Abstract
Purpose:
To describe results of study evaluating a Projected Augmented Reality P-AR system for its potential to enhance nursing education about pressure injuries.
Design:
Pilot evaluation survey.
Subjects and Setting:
The sample comprised nursing students and faculty at a school of nursing in a large, Midwestern public university.
Methods:
The P-AR system was prototyped using commercial-off-the-shelf components and software algorithms, applied to pressure injury nursing education content. After interaction with the P-AR system, participants completed a survey evaluating the following features of the P-AR system for potential: engagement, effectiveness, usefulness, user-friendliness, and realism, users’ overall impression and satisfaction with system features. Evaluation statements used a 5-level Likert-scale; open-ended questions about what was liked, disliked or anything else offered opportunity for comments.
Results:
A total of 32 participants, which included 27 students (30% BSN, 44% MN, and 26% DNP students, 81% female) and 5 faculty (80% female) participated. Student and faculty median evaluation scores were 5 (strongly agree or very satisfied) and 4 (agree or satisfied) for nearly all evaluation and satisfaction statements. Students’ satisfaction with “realism” received a median score of 3 (neutral). The P-AR system was refined to include realistic still and animated images.
Conclusion:
P-AR, an innovative technology using three-dimensional, dynamic images, was applied to nursing education content about pressure injury and was evaluated as having potential to enhance pressure injury teaching and learning. Education about complex processes of pressure injury development and management may benefit from using cutting-edge simulation technologies such as P-AR.
Keywords: Pressure injury, nursing education, augmented reality, simulation, geriatrics
Introduction
The benefits of simulation in the education of nurses and other healthcare clinicians are well recognized.1 Simulating patient care scenarios through the use of technologies such as interactive software, virtual reality (VR), augmented reality (AR), and mannequin trainers allows for students and clinicians to learn, practice, demonstrate and test knowledge, psychomotor skills, and critical thinking before contact with real patients.2,3 Simulation can be especially useful for the beginner student or novice clinician. Meta-analyses concur that simulation-based education of nurses results in higher skill acquisition than traditional teaching methods despite variability in the measurements used in studies.2,3 Simulation can also assist experienced clinicians to master advanced psychomotor skills, increase their confidence and self-efficacy in a new role, refine their communication abilities, and effectively work on teams.2,3
Simulation provides an alternative to educational experiences in clinical settings, which may be challenging to organize or occur infrequently, such as treating a stage 4 pressure injury. Other factors driving the widespread growth in adoption of simulation in education include the need to better prepare students to manage scientific and technological innovations in clinical practice; decreasing numbers of nursing faculty; the increase in pre-licensure programs, accelerated degree-granting programs that are shorter than the traditional four-year baccalaureate degree; competition among schools for limited clinical practice sites; and advances in educational technologies that enable more realistic simulations.4–6
Although there are many varieties of healthcare simulators, from simple physical models to haptic-enabled VR systems, for example those that simulate the sense of touch using VR gloves and controllers with vibrational feedback, perhaps the most common simulator is the full body mannequin which is designed to approximate the appearance and some of the clinical responses of a human patient.7,8 Costs of the mannequin simulators can range from $1,000 to over $100,000 depending on fidelity and specialized purposes.8 Despite their substantial benefits, a fundamental limitation of mannequin-based training is that they are primarily static objects made of plastic with internal structures that appear unrealistic. Another shortcoming is that it is impractical to have a physical mannequin to represent every stage and presentation of a disease or health problem, body type, or skin color. This limits the ability for a learner to experience dynamic changes over time, and to explore disease variations, progressions, and the consequences of interventions. For instance, the formation and healing of pressure injuries is a complex, multifactorial process.9–11 However, current simulation-based education regarding pressure injuries is primarily static in the sense that students might inspect or dress a pressure injury at a certain stage painted onto a mannequin, but they are unable to observe its formation, improvement, or worsening over time.
