodologia que envolveu a utilização da técnica de simulação mista realidade-simulação contou com a participação de 42 internos de Anestesiologia na simulação de um evento adverso e na sua comunicação ao doente. Este estudo permitiu a prática de um conjunto de respostas aos doentes ao longo das diferentes fases do luto. Os instrumentos para avaliar o desempenho e a prática da comunicação do efeito adverso pelos internos de Anestesiologia, apresentaram uma excelente fiabilidade e elevada consistência interna (p<0,05). O programa de formação de competências para internos portugueses de Anestesiologia, desenhado de acordo com os conteúdos programáticos definidos pelo Colégio de Anestesiologia da Ordem do Médicos, contou com a participação de 340 médicos: 76 internos do primeiro ano, 89 do segundo, 82 do terceiro e 93 do quarto e último ano. Para a avaliação deste programa foram construídos questionários de autoavaliação para serem aplicados antes e depois de cada módulo do programa de simulação. A consistência interna foi testada e considerada elevada em todos os questionários. Os participantes avaliaram a importância atribuída a diversos conceitos técnicos em Anestesiologia, e a sua formação e experiência antes e depois de cada curso de simulação. Os resultados foram estatisticamente significativos na maioria das comparações (p<0,05). Da mesma forma, os questionários permitiram autoavaliar a evolução do desempenho clínico e competências não técnicas, tais como a consciência situacional, o pedido de ajuda, a comunicação e o trabalho de equipa. Ao longo do tempo, na perspetiva dos internos, a necessidade de apoio e o número de erros aumentaram (p<0,001). Os médicos internos assumiram também que ao longo do internato houve uma melhoria da capacidade de comunicação, uma vez que mais facilmente expressam a sua opinião, mesmo discordando do anestesiologista sénior. Realça-se a unanimidade em relação à importância das competências não comportamentais para a excelência da prática clínica, identificada pelos internos do 4º ano no final das formações com simulação. Por fim, os participantes deram elevada importância a todos os conteúdos programáticos abordados durante os módulos de simulação, com maior relevância nos temas abordados no último ano. Conclusões: O instrumento de avaliação dividido em duas partes demonstrou fortes propriedades psicométricas para avaliar o desempenho da comunicação ao doente da ocorrência de um efeito adverso. O conceito misto de realidade-simulação permitiu que os internos estivessem envolvidos num evento adverso e treinassem a sua comunicação antes do contato direto com um doente. A construção de um programa de simulação de acordo com os conteúdos pedagógicos do Internato de Anestesiologia melhora não só a formação nesta área, sem colocar os doentes em risco, como tem repercussão no reconhecimento do erro, enriquecendo o valor da autoconfiança e o papel fundamental das competências comportamentais. No final, este estudo mostrou que a simulação também tem repercussão na identificação de lacunas que devem ser ultrapassadas antes que os internos se tornem independentes, culminando na melhoria da segurança do doente. Em conjunto, os resultados obtidos vêm enfatizar o impacto positivo da simulação como instrumento de aprendizagem do Internato Médico de Anestesiologia

Air Bubble Growth in Water

1 describing experiments of air bubble growth in water during exposure to 100% nitrous oxide, 100% xenon, or 50% xenon-50% oxygen. Although the experiments were nicely conducted, they explore a physics of gas flux in an unconstrained bubble permitted to grow spherically. Importantly, this geometry has limited biologic relevance for bubbles occluding vessels in the size range they have studied. The authors have referenced our previous work on xenon transport, 2 but they have mistakenly interpreted the findings presented therein to indicate the growth of bubbles as spheres. Rather, that study presents some simulations for bubbles that are initially spherical and just fill the vessel lumen. Such bubbles cannot grow radially because they are constrained by the vessel wall and therefore elongate during growth while maintaining a fixed curvature on the interface. This results in a much different force balance across the gas-liquid interface and, hence, a different pressure condition on the interior of the bubble from that which occurs in the case of a time-varying interfacial shape, which the authors have studied. We have described these differences in our previous theoretical and experimental studies of intravascular gas embolism. [2][3][4] 2 Whereas others have studied growth of similarly unconstrained air bubbles during cardiopulmonary bypass, 6 our work has not provided any data for direct comparisons such as the authors have made, based on the different gas constituents and the governing physics dictated by the shape constraint. I find it fascinating, however, that they have couched their results in terms of bubble diameter growth. When transferred to the volume domain, one readily sees that the spherical bubbles exposed to 100% xenon or 100% nitrous oxide had grown to more than twice their initial volume in 25 min (figs. 2 and 3) and continued growing when the solutions were switched (downward arrow). The time required for this is surprisingly similar to the volume doubling times we reported for many of the cases we explored, despite the differences in our model and these experiments. The curve fitting by a double exponential suggests that there will be continuous exponential growth of bubble diameter. So although the physics and gas transport are different from what we studied, the indication of the studies are the same. In Reply:-Our article 1 on the expansion of gas bubbles by xenon and nitrous oxide investigated how air bubbles of various dimensions in aqueous solution would expand when suddenly exposed to solutions containing certain gas mixtures (particularly mixtures containing xenon). The motivation behind this work was simple: Would air bubbles that were entrained while on cardiopulmonary bypass during cardiac surgery expand to a worrying extent if xenon were used during the procedure, hence potentially exacerbating damage caused by air emboli? Xenon has been proposed for use as a neuroprotectant, 2 and it might be beneficial in reducing the cognitive deficits that are known to occur during cardiopulmonary bypass. 3 However, if entrained gas bubbles expanded greatly, xenon may do more harm than good. Indeed, Dr. Eckmann and his colleagues have suggested exactly that, 4 based on theoretical calculations that concluded that small gas bubbles would expand rapidly and indefinitely if they were trapped in fine blood vessels. (We fully understand that the model assumes that the bubbles are constrained by the size of the capillaries.) For example, their calculations suggest that a 50-nl bubble of oxygen exposed to 70% xenon-30% oxygen would grow to 250 nl in approximately 20 min with an ever-increasing rate of growth. Because we thought that these predictions were implausible, and because there were a large number of variables that had to be estimated, we conducted our experiments, which were designed to measure bubble growth directly under a well-defined set of conditions. We studied the expansion of both air and oxygen bubbles, and the results were similar; our data show bubble expansions of the order of 10% in diameter and 30% in volume under conditions likely to be encountered during cardiopulmonary bypass. We concluded that this is unlikely to represent a significant clinical problem. We disagree with Dr. Eckmann&apos;s claim that his calculations predict similar expansions to those we observed. Apart from the extent of the volume expansions that were predicted, 4 their most striking aspect was the ever-increasing rates of expansion that seemed to predict unlimited bubble growth. In contrast, we observed limited bubble growth with volumes tending toward finite equilibrium values. Even making allowances for the differences between the model and the gas compositions, we believe our experimental observations probably better reflects reality than the theoretical calculations that Dr. Eckmann has published. Furthermore, in our recently published feasibility and tolerability clinical study involving exposure of cardiac surgical patients to xenon while on cardiopulmonary bypass, there was no Drs. Franks and Maze have a financial interest in an Imperial College spin-out company (Protexeon Ltd., London, United Kingdom) that is interested in developing clinical applications for medical gases, particularly xenon, and both are paid consultants for this activity. Drs. Franks and Maze also sit on a Strategic Advisory Board that advises Air Products, Allentown, Pennsylvania, on possible medical applications for gases, including anesthetic gases. The funding for the current study was provided by Carburos Metálicos, a wholly owned subsidiary of Air Products