Abstract
Background
Peer physical examination is a clinical teaching-learning approach used for decades because of the convenient sample of peers for practicing. However, this approach has limitations when learning to assess abnormalities and threatens psychologically safe learning. A wearable simulator system was designed for learning physical examination skills to minimize ethical and learning challenges.
Sample
The sample consisted of fifty prelicensure nursing students and ten faculty in an upper Midwest university.
Method
The wearable simulator was constructed into a vest with RFID tags and ribcage landmarks. An observational, evaluative design was used for participants to rate seven categories during a one-hour evaluation session of the wearable simulator worn by a standardized patient trained to portray an individual with pneumonia.
Results
Satisfaction was rated highly among participants. More than 80% of student participants indicated the wearable simulator promotes privacy and reduces embarrassment.
Conclusion
The wearable simulator system offers a promising teaching-learning alternative with scenario-specific auscultation and palpation feedback to provide a safe, repeatable, and consistent simulation experience.
Keywords: simulation, wearable, physical exam, health assessment, psychological safety, privacy
The use of peer physical examination (PPE) has been a long-standing tradition in clinical education across the health sciences. The use of peers as surrogate patients for teaching and learning physical examinations (PE) skills has been regarded as practical and cost effective, yet this approach is more aligned with convenience of a readily available sample of students, rather than scientifically grounded in best practices of teaching and learning. The limitations of this approach in teaching and learning physical assessment of abnormal signs of health problems are well-known, particularly ethical concerns related to student privacy (Slater et al., 2016). Moreover, the traditional expectation of the use of peers for assessing physical, yet private, health status information threatens efforts to cultivate psychologically safe learning environments, raising questions about the acceptability of this practice. This paper describes the development and evaluation of a wearable vest simulator as a teaching-learning resource for teaching PE skills.
Background
Peer Physical Examination
Physical examination skills are foundational to nursing education because of the importance of health assessment for nurses providing safe, high-quality patient care (Demiray et al., 2020; Fusner et al., 2020; Tan et al., 2021). The integration of PE skills into nursing practice is a core competency of the professional nurse and the first step of the nursing process (American Academy of Colleges of Nursing [AACN], 2021). Physical examination skills equip the nurse to systematically gather physiological patient data, which requires the ability to inspect, palpate, percuss, and auscultate to understand the patient’s physiological status (Fusner et al., 2020).
Providing appropriate learning opportunities for nursing students that support incremental competence achievement of these critical skills is challenging for nurse educators (Alamri & Almazan, 2018; Demiray et al., 2020). Live patient settings do not consistently offer adequate opportunities or time for improving PE skills due to nurse staffing shortages, faculty shortages, and patient safety initiatives (Demiray et al., 2020). Yet, the lack of opportunities for students to practice assessment can hinder their learning and subsequently negatively impact patient outcomes (Alamri & Almazan, 2018). This lack of practice opportunities leads to a lack of confidence in PE skills, which has been reported by learners as a significant barrier to acquiring PE skills (Doğdu et al., 2021) (Douglas et al., 2015).
The use of peer students for learning and practicing PE has been a common practice across the health sciences because it is cost-effective, convenient, and does not require additional planning, scheduling, or resources (Hattingh & Labuschagne, 2019). The use of PPE protects patients from the discomfort of repeated examinations by multiple students, while also allowing students opportunities to develop empathy by understanding the patient’s perspective (Hattingh & Labuschagne, 2019; Roche & Woolley, 2013). Across nursing education, faculty have used PPE to increase time spent practicing PE skills outside of clinical environments with patients.
While this approach may provide a convenient and accessible sample, the use of PPE is not without barriers and ethical concerns (Grace et al., 2019; Hattingh & Labuschagne, 2019). Changing social values and greater respect for students’ rights have impacted student attitudes toward being required to participate in PPE (Grace et al., 2019). Students have reported feeling pressured or coerced to participate, fearing repercussions for declining to do so (Hendry, 2013; Koehler & McMenamin, 2014; Wearn & Bhoopatkar, 2014). Historically, the willingness of students to take part in PPE may have been assumed by educators; the risks to psychological safety and learner wellbeing were minimized because of the perceived benefits of PPE (Grace et al., 2019). There are also growing concerns of the continued use of PPE amidst the broadening diversity of student populations in nursing programs related to gender identification, ethnicity, and religious and cultural customs (Grace et al., 2019; Hendry, 2013; Reid et al., 2012). Other barriers include requiring students to remove clothing or expose parts of their bodies, touch their peers’ bodies, and disclose personal health information (Grace et al., 2019) which can lead to students’ concerns of body image and embarrassment (Hendry, 2013; Reid et al., 2012). Students have also reported discomfort in practicing on peers, fearing it would impact their personal relationships (Hendry, 2013; Slater et al., 2016).
In addition to the reported negative effects of PPE, this practice also puts instructors and institutions at risk for possible litigation for not ensuring the welfare of their students (Grace et al., 2019). New ethical frameworks have been recommended (Grace et al., 2019) that support ethical principles including beneficence, non-maleficence, and justice/fairness (Hattingh & Labuschagne, 2019).
