The authors discuss using a Virtual World to Teach IPE.

Interactive virtual patients in immersive clinical environments - the potential for learning inter-professional teamwork and communication for medical undergraduates. 

InterProfessional Education (IPE) is a pedagogical approach for health practitioners to develop an understanding of the roles, expertise, contributions of their disciplines as well as other health care providers. It helps build effective team relationships leading to safe healthcare delivery. IPE, however, is difficult and complex to develop and deliver and is labor and resource intensive. Simulation with mannequins and standardized patients has been shown to enhance teamwork and communication skills with healthcare providers, patients, and relatives. The difficulties in delivering IPE was recognised at Charles R. Drew University School of Medicine and as a result a novel approach using collaborative immersive virtual environments was developed. This new approach enabled the delivery of team-based IPE simulations in realistic clinical settings.

This article explores the challenges in the delivery of IPE, how those challenges can be addressed using collaborative immersive virtual environments, how the Charles R. Drew developed and delivered its immersive IPE experience, the results from a formal comparative trial and lessons learnt for the future.

The Challenges

There are a range of approaches available to teaching IPE including problem-based learning discussions, didactic lectures, web-based PowerPoint lectures, workshops on IPE, mannequin/standardized patient hybrid IPE simulation, etc. In summary, the challenges in delivering IPE simulation are temporal, geographic, logistical, and limited resources. Examining each of these challenges to delivering IPE:

  • Temporal – the need for students, faculty and other resources to be co-present at the same time to deliver IPE
  • Geographic – the need for students, faculty and other resources to be co-present at the same time
  • Logistic – the requirement for resources e.g. faculty, simulation equipment to be available at a specific time and specific place
  • Resourcing – the requirement for the resources to be available in the first place to deliver IPE
At Charles R. Drew it was felt that collaborative immersive virtual environments offered the following potential for the delivery of IPE:
  • Temporal - the scheduling of events could be more flexible and arranged according to availability of students and faculty. Simulations can be more frequent since preparation is not as extensive as traditional case simulation.
  • Students and facilitators no longer need to be present at the same location - virtual simulations allow us to undertake sessions anywhere where there is good internet connectivity. It is very convenient as people do not have to travel to be physically present in the same location.
  • Geographic - participants can in theory be anywhere. Students can be on campus, in a classroom, in the library, at home, at a public place, or in a different state/country as long as the internet connectivity is capable and they can be in a quiet place that allows them to talk, be heard and allowed to focus during the session. Likewise, faculty can be remotely located.
  • Logistic - the major challenge is faculty availability and scheduling. In addition, faculty training is a further challenge, the main hurdle being the training together of medical and nursing faculties due to persistently busy schedules. The process of virtual session planning and organizing so all the resources required are in place prior to each session to include the availability of back-up headsets and computers with preinstalled or downloaded CliniSpace application, availability of standardised patient actors, availability of trained assessors where video captured sessions are streamed and the scheduling of learners. Once everything is set-up, multiple sessions can be repeated. This is not possible with the traditional face-to-face simulations.
  • Limited resources - Virtual simulation incurs costs during set-up. Once everything is in place, repeated multiple and frequent sessions can be done at less cost compared to face-to-face sessions.
It is challenging to set-up a virtual case scenario to make sure that the IPE objectives are delivered, since paper case scenarios are further dissected to fit into the virtual dynamics to make the simulation as interactive and realistic as possible. The period spent in a well-built virtual IPE scenario is worth the time. Once it is in place, you can vary the complexity of scenarios to adjust to the levels of different learners. Once set-up it is up to the imagination of the faculty facilitator to enrich the environment to adjust to learners’ needs.

Learning and IPE

Three basic pre-requirement skill sets are needed for learners prior to joining a simulation session and have a meaningful encounter with the virtual patient. These are the same basic skills to be nurtured during the training of healthcare professionals in real life:

  • Technical Skills (including literacy and comfort in computer technology) – in clinical practice, you cannot thrive without being computer and technology literate.
  • Cognitive (Basic Standard of Care) – students must know how to recognise specific conditions e.g. asystole.
  • Non-technical/Soft Skills (Teamwork, Collaboration, Communication)
In practice-based healthcare professions, methods of teaching and learning focus on enabling students to assimilate clinical knowledge and skills. These concepts, previously taught in silos, were integrated to mirror how they worked inter-professionally in clinical practice. There is an increased recognition of the importance of inter-professional training for professional accreditations. Inter-Professional Education (IPE) is usually taught as a combination of didactic lectures and case scenarios.

