Is the Future HOLO?

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”.

HoloHuman depicts layers of the body in a cross sectional view. Image credit: University of Canberra.

Nursing schools across the globe have spenthundreds of thousands of dollars on simulation suites and high technologymanikins. Simulation is not new to health care and there are already hundredsof products on the market and a multitude of techniques being employed. Withclinical practice hours for undergraduate students at a premium there iscurrently a body of work that is promoting the idea that simulated learning canreplace clinical practice hours. How to do this and in what form this shouldtake has yet to be answered, however research in the US suggests that up tofifty percent of clinical training hours could be replaced by simulation(Hayden et al, 2014).

Over the last decade there has been a hugeinflux of both virtual reality and augmented reality platforms introduced intohigher education particularly in the health space. Virtual reality (VR) isusually fully immersive and takes place in a computer-generated environment,whereas augmented reality (AR) is where digital elements are placed into thereal world. Mixed reality (MR) exists on the technology continuum and has beendefined by Milgram and Kishino (1994) as a subset of VR. MR merges both thereal and virtual worlds. Microsoft HoloLens is a head mounted MR device.

At the University of Canberra work isunderway using mixed reality headsets in the form of the Microsoft HoloLens tocreate new learning experiences for students. This technology has not been usedto replace other simulation methods rather to augment existing approaches. Twospecific application are gaining traction in the field, these are HoloHuman, ananatomy application and HoloPatient, an application that has been designed toshow holographic standardized patients. HoloHuman and HoloPatient areapplications developed by Pearson.

HoloHuman

Imagine for a moment being able to view theorgans inside a body with no cadaver required. This has been possible in VRplatforms for some time but in a MR format the human anatomy can be viewedthrough holographic displays that can be projected at the bedside or on top ofmanikins or part task trainers (sections of a manikin used for skillsdevelopment) the learner can still see the classroom environment and thisallows more than one person to use the technology as they remain aware of eachother in the space. In a recent nursing classroom, the HoloHuman applicationwas used to enhance skills development in female catheterization.

Traditionally skills development is taughton manikins or part task trainers, using relatively low fidelity simulation.But in this class the learning was augmented with mixed reality. Students weregiven headsets to use in a group as they negotiated the task. HoloHuman allowedstudents to explore the body, to literally walk through the holographic imagewhich was rotated to mimic the position of the manikin. As you move into thehologram the image slowly disappears to reveal the layers of the body in across-sectional view. Students could follow the route a catheter would take (orrather should take when placed correctly) through the body and observe thestructures at either side of the urethra and bladder. It has also been used toexplore the placement of intramuscular injections and to provide deeperlearning and spatial understanding of structures in the body to reinforce thereasons for using for example, the deltoid muscle. This gives the students muchmore than a text book image, it allows students to visualize in 3D, to dissectthe body and to enhance their knowledge and skills relating to specific tasks.

HoloPatient: Holographic image of anaphylaxis. Image credit: University of Canberra.

HoloPatient

HoloPatient offers an aspect to simulationthat has so far been difficult to create in other ways. As an early adopter ofthe technology, I have been using HoloPatient for several years.

HoloPatient is a holographic image of apatient that is displaying realistic symptoms of a condition/disease process.One of the difficulties of recognizing patient symptoms and deterioration isbeing able to identify signs and symptoms as they develop. A manikin can showdeterioration on a monitor, or on auscultation, but not accurately portray thesymptoms of breathlessness. Additionally, manikins cannot be easily positionedto show a realistic stance for someone who is breathless, for example thetripod position. An actor or standardized patient can sometimes give arehearsed performance of symptoms, but this cannot usually be sustained.

HoloPatient is a 3D holographic image thatcan be used to allow students to visualize symptoms, to develop skills invisual assessment, and to promote critical thinking and clinical judgement. Patientsafety is a key healthcare priority and early recognition of the deterioratingpatient is paramount. Learning to notice deterioration and/or change isimportant and we should not be relying on solely on patient monitors as weoften do in simulation with manikins to recognize this deterioration.