Pressure injuries cause pain, decrease quality of life, and increase the risks of higher treatment costs, associated morbidity and death, and expensive lawsuits.12–15 The estimated healthcare costs of pressure injuries in the United States is $9.1-$11.6 billion annually.15,16 Complications of pressure injury can result in death, and the risk of death in older adults with pressure injury is nearly twice that of older adults without pressure injury.17 Furthermore, pressure injury prevalence is high among older populations in various settings. Recent reports from several countries of overall prevalence of pressure injuries in older adults show rates of 10%18 and 12.7%19 in elderly living in the community and 10.8% in those in hospitals within 36 hours of admission;20 in nursing home/long-term care facilities, prevalence ranges 5.7% to 11.6%.21–23 The average overall age of patients with at least one pressure injury in the National Inpatient Sample database from 2008- 2012 (n= 670,767 patients) was 71.2 years, and the rate of pressure injury increased with age.24 Effective pressure injury prevention, risk assessment, and early detection and treatment play pivotal roles in improving the health outcomes of those at risk.25 Therefore, educating nurses about pressure injuries, especially in older adults, is critical for better patient health outcomes.
We describe the results of a pilot study that evaluated features of a newly developed Projected (P)-AR system prototype for its potential to enhance nursing education about pressure injuries. In addition to the P-AR system prototype, we report the results of its evaluation, and how those results were used to refine the system. The P-AR was applied to educational content about pressure injuries ranging from risk factor identification to treatment.
Methods
We conducted a pilot evaluation study of our P-AR system for its potential to enhance nursing education through simulations about pressure injuries that included nursing students and faculty. Our study team developed the content, simulation modules and evaluation metrics and consisted of university nursing faculty investigators who are experienced educators, staff of two companies with engineering, animation, production and marketing expertise, a biostatistician, and an advanced practice nurse consultant certified in wound care with more than 15 years of wound care experience. The study was approved by the University of Minnesota institutional review board, Minneapolis, MN (study# 00001044, 4/9/18). Participants provided informed consent.
Description of the P-AR System
The desired functionality of the P-AR system is to precisely detect and track real-world objects such as medical humanoid mannequins, and overlay projected, dynamic imagery onto them. With this type of technology, low-cost and low-fidelity mannequins can become an “interactive learning surface” where interactive media can be displayed allowing students to explore disease progression and the consequences of their interventions; see layered views to observe the corresponding internal anatomy; toggle between photorealistic and animated view modes; and view multiple expressions of a disease and how they appear on different skin tones. Importantly, unlike solo-use VR or AR headsets that interpose hardware between students, teachers, and the classroom, the P-AR technology supports collaborative learning scenarios whereby groups of students can work together while interacting with physical objects.
The P-AR system was rapidly prototyped by incorporating commercial-off-the-shelf (COTS) components. The main elements were a high-definition projector, central processing hardware, and specialized sensing electronics. The system can be used with multiple varieties/types of mannequin simulators. The prototype is designed to mount securely on a frame above a simulation area with a humanoid mannequin, which allowed groups of students to interact around the mannequin. An illustrated depiction of the prototype P-AR system is provided in Figure 1. Custom, proprietary software was developed to detect and track the 3D properties of the mannequin and user controlled objects including their shape, presence, location, and orientation. Utilizing this knowledge, the P-AR system then maps educational information, animations, models, and images through the projector and onto the surface of the objects and mannequin, thereby retexturing them as they are moved within a simulation area. Retexturing refers to recoloring and shading the images or surfaces of objects as they move so they effectively become dynamic, interactive displays.
Figure 1.
Illustration of the setup of the Projected Augmented Reality (P-AR) system
Interactive control of the AR system is provided by users physically interacting with 3D objects such as the mannequin or by using “AR Tools.” The initial AR Tool that was developed in this study by the engineer team members with input from the faculty members is a “Smart Wand.” The Smart Wand is a specialized remote control whose position and buttons are used for multiple interactive functions such as activating virtual controls, selecting points of interest, dragging and rotating virtual objects, and responding to virtual quizzes. The P-AR system’s capabilities were applied to nursing educational content for pressure injury related to pathogenesis, risk factor identification, assessment, stages, prevention, and treatment. Animated models were developed for the content. The system integrated a variety of active learning strategies using multi-modal (e.g., reading, observational, tactile) interactions enabling demonstrations, hands-on interactions, discussions, and critical thinking of participants. The software was iteratively designed and tested using standard Agile software development processes to verify operation and identify bugs prior to demonstrating to subjects. Specifically, incremental adjustments were made throughout multiple engineering phases to troubleshoot any problems that arose, and incorporate feedback from the team. For the sessions evaluating the P-AR system, a broad set of the system’s features in relation to pressure injury education and various interactive learning activities were selected to be showcased. Additional animated models (not part of the evaluation) were also developed for other skin conditions common in older adults such as shingles, lesions, and age spots.