Staff approaching Charge Nurse. Image Credit: CliniSpace
Staff approaching Charge Nurse.Image Credit: CliniSpace

Learners in CliniSpace cooperating in treating a patient. Image Credi: CliniSpace
Learners in CliniSpace cooperating in treating a patient.Image Credi: CliniSpace

Debriefing outside virtual patient room in CliniSpace. Image Credit: CliniSpace
Debriefing outside virtual patient room in CliniSpace.Image Credit: CliniSpace

Building the Virtual IPE

Designed to run on personal computers, interactive immersive simulation platforms are based on commercial games technology developed to captivate, engage and introduce learners to new knowledge or skills. After thorough research, Charles R. Drew chose the CliniSpace TM platform, because of the virtual gaming technologies available during the planning phase for IPE simulation. It offered the appropriate clinical content applicable to medical and nursing students. In addition, it offered embedded interactive virtual patients plus the capability for non-IT experts to customise virtual patients and scenarios via a stand-alone case authoring tool. This was a key requirement as it enabled the development and re-use of cases already developed for traditional IPE mannequin/standardised patient based simulation.

CliniSpace Virtual Simulation Center (VSC) is a 3D immersive clinical environment, with interactive virtual patient avatars that satisfy learning needs for junior and advanced learners. Accurate portrayal of medical environment, procedures, scenarios and patient pathophysiology prepares learners for real world practice. Tracking and recording of performance helps proper analysis of learning objectives. It provides collaboration in the multi-user environment via text and voice chat. It is a practical tool for nurses and other healthcare personnel, focusing on patient assessment, patient management and communication protocols, collaboration with physicians, charge nurse and other team members.

In practical use learners enter the virtual hospital where the patient avatar(s) await(s). If conscious, the ‘patient’ can be ‘interviewed’ either by text or potentially by voice. The patient avatar is examined e.g. to auscultate the heart or chest, physiological monitors can be attached e.g. BP cuff and data and displays appear. The clinician is able to treat or order treatments for the patient on the basis of a diagnosis (normally recorded on in-world medical record) e.g. IV, oral medication, etc. On the basis of the intervention the virtual patient may respond physiologically e.g. heart rate drop. During this time the virtual environment will be capturing clinical activity for reporting or assessment.

Briefing by a facilitator provides case scenarios to the students as well as a narrative text given as they log-in to the virtual world and reinforced by the patient Electronic Medical Record. Case development is stored in the case authoring tool.

Implementing the Virtual IPE at Charles R. Drew

Charles R. Drew recognised that Virtual IPE should be introduced in a controlled trial to validate the efficacy of the approach. In 2015 an experimental randomized controlled trial, with an intervention and control group of medical and nursing students randomly to group was begun. The intervention group had a one-hour Virtual IPE training session prior to the IPE session on-site, while the control group did not.

Learners were given basic computer IT training on how to download the CliniSpace application into their personal computer, how to login and check on their audio capability and be able to talk and be heard in the world to enable them to be interactively communicating with the other avatars.

Learners were briefed with critical action checklist: (1)Standard of care such as sanitizing the hand, infection control by wearing gowns and gloves before approaching the patient, disposing the gloves in proper garbage receptacle, etc. (2)Teamwork – leadership and followership where they use and maintain close loop communication (1st team member call out request or action, 2nd team member uses a check-back to confirm request or action, then 2nd team member confirm request fulfilled/action performed). (3) Communication - uses SBAR – situation, background, assessment, and recommendation to communicate between team and consultant provider; communicate with the pharmacist as needed, and inform the relatives on patient updates and status.

Each virtual case includes a medical crisis that the student team has to respond to by working together collaboratively using teamwork and communication. The event had to be managed with all the team members observing role clarity, communication, personnel support, knowing the resources (supplies and equipment) available to them, global assessment, and then stepping back to reassess the situation.

Students were briefed to observe closed loop communication: teller informs the teammate, the teammate repeats and acknowledges, then the teller confirms. Crisis are presented to student learners, so that they can apply the crisis resource management principles (From Rall/Gaba in (Miller, 2005)).

The in-world facilitator makes sure that the students are on track and are in line with the objective of the session. The facilitator will also manage the end of session debriefing where learners are given a chance to ‘air out’ and self-reflect on their actions.

Results

Virtual IPE Simulation Trial Study shows that Virtual IPE is an effective simulation-based modality to teach IPE, in our case study using a preparatory Virtual IPE session for the intervention group improved performance in the on-site IPE Simulation versus the control group without a virtual IPE preparatory exposure.

The Nontechnical & Cognitive Skills (NTCS) faculty rating tool was used to compare the performance of the Intervention and Control groups in the on-site IPE session. The NTCS tool consists of 17 questions scored with 1-7 Likert scale. The NTCS addresses the overall performance of the team, ability to do standard of care, teamwork and communication.

TABLE 1 – Summary of Results

NTCS 2015 (n=117)

 

 

Category

NTCS by Raters

 

VS1

(n=64)

VS2

(n=53)

p-value
Overall performance for management of this simulated scenario or emergency (Q1)  

5.67±0.84

 

5.47±0.72

 

0.197

Executing established protocol sequence/timing correctly (Q2)  

5.64±0.77

 

5.32±0.77

 

0.027

Initiating critical treatments in timely manner (Q3)  

5.63±0.74

 

5.30±0.85

 

0.027

Teamwork & Communication (Q4 through Q16)  

5.76±0.66

 

5.43±0.71

 

0.010

Exercising good diagnostic decision making skills (Q17)  

5.70±0.74

 

5.32±0.83

 

0.009

Two sample two-sided t-tests were performed to compare differences of above five categories between VS1 (experiment) and VS2 (control).

