This is the author’s version of a work that was submitted/accepted for publication in the following source: Brown, Ross A., Rasmussen, Rune K., Baldwin, Ian, & Wyeth, Peta (2012) Design and implementation of a virtual world training simulation of ICU first hour handover processes. Australian Critical Care, 25(3), pp. 178-187. This file was downloaded from: http://eprints.qut.edu.au/48523/

c Copyright 2012 Australian College of Critical Care Nurses Ltd.

Published by Elsevier Australia

Notice: Changes introduced as a result of publishing processes such as copy-editing and formatting may not be reflected in this document. For a definitive version of this work, please refer to the published source: http://dx.doi.org/10.1016/j.aucc.2012.02.005

This is the author’s version of a work that was submitted/accepted for publication in the following source: Brown, Ross A., Rasmussen, Rune K., Baldwin, Ian, & Wyeth, Peta (2012) Design and Implementation of a Virtual World Training Simulation of ICU First Hour Handover Processes. Australian Critical Care Journal. (In Press) This file was downloaded from: http://eprints.qut.edu.au/48523/

Notice: Changes introduced as a result of publishing processes such as copy-editing and formatting may not be reflected in this document. For a definitive version of this work, please refer to the published source:

1

Design and Implementation of a Virtual World

2

Training Simulation of ICU First Hour Handover

3

Processes

4

Ross Brown PhD, BComp (Hons)a

5

Rune Rasmussen PhD, BIT (Hons)a

6

Ian Baldwin RN, ICU Cert., MN, PhDb

7

Peta Wyeth PhD, BInfTech (Hons)c

8 9

a

Information Systems School, QUT, 2 George St, Brisbane, Qld, 4000, Australia

10

b

Intensive Care Unit, Austin Hospital, Studley Road, Heidelberg, Melbourne, Victoria

11

3084, Australia

12

c

13

Qld, 4000, Australia

Electrical Engineering and Computer Science School, QUT, 2 George St, Brisbane,

14

1

15

Extra Contact Information:

16

Ross Brown, [email protected], +61 7 3138 9481, +61 7 3138 9390

17

Rune Rasmussen, [email protected], +61 7 3138 1198, +61 7 3138 9390

18

Peta Wyeth, [email protected], +61 7 3138 2868, +61 7 3138 9390

19

Ian Baldwin, [email protected], +61 3 9496 4831, +61 3 9458 4779

20 21

2

22

Summary:

23

Nursing training for an Intensive Care Unit (ICU) is a resource intensive process.

24

High demands are made on staff, students and physical resources. Interactive, 3D

25

computer simulations, known as virtual worlds, are increasingly being used to

26

supplement training regimes in the health sciences; especially in areas such as

27

complex hospital ward processes. Such worlds have been found to be very useful in

28

maximising the utilisation of training resources. Our aim is to design and develop a

29

novel virtual world application for teaching and training Intensive Care nurses in the

30

approach and method for shift handover, to provide an independent, but rigorous

31

approach to teaching these important skills. In this paper we present a virtual world

32

simulator for students to practice key steps in handing over the 24/7 care

33

requirements of intensive care patients during the commencing first hour of a shift.

34

We describe the modelling process to provide a convincing interactive simulation of

35

the handover steps involved. The virtual world provides a practice tool for students

36

to test their analytical skills with scenarios previously provided by simple physical

37

simulations, and live on the job training.

38

facilitation of remote learning, high flexibility in study hours and the automatic

39

recording of a reviewable log from the session. To the best of our knowledge, we

40

believe this is a novel and original application of virtual worlds to an ICU handover

41

process. The major outcome of the work was a virtual world environment for training

42

nurses in the shift handover process, designed and developed for use by

43

postgraduate nurses in training.

Additional educational benefits include

44 45

Keywords: ICU Training, Virtual Worlds, Handover

46

Introduction

3

47

Intensive care education is expensive and time consuming with high standard

48

outcomes of proficiency and safety expected from staff and students alike1.

