Utility and Effectiveness of a Remote Telepresence Robotic System in Nursing Education in a Simulated Care Environment
Debi Sampsel, DNP, MSN, RN,1 Patricia Vermeersch, PhD, GNP,2 and Charles R. Doarn, MBA3 1
College of Nursing, University of Cincinnati, Cincinnati, Ohio. Kent State University, Kent, Ohio. 3 Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio. 2
Abstract Background: There is a growing shortage of nursing graduates and faculty to prepare students for careers in nursing. One way to ameliorate this paradigm is to integrate technology such as a remote presence robot (RPR) in both clinical and educational settings. Materials and Methods: The InTouch Health (Santa Barbara, CA) RP-7, an RPR, was deployed in a simulated, multigenerational home where nursing students and faculty interact in a variety of activities. Seventy students and five faculty members were instructed by a remotely located instructor who controlled the RP-7 from a distant site. Students and faculty, using questionnaires, provided feedback on the didactic interaction. Results: Of the 70 student participants, 56 (80%) responded, and faculty and clinical staff were 100% compliant, resulting in 69 total respondents. Using Krippendorf’s themes of (1) usefulness, (2) acceptability, and (3) impact, the data indicated the following. The majority of the students (89%) had no previous experience with the RPR, but the majority (75%) felt that the RPR was a good faculty extender. The students were initially evenly split on first exposure in (a) a positive experience, (b) a negative experience, or (c) a mixed experience. Although there were some technical challenges in operations, these were not deemed significant; nevertheless, they must be addressed. Conclusions: The results of this study support the use of RPRs as faculty extenders to facilitate course quality assurance when the lead faculty is not on site. Both faculty and students perceive this type of technology as a potential faculty extender, but both faculty and students need preparation for the experience. Key words: telenursing, robotics, e-health, pedagogy, simulation
growing needs. There is a concomitant growing shortage of doctors, nurses, and allied health workers nationwide. This is a challenge not only in clinical practice at all levels in the continuum of care but also in the education of future practitioners as well. This is especially profound in nursing education. At the national level, the Institute of Medicine has reported a growing shortage of skilled nurses and qualified faculty to teach future nurses. As Finkleman and Kenner1 reported, this will have a significant impact on the quality of healthcare in the United States and therefore broaden the current chasm. Bleich et al.2 also provide a summary of the nursing workforce crisis and how a strategy needs to be developed to ameliorate the growing gap. This shortage is not only in graduates but also in faculty who guide future nurses through their training. This gap has been observed nationwide. The Nursing Institute of West Central Ohio commissioned a regional workforce study in 2004 and in 2006. They reported on a workforce profile that depicted a steady shortage of faculty.3 Over half of the faculty completing the survey indicated that they would enter retirement within the next few years. The age of the faculty and the reported predictions set this particular region 2 years ahead of the national average. More recent workforce projection studies indicate that the nursing workforce will affect not only direct care staff but also faculty positions. According to the National League of Nurses, the faculty shortage is expected to climb 6.9% or more per year.4,5 This shortage will be compounded by the current aging of the faculty and faculty freedom to work either at home or another location due to the rapid growth of proven online programs of nursing.5 This makes recruiting seasoned staff a greater challenge for nursing schools that are not located in the most ideal geographical areas, and thus pedagogy will be impacted. As online programs continue to flourish, the use of technology will continue to be integrated into nursing and healthcare as well. One of the most desirable technologies that may assist nursing schools is the use of telepresence robotics in the classroom as well as in the clinical setting. The remote presence robot (RPR) offers a great alternative solution for faculty who want to work from desired locations across the United States. These devices serve as the physical presence that can emulate faculty members who can now be present virtually.