Application of P-AR to Pressure Injury Education
During the initial technology development phase of the study, P-AR technology was successfully applied to pressure injury education. An introduction to the application of the P-AR system to pressure injury education began with projection of a skin layer onto a mannequin; then, while turning the mannequin onto its side and back, participants were able to observe how the skin projection maintained its position on the mannequin.
Figure 2 showcases the capabilities of the system to show images of internal bony skeletal structures underlying the external pelvic and sacral areas of the body and skin, where pressure injuries commonly occur; groups discussion focused on using these types of projections to increase understanding of pressure injury pathogenesis and benefits of prevention measures such as pressure off-loading. An animated simulation by the P-AR system was also shown during the evaluation session, in this case, the formation of a left ischial pressure injury (See Figure 3).
Figure 2.
Illustration showing capabilities of levels of Projected Augmented Reality (P-AR) relevant to pressure injury. In the first 3 panels on the left, images are from a typical mannequin without any projection, with skin projected on the mannequin front and back. Panel 4 shows a projection of the vascular system while panels 5 and 6 show the skeletal system with bony prominences with and without muscles.
Figure 3.
A sample animation reel of a pressure injury wound at various stages of formation created by the team
Participants experienced the functions of the Smart Wand when they were asked to point to body locations on the mannequin where pressure injuries commonly develop, and projection of a pressure injury appeared when the wand was pointed at the correct locations but not at incorrect locations. They also used the Smart Wand to control projections of different stages of a pressure injury and a time-elapsed dynamic process in which a pressure injury worsened through different stages. Participants engaged with and discussed other capabilities of the P-AR system including: 1) projection of text explaining what users were observing (e.g., text descriptions of the characteristics of pressure injury stages); 2) a magnified graphic of a pressure injury for facilitating assessment of exposed tissues and depth; and 3) a video of a treatment procedure, in this case, instructing how to apply a certain type of dressing. This feature allows other videos about different treatment options to be included.
Recruitment of Evaluators
To evaluate the P-AR system for its potential to enhance nursing education about pressure injury, students in pre-licensure baccalaureate (BSN) and Master’s (MN) degree programs and the advanced practice Doctor of Nursing Practice (DNP) program, and faculty at a school of nursing in a large Midwestern public university were recruited. Students in the PhD nursing program were excluded as that program focuses primarily on research and not pressure injury content. Recruitment strategies included verbal announcements during class or faculty meetings, email messages to their listservs, flyers hung around the school and student organization offices, and postings on the school’s social media (Facebook and Instagram) accounts.
Evaluation of the P-AR System
The pilot study evaluating the features of P-AR system used an observational, evaluative design. Investigators developed paper-based demographic and evaluation surveys upon which student and faculty participants self-reported the following features of the P-AR system for their potential to enhance nursing education of pressure injury: potential user-friendliness, engagement, effectiveness, usefulness, and realism, and their overall impression of the system. Participants also rated their satisfaction with the following system features: its potential user-friendliness, engagement, effectiveness, usefulness, and realism, as well as its innovation, look or appearance, and quality.
Each of the features of the P-AR system and the overall impression category were described using two to five statements, and the central idea of each statement is listed in Table 2. For example, the central ideas of the statements describing potential engagement of the P-AR system were designed to assess potential to engage learning, offer interaction, keep one’s attention, and offer something new. The central ideas of statements describing potential effectiveness of the P-AR system were developed to assess potential to improve knowledge, clinical skill, clinical decision-making, and confidence. There are no standard tools, criteria, or features for evaluating P-AR or other simulation systems in relation to enhancing education in general or of any particular topic (such as pressure injury education). Therefore, the system features and their descriptive statements evaluated in this study were developed by the investigators based on their knowledge and experience and their relevance to P-AR technology.
Table 2.
