Technology in Healthcare: Medical Education Hardware for Simulations
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Video game enthusiasts have long enjoyed escaping reality to roam simulated worlds and alternate universes, from prehistoric jungles to sci-fi fantasy lands. However, the two-dimensional nature of video games has always been a glass ceiling, blocking the complete suspension of disbelief that gamers seek.
Now, with a virtual reality (VR) headset and a pair of handheld controllers, players can fully immerse themselves in three-dimensional realms, adding a level of agency to the experience that mimics reality more closely than ever before.
While most of us know how VR is amplifying entertainment, educators see an opportunity to work immersive technology into their pedagogy, creating a new medium of learning that could mark the beginning of a revolution in higher education.
Meet the Experts
Dr. Leila Casteel is associate vice president of curriculum and innovation at Herzing University and a nationally certified family nurse practitioner. She has 17 years of advanced practice nursing in emergency medicine and internal medicine and over 27 years in medical, surgical, pediatric, and oncology nursing.
Dr. Casteel is also a long-time gamer passionate about the potential of gamification to enhance students’ learning outcomes. In her role at Herzing University, she has sought to increase the immersive learning experiences that its nursing students receive.
For more than a decade, Dr. Casteel has been spreading the word about how higher education can benefit from elements of computer and video games. Watch her Youtube video from early 2012 in which she predicts the future of gamification in nursing education.
Dr. Randy Stout is a neuroscientist, cell biologist, and associate professor of biomedical sciences at the New York Institute of Technology. He is the director of the biomedical science school’s Center for Biomedical Innovation. He is also leading scientific planning for the Biomedical Research Imaging Innovation Center, which is being established in 2023.
Dr. Stout also organizes VR Interest Group meetings within the university, bringing together New York Tech faculty, staff, and students from many departments and disciplines to build new VR and computation-focused research and educational technologies.
What is a Simulation? History and Applications
Today, we often associate simulation with some application of digital technology and/or robotics. But in education, simulation has been used for centuries to allow students to role-play future scenarios they will face in their work.
One of the first known instances of surgical simulation was around 2,500 years ago, when leaf and clay models were used to conceptualize nasal reconstruction in India. More recently, the use of cadavers and robotics are some of the most common trusted ways to simulate surgical procedures.
In the mid to late 1800s, nursing students used limb models to practice tasks like bandaging and bathing patients. By the early 1900s, adult-size models featured arm injection ports and internal reservoirs, which eventually evolved into specialized manikins with physiological features like realistic breathing and heartbeats.
Many emergency medical services schools, which train emergency medical technicians (EMTs) and paramedics, offer similar simulation activities, allowing students to practice tasks like lifting and moving lifelike manikins and administering care on the way to the hospital.
Besides providing realistic patient models, schools of various healthcare specialties have created simulation centers on campus that mimic real workplaces, such as emergency rooms, operating rooms, and maternity wards.
Even STEM professions that are lower risk in terms of patients’ immediate safety, such as clinical psychology and lab sciences, have been incorporating simulation to give students a chance to apply concepts they’ve actively learned in class, boosting retention and learning outcomes.
The Digitization of Medical Simulation
Over the past few years, colleges and universities across healthcare disciplines have begun expanding their simulation offerings into the virtual realm.
Virtual simulation, also called screen-based simulation (SBS) provides an interface comparable to well-known computer/video games like The Sims or World of Warcraft, where the user interfaces in an animated environment.
Instead of navigating through SimCity or the Eastern Kingdoms, healthcare students interact in animated clinical settings, like hospital rooms, which are designed to look as realistic as possible with IV stands, patient monitor screens, and cabinets of medical equipment.
For nursing students, software like vSim or SimforHealth, may present the user with a challenge like what to do when a patient is given a lethal amount of morphine. The user completes actions like activating a “code blue” by pushing the emergency button and selecting the correct medicine and dosage that will save the patient.
Dr. Leila Casteel—associate vice president of curriculum and innovation at Herzing University, advanced practice nurse, and vocal advocate of the benefits of gamification in learning—says the main benefit of the gamelike format is the opportunity for students to make errors.
