Jessica Ray, PhD and colleagues discuss how wearable technology improves simulation scenarios and outcomes. 

Jessica Ray, PhD and colleagues from Yale-New Haven Health System’s SYN:APSE Center for Learning, Transformation, and Innovation describe how they are enhancing simulations for patient and providers through the use of Google Glass.

Today healthcare simulation is utilized to enhance a broad scope of learning and systems improvements, including clinical skills training, teamwork and communication, and development of better work processes. Modeling patient physiology and psychology in a safe environment allows providers the opportunity to practice, develop, and refine critical skills and interactions, ranging from line placement to difficult conversations.

Until recently, capturing the perspectives of either the patient or the provider in these interactions was limited to observation, individual recall of the experience, and video captured from a birds eye view. Today, wearable technologies are advancing our ability to easily capture the view from the bed or the bedside. In this second article in our series, we explore how wearable technologies such as Google Glass allow us to enhance provider education, and ultimately patient care, by capturing a provider’s point of view for training, feedback, and consultation.

The following sections describe how this new perspective can advance training for both clinical and communication skills, support simulation-based analysis of work processes and patient safety, as well as how wearable technology can be employed to advance various instructional methods often utilized in simulation-based training. The final section considers how wearable technology can enrich patient care beyond training.

Advancing Clinical Simulation

The use of wearable technology enhances training for both clinical and non-technical skills by conveying the provider’s perspective of the patient, procedure, and team engagement. Consider perhaps the most fundamental element of simulation-based activities, that of procedural skills training. Utilized as a tool to capture an expert’s perspective of complex procedural skills such as a central line placement, Google Glass allows trainees an opportunity to see first through their instructor’s eyes. While video technology is often employed in this role, moving from a birds-eye camera view to a first person perspective offers learners a more detailed experience by capturing nuances such as hand position and visual attention between ultrasound guidance and needle placement. As learners progress from observing a demonstration to practicing their initial skills, they can don the wearable technology to capture a broader range of inputs for later discussion. The device affords instructors a new perspective to guide learners with real time feedback and prompts, as they advance along the expertise gradient. As learners progress in skill acquisition, this same view facilitates learner reflection through video review following completion of the procedure. While further research is warranted to investigate the learner outcomes in traditional versus learner perspective video enhanced debriefing, this enhanced reflection may offer intriguing prospects for enhancing the debriefing experience.

Beyond the realm of clinical skills training, simulation provides a powerful learning environment in which to practice critical teamwork and communication. Simulating emergent situations, such as response to a cardiopulmonary arrest, brings together the interprofessional team in a controlled time and space designed to teach techniques such as situation monitoring, directed speaking, call backs, and challenges. At Yale New Haven Hospital, code blue simulations provide practice in teamwork, communication, and leadership for a diverse interprofessional team including medical residents, nursing, anesthesia, respiratory therapists, and pharmacists.

Viewing the scene from the eyes of the provider provides a new perspective for debriefing.
Viewing the scene from the eyes of the provider provides a new perspective for debriefing.

Pilot sessions with Google Glass demonstrate the potential to see through the eyes of various team members. For example, from the team leader’s perspective, we are able to capture flow and pace of information transfer in a powerful way. In contrast to the birds-eye view, the team leader view is limited by realistic constraints such as a person’s height and physical location in the room, the number of people crowding the room and bedside, and the difficulty of creating clear visual paths with all team members to facilitate directed speaking or check-ins. By placing wearable technology on multiple providers we are able to demonstrate the complexity of communication and coordination in the room. In this same pilot session, introducing Google Glass allows us to demonstrate the role of line of site for communication between the team leader and documenter. It is in these settings that we envision the true power of wearable technologies as a training tool to be realized.