Standardized Patients for PPE
Standardized patients (SPs) are trained individuals commonly used in the health sciences to portray a patient with realistic physical findings and behaviors during a simulation learning experience (Bradley et al., 2022). In a study testing the use of SPs as an alternate method for teaching nursing health assessment skills, students reported the use of SPs improved their critical thinking skills (p = .003), while students who used PPE instead of SPs perceived they used more memorization than thinking (p = .04) (Slater et al., 2016). Students also reported the use of SPs as more realistic than learning with PPE (p = .006).
The use of SPs has increased for students to practice history taking, physical examination skills, and communication skills (Berg, 2019). However, like the use of peers for PE, SPs are healthy subjects and therefore fundamentally limited in their ability to simulate physiological signs such as heart murmurs or lung sounds. While the practice of engaging SPs to achieve health assessment learning objectives has increased, this too brings challenges including availability of SPs for hire, recurring costs each semester, as well as staff resources for recruiting, scheduling, and training. Since working as an SP is typically not a full-time job, SP availability can be limited. It is also impractical to schedule an SP for short sessions or quick demonstrations.
Wearable Simulator Technology
One promising option that has the potential to improve teaching and learning PE skills while reducing the challenges of PPE are wearable simulators. The use of wearable technology is a form of hybrid simulation, which is the combination of multiple teaching modalities in one learning activity; a common form of hybrid simulation is the combination of an SP and wearable technologies (Brown & Reid, 2022; Unver et al., 2018). A hybrid simulation is an effective method that supports technical skills training, communication, knowledge acquisition, critical thinking, and self-confidence (Brown & Reid, 2022; Unver et al., 2018).
Currently available wearable simulators include pregnancy and obesity empathy suits, an electrocardiography training vest, and a felt vest with speakers similar to those used in manikins (Berg & Berg, 2019). However, the wearable simulator market has lacked a product that could be worn by a student or an SP that provides a lifelike look and feel, with increased realism to portray the true clinical presentations of disease processes commonly seen in patients. A wearable simulator system could also provide a psychologically safe alternative for students to practice PE skills in didactic, laboratory, and simulation learning environments. Therefore, the aims of this study were to 1) create a production-ready wearable health examination simulator (wearable sim) system, 2) develop a set of simulation case studies focused on nursing assessment as examples to use with the wearable sim system, and 3) evaluate the system using a sample of nursing faculty and prelicensure students.
Material and Methods
Aim 1
A new, production-ready wearable health examination simulator in the physical form-factor of a vest was collaboratively designed and produced by the Innovative Design Labs and Realityworks engineering teams over a 12-month period (Figure 1). The three main core components of the wearable sim system were: 1) a base layer with ribcage landmarks to support palpation; 2) gray synthetic skin-like fabric and padding layers to insulate the wearer; and 3) a network of embedded small modular radiofrequency identification (RFID) tags integrated into the vest fabric which are sensed by interactive examination tools to provide auscultation training. The vest covers the torso of the wearer and is secured along the upper back using a hook and loop fastener band. The size of the vest is “one size fits most,” with ribcage and auscultation region anatomy proportionally sized to it. The construction materials and processes, which have been used and tested on prior Realityworks products, are proprietary and are designed to be both washable and antiallergenic. Future iterations of the product are planned to include different sizes and to cover the outside with simulated skin for a more realistic look and feel.
Figure 1.
An illustration of the wearable health examination simulation system and interactive stethoscope tool.
Individuals conducting PE using the wearable sim system use an interactive examination tool (i.e., a stethoscope module) that simulates physiologic sound signals by sensing the RFID tags in the wearable sim system (Figure 1). Over 100 RFID tags of various sizes were embedded and affixed inside the vest using a proprietary manufacturing process. The stethoscope module attaches over the discshaped resonator of a standard stethoscope and plays audible sounds through the stethoscope earpieces when placed at specific locations on the simulator. Sound signals are controlled based on the sensed tag, relative proximity of the stethoscope module to the tag, and applied pressure. There are various computer-controlled PE scenarios of programmable normal health states and diseases that can be selected via a mobile application.
Aim 2
A team of four nursing faculty with expertise in nursing and simulation education worked collaboratively to develop and validate case studies of five commonly encountered health problems appropriate for prelicensure nursing curricula. The case studies included a variety of abnormal heart, lung and bowel sounds to assess by auscultation. Each case study was designed as a simulation scenario according to the Healthcare Standards of Best Practice™ Simulation Design (Watts et al., 2021), including a patient summary, learning objectives, medical history, social history, and an SP script.
Aim 3
Design and Ethics Approval
The research study used an observational, evaluative design. The study was reviewed by the university’s Institutional Review Board (and determined to be exempt from federal policy requirements). All participants provided informed consent.