Dean, Williams and Balnave (2017) suggestthat the use of high technology manikins in simulation is leading to a lack ofempathy in nurses. It is perhaps ironic to suggest MR technology maybe asolution that can be used to allow students the opportunity to really ‘see’their patient rather than relying on monitors. Additionally, students describeda benefit in the ability to explore the patient’s symptoms without having tonegotiate personal space issues. Students also found that MR allowed them timeto look and to think (without the need to respond) and to brainstorm possiblecauses of symptoms. Group discussion that arose also drew on peer learningstrategies and allowed problem solving to occur organically.

HoloPatient gives a standardized image thatis useful for consistent teaching and has potential in assessment, developedfor a nursing audience the University of Canberra has also trialed thisapplication in other disciplines such as pharmacy and occupational therapy withgood results. Furthermore, the HoloPatient has additional benefits in teachingprofessional terminology regarding symptoms and deterioration.

It is important when embracing newtechnology that we understand what benefits the new technology is providing.Pedagogy before technology, I hear the cry. The above examples draw on activelearning and experiential learning strategies and provide the activity orexperience that is then discussed. Debrief is widely recognized as an importantcomponent part of simulation experiences and using the HoloLens is nodifferent. These new applications need to be introduced in a considered way tosecure their place in meaningful education. Perhaps in the next few years asheadsets become cheaper and more accessible, they will be common place in thenursing classroom. This has not happened to date, but there is definitepotential in using MR to create powerful learning moments.

University of Canberra students using the HoloLens. Image credit: University of Canberra.

Vision

Introducing new technology into curriculatakes a vision and purpose, an advocate and access to and investment in thetechnology. 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 itincreases motivation, engagement and increases learning (Zhu et al, 2014). MRas a more immersive platform has the potential to replicate and increase thesebenefits for learning.

HoloPatient and HoloHuman are usefulresources that have promoted engagement with content in my classroom, and thehead mounted devices are developing rapidly. Additionally, HoloLens 2 promisesadditional features and a larger range of vision as well as new opportunitiesto explore learning with the incorporation of eye tracking facilities.

We are not there yet. Future learners willuse HoloLens technology, or its successor, and VR and MR will feature heavilyin the simulation space and will no doubt become a staple element in simulationcentres and curriculums. With the complexities of nursing and of healthcare ingeneral it is unlikely that any one simulation technique or technology willprovide 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), MScNP, DNP, GCTE, SFHEA, is an Associate Professor inNursing, and Program Director for Nursing Midwifery and Public Health atUniversity of Canberra. Jane is a Senior Fellow of the Higher EducationAcademy. Jane is an experienced educator, endorsed Nurse Practitioner, andNurse academic. In 2017, Jane was the first person in Australia to be conferredas a Doctor of Nurse Practitioner. Jane has had an extensive clinical careerand is passionate about the role of the nurse in improving patient care. Janeenjoys teaching and employs innovative techniques to prepare students for therealities of clinical practice. She understands the importance of responding toindividual patient needs and endeavours to develop the art of therapeuticcommunication in her students. Jane is considered a leader in using simulationto create authentic learning experiences.

HoloLens 2

Microsoft have announced the next versionof the HoloLens called HoloLens 2. It is expected to be released into themarket sometime in August 2019 or soon thereafter. For more information see thelink www.microsoft.com/en-us/hololens/hardware# The HoloLens 2 has significantimprovements including a wider (i.e. more than double) field of view, thedevices are lighter, better balanced and more comfortable, and the method ofinteracting will use full hand articulation making hand gestures more naturaland intuitive. In the future, the eye tracking and AI feature will enable appsto provide increased knowledge to the teacher and learner about the learning.Pearson apps will be compatible with HoloLens 2 before the product is releasedinto the market.

References

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 nationalsimulation study: A longitudinal, randomized, controlled study replacingclinical hours with simulation in prelicensure nursing education. Journal ofNursing Regulation.

Milgram, P. and Kishino, F., 1994. Ataxonomy of mixed reality visual displays. IEICE TRANSACTIONS on Informationand 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.