The first article of this series addressed how Google Glass allowed us to capture the patient experience. Ultimately, building a successful patient experience depends both on a provider’s understanding of the patient point of view and stepping back to reflect on their own presentation. Features such as vocal tone and intonation as well as the non-verbal presentation greatly influence patient and family interaction and communication, yet are difficult to highlight in simulation without targeted audio and visual records. Capturing the provider’s view of interactions with patients and family members during simulation provides a unique perspective for reflection on action.

From this view, providers are challenged to consider small, yet important actions such as positioning themselves on a similar visual level as the patient or family member. This allows instructors to underscore how a provider can adjust a conversation tone through physical location related to their conversation partner, the pace of their speech, their inflection, the tilt of their head, or the direction of their gaze. By titrating these subtle conversational tools, a provider may build a stronger bond with the patient and family. Utilizing wearable technologies in training provides the opportunity to teach interpersonal communication skills both through reflection on personal actions as well as through the identification of various verbal and non-verbal feedback cues often encountered during conversation.

The customized feedback from the wearable technology may also improve practitioner training in utilizing an electronic medical record (EMR) at the bedside. EMRs are becoming a regular feature in medical settings and the patient experience. By employing Google Glass to capture the provider’s perspective, we are able to analyze and discuss how to engage electronic patient information as part of the patient-provider conversation. By following the provider’s view of the physical space we are able to advance consideration of mobile workstation placement to allow for correct documentation and information transfer without interrupting the conversation between provider and patient. Capturing these environmental views from the provider allows us to present more advanced simulations to examine how new devices impact both a practitioner’s workflow and ultimately their interactions with patients and family.

Simulation is being engaged as a method for examining how health care is delivered. Focusing on the interactions between providers and their environment, these simulations promote both increased work efficiency and patient safety. Sharing features with user experience research (Gosbee & Gosbee, 2012), these simulations model routine or emergent patient care in the clinical environment. Cognitive interviews, talk aloud, and systematic observation are utilized to identify potential system improvements. Utilizing technologies such as Google Glass to capture work patterns and interactions in the environment enhances the observations. As we employ simulation as a method for rapid cycle development of system improvements, Google Glass allows us to capture the subtle variation in work processes through comparison of multiple provider perspectives in the same scenario. This will facilitate a faster, smoother development cycle.

Enhancing the Learning Experience

While technology has the power to enhance training, the development and application of appropriate instructional methods is fundamental to a successful training program (Cook et al, 2013). A variety of teaching methods including deliberate practice, simulation with pauses, to experiential simulation followed by debriefing, allow instructors to introduce and reinforce both clinical and non-technical skills across a variety of learner experience levels. Embedding smart glass technology allows facilitators to capture and quickly address key learning opportunities from a new perspective.

When introducing any type of new skills to novice learners, following a deliberate practice method may facilitate learning more effectively than traditional educational methods (McGaghie, Issenberg, Cohen, Barsuk, & Wayne, 2011). Similarly guided approaches such as the use of clinical pauses allow for error correction within a single simulation experience. In teaching models employing deliberate practice or clinical pauses, wearable technology can advance the ability of the facilitator to target specific stimuli and behaviors. Consider, for example, coaching a new team leader in the skill of situation monitoring during a code blue scenario. From the perspective of an observer in the room the instructor is left to interpret the visual field and focus of the team leader based on the learner’s verbalization, behaviors, and non-verbal actions. In this scenario, clinical pauses are triggered by the trainee’s actions. In contrast, wearable technology such as Google Glass provides opportunity for facilitators to teach at a more granular level. Seeing through the learner’s eyes, pauses or prompts can be implemented to guide the learner’s attention to critical situational details such as rotation or fatigue level of individuals performing compressions, a rhythm on the monitor, or a glance to check-in with the individual monitoring the airway.

Figure 1 a

Capturing multiple perspectives from the team enhances the training of both clinical and non-technical teamwork and communication skills.
Capturing multiple perspectives from the team enhances the training of both clinical and non-technical teamwork and communication skills.