49

Concomitant with these standards are a need to ensure healthcare process

50

compliance within the student cohort. Students involved in critical care training within

51

Australia are postgraduate students undertaking further specialist training. Often the

52

trainee is released into the real-life intensive care scenario with sub optimal

53

preparation and therefore a level of anxiety for the student concerned, and some risk

54

for the management level nurses, as patient safety is paramount2.

55

preparation places a strain on the allocation of teaching and equipment resources to

56

teaching, as students require greater levels of supervision.

57

This lack of

One solution to this problem of training resources is to create computer

58

simulations of the training scenario3.

59

simulation on computers as a form of process training, including the military2, large

60

industry4, emergency services5 and mining6, to name but a few. In particular, there

61

has been an increase in the use of virtual worlds for such training in health and allied

62

professions7, 8. What remains to be seen is whether these virtual world tools are as

63

successful as the physically-based simulations presently used in nursing training3, 9.

64

While this question has not been answered specifically, early results are positive on

65

the training effects of virtual worlds in health10, 11, 12.

Many other disciplines have implemented

66

In each case, interactive computer simulations have been used to assist with

67

education and training that is expensive, repetitious in context and potentially

68

dangerous when the student is deployed in a real environment. Critical care nursing

69

training has these characteristics, with high costs involved in the development of

70

training approaches, often involving expensive physical manikins for patient care

71

training. In addition, the nursing training is potentially dangerous for patients who are

72

placed in the care of inexperienced staff13.

4

73

We believe that virtual world simulations may assist with meeting professional

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training standards, as outlined by the ACCCN1. The following list of virtual world

75

features can be utilized to meet such requirements:

76 77

●

Development of appropriate standards of practice - by the on demand

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provision of remotely accessible training environments, facilitating repeated

79

practice by students until mastery is obtained.

80

●

81 82

training environments, such as physical manikins and training rooms. ●

83 84

Efficient usage of physical training resources - via the releasing of other

Scalability – having many virtual classes performed at once, as compared to the logistical limitations of small numbers of physical training rooms.

●

Variety - such environments allow for easy configuration of scenarios. In

85

addition, the use of simulators can add variety to previously dry, or ineffective

86

teaching approaches.

87

●

88 89

Integrated documentation - easy to record outcomes using digital interfaces to document management systems.

●

Remote flexible access for students - networked access from current

90

standard desktop computers, for students and staff to remotely interact with

91

each other in real time, facilitating team training.

92 93

Five virtual world educational capabilities have been identified that guide future

94

research and development in the educational use of virtual worlds14.

95

capabilities include:

These

96 97

● Facilitation of tasks that lead to enhanced spatial knowledge representation -

98

due to the high fidelity 3D hospital or community health domain environments

99

that can be modelled.

5

100

● Greater opportunities for experiential learning - interaction and immersion

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levels in such environments begins to approach real scenarios in many

102

dimensions. Health technology can be modelled and simulated for high levels

103

of interaction and collaboration.

104

● Increased motivation/engagement - due to the immersive and personalisation

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capabilities of the environments, the student(s) can be motivated and

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engaged at high levels, promoting knowledge transfer of highly technical and

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precise health training information for the real world; and for such information

108

to become a life long attribute.

109

● Improved contextualisation of learning - training is enhanced by the situated

110

learning that takes place, often proving superior to simple textbook

111

approaches, and is a corollary of findings with physical applications of training

112

15

113 114

.

● Richer/more effective collaborative learning as compared to tasks made possible by textbook alternatives14.

115 116

These features align strongly with pedagogical requirements in critical care training to

117

make meaningful associations between patient and staff interactions, for meaningful

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care standards, safety and work flow in a busy and complex environment such as an

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ICU9, and are supported by results with other health training analyses in 3D Virtual

120

Worlds12.

121

Virtual World Health Training Research

122

Virtual world applications of health education have become a major driving force in

123

much virtual world research

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in education, such as student engagement and encouragement of reflective learning,

125

potentially map well onto the capabilities of virtual worlds16, and many research

5, 12, 16, 17, 18, 19, 20, 21, 22, 23, 24, 11, 7, 8, 25, 26

. Key requirements

6

126

groups have taken up this technology in both research and application. It is seen as

127

the next logical extension to the developing interest in web 2.0 interactive social

128

research in health27; web 2.0 being the use of social network services, for example

129

Facebook28, to form communities to assist with provision of services, health

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education and training.