Nursing Student and Faculty Scores for Evaluation of and Satisfaction with Projected Augmented Reality (P-AR) System’s Potential to Enhance Nursing Education for Pressure Injury
| Topic | Student Score (n=27) |
Faculty Score (n=5) |
|---|---|---|
|
| ||
| Median (Range) | ||
|
| ||
|
Feature of (P-AR) System Key idea of descriptive statement about the P-AR system’s feature |
Evaluation Score** | |
| Potential* Engagement | ||
| Engages learning | 5 (4-5) | 4 (4-5) |
| Offers interaction | 4 (2-5) | 4 (3-5) |
| Keeps attention | 4 (4-5) | 4 (4-5) |
| Something new | 4 (4-5) | --- |
| Potential User-Friendliness | ||
| Easy to learn | 5 (3-5) | 5 (4-5) |
| Easy to use | 4 (2-5) | 4 (3-5) |
| Potential Effectiveness | ||
| Improves knowledge | 4 (3-5) | 4 (4-4) |
| Improves clinical skill | 4 (3-5) | 4 (3-4) |
| Improves clinical decision-making | 4 (3-5) | 3 (3-4) |
| Improves confidence | 4 (3-5) | 4 (3-4) |
| Potential Usefulness | ||
| Would seek courses with it | 4 (3-5) | 4 (4-4) |
| Helps learning | 5 (3-5) | 4 (3-4) |
| Recommend to others | 4 (3-5) | 4 (4-5) |
| Realism | ||
| Realistic | 4 (2-5) | 4 (3-4) |
| Accurate | 4 (2-5) | 4 (3-4) |
| Effective | 4 (2-5) | 4 (3-4) |
| Overall Impression | ||
| Positive first reaction | 4 (1-5) | 5 (4-5) |
| Innovative | 4 (4-5) | 5 (4-5) |
| Captures interest | 5 (3-5) | 5 (4-5) |
| Look/appearance | 4 (3-5) | 4 (4-5) |
| Satisfaction with P-AR system features | ||
|
| ||
| Potential Engagement | 5 (4-5) | 4 (3-5) |
| Potential User-friendliness | 4 (3-5) | 4 (3-5) |
| Potential Effectiveness | 4 (3-5) | 4 (3-5) |
| Potential Usefulness | 4 (3-5) | 4 (4-5) |
| Potential Realism | 3 (2-4) | 4 (3-4) |
| Innovation | 5 (3-5) | 4 (4-5) |
| Look/Appearance | 4 (3-5) | 4 (4-4) |
| Quality | 4 (3-5) | 4 (3-4) |
Potential refers to the potential of this feature of the P-AR system to enhance nursing education for pressure injury per the perception/opinion of the evaluators
Possible scores ranged from 1 to 5 (strongly disagree to strongly agree) and for satisfaction (very dissatisfied to very satisfied)
Ratings of features of the P-AR system used a 5-level Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, 5 = strongly agree). Ratings of satisfaction used a 5-level Likert scale (1 = very dissatisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied, 5 = very satisfied). The evaluation survey also included three open-ended questions asking participants to comment on one thing that they liked, disliked, and anything else of their choosing about the P-AR system, respectively.
Evaluation Study Procedures
Students and faculty participated in separate small group sessions for interaction with the P-AR system. Each group session lasted a total of one hour with approximately 30-40 minutes for interaction with the P-AR system. There were three sessions of student participants ranging from 6 to 12 members, and two sessions of faculty with two to three members. At the start of the evaluation session, participants received verbal and written instructions about the study procedures and completed a background survey containing questions about their demographics, simulation education experience related to their roles, and self-rated level of general knowledge about pressure injury and nursing care of older adults as older adults are at risk for pressure injuries. They completed their background and evaluation surveys individually and anonymously at the end of the session. All participants received a $20 gift card to a large online shopping company after completing study procedures.
Data Analysis
Evaluation data collected from participants were entered into SPSS statistical software version 25.0 (Statistical Package of Social Science, Armonk, New York) and checked for completeness and accuracy. Both SPSS and SAS software version 9.4 (SAS Statistical Institute, Cary, North Carolina) were used for the analyses. Descriptive statistics (median [range] or mean [SD] for continuous data and n [%] for categorical data) were used to descriptively summarize the data. Demographic characteristics of the participants such as age, background information including simulation experience, general knowledge of pressure injury and care of older adults, student program, preferred learning method (nursing students only) and years teaching (faculty only) were summarized and reported. Students’ and faculty’s evaluation scores of the P-AR system’s features (potential engagement, user-friendliness, effectiveness, usefulness, realism, and overall impression) for enhancing nursing education of pressure injuries and participants’ satisfaction with system features were also summarized and reported. Participants’ comments in response to the open-ended questions were typed verbatim. Three members of the study team independently analyzed the responses for their main themes, and any differences were discussed until consensus was reached.