Setting, Eligibility, and Recruitment
The research study was conducted at a large, public university in the upper Midwest of the United States. A convenience sample of prelicensure nursing students and nursing faculty was used. Students were eligible to participate if they were 18 years or older and enrolled in one of the university’s prelicensure nursing programs. The Bachelor of Science in Nursing (BSN) program is a traditional four-year undergraduate program while the Master’s in Nursing (MN) program is 15 months long for students with a prior college degree. Faculty were eligible if they were adults employed by the school of nursing as a faculty member.
Recruitment strategies for students included short verbal announcements about the study by research assistants in nursing classes, written announcements in the general announcement section of course websites, email messages to student listservs with a link to a short recruitment video, posting of flyers on bulletin boards at the nursing school, and word of mouth among students. Recruitment of faculty used announcements at faculty meetings, email messages to the faculty listserv, flyers on school of nursing bulletin boards, and word of mouth. Pre-paid debit cards of $20 (i.e., Clincards) were offered to student participants, and Amazon gift cards of $20 were offered to faculty per their preference as recruitment incentives to compensate for their time and efforts. Compensation was reviewed as part of the consent process as required by our IRB.
Data Collection Surveys
Data collection surveys were developed by the research team for student and faculty participants for use in the study because established, appropriate tools were lacking. For students, a Demographics and Background survey collected information about their demographic characteristics, history of simulation education, and knowledge of and clinical experience in physical assessment. For faculty, the Demographics and Background survey collected information about their demographic characteristics, experience in teaching with simulation, and knowledge of and experience in teaching physical assessment.
Surveys for evaluating the wearable sim system included 25 items in six sub-scales to rate the simulator system’s realism, user-friendliness, engagement, usefulness, effectiveness, and privacy and comfort. The items in the usefulness subscale were focused on learning in the student version, while the faculty version focused on teaching.. A five-point Likert scale was used for scoring with options of strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree. A seventh subscale included nine items to rate satisfaction with the product features: realism, user-friendliness, engagement, usefulness, effectiveness, innovation, overall look or appearance, quality, and ability to promote privacy and decrease uncomfortableness. Data collection forms had a number code written on them (instead of a name) and thus were de-identified to maintain confidentiality. Evaluation data collected from study participants were entered into SPSS software version 27.0 (IBM SPSS Statistics, Armonk, New York) and data were verified for completeness and accuracy.
Evaluation Session Procedures
One of the five case studies was adapted for the evaluation sessions during which an SP wore the wearable sim system underneath a hospital gown and portrayed a patient who presented to a clinic with symptoms of pneumonia in an abbreviated simulation. Only one case was used in the evaluation session for the sake of time and consistency among evaluators. The pneumonia case was selected for use as all potential student participants had opportunities to learn health assessment and nursing care of a patient with pneumonia. The debriefing was not included in the session because the purpose of the session was for evaluation of the wearable sim system, and not for student learning. The SP, who was employed by and trained in the university’s SP program, received a training about the research study and the format of the evaluation session. The SP was trained by the university’s SP program director to portray the patient described in the pneumonia scenario. Separate evaluation sessions were held for students and faculty. Due to restrictions of the COVID-19 pandemic, no more than three participants at a time were permitted to interact with the SP. The SP and participants wore a face mask and face shield, equipment was cleansed with alcohol in between users, and participants used hand sanitizer before beginning.
The evaluation session lasted approximately 60 minutes and was organized into an initial and final data collection period and three breakout periods, each in a separate room to allow for spacing. After checking in and completing the Demographics and Background survey, participants received a short demonstration of various capabilities of the wearable sim and were instructed that the session was designed as an abbreviated simulation to provide context for evaluating the wearable sim system, rather than as a learning activity. Participants were read a prebriefing script and instructed to assess the patient as they would in a simulation. Because the purpose of the session was to evaluate the wearable sim system, all components commonly required for a simulation were not included. In the next period, half of the participants interacted with and assessed the SP wearing the simulator while the other half examined samples of artificial skin used on simulators; the groups switched to allow all participants opportunities to assess the wearable sim and the synthetic skin. In the final period, participants completed their evaluation forms and received compensation. A box lunch was provided to participants whose evaluation session was held over the lunch hour in between classes.
Data Analyses
Data reported on the Demographics and Background survey Evaluation form were analyzed separately for student and faculty participants using descriptive statistics appropriate to the type of data and then tabulated. SPSS software version 27.0 (IBM, 2020) and SAS software version 9.4 (SAS Institute, 2013) were used for data analyses and presentation.
Results
Aim 1
A complete wearable sim system was created and released in 2022 as a commercial product for purchase (Realityworks, 2022a). It was awarded Gold in the 2022 Better Future New York Design Awards for its creative and innovative design (Realityworks, 2022b). Over 100 RFID tags were embedded inside the vest corresponding to associated auscultation sounds suitable for teaching correct stethoscope placement, how to accurately recognize heart, lung, and bowel sounds, and rib palpation. Lung sounds are located by lobe regions over a large area (Figure 2). Heart sounds are located in a small area, aligning to the proper anatomical region while bowel sounds are located in each abdominal quadrant over a large area.
Figure 2.