131

Health training is a popular domain application in virtual worlds, especially so in

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the popular site known as Second Life, which is a commercial world where users can

133

create 3D spaces and interact with each other via a software application known as

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the Second Life Viewer29. A recent review has found 68 sites in Second Life alone,

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devoted to health education and related training and research17.

136

implementations exist in research literature18,

137

this rise in interest by the health community as a field of much potential in education,

138

conferencing and training16. The implementations cover wide areas of education and

139

training, from Emergency Triage12,

140

and interviewing skills18, to logistics for hospital supply chain management22.

5

12, 19, 20, 21

Many other

. In addition, researchers see

Community Health Education19, communication

141

Amongst these research projects, there is a general consensus of positive

142

subjective responses from the users of such simulation systems in health

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education23,

144

capabilities30.

145

positive results recorded for the training effect, and subjective sense of teamwork

146

and collaboration31; which is key to the context of the nursing handover simulation

147

developed in this project.

30, 24, 19

. In particular, they report strong engagement23 and immersion

These results also cover teamwork collaboration scenarios, with

148

One of the major positive findings has been the quantitative results showing the

149

superior capabilities of such virtual worlds in knowledge transfer in training

150

scenarios12, 11, or at least that they are equal to present physical methods21. This is

151

consistent with theoretical models presenting a proposed hierarchy of simulation

152

above other less interactive approaches, producing better learning outcomes via

153

greater retention of information32.

7

154

In addition, virtual world learning evaluation methodologies are being developed to

155

aid this outcome assessment process that incorporates thorough multi-dimensional

156

assessment models10. While this work is on going, it indicates that the field of virtual

157

world education is forming a rigorous discipline, with sound pedagogical bases.

158

Training virtual worlds are now regularly used as educational tools in a number of

159

nursing schools in the United States7, 8, providing a variety of environments to

160

augment the present curricula used in training. At present there are Australian and

161

New Zealand researchers investigating this teaching medium in health25,

162

work is preliminary in nature, and, to our knowledge, is not being used regularly by

163

any Australian nursing institutions.

26

, but the

164

This research has motivated the project described here, with the belief that virtual

165

world systems can meet training system requirements, and will assist in the delivery

166

of key training programmes within nursing.

167

handover processes within ICU wards was selected. Our research prototype was

168

developed at the Austin Health ICU, Melbourne, Australia. However, we expect that

169

the process of Austin ICU shift handover (refer to Figure 1) is similar in other national

170

and international wards, and so this module will generalise (at least in a large part) to

171

other ICUs. This module was selected for such exploratory development due to the

172

high levels of collaboration required between nurses during the handover process,

173

via a mixture of steps, including: briefing meetings, bed-side discussions and the

174

monitoring of instrumentation. In addition, the ICU handover process involves a large

175

amount of process oriented training, requiring a mixture of process compliance, and

176

ad-hoc collaboration skills.

177

In our case, a module related to

Figure 1 goes here.

178

In this study, the nursing handover is an activity requiring nurses for the shift to

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attend a meeting room and listen to a brief overview of the ICU and all the patients

180

admitted; key areas covered for each patient are diagnosis, current treatments used

181

and any social or family issue of importance. This is followed by the allocation of an

8

182

individual nurse to each patient, recognising different levels of acuity with the patients

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and different levels of knowledge, experience and skills of each nurse; providing a

184

matching of most appropriate nurse for patient to be in their care for a shift. Nurses

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then leave this room and walk to the bedside or patient area allocated to gain a more

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comprehensive handover of the patient which includes a series of cross checks with

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life support equipment in use, drug administration schedules, note taking and sign off

188

for treatments. This is a time sensitive task and is a skill to be learnt by inexperienced

189

nurses.

190

Evidence from the literature indicates that virtual worlds may meet a number of

191

key requirements for modern forms of education in intensive care nursing.

192

elements of pedagogy benefiting from this prototype study are; listening skills, verbal

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articulation, ability to summarize, synthesise, prioritise, exhibiting thoroughness and

194

emphasis in a complex and distracting environment.