“We give [nursing students] very little opportunity to fail, but that’s how you learn how to rethink [situations],” Dr. Casteel says.
“I always think about some of the best video games… [when] you try something and it doesn’t work, you fail, you go back, and you think about what to do differently. You may do that 65 times before you finally accomplish whatever it is you need to accomplish,” she says.
While high-fidelity on-campus simulation is meant to provide a fail-safe environment for nursing students to try out their clinical skills, according to Dr. Casteel, many students experience significant anxiety levels because other students and faculty are watching them attempt a clinical task for the first time.
“[Virtual simulation] builds confidence in the students even before going forward to the [on-campus simulation] lab because they’ve done it before and they get the feedback from the system,” Dr. Casteel says.
Rather than being distracted by the pressure of trying to remember the order of operations of a specific procedure, students come to on-campus simulations having already acted out the steps of a procedure as often as they would like in the SBS interface.
Then, the anxiety of memory recall is reduced and the student can better focus on tactile elements that are not portrayable in virtual simulations—such as how to wrap a blood pressure cuff or how much pressure to apply to a syringe plunger.
Herzing University had already been working on a new framework for its pre-licensure nursing programs before Covid, including combining SBS, high-fidelity on-campus simulations, and in-person clinical rotations.
“It was really interesting because when the pandemic hit, it certainly increased our need to lean into those [virtual] resources,” she says. “For a period of time, high fidelity on-campus simulation was completely taken off the table because of the need for distance when we were all in quarantine.”
The change in the curriculum was headlined by Dr. Casteel, who saw the potential to apply elements of screen-based games to nursing education long before it was considered a real possibility.
Fitness tracking apps like those of Fitbit and Peloton are great examples of how “gamification” can increase users’ engagement in an activity. These apps make hitting fitness goals feel like a competitive game. For example, in the smartwatch Fitbit’s app, you can see which of your friends has completed the most steps in a month. With the digitally-enabled home exercise bike Peloton, you can earn badges based on calorie output and pedal speed.
Over the last few years, Herzing University’s faculty and students—along with other universities that have implemented screen-based learning modules—have had the opportunity to observe the unique benefits that gamified learning can bring to education. It makes learning more fun and engaging and increases the number of opportunities students have to put theory into practice.
Recently, the potential to bring elements of gamification demonstrated by SBS into a more interactive, immersive environment became clear as VR companies entered the scene.
Virtual Reality: Bringing Screen-based Simulation to the Next Level
Science fiction writers and imaginative optometrists have described the idea of VR for decades. Still, it wasn’t until the 1980s, 1990s and 2000s that multiple VR hardware companies attempted to bring the concept to reality. To the disappointment of gamers, their prototypes left much to be desired.
Poor screen resolution made animation look cartoonish. And positional tracking, which detects the precise position of head-mounted displays, was poor and disorienting. Further, most models were exorbitantly expensive.
Oculus, which was and remains one of the top VR hardware companies, was formed in 2012 to bring the imagined potential of VR to fruition finally. The startup quickly gained interest and funding from investors and released various prototypes over the following four years.
In 2016, it debuted the first high-quality, affordable VR headset: the Oculus Rifts. Not only were the headsets’ screen resolutions vastly improved, but the first handheld controllers enabled players to bring the use of their hands into the virtual world—marking a key turning point for VR.
As the first VR games were released for entertainment, the idea of applying the new 3D format to the education sector began gaining momentum, piquing the interest of educational leaders like Dr. Casteel and neuroscientist Dr. Randy Stout.
Dr. Stout, an associate professor of biomedical sciences and director of the Center for Biomedical Innovation at New York Institute of Technology College of Osteopathic Medicine (NYITCOM), has been exploring how VR can enhance students’ experiences in recent years. He has headlined multiple projects to virtualize different subjects within the college, such as neuroanatomy and cellular neuroscience.