Locations of RFID tags inside the wearable simulator
The system currently has a library of scenarios divided into Practice and Assessment modes. In Practice mode, users only hear sounds associated with the selected condition. In Assessment mode, users hear normal sounds everywhere else on the vest except in the location with abnormal sounds associated with the selected condition. The app can be used to edit the assessment mode to create scenarios for student practice and evaluation.
Aim 2
Five case studies were developed for this study focused on the clinical problems of heart failure, pneumonia, urinary tract infection (UTI), chronic obstructive pulmonary obstruction (COPD) exacerbation, and sepsis. Table 1 lists the focus of the physical assessment findings to be programmed in the wearable sim system for each case.
Table 1.
Case Study Clinical Conditions
| Heart Failure | Pneumonia | Urinary Tract Infection | COPD Exacerbation | Sepsis | |
|---|---|---|---|---|---|
| Upper Lobes | Coarse crackles | Clear | Clear | Wheezes, distant breath sounds | Diffuse ronchi |
| Lower Lobes | Coarse crackles | Right sided Bibasilar crackles | Atelectasis | Distant sounds, diminished in bases, wheezes | Diffuse ronchi |
| Respiratory Rate | Tachypnea Rate = 30 |
Tachypnea Rate = 24 |
Tachypnea Rate = 28 |
Tachypnea Rate = 30 |
Tachypnea Rate = 28 |
| ECG | Atrial fibrillation | Sinus rhythm w/ PVCs | Sinus tachycardia | Normal | Normal |
| Heart Rate | 95 Audible S3 |
>100 | >100 | 70s | >100 |
| Pulse | Irregular | Regular | Regular, weak, thready | Regular | Regular, bounding during hyperdynamic phase after receiving fluid |
| Bowel Sounds | Normal | Normal | Hypoactive | Normal | Hypoactive |
| Blood Pressure | Hypertension | Normal | Hypotension | Hypertension | Slightly hypotensive |
Aim 3
Sample
Fifty student and 10 faculty participants completed the study over three months. The characteristics of the student sample are described in Table 2. Most student participants were female (80%), white (80%), and in the BSN program (82%). The preferred learning method reported by 64% of the student participants was by doing or practicing, followed by watching in 16%. All student participants reported having simulation learning activities in physical assessment, and 84% said they had a moderate amount. The majority of student participants (84%) reported a moderate level of knowledge of physical assessment. Their self-reported level of clinical competence in physical assessment was beginner in 82% and intermediate in 18%.
Table 2.
Characteristics of Student (n=50) and Faculty (n = 10) Participants
| Characteristic | Student | Faculty | |
|---|---|---|---|
| mean (sd) | |||
| Age (years) | 22 (5.0) | 47 (15.3) | |
| n (%) | |||
| Gender | |||
| Male | 8 (16) | 2 (20) | |
| Female | 40 (80) | 8 (80) | |
| Non-binary | 2 (4) | – | |
| Race | |||
| White | 40 (80) | 10 (100) | |
| Black, African American, or African | 2 (4) | – | |
| Asian, American Indian or Alaska Native | 5 (10) | – | |
| Native Hawaiian or other Pacific Islander | – | – | |
| More than one race | 3 (6) | – | |
| Hispanic/Latino Ethnicity | 1 (2) | 1 (10) | |
| Nursing Program | – | ||
| Pre RN-licensure BSN | 41 (82) | – | |
| Pre RN-licensure MN | 9 (18) | – | |
| Highest Level of Education | |||
| Baccalaureate Degree | – | – | |
| Master’s Degree | – | – | |
| Doctoral of Nursing Practice | – | 6 (60) | |
| Doctor of Philosophy | – | 4 (40) | |
| Years Teaching | |||
| 0–5 years | – | 7 (70) | |
| 6–10 years | – | 1 (10) | |
| 11–15 years | – | – | |
| 16–20 years | – | – | |
| 20+ years | – | 2 (20) | |
| Preferred Learning Method | – | ||
| Reading on my own | 3 (6) | – | |
| Listening | 2 (4) | – | |
| Watching | 8 (16) | – | |
| Doing or Practicing | 32 (64) | – | |
| More than 1 method | 5 (10) | – | |
| Amount of Simulation Education | |||
| None | 5 (10) | – | |
| A Little | 26 (52) | – | |
| A Moderate Amount | 14 (28) | – | |
| A Lot | 5 (10) | – | |
| Perceived Knowledge of Physical Assessment | |||
| None | – | – | |
| A Little | 7 (14) | 3 (30) | |
| A Moderate Amount | 42 (84) | 4 (40) | |
| A Lot | 1 (2) | 3 (30) | |
| Level of Clinical Practice in Physical Assessment | |||
| Beginner | 41 (82) | – | |
| Intermediate | 9 (18) | – | |
| Expert | – | – | |
| Level of Experience Teaching Physical Assessment | |||
| Beginner | – | 7 (70) | |
| Intermediate | – | 3 (30) | |
| Expert | – | – | |
| Experience Teaching with Simulation | |||
| None | – | 2 (20) | |
| A Little | – | 5 (50) | |
| A Moderate Amount | – | 1 (10) | |
| A Lot | – | 2 (20) | |
| Experience Teaching Physical Assessment Using Simulation | |||
| None | – | 3 (30) | |
| A Little | – | 4 (40) | |
| A Moderate Amount | – | 1 (10) | |
| A Lot | – | 2 (20) |
Faculty Characteristics
All faculty participants were registered nurses; their characteristics are described in Table 2. A doctoral degree was the highest degree in all faculty participants (DNP in 60% and PhD in 40% of faculty). Most of the faculty participants reported less than five years teaching experience (70%), and 20% had 20+ years teaching experience. Forty percent of faculty participants thought they had a moderate amount of knowledge of physical assessment with 30% each perceiving a little or a lot of knowledge. All faculty participants had experience teaching physical assessment; 70% thought their teaching experience was at a beginner level and the remainder (30%) were at an intermediate level. Experience teaching simulation or physical assessment using simulation ranged from none (10–20% respectively) to a lot (20%).