195

Virtual World Technology Background

196

A virtual world is a virtual 3D space where users can immerse and remotely interact

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with 3D objects. These systems have developed over time to incorporate more and

198

more visually realistic representations, and extra programmed functionality, such as

199

virtual societies and economies33. A key continuing innovation is the ability to enable

200

people to engage with complex work tasks remotely in real time, via intuitive 3D user

201

interfaces.

Key

202

The prototype simulation presented here is based on a virtual world known as

203

Open Simulator, which allows arbitrary building, modification and testing of virtual

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content. Open Simulator, is an open-source virtual world that allows users to create

205

and deploy virtual worlds over the private internal network of an organisation34.

206

In most virtual worlds, users interact with the system through a figure called an

207

Avatar, which is a controllable proxy for the user, with options for personalisation

9

208

(see human representation in Figure 2). In social play, an avatar is a playing piece

209

that offers the user presence and social interactivity that can easily involve

210

negotiations and cooperation with other users towards achieving collective goals35,

211

such as those required in an ICU handover simulation. Users are able to connect to

212

Open Simulator servers using a client called a viewer. Once the viewer has

213

established a connection with an Open Simulator server, the user is logged into the

214

interactive simulation of a 3D world (refer to Figure 2).

215

Figure 2 goes here.

216

Austin ICU Handover Prototype Design

217

The prototype system is built around the intention of simulating the standard process

218

involved in the handover of patients in the first hour of a shift at an ICU. In particular

219

it simulates the collaboration involved in the conversations and bay checking

220

performed by the two nurses involved in the shift handover process. At present, this

221

process is taught with a lecture, tutorials and observation under guidance, before

222

being sent in to a live ICU.

223

The steps involved are based upon the processes used at Austin Health,

224

Melbourne, Victoria, but are similar for many Australian and international ICU

225

centres.

226

critical user requirements at each session. A process model, used to guide present

227

lesson structures, was used to provide a basis for the design of the prototype. Figure

228

1 illustrates the Austin Health, ICU bedside comprehensive nurse-to-nurse handover

229

as a step-by-step flow diagram. The process model steps map to key components of

230

the prototype, which are detailed in the following user requirements.

The design process involved interviews with teaching staff, extracting

231 232

Requirement one

233

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234

Develop a physical simulation of the first hour of the nursing shift, including the

235

patient handover processes in ICU, consisting of models of the patient, the physical

236

ward, pod and bay areas. The bay in this instance refers to the area occupied by a

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patient, with their bed, life support equipment and other facilities. A number of these

238

bays make up a pod, while a number of pods make up the full ICU ward. We have

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created a model containing a single pod of bays, providing a 3D simulation of the

240

process, where the patient is evaluated along with the connected instruments and

241

medical equipment. For each scenario, the patient can be queried by touching parts

242

of their body to show information such as temperature or blood pressure (see Figure

243

2). In addition, images can be shown on a screen to indicate symptoms the patient

244

may be exhibiting.

245 246

Requirement two

247 248

Develop a simulation of the collaboration that occurs between nurses in a handover

249

session, thus providing the teamwork training required in most of the process steps

250

exhibited in Figure 1.

251

representations of users in world, and via audio and text chat for real-time

252

communication user to user. In addition to the above process for each patient in

253

ICU, there is a collective briefing meeting that lasts for approximately ten minutes to

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inform staff of the arrangements and status of the patients and the bays in the

255

different sections of ICU; medical and surgical. We have created a meeting room in

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the virtual hospital to simulate briefing sessions (refer to Figure 3).

257

Virtual worlds facilitate this easily via the use of avatar

Figure 3 goes here.

258 259

Requirement three

260

11

261

The system should facilitate document analysis and note recording from students. A

262

key outcome of simulation scenario is the information they record from the lesson,

263

supporting a reflective approach to learning. A number of the process steps involve

264

the analysis of patient data, including patient entrance data, current management

265

plan, and social relationships, with respect to the formulation of a care plan for the

266

day’s shift in the ICU. The real ICU uses paper and online documents to handle this

267

process.

268

handover processes.

