Technology can help nurses gain empathy and navigate difficult conversations.

Takeaways:

• Extended reality (virtual, mixed, augmented) technology is rapidly expanding and finding a space in healthcare professional education.
• The positive impact of these technologies are shared, along with strategies that can be implemented in continuing education and staff development.

EVERY DAY, nurses face situations that require an aptitude for insight and empathy to meet patient needs. These skills typically are achieved with experience, but imagine if opportunities to enhance empathy could be presented during new-hire orientation or in staff development activities. Using virtual reality (VR) technology, focused experiences related to patient perspectives and challenging situations can prepare nurses for real-world clinical settings.

According to Tiffany and Forneris, VR technology use is rapidly expanding, with the potential for as much as 45% growth by nursing programs within the next 5 years. Opportunities exist to integrate augmented reality (AR) experiences in nursing with computer-generated content, but immersive experiences such as VR and mixed reality (MR) offer a unique way for learners to experience active presence in a simulated environment. (See What is virtual reality?)

A team of two nursing faculty and one media technology specialist in the nursing program at California State University Channel Islands piloted three approaches to immersive learning:
• AR 360 imaging for hospital orientation
• MR simulations to practice difficult conversations
• immersive virtual patient perspective experiences to foster empathy.

AR: Exploring environments

Hospital orientation for nursing students and new staff can be overwhelming, labor intensive, and too time limited to adequately familiarize them with the facility’s environment. To allow students and new staff to explore and interact with the facility on their own time, 360 images (panoramic views) of hospital rooms were obtained by the media technology specialist. The images were then uploaded to a web-based digital tool, where embedded content, including video tutorials of equipment, images of important room features, larger still images, and short quizzes, made the AR interactive. (See Hospital orientation.)

Feedback

In voluntary feedback, students generally were very positive about the activity, were encouraged by the opportunity to explore the hospital environment, and enjoyed the virtual interaction to prepare for clinical experiences.

“I liked how easy it was to use. I also loved when there were videos attached to the equipment we will be using. I feel like this will take some of the anxiety away from being unsure how to use some of the complicated medical equipment.”

“It was very realistic and gave you a 360 view of each room.”

“I liked that there were tutorials on the facilities equipment, like the pump, suctioning, etc. as some that we go to have different equipment.”

MR: Practicing difficult conversations

Senior-level nursing students practiced difficult end-of-life conversations using MR with interactive avatars as stand-ins for a patient’s family. In small groups, one student at a time sat in the “hot seat” and engaged directly with the avatars while the other students acted as the support or “brain.” Two faculty experts guided the timing of the session, directed student role rotations, and provided ongoing debriefing and support during session pauses initiated by the student or expert as needed. Faculty experts also guided prebriefing and debriefing sessions. (See Difficult conversations.)

This MR application facilitates in-action and guided reflective learning. It offers participants an opportunity to practice communication skills and navigate difficult conversations in a safe environment so they’re prepared for real, frequently emotional conversations in clinical settings. This format also can be used in staff development to practice challenging interactions with patients or families, intraprofessional communication, and other situations where effective communication is critical.

Feedback

Students provided anonymous feedback via an emailed survey link to open-ended questions about the experience.

“I thought it was a great exercise in practicing difficult conversations. The reality of the simulation really enhances the experience and I appreciated the group acting as the brain and being able to discuss pertinent topics during the simulation.”

“It was such a raw experience, which I loved. It felt so real and really made me think about an important conversation such as this one. I would not have known how to handle it in the actual clinical setting had we not done this.”

“I found it to be a very heavy and emotional situation. I remember having to breathe out heavily when it was done. I really liked it though because I feel it presented us with a good learning situation in a safe environment.”

VR: Embodying the patient experience

Students had an opportunity to experience the effects of various conditions or diseases from the patient perspective using a commercially available immersive VR learning platform (Embodied Labs) that included VR headsets. Sophomore- and senior-level nursing students enrolled in medical-surgical courses wore the headsets to “become” Alfred, a 74-year-old man with macular degeneration and hearing loss. In one scenario, when students don the VR headset, they see a large black spot that occludes their vision; in another scenario, their voices are muffled and difficult to understand. Participants experience what it’s like to be Alfred when he knocks over a glass at his birthday dinner and when he tries to complete a written cognitive test at a doctor visit.

In another set of scenarios, students engaged in three experiences as a middle-age Latina woman, Beatriz, who progresses from early to late stages of Alzheimer’s disease. As Beatriz, the students see and feel the disruption in daily life with family relationships, the reduced ability to make decisions, and the increased dependency on others. The scenarios (approximately 8 minutes each) are viewed separately.

Sophomore students experienced one of the Alfred scenarios and senior students experienced both Alfred scenarios, followed by the Beatriz scenarios a few weeks later.