While tech companies like Labster and SimX have debuted commercial educational VR software designed to correspond with various different STEM degree programs’ curricula, Dr. Stout and his colleagues created their own custom software. As he explains, they wanted the ability to customize the students’ interface.
Stout and his colleagues saw the opportunity to virtualize subjects like kidney anatomy and neuroanatomy.
Traditionally, biomedical sciences students dissect cadavers or body parts to learn anatomy, which have long been considered the most realistic and detailed resources for learning these subjects. However, these resources have their limitations—especially when understanding something as complex as the brain.
“There are all of these really important nuclei that connect with the nerves that come out of the brainstem … It’s very difficult because they’re small and they’re all intertwined around each other in three-dimensional space,” he explains. “… So, that’s where the ability to enlarge things that you can do in a digital space [becomes beneficial].”
Additionally, the availability of cadavers is limited, restricting students’ opportunity to master the subject matter.
In VR, students can visually place themselves inside of the anatomy and view connective tissue around them in a 360-degree immersive environment, giving them ample opportunity to study it close-up from different angles.
A study conducted by professors at the University of Copenhagen published in 2022 that sought to observe the effectiveness of teaching complex scientific subjects in VR demonstrated this advantage.
The lesson taught college students how to sequence DNA, allowing them to see the process inside a next-generation sequencing machine in 3D close-up animations. It found that teaching the subject in VR boosted students’ conceptual and procedural knowledge acquisition compared to traditional teaching methods.
Dr. Stout also points out how technology can improve students’ ability to interact with each other and the learning material compared to screen-based learning.
“This can be a powerful tool to make learning more collaborative and expand possibilities for problem-based learning,” he says.
Meanwhile, Herzing University’s nursing students have resumed participation in live simulation and clinical rotations since stay-at-home orders ended, but the university is not slowing down its investment in virtual simulation. In 2023, it also added VR to its nursing curriculum.
According to Dr. Casteel, the primary benefit of VR in nursing education is related to its ability to improve students’ clinical judgment skills: one of the main pillars of nursing.
“Clinical judgment [is] the ability to make decisions and understand why you’re making them and prioritize based on those decisions,” Dr. Casteel explains.
“We have to teach them how to think, and not just how to make decisions, but how to act, how to reflect on the decisions they make and why they make them, and what alternative decisions could have been made.”
Like SBS in nursing, VR can simulate various clinical judgment scenarios that nurses face, but VR increases the immersive element of the user experience.
Additionally, adding VR to students’ roster of simulative experiences means that students can be exposed to more clinical scenarios—potentially even more than live clinical experiences can provide—allowing students to practice their reactions on various situations.
“When we send [students] out to a live clinical environment… you can’t predict what the patients will see; there are certain things that students may never see,” she says. “They may never be in an operating room. They may never actually see a baby delivered. They may never be in a situation where a patient is coding (in cardiopulmonary arrest.)”
VR can ensure that nursing students experience many scenarios immersively, if virtually.
This isn’t to say that there isn’t value in using cadaveric specimens in science education or of traditional clinical experience in nursing education, but that VR adds another opportunity to conceptualize complex subject matter and gain valuable practice in a fail-safe environment.
VR is still very new and has its full potential. Two major areas it is set to expand are incorporating “metaverse” elements, which will allow for more interaction among users in the 3D classroom, and the invention of hardware, such as gloves with haptic feedback, to make VR a more physical, tactile experience.
Addressing Skepticism of VR
Virtual simulation in healthcare and STEM education has received some skepticism for one primary reason; there’s no true substitute for hands-on experience.
Advocates of immersive technology like Dr. Casteel and Dr. Stout acknowledge this perspective but distinguish that including immersive technology in curriculum does not mean fully replacing traditional learning experiences.
Rather, VR should be incorporated alongside other learning methods to make for a more comprehensive educational experience, ultimately boosting students’ comprehension, retention of information, and preparation for the real world.
In the end, every medium of learning—whether a traditional lecture, an in-person clinical rotation, a gamified two-dimensional interface, or an immersive VR experience—enriches a student’s understanding of a subject differently.