We have modelled the forms in a web-based database to support the

269 270

Requirement four

271 272

Facilitate scenario generation for training staff, to provide contextualised and

273

configurable lessons to suit student cohorts. In addition, the ability to review notes

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taken by students is required for later discussion with class members regarding their

275

ICU handover processes.

276

ICU Information System

277

The simulator involves an information system that presents web-based documents to

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the users during a handover simulation (see Figure 4). From the perspective of a

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user, the web-content appears while interacting with the virtual environment and may

280

appear in either a standard web browser or a web browser built into the viewer. A

281

supporting database has been configured to represent patients, staff, admissions

282

details, plans of care and the state of an ICU in terms of the admission cases

283

assigned to beds, as one may find at Austin Health. As a generalisation of the

284

database, the simulator and its data have been categorised into four data

285

perspectives: Spatial & Visual, Admissions, Plan-of-Care and Handover Notes.

286

These perspectives are drawn from data that is recorded and managed by student

12

287

nurses and educators, in the actual ICU ward at Austin Health, and from previous

288

physically-based simulation scenarios3.

289 290

Figure 4 goes here.

291 292

Spatial and Visual

293 294

Certain data items have been defined to deal with the physical position of patients in

295

the virtual environment and the visual features that may be associated with each

296

admission case. This includes the data that relates to the beds in the virtual world,

297

sets of images that can be displayed above patients to present signs of illness and

298

patient conditions, and a list of data for devices such as drug infusers, vital signs

299

monitors and even patients, along with display data for each device that can be

300

selected by a mouse. All provided to facilitate collaborative student conversations.

301

In the setup of a handover scenario, the instructor may assign a patient to a bed

302

via the Administration web page. This action makes all data associated with the

303

patient’s admission case accessible to users through mouse clicks over various

304

objects in the local space of the bed. Figure 5 shows the local space of a bed for an

305

admission case. In this space, the admission and plan-of-care details may be

306

accessed by clicking on the workstation marked ‘A’. In addition, any values that the

307

instructor may have assigned to different bedside medical devices may be accessed

308

by clicking objects marked ‘B’. Finally, any visual patient signs that the instructor has

309

assigned to the admission case lying on the bed, are accessible to users by clicking

310

on the left and right arrows on the slide-show panel marked ‘C’.

311 312

Figure 5 goes here.

313 314

Admissions

13

315 316

An objective for the handover simulator has been to simulate the admission of

317

patients with web content resembling the forms that nurses would routinely encounter

318

in a real ICU. In terms of data, the admissions perspective involves patient personal

319

and diagnostic details, nurse ID information, and admission information, such as,

320

admission ID, patient ID, date of admission, admitting nurse, diagnosis, past history,

321

family geno-gram, etc.

322

With respect to admissions, the instructor may either admit a patient already in the

323

database or add and admit a new patient from the “Setup Patient Admission” option.

324

Once an admission process has begun for a patient, the instructor will be presented

325

with an admission form (see Figure 6). The system stores the data supplied by the

326

instructor to the admission form in the database, where it will be available to staff

327

participating in the simulation through a web page having the same format as the

328

form in Figure 7.

329 330

Figure 6 goes here.

331 332

Figure 7 goes here.

333 334

Plan-of-care

335 336

This perspective deals with the planning and operations of patient care, needed to

337

inform care processes after handover. These plan of care documents store the

338

following information: admission details from the patient admission form, a list of

339

problems presenting for each patient, along with dates for problem resolution and a

340

plan list that associates problems to specific interventions to be carried out by a

341

nurse during management of the patient.

14

342

The user can access the plan-of-care information by selecting the workstation

343

object shown in Figure 5 and marked ‘A’. On selecting the workstation object, the

344

user will be presented with the admission details as shown in Figure 6, but with an

345

additional option that allows the user to select the plan-of-care form. The instructor

346

may pre-populate a plan-of-care form via the Administration web page. However, if

347

the objective of a handover simulation is to train staff to setup plans of care, then

348

plan-of-care forms may also be modified by users during a simulation.