Results
A total of 32 participants, which included 27 nursing students and 5 faculty members evaluated the application of the P-AR system for educating nurses about pressure injury. The majority of students were female and white (both 81.5%) (Table 1). Regarding student evaluators, 30% were in the BSN program, (44%) were in the MN program, and 26% in the DNP program. The preferred learning method of more than half of the students (59%) was by “doing or practicing,” followed by “listening” (26%). All students had previously participated in simulation learning, with only two having “a lot” of experience (7.4%). Only one student (3.7%) reported having “a lot” of general knowledge of pressure injury, and 85% reported having “a moderate” amount of knowledge. All students had general knowledge about nursing care of older adults with a majority (74%) reporting “a moderate” amount of knowledge. The majority of faculty participants (80%) were female (Table 1). All were white and one was Hispanic/Latino. One faculty who had experience in technologies was not a nurse. Two faculty (40%) had five or fewer years of teaching experience while the others had 6-15 years teaching experience. Two faculty (40%) had a lot of experience teaching with simulation while the same number did not have any experience teaching with simulation. All faculty had some knowledge about pressure injury, with 40% reporting that they had a moderate level of knowledge about both topics. All faculty had knowledge of geriatrics care with a majority (60%) reporting a moderate amount of knowledge.
Table 1.
Characteristics of Nursing Student and Faculty Evaluators
| Characteristic | Student (n=27) |
Faculty (n = 5) |
|
|---|---|---|---|
|
| |||
| n (%) | |||
| Gender | |||
| Male | 5 (19) | 1 (20) | |
| Female | 22 (81) | 4 (80) | |
| Race | |||
| White | 22 (81) | 5 (100) | |
| Black, African American, or African | 1 (4) | 0 (0) | |
| Asian | 3 (11) | 0 (0) | |
| More than one race | 1 (4) | 0 (0) | |
| Hispanic/Latino | |||
| No | 27 (100) | 4 (80) | |
| Yes | 0 (0) | 1 (20) | |
| Student Program | |||
| Pre-licensure BSN | 8 (30) | --- | |
| Pre-licensure MN | 12 (44) | --- | |
| DNP | 7 (26) | --- | |
| Years Teaching | |||
| 0-5 years | --- | 3 (60) | |
| 6-10 years | --- | 1 (20) | |
| 11-15 years | --- | 1 (20) | |
| Preferred Learning Method | |||
| Reading on my own | 3 (11) | --- | |
| Listening | 7 (26) | --- | |
| Watching | 1 (4) | --- | |
| Doing or Practicing | 16 (59) | --- | |
| Simulation Experience | |||
| None | 0 (0) | 2 (40) | |
| A little | 13 (48) | 1 (20) | |
| A moderate amount | 12 (44) | 0 (0) | |
| A lot | 2 (8) | 2 (40) | |
| Pressure Injury Knowledge | |||
| None | 0 (0) | 0 (0) | |
| A little | 3 (11) | 2 (40) | |
| A moderate amount | 23 (85) | 3 (60) | |
| A lot | 1 (4) | 0 (0) | |
| Knowledge of Geriatrics Care | |||
| None | 0 (0) | 0 (0) | |
| A little | 4 (15) | 1 (20) | |
| A moderate amount | 20 (74) | 3 (60) | |
| A lot | 3 (11) | 1 (20) | |
Evaluation Survey Scores
Student and faculty scores (median [range]) for evaluation of the potential user-friendliness, engagement, effectiveness, usefulness, and realism, and their overall impression of the P-AR system for enhancing nursing education about pressure injury are reported in Table 2. Student median scores for statements describing potential user-friendliness, engagement, effectiveness, usefulness, and realism of the P-AR system were 5 or 4 indicating “strongly agree” or “agree” respectively. Student median scores for statements about the overall impression of the system category were also 5 or 4. Student median scores for satisfaction with P-AR system features were 5 (very satisfied) for “innovation” and “engagement,” 4 (satisfied) for “user-friendliness,” “effectiveness,” “usefulness,” “look/appearance,” and “quality,” and 3 (neutral) for “realism.”
The faculty median scores for statements describing potential user-friendliness and overall impression of the P-AR system were 5 and 4 (Table 2). Faculty median scores were 4 (agree) for all statements describing the system’s potential engagement, usefulness, and realism. Regarding the system’s potential effectiveness, faculty median scores were 4 (agree) for “improves knowledge,” “improves clinical skill,” and “improves confidence” and 3 (neither agree nor disagree) for “improves clinical decision-making.” Regarding satisfaction with the P-AR system, faculty median scores were 4 (satisfied) for all statements (Table 2).