Evaluations of Student Participants
Table 3 presents the evaluation ratings of the wearable sim system of the student participants. The majority of student participants agreed or strongly agreed with each of the evaluation items. Less than 10% of student participants disagreed or strongly disagreed with any individual evaluation item. More than 80% of student participants agreed or strongly agreed that the wearable sim system promoted privacy and reduced embarrassment. The evaluation items receiving a rating of strongly agree from more than half of student participants were that the wearable sim system is Innovative, Captures interest, Engages learning, Keeps my attention, Offers interaction, is Something new, Improves clinical skills, Improves confidence, Helps learning, is Relevant to education, and Promotes privacy. The evaluation items receiving a rating of agree from more than 50% of student participants were that the wearable sim system is Realistic, Accurate, Effective, and Improves understanding. The evaluation items receiving the highest percentages of neutral ratings from student participants were Look/appearance of wearable sim system (30% of student participants), it Improves knowledge (24%), and is Realistic and Accurate (22% each).
Table 3.
Evaluations of Nursing Students (n = 50)
| Variable | Strongly Disagree | Disagree | Neither | Agree | Strongly Agree |
|---|---|---|---|---|---|
| n (%) | |||||
| Overall Impression | |||||
| Positive first reaction | -- | 1 (2) | 2 (4) | 24 (48) | 23 (46) |
| Innovative | -- | -- | 3 (6) | 16 (32) | 31 (62) |
| Captures Interest | -- | 1 (2) | 1 (2) | 18 (36) | 30 (60) |
| Look/appearance | 1 (2) | 4 (8) | 15 (30) | 22 (44) | 8 (16) |
| Realism | |||||
| Realistic | -- | 3 (6) | 11 (22) | 30 (60) | 6 (12) |
| Accurate | -- | -- | 11 (22) | 28 (56) | 11 (22) |
| Effective | -- | -- | 9 (18) | 29 (58) | 12 (24) |
| Engagement | |||||
| Engages Learning | -- | 1 (2) | 1 (2) | 18 (36) | 30 (60) |
| Keeps My Attention | -- | 1 (2) | 2 (4) | 17 (34) | 30 (60) |
| Offers Interaction | -- | -- | 3 (6) | 21 (42) | 26 (52) |
| Something New | -- | 3 (6) | 2 (4) | 10 (20) | 35 (70) |
| User-Friendliness | |||||
| Easy to Use | -- | 1 (2) | -- | 24 (48) | 25 (50) |
| Effectiveness | |||||
| Improves Knowledge | -- | 2 (4) | 12 (24) | 25 (50) | 11 (22) |
| Improves Understanding | -- | 1 (2) | 6 (12) | 31 (62) | 12 (24) |
| Improves Clinical Skills | -- | -- | 2 (4) | 20 (40) | 28 (56) |
| Improves Clinical Decision Making | -- | 1 (2) | 6 (12) | 19 (38) | 24 (48) |
| Improves Confidence | -- | 2 (4) | -- | 19 (38) | 29 (58) |
| Usefulness | |||||
| Seek Courses with it | -- | 3 (6) | 6 (12) | 21 (42) | 20 (40) |
| Helps Learning | -- | 2 (4) | 1 (2) | 21 (42) | 26 (52) |
| Recommend to others | -- | 1 (2) | 4 (8) | 22 (44) | 23 (46) |
| Relevant to Education | -- | -- | -- | 15 (30) | 35 (70) |
| Privacy and Comfort Issues | |||||
| Promotes student privacy | --- | --- | 6 (12) | 15 (30) | 29 (58) |
| Reduces student embarrassment | --- | 1 (2) | 8 (16) | 19 (38) | 22 (44) |
| Does not cause student discomfort | --- | 3 (6) | 4 (8) | 20 (40) | 23 (46) |
|
| |||||
| Very Dissatisfied | Dissatisfied | Neutral | Satisfied | Very Satisfied | |
|
| |||||
| Satisfaction with Features | n (%) | ||||
| Realism | -- | 2 (4) | 7 (14) | 29 (58) | 12 (24) |
| User-friendliness | -- | 1 (2) | 7 (14) | 21 (42) | 21 (42) |
| Engagement | -- | -- | 1 (2) | 17 (34) | 32 (64) |
| Usefulness | -- | -- | 1 (2) | 15 (30) | 34 (68) |
| Effectiveness | -- | -- | 3 (6) | 24 (48) | 23 (46) |
| Innovation | -- | -- | 3 (6) | 13 (26) | 34 (68) |
| Look/appearance | 1 (2) | 2 (4) | 14 (28) | 24 (48) | 9 (18) |
| Quality | -- | 2 (4) | 7 (14) | 24 (48) | 17 (34) |
| Promotes privacy/minimizes discomfort | -- | 1 (2) | 6 (12) | 12 (24) | 31 (62) |
Satisfaction with the wearable sim system was high among student participants with < 5% dissatisfied or very dissatisfied with any item (Table 3). More than 50% of students were very satisfied or satisfied with the wearable sim system’s Realism, Engagement, Usefulness, Innovation, and Promotion of privacy/minimizing discomfort. The highest percentage of neutral ratings was for Look/appearance (28%).