349 350

Handover notes

351 352

Finally, the simulator provides a document interface for note taking during a

353

handover simulation as a reference point for the handover and may be used in

354

assessing student handover performances. This information consists of a list of

355

student notes associated with admission cases discussed in handovers.

356

In handover simulations, users have access to a note taking facility that can be

357

selected via a device called a heads-up display, which is a rectangular banner that

358

may be positioned anywhere in their viewer. The left part of Figure 8 shows the

359

Notes heads-up display as a box with the label, “Notes”. During a handover meeting,

360

students may take notes by selecting the Notes heads-up display, which presents a

361

form shown in the right of Figure 8 for note entry. This note entry form allows

362

students to select a particular admission case, to see previous notes for a case and

363

to add new notes. In addition, students may select the admission form for a particular

364

case for reference during note taking.

365 366

367

Figure 8 goes here.

Future Work 15

368

Our initial prototype will now be tested and evaluated with a cohort of ICU students at

369

Austin Health.

370

research findings will confirm an increase, or similarity, in knowledge retention for the

371

new ICU handover simulation, as compared to present methods10.

372

experimentation will seek to find its particular place in an ICU training curriculum. For

373

example, the system may be suited to particular points in the training process, such

374

as pretraining before, reinforcement during, or post testing after student clinical

375

experience, as a form of summative theory assessment.

We hypothesise that, similar to references cited in our paper,

Further

376

Part of the future work will investigate and report on effective governance of such

377

a simulation environment within the organisational structures of a teaching hospital.

378

While the software is freely available, technology management issues have not been

379

fully addressed, as some resources must be applied to the maintenance of the

380

system.

381

hospital computing services and related provision of training will be analysed and

382

reported to inform potential users of such technology.

383

In particular, issues surrounding installation of simulators into present

In addition, there are a number of technology questions to answer in future

384

version of this system.

385

performing training simulations integrated into a larger virtual hospital, with

386

continuous scenarios that may be re-entered at varying intervals in the training

387

program of the students. Finally, other areas of nursing training may be able to

388

benefit from such a training approach, including drug management, admission and

389

discharge routines, and administration or management tasks.

390

Conclusions

391

Virtual worlds are increasingly being used in health and medical training in order to

392

provide better utilisation of resources, flexible learning options, and to enforce

393

standards via repetition in a safe environment that leads to greater retention of

Scalability becomes a factor, with large student teams

16

394

knowledge. In this paper we described the design and implementation of a prototype

395

ICU nursing handover trainer, leveraging specific features offered by virtual worlds to

396

provide a useful and flexible training experience for ICU post graduate students. This

397

is indeed an exciting field of endeavour, potentially bringing many new possibilities in

398

intensive care nursing, including improvements in training quality and related cost

399

savings.

400

exploration and research into utilising virtual world technology for higher quality

401

health training outcomes in acute care.

402

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Captions

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Figure 1 Flow diagram, slightly modified from a document used at Austin Health, of

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the major steps of intensive care unit nurse to nurse handover process.

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Figure 2 Illustration of the patient being examined by two collaborating nurses via

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their avatars. The image also shows the information available to students via

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interaction with objects – text situated above the patient and the monitoring device.

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Figure 3 Staff and student avatars attending a virtual in-world briefing session at the

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commencement of the shift.

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Figure 4 Clicking on a clipboard in the centre of the ward simulation (left) reveals the

510

scenario generation interface (right) that can be utilised by the educator to create and

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manage teaching scenarios.

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Figure 5 An overview of different objects in the local space of a bed that may be

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selected to display information about the assigned admission case.

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Figure 6 During the setup of an admission case, the instructor will be presented with

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this patient admission form that will require the same input data as an admission

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case in a real intensive care unit.

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Figure 7 An overview of the plan-of-care form that users participating in a handover

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simulation may view or update as part of a training program.

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Figure 8 Upon clicking on Notes (labelled rectangle on the upper-left image) the note

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taking web form on the right appears for students to record handover information as

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they perform their lesson in the virtual world.

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21

523

Figures

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Fig 1

526 527

Fig. 2

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Fig 3.

530 531

Fig. 4.

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532 533

Fig. 5.

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Fig. 6.

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Fig. 7

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Fig. 8.

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