CARE – Fall 2020 | Real Knowledge, Simulated World

Real Knowledge, Simulated World

Virtual reality is making its way into practical nurse education, making it possible to practice skills and attain more standardized student evaluations.

At a glance, Chantelle McLean might be mistaken for a young practical nurse coming off the ward — if not, that is, for the sleek black rectangle affixed in front of her eyes by a halo of straps.

In plum scrubs, McLean moves purposefully around a small square of carpet with no clear boundaries, using her hands to manipulate a set of controllers as she focuses intently on the task she’s completing.

Animated versions of her hands are displayed on a large television mounted on a wall to her right, where observers share her perspective as she moves through a hospital room. She washes her hands, greets a female patient tucked in under a pale blue blanket, and carefully tends to the woman’s intravenous (IV) line.

The world is virtual, but the scenario is real.

Chantelle McLean, practical nursing student

McLean is completing a task that licensed practical nurses need to know on the job: maintaining an IV line for a patient with nausea. But she is practicing it in a place where the stakes are lower and the supplies seemingly endless — a virtual reality (VR) scenario, set up in an experimental classroom at NorQuest College in Edmonton, where McLean starts the final year of her practical nursing program this fall.

“It’s kind of like a game,” she says. “I feel it’s more calming than the lab work. I’m able to do much better here than in the lab, where I’m a little bit nervous.”

An entertainment tool in rec rooms across the country, VR is increasingly finding its way into workplaces and educational settings, including Alberta post-secondary institutions that offer the practical nurse diploma program, such as NorQuest College and Bow Valley College.

“The modality of education is changing, so we’re trying to adapt to that,” says registered nurse Sima Mehrabi, an instructor in NorQuest’s practical nursing program.

For the past year or so, practical nursing students there have been getting opportunities to complement their lab courses and clinical training with VR software designed to test their knowledge and hone their skills in IV maintenance and insulin administration.

The medication administration focus was very carefully selected based on student performance in existing clinical courses, instructor feedback, and scope of practice considerations for licensed practical nurses, explains Dustin Chan, senior manager in projects and innovation for NorQuest’s Faculty of Health and Community Studies.

“In the past few years, we’ve been tracking every single clinical course, and all the concerns that have come up and the pieces where students had needed some level of remediation, and these two are really up there,” says Chan, who holds a Bachelor of Science in Nursing.

The faculty decided to focus on step-intensive medication administration processes where mistakes can have serious consequences. To avoid mistakes, practical nurses learn to systematically follow a medication administration checklist and doublecheck that they are providing the right medication, at the correct dose, to the proper patient at an appropriate time—steps that take time and practice to perfect.

“From experience, and other feedback, we’ve noticed that there are some students who do want more practice,” says NorQuest practical nursing instructor and primary lecturer Patrick Kelly, a registered nurse.

In the real world — be it the lab or clinic — that practice comes at the cost of materials such as IV tubes that can quickly add up, he explains. With VR, on the other hand, the NorQuest team hopes to offer students a sustainable, low stress, and fun way to learn, making the experience as realistic as possible, with gaming elements that allow students repeated practice opportunities until they have perfected their skills and knowledge.

At NorQuest College, L-R: Senior manager Dustin Chan; Chantelle McLean and Teodoro Melchionno, practical nursing students; instructors Patrick Kelly and Sima Mehrabi

At the end of each virtual scenario, the student sees an on-screen summary of how they did, Chan notes, seeing exactly which steps they hit and any that they missed. The goal of that gamification is to get students to attempt the scenarios over and over until they get everything right.

“Really that’s our evaluation of its effectiveness: does someone want to come back and play it again?” Chan says.

A few hundred kilometers to the south, a newlyestablished VR laboratory for practical nurse students at Bow Valley College in Calgary is turning to VR for a different, less game-focused application: evaluating student performance on adult health assessment — another key competency in real-life nursing.

There, the goal is not just to provide students with another way of practicing their skills, but to establish a more standardized, objective, and efficient way for instructors to evaluate student performance on health assessment scenarios.

“We’ve always tried to identify where we could remove some of the subjectivity that comes with having a variety of people assessing our learners,” says Nora MacLachlan, Dean of Health and Community Studies at Bow Valley College. “That was one of the problems that we wanted to solve.”

The Bow Valley VR lab officially opened in February 2020, and features 11 VR stations set around the room’s perimeter, along with a central control station for instructors to monitor student progress.

Kristen Cameron, practical nursing student

Working with Calgary’s ICOM Productions, Kim Hogarth, Associate Dean of Nursing at Bow Valley College at the time of writing, helped develop the adult health assessment software currently used in the lab, which features nine diverse, expressive patient avatars from different backgrounds with different conditions.

Back at NorQuest, Kelly and Chan worked with a software development team at the Edmontonbased VR company, Dynacor Media. The company was contracted to come up with the practical nursing program’s VR software after meeting with Jennifer Mah, Dean of the Faculty of Health and Community Studies.

The centre’s VR program launched in early 2019, featuring software owned by NorQuest and a pair of VR systems set up in a central location in a classroom to encourage interactions between students practicing in the virtual world and their peers.

In its first year, the technology was primarily used as a practical tool for students in an acute care course, though there are plans to more fully integrate it into the curriculum starting this spring.