Evaluations of Faculty Participants
Table 4 presents the evaluation ratings of the wearable sim system of the faculty participants. The majority of faculty participants agreed or strongly agreed with each of the evaluation items; none of the faculty strongly disagreed with any of the items. Ninety to 100% of faculty agreed or strongly agreed that the wearable sim system promoted privacy and reduced embarrassment, respectively. The evaluation items receiving an evaluation of strongly agree from more than half of the faculty participants were that the wearable sim system is Innovative, Captures interest, is Easy to use, is Something new, and Meets Teaching Needs. The evaluation items receiving an evaluation of agree from 50% or more of faculty participants were Positive first reaction, the Look/appearance of the wearable sim system, it is Realistic, would Recommend to faculty, would Improve student knowledge and it Reduces student embarrassment. Only 10%−20% of faculty participants disagreed with an evaluation item and those items stated the wearable sim system was Realistic, Accurate, Effective and Improves student understanding. None of the faculty participants had a rating of strongly disagree for any individual evaluation item. The evaluation items receiving neutral ratings from the highest percentage of faculty participants (30%) were that the wearable sim system was Accurate, Does not cause student discomfort, and faculty would Utilize it within their classroom. Most faculty (more than 50%) were very satisfied with the wearable sim system’s Innovation and Promotion of privacy/minimizing discomfort.
Table 4.
Evaluations of Nursing Faculty (n = 10)
| Variable | Strongly Disagree | Disagree | Neither | Agree | Strongly Agree |
|---|---|---|---|---|---|
| n (%) | |||||
| Overall Impressions | |||||
| Positive first reaction | --- | --- | --- | 6 (60) | 4 (40) |
| Innovative | --- | --- | --- | 1 (10) | 9 (90) |
| Captures interest | --- | --- | --- | 2 (20) | 8 (80) |
| Look/appearance | 2 (20) | 7 (70) | 1 (10) | ||
| Realism | |||||
| Realistic | --- | 1 (10) | 2 (20) | 6 (60) | 1 (10) |
| Accurate | --- | 2 (20) | 3 (30) | 4 (40) | 1 (10) |
| Effective | --- | 2 (20) | 2 (20) | 5 (50) | 1 (10) |
| User-Friendliness | |||||
| Easy to use | --- | --- | 1 (10) | 3 (30) | 6 (60) |
| Engagement | |||||
| Engaging | --- | --- | --- | 5 (50) | 5 (50) |
| Something new | --- | --- | --- | 3 (30) | 7 (70) |
| Usefulness | |||||
| Enhances teaching | --- | --- | --- | 5 (50) | 5 (50) |
| Meets teaching need | --- | --- | --- | 4 (40) | 6 (60) |
| Utilize within classroom | --- | --- | 3 (30) | 2 (20) | 5 (50) |
| Recommend to faculty | --- | --- | --- | 6 (60) | 4 (40) |
| Useful to education | --- | --- | --- | 5 (50) | 5 (50) |
| Effectiveness | |||||
| Improves student knowledge | --- | --- | 2 (20) | 6 (60) | 2 (20) |
| Improves student understanding | --- | 1 (10) | 2 (20) | 4 (40) | 3 (30) |
| Improves student clinical skills | --- | --- | 1 (10) | 5 (50) | 4 (40) |
| Improves student clinical decision-making | --- | --- | 2 (20) | 5 (50) | 3 (30) |
| Improves student confidence | --- | --- | 1 (10) | 4 (40) | 5 (50) |
| Privacy and Comfort Issues | |||||
| Promotes student privacy | --- | --- | 1 (10) | 4 (40) | 5 (50) |
| Reduces student embarrassment | --- | --- | --- | 7 (70) | 3 (30) |
| Does not cause student discomfort | --- | --- | 3 (30) | 5 (50) | 2 (20) |
|
| |||||
| Very Dissatisfied | Dissatisfied | Neutral | Neutral Satisfied | Very Satisfied | |
|
| |||||
| Satisfaction with Features | n (%) | ||||
| Realism | --- | --- | 2 (20) | 7 (70) | 1 (10) |
| User-friendliness | --- | --- | 2 (20) | 4 (40) | 4 (40) |
| Engagement | --- | --- | --- | 5 (50) | 5 (50) |
| Usefulness | --- | --- | 1 (10) | 5 (50) | 4 (40) |
| Effectiveness | --- | --- | 4 (40) | 4 (40) | 2 (20) |
| Innovation | --- | --- | --- | 4 (40) | 6 (60) |
| Look/appearance | --- | --- | 3 (30) | 5 (50) | 2 (20) |
| Quality | --- | --- | 1 (10) | 6 (60) | 3 (30) |
| Promotes privacy / minimizes discomfort | --- | --- | 1 (10) | 3 (30) | 6 (60) |
Discussion