Open-Ended Responses
Themes of the students’ open-ended comments about the one thing they liked about the P-AR system included its realism, ability to promote interaction and manipulation during learning, and its three-dimensionality. One student commented, “I like that it is touch sensitive so you can see realistically where things such as pressure ulcers may occur and excluding where they do not occur.” Another student wrote, “It is interactive. I like that you can view the ulcers in different areas and at different depths. I like [seeing] the progression through the [pressure injury] stages.” A third student commented that they liked “its capability to show more than just the ulcer—like showing common locations, questions, videos.”
The major theme of what students disliked was the early version of the graphics or images that did not seem as realistic as the students would like as noted in this comment, “The image quality, but I’m assuming there will be improvement.” Student responses to the question “What else would you like us to know,” had themes focused on the system’s innovation, excitement that it generated, the variety of simulations that could easily be presented, and its potential use for health problems other than pressure injury. One student commented, “This was super engaging and fun to interact with.” Another wrote, “I like the idea of having [pressure injuries] in patients with different skin color and body types.” Other students commented about its potential usefulness, for example, “The idea and potential permutations and applications of this product are extremely exciting! If allowed to develop…this would be an excellent product to add to the classroom laboratory” and “I think this has great potential…I think it’s important to focus on things that will really add value and don’t already exist in teaching tools-what is hard to show with a static model, etc.”
The themes of faculty’s open-ended comments about the one thing they liked about the P-AR system were its promotion of interactive learning, its versatility (e.g., ability to control and vary different aspects of the simulation easily, and the time lapse feature (e.g., show healing of a pressure injury that would take time). One faculty commented about liking the “ability to just project on a certain area…and [the projection] can change if front or back” and another about “the ability to have a 3D, interactive experience.” Comments indicated there were nothing disliked: “Nothing at this point.” Regarding the question about “What else,” themes of faculty comments centered on its potential for teaching about complex problems. One faculty stated, “I think there is tremendous potential with this technology,” and another said, “The potential is great-like the idea especially for more complex, multiple issues for the learner to assimilate.”
Refinement of AR Projection
In response to the evaluation survey results and comments, the P-AR system was refined. The major area of refinement directly addressed the major theme that the evaluators wanted improved realism. Hence the team developed processes to convert and integrate real-world (i.e., non-animated) models from photographs of injuries and skin conditions into the P-AR system. Imagery was selected by leveraging the expertise of an advanced practice nurse consultant certified in wound care with more than 15 years of wound care experience. Figure 4 showcases improvements to the realism of wound and skin conditions afforded by the system. Additional engineering was performed on graphics resolution, contrast, and alignment. Object detection and projection latency were optimized to enhance simulation immersion and interaction response time.
Figure 4.
Projected Augmented Reality (P-AR) 3-D images of various pressure injuries on different tones of skin color. Different angles of the wound as well a close up of the depth of layers can be highlighted.
Discussion
To our knowledge, this is the first application of P-AR for nursing education about pressure injury, which remains a significant health problem. Results of the evaluation by nursing students and faculty indicate that P-AR has potential to enhance nursing education about pressure injury in an innovative, highly engaging, and interactive simulated manner. Among the advantages of P-AR shown in this study is that multiple users can simultaneously engage in hands-on interaction with a mannequin, supporting small group or partnered learning. Additionally, the use of VR headsets is not required. The VR headsets are fragile, increase expenses, and pose hygiene issues when shared between users. Our results showed that nursing students and faculty considered P-AR to have potential to enhance learning and teaching about pressure injuries, their prevention, and their management. Wound, ostomy, and continence (WOC) nurses rely on general nurses outside their specialty to identify, prevent, and help manage pressure injuries. Improving the knowledge and skills of nurses who collaborate with WOC nurses can support the clinical effectiveness of both.
Results also showed that realism of an animation or representation is important to learners and teachers. During the evaluation sessions, the investigators/study team demonstrated varying levels of realism in examples of pressure injury that they were considering. Evaluators’ responses guided the refinement of projections towards enhanced realism. These responses may reflect evaluators’ opinions that a new technology such as P-AR has potential to improve upon what is currently provided by simulation systems or textbooks and be a valuable addition to educational resources. Furthermore, optimal learning about pressure injury may rely on some exposure to highly realistic images as supported by results of Garrigues and colleagues26 who described how observing stage 4 pressure injuries of patients positively influenced attitudes of nursing students about the importance of pressure injury care, in particular, their prevention. Not all nursing students may have an opportunity to observe a pressure injury; hence, exposure to realistic images via P-AR may fill a gap in experiences that promote commitment of students to best clinical practices.