Feedback

Student survey feedback after the sessions indicated a more in-depth understanding of the disease processes and patient perspective than they reported before the sessions, similar to research findings from medical students who had completed the scenarios. Anecdotally, one week after the Alfred sessions, students in the clinical setting were observed reporting on vision and hearing impairments more frequently during their assigned care of telemetry unit patients, which hadn’t been the case in previous clinical weeks.

“I learned that up until this point, we could read symptoms in books and perform simulations with patients in the lab, but very few experiences have allowed us to embody and be aware of the sensory deficits of degenerative diseases.”

“It gave me an increased empathy for patients who are struggling with these health problems. It gave me a physical understanding of what it is like to have vision and hearing problems.”

“I learned just how much this disease really affects someone’s life. I got so emotional at the end because Beatriz could not communicate and hardly recognized her own family. It was heartbreaking. I feel that I can offer more compassionate care to patients who experience this because I got to see a little glimpse of what they go through.”

“I think the VR experience was positive because we always talk about stepping into the patient’s shoes but you never really have the chance to actually do it. At least through VR we can experience some of the struggles that we don’t understand.”

Making an impact

Continuous education is critical to professional nursing success. Preliminary feedback on all three extended reality (XR) experiences indicates that it should be considered for integration into nursing curriculum. However, formal data collection is needed to explore the impact on learning and practice.

Well-designed training that uses high-impact technology has the potential to positively affect care quality and outcomes, patient satisfaction, and nurse retention. XR technology could be part of prelicensure nursing curriculum and staff nurse (or other healthcare provider) development in high-value areas of healthcare delivery (including adhering to standardized procedures, fostering interprofessional communication, and developing approaches to avoid sentinel events). Improving nurses’ preparation related to workplace logistics, effective communication, and empathy for specific types of patients might result in greater employee satisfaction and reduced employee turnover, which in turn might increase patient satisfaction and improve outcomes. In addition, XR equipment and facilitation is relatively inexpensive, so it may prove to be cost and time effective.

The most exciting aspect of XR is its ability to break down barriers and effectively immerse participants in a realistic virtual world in less than 15 minutes. Meeting high expectations for patient satisfaction via patient-centered care and effective communication is critical in all healthcare settings. Innovative XR approaches to nursing education have resulted in a powerful impact on students and can be integrated into many aspects of nursing staff development and continuing education.

The authors work at California State University Channel Islands in Camarillo. Jaime Hannans is an associate professor of nursing. Colleen Nevins is an assistant professor of nursing.

Selected references

Agency for Healthcare Research and Quality (AHRQ). Healthcare simulation dictionary. December 2017. ahrq.gov/professionals/quality-patientsafety/patient-safety-resources/research/simulation-dictionary/index.html

Albright G, Bryan C, Adam C, McMillan J, Shockley K. Using virtual patient simulations to prepare primary health care professionals to conduct substance use and mental health screening and brief intervention. J Am Psychiatr Nurses Assoc. 2018;24(3):247-59.

Levett-Jones T, Bowen L, Morris A. Enhancing nursing students’ understanding of threshold concepts through the use of digital stories and a virtual community called ‘Wiimali.’ Nurse Educ Pract. 2015;15(2):91-6.

Marr B. What is extended reality technology? A simple explanation for anyone. Forbes. August 12, 2019. forbes.com/sites/bernardmarr/2019/08/12/what-is-extended-reality-technology-a-simple-explanationfor-anyone/#53d659707249

North of 41. What really is the difference between AR/MR/VR/XR?Medium.com. March 20, 2018. medium.com/@northof41/what-reallyis-the-difference-between-ar-mr-vr-xr-35bed1da1a4e

Ousey K. Virtual and augmented reality: Enhancing nurses’ wound care management skills. Wounds UK. 2018;14(2):8-9.

Strekalova YA, Krieger JL, Kleinheksel AJ, Kotranza A. Empathic communication in virtual education for nursing students: I’m sorry to hear that. Nurse Educ. 2017;42(1):18-22.

Tiffany J, Forneris S. The forecast for tech usage and growth in nursing education: Part 4 of the series “The future of technology in nursing education.” NLN TEQ. February 7, 2018. nlnteq.org/2018/02/07/the-forecast-for-tech-usage-and-growth-in-nursing-education-part-4-ofthe-series-the-future-of-technology-in-nursing-education/

Washington E, Shaw C. The Effects of a VR Intervention on Career Interest, Empathy, Communication Skills and Learning with 2nd Year Medical Students. Embodied Labs. static1.squarespace.com/static/57237ac420c647f685d44510/t/5b0799a48a922d804a8f5a19/1527224745768/EL+Whitepaper+-+Effects+of+a+VR+Intervention.pdf