While deliberate practice and clinical pauses have seen growing consideration in the field, simulation-based training most often consists of a hands-on experience followed by a facilitated debrief. This provides the opportunity for learning by guiding the trainee through a discussion of the simulation experience and learner actions to identify gaps or misconceptions in mental models (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007; Zigmont, Kappus, & Sudikoff, 2011). Facilitator observations and/or video playback prompt participant reflections during debrief. In both cases, facilitation is shaped by a view independent of the learner’s original perspective. While skilled educators allow the learner to adapt the debrief to their recollection, capturing the moment of action from the learner’s eye remains a challenge. With wearable technologies, it is now possible to document the simulation experience through an unobtrusive recording of the trainee’s view of the environment. This targeted perspective provides the opportunity to enhance simulation-based training in a variety of ways; comparing expert views of the environment to the view of a trainee, providing real-time coaching, and enhancing debriefing through video of the trainee’s standpoint.

Beyond Simulation

Google Glass and similar wearable technologies hold promise far beyond simulated environments. In the real patient care environment, Google Glass provides the capability to advance information access by facilitating real time delivery of x-rays, lab results, or patient records during treatment. Moreover, the ability to see the provider’s perspective from a remote locale promises great advances for telemedicine and remote consultation. Here, we envision a key role for wearable technologies in advancing transitions of care. For instance, picture a young boy struggling to breathe rushed by his parents to a local community hospital’s emergency department. As the emergency department providers stabilize the child, they recognize his need for more specialized care at a regional children’s hospital. Capturing the view of the patient from the local care provider’s view allows for timely and more informed consultation with remote specialized care providers. A transport treatment team is dispatched to attend to the child enroute. By generating a real time view of the ill child, the transport team can continuously refine their treatment plan during their response to the local hospital. The same approach may assist the tertiary care team to mobilize necessary resources prior to patient arrival. In each step, facilitating specialized care through tele-consults holds the promise to advance the efficiency of health care services.

Introducing new information technology to the healthcare setting is not without challenges. In our third and final article in this series, we will explore the path to deploying Google Glass and other wearable technologies in both simulated and clinical settings. From privacy concerns to technical considerations we discuss the barriers to implementation. We further consider our lessons learned in usability and necessary user training to ensure quality video capture.

About the Authors

Jessica M. Ray, PhD is a Simulation Learning Consultant with Yale New Haven Health System. She holds a PhD in Applied Experimental and Human Factors Psychology. Her background includes specializations in observation and training for complex environments.

Cheryl Mayeran, MPH is a Simulation Learning Consultant with Yale New Haven Health System. Her background includes specialization in program development and project management in EMS, and public health.

David Dias is a Simulation Assistant for the SYN:APSE Simulation Center. He is studying Computer Engineering at the University of New Haven with an emphasis on Mobile Technologies.

Stephanie Sudikoff, MD is the Director of Simulation at Yale-New Haven Health System’s SYN:APSE Center for Learning, Transformation, and Innovation. She is also an Associate Clinical Professor of Pediatrics in Pediatric Critical Care at the Yale School of Medicine

References

Cook, D. A., Hamstra, S. J., Brydges, R., Zendejas, B., Szostek, J. H., Wang, A. T., Erwin, P. in J.,Hatala, R. (2013). Comparative effectiveness of instructional features simulation-based education: Systematic review and meta-analysis. Medical Teacher, 35, e867-e898.

McGaghie, W. C., Issenberg, S. B., Cohen, E. R., Barsuk, J. H., & Wayne, D. B. (2011). Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine, 86(6), 706-711.

Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: 
Combining rigorous feedback with genuine inquiry. Anesthesiol Clin 25:361-376

Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). The 3D model of debriefing: Defusing,

discovering, and deepening. Seminars in Perinatology, 35(2), 52-58.

ADDITIONAL READING

www.yalenewhavenhealth.org/synapse

http://halldale.com/search/node/google%20glass

http://issuu.com/halldale/docs/medsim_5_2014/11?e=1283403/9996543