“We’re teaching them a skill in lab, and yes, they’re doing it over and over again,” Chan says. “But now I’m going to put you in an open environment that’s supposed to feel real. There are no step-by-step instructions. You just have to play it until you figure it out, and then you’ll get feedback at the end, which is kind of neat.”

So far, instructors like Mehrabi are getting positive feedback from students.

“[Students today are] much more tech-savvy,” she says. “This is what they can relate to.”

Practical nursing student Teodoro Melchionno, a past student in Mehrabi’s class, agrees. Moreover, the VR scenarios often serve to highlight “small errors you can make,” he says, “and make you better every single time.”

“I think [VR] could be implemented from the first nursing course we take,” he adds. “Even health assessment. Why not?”

At Bow Valley, where adult health assessments are already the focus, the VR program has so far been tailored to looking at how students fare with some of the most common health assessment scenarios practical nurses might face in real life.

“In our course, Adult Health Assessment, we teach the learners to do focused assessments,” Hogarth explains, noting that “it helps them to ask the right questions to determine what assessment they’re going to complete.”

If a patient avatar says she is unusually short of breath, for example, a student needs to recognize that the patient requires a focused respiratory assessment. Another patient avatar might describe symptoms that are characteristic of a cardiac or allergic condition.

Before the advent of VR, practical nurse students would typically assess each other when learning adult health assessments, with one acting as the student and the other the nurse, MacLachlan explains. But because students are often young and relatively healthy, abnormal sounds or findings on these assessments are rare, meaning students may not encounter any symptoms of concern until they reach the clinical setting.

On an afternoon in late January, practical nursing student Kristen Cameron is interacting with one of these avatars, an elderly man sitting up on a hospital bed with his legs dangling over the side. In a virtual world that she sees through a headset and that observers can watch on a screen in front of her, she gently places her transparent, outlined hands on the delicate, slightly grey skin on the patient’s back as he draws a breath.

Along with what she can see through the headset, Cameron uses her virtual hands and virtual stethoscope to feel and hear the sounds within. When she places them in the correct places to check for disease symptoms, known as landmarks on the body, the program follows her performance — as it does for other students in other scenarios.

At Bow Valley College, L-R: Associate Dean of Nursing Kim Hogarth; Kristen Cameron, practical nursing student;

Such computerized tracking takes the guesswork away for instructors tasked with evaluating students’ health assessment savviness, Hogarth says, since each student gets evaluated using the same standards.

“When they’re listening or auscultating a chest with a stethoscope, it will track which landmarks they listen to,” she says. “It will also tell us how long they listened, because that’s also so important—you need to listen for that full breath sound.”

After completing the assessments, students complete their charting, reporting whether they identified any unusual features in the patient avatars at their virtual hospital. While one-on-one evaluations with an instructor might lead to some nerves or distraction for students, “You kind of feel like you’re in your own world” with VR, says Cameron, who donned a VR headset to try out a trial version of the practical nurse program’s software last year.

“It didn’t feel like anybody was around you watching,” she remembers, “and I actually found it was easy to pick up the abnormal sounds, because you are used to hearing normal lung sounds, typically.”

Bow Valley’s Hogarth has already started working on five additional scenarios that will represent atrial fibrillation and other conditions.

“All of our learners that are taking adult health assessment this term, we’ll start to roll through the lab to be assessed [after learning and practicing the assessments],” she says.

Though the goal is to eventually replace subjective, real life evaluations, the students will continue doing assessments in the lab for the time being, until the VR tool is more fully tested and validated.

Faculty at both Bow Valley and NorQuest have ambitious plans for applying and expanding their VR programs. For example, MacLachlan notes that the kinds of VR scenarios being used at Bow Valley might prove useful for looking at how well individuals who are returning to nursing or transitioning into the field perform when it comes to adult health assessments.

Teodoro Melchionno, practical nursing student

Back at NorQuest, Chan and his colleagues are pondering the possibility of providing remote learners with VR educational tools as the technology continues to become more self-contained and streamlined.

They are also wondering aloud about the prospect of developing additional scenarios to tackle “soft skill” development, to support students as they learn how to talk to patients and navigate a healthcare setting more comfortably.

The VR software currently used at NorQuest provides detailed feedback on student performance, meaning it might find favour as an evaluative tool at some point. For the moment, though, it is mainly being used as a fun, interactive way to complement other teaching tools.

The institutions are also contemplating the possibility of commercializing the VR software they’ve developed, which could eventually bring complementary VR software from one practical nurse program to another or into other fields of healthcare that encompass the same skills.

In the meantime, the institutions are considering ways to measure what success with VR looks like for their students. With that in mind, representatives from Bow Valley recently submitted a grant to support research into VR outcomes at the centre, particularly in the areas of student anxiety and confidence.

Hogarth, a graduate nurse practitioner who also completed Bachelor of Nursing and practical nursing programs, knows that graduates embarking on a new career may have some trepidation about their new roles—anxiety that just might decrease for students who have demonstrated their skills successfully in the virtual world.

“If there’s a way to give them a few more tools, a little bit more knowledge, and a little bit more confidence, it’s going to help them, it’s going to help the employer, and it’s going to help the patient,” she says. n

Interviews and photography for this story were completed pre-pandemic, in January 2020.