Additionally, P-AR offers an opportunity to improve education about pressure injury on darker toned skin which may result in improved nursing assessment and patient outcomes. Darker skin presents challenges for early identification of skin damage including pressure injury since “redness,” considered one of first signs of skin damage, can manifest as a purplish color or more subtle discoloration of usual skin tone and may be missed.5,27 There are differences in the prevalence of pressure injury in older nursing home residents by race and ethnicity; specifically Blacks had the highest prevalence followed by Hispanics with the lowest rates found in whites.28,29 In a large study analyzing disparities in the time to development of pressure injuries after nursing home admission, more Black residents developed pressure injuries sooner than expected compared to a white group of residents.30 Moreover, pressure injury associated deaths are four times higher in Blacks than in whites.31 Innovative simulation technologies such as P-AR may assist nursing students and nurses in their assessment and identification of pressure injuries on darker skin and understanding prevention interventions and reduce racial disparities in health problems.
Strengths and Limitations
Among the strengths of this study is the interdisciplinary research team including an expert WOC nurse consultant. Another strength is eliciting and responding to feedback from faculty and student stakeholders for refining the final product. To our knowledge, our P-AR system is one of the first to apply this innovative technology to educational topics within the WOC specialty. The limitations of this project include an evaluation of an early-stage prototype of the P-AR system for nursing education. Further research is needed about its actual impact on learning and critical thinking. The convenience sample was from one school of nursing in a large public university, and results may be different for participants from other types of colleges, nurses studying to be WOC specialists, and WOC nurses in practice. The sample of nursing students included pre-licensure as well as advanced practice nurses; whether students with different levels of clinical experience might respond differently was not assessed due to small numbers of each type.
The results of this preliminary study are currently being used to inform a follow-up study. In the follow-up study, content about pressure injury is being included in P-AR-enhanced case studies for nursing students focused on learning about complex health conditions with multi-system effects and their prevention and treatment; pressure injuries are an exemplar of such conditions. For example, instead of having a simulation of the appearance of a pressure injury of a certain stage only, the P-AR-enhanced cases can illustrate how decreased perfusion and oxygenation of skin tissues in a patient with acute heart failure and reduced mobility can increase the risk of pressure injury. P-AR can also show though animation the underlying principles and effects of appropriate nursing interventions to prevent and manage pressure injury. P-AR has the capability to illustrate and provide health context to the development of a pressure injury with dynamic, three-dimensional images. By illustrating pathophysiological principles and physical responses and engaging users in the scenarios presented, the cases using P-AR aim to support better understanding of health conditions that affect multiple systems and critical thinking to promote improved nursing practice.
At this time, we do not know which learning domains may be influenced by the P-AR system as we did not assess learning. In addition to the cognitive domain, psychomotor skills related to repositioning and pressure off-loading or dressing a pressure injury may be improved after interactions with the system or watching accompanying videos about treatment. The affective domain related to valuing pressure injury prevention may be influenced after observing realistic projections of severe pressure injuries and mechanisms of prevention, as reported by Garrigues and colleagues.26
Conclusion
Our study of a cutting-edge simulation technology, P-AR, was applied to educational content about pressure injury; evaluation of the features of the P-AR system showed they had potential for enhancing nursing education about pressure injuries. Our P-AR has numerous advantages over simulation using standard mannequins. Nursing student and faculty evaluation about using the P-AR system to enhance learning and teaching about pressure injuries was very positive. P-AR offers potential to better educate and prepare novice nurses to collaborate with specialty WOC nurses in practice. Further development of P-AR also has potential for application in specialty education of WOC nurses and in treating complex wounds. The P-AR system is currently in final development and not yet commercially available due to delays related to the COVID-19 pandemic.
Acknowledgements
Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under award numbers R43AG057257 and R44AG057257. All study costs were financed under these grants. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors appreciate the assistance of research assistants, Emma Kuznia, Megan Nolley, Elise Gannon, BSN, RN, and Kjerstie Wiltzen, BA, BSN, RN, students in the University of Minnesota School of Nursing at the time of the study.
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