This study sought to develop and evaluate a wearable sim system that could increase the realism of a simulated patient torso for improved teaching and learning of PE skills. Because of the growing concerns of the acceptability of the use of peers for teaching and learning PE skills, alternate methods are needed to ensure consistent and realistic learning opportunities. This study demonstrated that a wearable sim system can offer a technologically advanced simulator to provide repeatable, diverse, and realistic learning opportunities with scenario-specific auscultation and palpation feedback. Overall, the wearable sim system was found to be a promising tool by both student and faculty participants because of the increased realism for auscultating numerous adventitious sounds and palpating the ribs for accurate stethoscope placement. Additionally, the wearable sim system provides opportunities to auscultate abnormal sounds that are consistent with a health problem presented in a case study or simulation scenario.
More than 80% of student participants and 90–100% of faculty participants agreed or strongly agreed that the wearable sim system promoted privacy and reduced embarrassment. This is an important finding, given the increasing reports of student discomfort with the traditional practice of using PPE for learning assessment skills. The traditional expectation of the use of peers for assessing physical, yet private, health data threatens recent efforts to cultivate psychologically safe learning environments across nursing curricula. The use of a wearable sim system could alleviate student discomfort with PPE, prevent potential ethical challenges, and provide a more psychologically safe option for nursing students when learning and practicing PE skills.
More than half of student participants strongly agreed that the wearable sim system could improve their clinical skills and their confidence in using PE skills, while over half of the faculty participants strongly agreed that the wearable sim meets their teaching needs. Because of the importance of teaching and learning PE skills in programs of nursing, the findings of this study suggest that a wearable sim system may offer nursing students and faculty an advanced technological resource for practicing PE skills in didactic or clinical lab courses, or for use in a hybrid simulation.
Limitations
There were several limitations to this study. Recruitment of participants was challenging due to the persistence of the COVID-19 pandemic. Masking and face shields during the evaluation sessions may have hindered a more thorough evaluation of the wearable sim system with the SP. The small sample size may limit the generalizability of the study findings. Findings encourage testing the use of this wearable sim system with a larger, more diverse sample representative of all types of programs of nursing as well as across the health sciences.
Conclusion
The findings of this study contribute evidence of the development and evaluation of a wearable sim system among nursing students and faculty. Findings demonstrated that a wearable sim system could offer a promising alternative for teaching and learning PE skills in nursing education. A wearable sim could potentially increase the competence and confidence of nursing students, offer a truer clinical representation of adventitious auscultation sounds, and foster a more psychologically safe learning environment in programs of nursing.
Highlights.
Peer physical examination limits learning and threatens psychologically safety.
A wearable simulator system offers more realism while protecting privacy.
An SP wearing a simulator was rated satisfactory by student and faculty participants.
Key point statements.
The use of peer physical examination in clinical education is based on tradition rather than empirical evidence.
The traditional use of peer physical examination threatens students’ psychological safety.
A wearable simulator provides a technological resource with improved realism.
A wearable simulator reduces student embarrassment and protects privacy.
Acknowledgements
The authors acknowledge and appreciate the assistance of nursing student research assistants, Emma Kuznia, Molly Conway, and Alexandra Weinberger in planning and implementing the evaluation sessions, entering data, and tabulating results.