The intervention group scored higher than control group in executing established protocol sequence/timing correctly, initiating critical treatments in timely manner, higher teamwork and communication score, and exercising good diagnostic decision making skills, 5.64±0.77 versus 5.32±0.77 with p value 0.027, 5.63±0.74 versus 5.30±0.85 with p value 0.027, 5.76±0.66 versus 5.43±0.71 with p value 0.010, and 5.70±0.74 versus 5.32±0.83 with p value 0.009, respectively.

TABLE 2: Multivariate regression after adjusting age, sex, race, student (medical vs nursing student)

Category   Difference between VS1 and VS2 p-value
Overall performance for management of this simulated scenario or emergency (Q1)   5.84-5.58=0.26 0.093
Executing established protocol sequence/timing correctly (Q2)   5.70-5.37=0.33 0.030
Initiating critical treatments in timely manner (Q3)   5.74-5.38=0.36 0.021
Teamwork & Communication (Q4 through Q16)   5.79-5.43=0.36 0.008
Exercising good diagnostic decision making skills (Q17)   5.74-5.34=0.40 0.011
After adjusting the factors of age, sex, race, type of learners whether medical or nursing student, using multiple regression analysis, there is a statistically significant difference with higher scores among the intervention versus the control in executing established protocol sequence/timing correctly (5.70-5.37=0.33 with p value 0.030), Initiating critical treatments in timely manner (5.74-5.38=0.36 with p value 0.021), Teamwork & Communication (5.79-5.43=0.36 with P value 0.008), Exercising good diagnostic decision making skills (5.74-5.34=0.40 with p value of 0.011).

Discussion

The rationale for the use of virtual patient and virtual world technologies in inter-professional medical education was specific: Medical and nursing students need to learn how to apply classroom learning in clinical contexts, more importantly, these concepts that used to be taught in silos will be integrated as they work inter-professionally in clinical practice.

The trial demonstrated the Virtual IPE can statistically improve the performance of students when undertaken prior to on-site IPE and is more effective than the use of preparatory study materials. Virtual IPE is a feasible, worthwhile endeavor as a preparatory instrument. The immersive clinical environment deployed, CliniSpace, is seen as capable of providing a realistically simulated clinical context to enable the learning of specific sets of integrated concepts that would otherwise be difficult to impart.

In addition, it is less resource intensive than traditional on-site IPE and can have potential influence in lowering barriers to wider deployment of IPE. Virtual simulation however does allow as minimum from one to zero faculty where students can do the simulation on their own. The trial in fact was able to use a minimum of one faculty to facilitate all the virtual sessions, versus the 16 faculty to facilitate the traditional IPE simulation sessions!

It proved the use of immersive clinical environments for the delivery of IPE improved the performance of students; that there is the potential for substantial staffing resource savings and that low cost repeatability is a key facet.

About the Authors

Peregrina Arciaga, MD is an associate professor in Anesthesiology Drew/UCLA, the director of Clinical Skills and Simulation Center and assistant dean of Medical Student Affairs at Charles R. Drew University of Medicine, Los Angeles. She has been in simulation and an active member of the SSH for 10 years. Her research focus is on Interprofessional Simulation Education for Patient Safety.

Parvati Dev, PhD is the president and CEO of Innovation in Learning Inc, which designs, develops, deploys and commercializes leading-edge learning technologies for the healthcare market, to meet the training and capacity building needs of health care institutions and enterprises anywhere in the world.

Dick Davies is the managing director of the Ambient Performance Inc. which specialises in providing immersive solutions to help solve difficult problems in a number of specific professional domains. These domains are healthcare, first response, highways and education and training. He has led the way in innovation in technology supported learning in both corporate and academic organisations for over 20 years.

Wm. LeRoy Heinrichs, MD, PhD, IIL’s co-founder and Exec. Medical Director, has 32 years of experience at Stanford University serving in roles of Professor and Chair of Ob/Gyn, and as Director of Gynecology, and Associate Director of SUMMIT has focused on surgical simulation and on development and study of virtual worlds.

REFERENCES

'Virtual Worlds in Healthcare: Applications and Implications'. Heinrichs WL, Davies D & Davies J. (2012) 'Virtual Worlds in Healthcare: Applications and Implications' in 'Serious Games in Healthcare' (Ed) Arnab S, Dunwell I & Debattista K. IGI Global. Hershey: IGI Global; 2013, pp. 1–22.

IIL. (2014). CliniSpace Virtual Sim Center. Retrieved from CliniSpace: http://virtualsimcenter.clinispace.com/

Miller, R. (2005). Miller's Anesthesia, 6th Edition. Philadelphia: Elsevier.

Talbot, T. S. (2012). Sorting Out the Virtual Patient: How to Exploit Artificial Intelligence, Game Technology and Sound Educational Practices to Create Engaging Role-Playing Simulations. Int. J. of Gaming and Computer-Mediated Simulations, 4(3) 1-19.