Funding:
This project was funded by a Small Business Innovative Research (SBIR) Interactive Digital Media (IDM) award from the National Institute of General Medical Sciences (NIGMS) from the National Institutes of Health (NIH), Grant R44GM137721
Footnotes
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References
- Alamri MS, & Almazan JU (2018). Barriers of physical assessment skills among nursing students in Arab Peninsula. International Journal of Health Sciences, 12(3), 58. [PMC free article] [PubMed] [Google Scholar]
- Berg D, & Berg K. (2019). S-Vest: a novel hybrid method to allow standardised patients to put on the objective physical examination findings of a disease. BMJ Innovations, 5(2–3), 78–81. 10.1136/bmjinnov-2018-000312 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Brown WJ, & Reid C. (2022). Implementing a cost effective and configurable hybrid simulation platform in healthcare education, using wearable and web-based technologies. Smart Learning Environments, 9(1). 10.1186/s40561-022-00201-1 [DOI] [Google Scholar]
- Demiray A, Kiziltepe SK, İlaslan N, & Acil A. (2020). The effect of high-fidelity simulation in improving the physical examination skills of nursing students. International Journal of Nursing, 7(1), 8–17. 10.15640/ijn.v7n1a2 [DOI] [Google Scholar]
- Doğdu AK, Arikan F, & Kol E. (2021). Physical examination skills used by nursing students and determination the barriers encountered in the use of these skills. Journal of Education and Research in Nursing, 18(3), 335–340. 10.5152/jern.2021.67944 [DOI] [Google Scholar]
- Douglas C, Windsor C, & Lewis P. (2015). Too much knowledge for a nurse? Use of physical assessment by final-semester nursing students. Nursing & Health Sciences, 17(4), 492–499. 10.1111/nhs.12223 [DOI] [PubMed] [Google Scholar]
- Fusner SM, Moots H, O’Brien T, & Sinnott LT (2020). Faculty perceptions of the importance of physical assessment skills taught in prelicensure nursing education. Nurse Educator, 45(5), 248–251. 10.1097/NNE.0000000000000763 [DOI] [PubMed] [Google Scholar]
- Grace S, Stockhausen L, Patton N, & Innes E. (2019). Experiential learning in nursing and allied health education: Do we need a national framework to guide ethical practice? Nurse Education in Practice, 34, 56–62. 10.1016/j.nepr.2018.11.003 [DOI] [PubMed] [Google Scholar]
- Hattingh M, & Labuschagne M. (2019). Health sciences lecturers and students’ perspectives on the ethical aspects of peer physical examination (PPE). Journal of Academic Ethics, 17(4), 375–387. 10.1007/s10805-019-09334-4 [DOI] [Google Scholar]
- Hendry GJ (2013). Barriers to undergraduate peer-physical examination of the lower limb in the health sciences and strategies to improve inclusion: a review. Advances in Health Sciences Education, 18(4), 807–815. 10.1007/s10459-012-9418-4 [DOI] [PubMed] [Google Scholar]
- IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp. [Google Scholar]
- Koehler N, & McMenamin C. (2014). The need for a peer physical examination policy within Australian medical schools. Medical Teacher, 36(5), 430–433. 10.3109/0142159X.2013.874551 [DOI] [PubMed] [Google Scholar]
- Realityworks (2022a). Wearable Auscultation Trainer. Retrieved December 20, 200 from https://www.realityworks.com/product/wearable-auscultation-trainer/
- Realityworks (2022b). Realityworks’ Auscultation Trainers Win Better Future New York Design Awards 2022. Retrieved December 20, 200 from: https://www.realityworks.com/blog/realityworks-auscultation-trainers-win-better-future-new-york-design-awards-2022/
- Reid KJ, Kgakololo M, Sutherland RM, Elliott SL, & Dodds AE (2012). First-year medical students’ willingness to participate in peer physical examination. Teaching and Learning in Medicine, 24(1), 55–62. 10.1080/10401334.2012.641489 [DOI] [PubMed] [Google Scholar]
- Roche P, & Woolley T. (2013). Enhancing medical student professionalism through peer physical examination: preliminary results of a longitudinal study. International Journal of Clinical Skills, 7, 84–89. [Google Scholar]
- SAS Institute Inc (2013). SAS/ACCESS® 9.4 Interface to ADABAS: Reference. Cary, NC: SAS Institute Inc. [Google Scholar]
- Slater LZ, Bryant KD, & Ng V. (2016). Nursing student perceptions of standardized patient use in health assessment. Clinical Simulation in Nursing, 12(9), 368–376. 10.1016/j.ecns.2016.04.007 [DOI] [Google Scholar]
- Tan MW, Lim FP, ling Siew A, Levett-Jones T, Chua WL, & Liaw SY (2021). Why are physical assessment skills not practiced? A systematic review with implications for nursing education. Nurse Education Today, 99, 104759. 10.1016/j.nedt.2021.104759 [DOI] [PubMed] [Google Scholar]
- Unver V, Basak T, Ayhan H, Cinar FI, Iyigun E, Tosun N, Tastan S, & Köse G. (2018). Integrating simulation based learning into nursing education programs: Hybrid simulation. Technology and Health Care, 26(2), 263–270. 10.3233/THC-170853 [DOI] [PubMed] [Google Scholar]
- Watts PI, McDermott DS, Alinier G, Charnetski M, Ludlow J, Horsley E, Meakim C, & Nawathe PA (2021). Healthcare Simulation Standards of Best PracticeTM Simulation Design. Clinical Simulation in Nursing, 58, 14–21. 10.1016/j.ecns.2021.08.009 [DOI] [Google Scholar]
- Wearn A, & Bhoopatkar H. (2014). Experience of a peer physical examination policy within a New Zealand medical programme. Medical Teacher, 36(9), 826–827. 10.3109/0142159X.2014.940878 [DOI] [PubMed] [Google Scholar]