Background
A
s the full effect of the Patient Protection and Affordable Care Act implementation is realized, the healthcare industry in the United States will see a large increase in patient population as more people seek healthcare. This will burden a system that is already maligned as a result of a labor force that is inadequate in numbers and ill equipped to address the
DOI: 10.1089/tmj.2014.0038
STRATEGIES FOR TURNING THE TIDE One way to enhance nursing practice and nursing education is to further introduce, adapt, and integrate technology. The integration of technology into nursing education and practice has been presented by several individuals. Simpson6 reported on how the integration of technology can enhance safety for patient and practitioner. Ball
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et al.7 also discussed how technology can transform healthcare delivery by impacting cost-effectiveness, productivity, and patient safety, and thereby revitalize nursing practice. In the practice of medicine, RPR systems, where a clinician can drive a robotic system from room to room while wirelessly tethered from a distant site, has shown promise. Reynolds et al.8 developed a lexicon for telehealth that is integrated into the intensive care unit. Furthermore, Reynolds et al.9 reported effective utilization of such remote systems in this setting. Lamb10 discussed how telehealth has been used in nursing care. In an interview of Dr. Yulun Wang in 2005 concerning his efforts in developing telepresence robotic systems, he commented on the utility of such systems in healthcare.11 In addition, the integration of simulation has been of great value in medicine and in nursing. High-fidelity simulators provide students and faculty alike unique opportunities to learn skill sets and then rehearse them repeatedly prior to actual practice.12,13 In the academic setting, the RPR has been used only in limited situations as the technology of choice for faculty extender nursing research. A research study by Sampsel et al.14 was one of the first in the world to test the use of this technology in an academic setting. Since that time, there have been other studies conducted within the academic setting where the use of RPRs and other two-way communication devices have been used to attempt to extend the reach of faculty.
REMOTE ROBOTIC SYSTEMS The RPR (InTouch Health, Santa Barbara, CA) is a remote-controlled device that permits synchronous communication between two different locations (Fig. 1). The device is controlled from a distant site via a communication link. The RPR has been approved by the Food
and Drug Administration and meets all the patient safety and Health Insurance Portability and Accountability Act compliance rules. The RPR is equipped with a ‘‘bionic’’ eye that is 10 times more powerful than the human eye. The user can zoom the camera to assess pupils and skin eruptions, as well as throat infections and other behaviors of a person that would indicate some sort of health deviation. The attachment of a stethoscope, telephone receiver, printer, and links to medical imaging files creates very extensive capabilities for completing a health physical, creating teaching images, and being able to communicate in real time with very little delay in timing. This system has been used in clinical settings as well as for education and training.15–17 The RPR in operational settings can also be monitored 24/7 by InTouch. The sophistication of the technology and the broadband transmission creates a reliable communication flow between the sender and the receiver. The real-time capability of the transmissions makes the sender seem virtually present. The other feature of the RPR is that the sender can drive the RPR all over the educational and healthcare setting with ease. A joystick is used to remotely control the robot. The computer keyboard allows the sender to zoom up close to the receiver and have complete privacy as needed through the use of the headphone sets. The sender has a panoramic view of the room, all participants, and the room furnishings. The sender also has the capability to obtain and store photographs as well as video capabilities. These two features are added bonuses for faculty and clinical adjunct personnel as the faculty sender can use photographs and DVDs to help illustrate case studies, to draw on them to emphasis certain lesson plan objectives, and to incorporate various disease processes into the educational experience.
OBJECTIVES The purpose of this study was to explore the application of the RPR in the role of course coordinator in oversight of a newly created simulation experience in a required undergraduate gerontological nursing course. The study was focused on evaluating the utility and effectiveness of the RPR and to evaluate the use of this technology as an extender for faculty who may not be in residence and must work remotely. The RPR has been demonstrated to be effective in the acute care environments for physicians and advanced practice nurses providing mental health services, stroke network interventions, and critical care rounds.12–14
Materials and Methods
Fig. 1. Remote presence robot from InTouch Health (courtesy of InTouch).
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The InTouch Health RP-7 was deployed in this study. A remotely located tenured faculty member (RLTFM) member, who served as the remote operator, was the instructor for the students and other adjunct clinical faculty. The RLTFM, located approximately 250 miles from the students and other faculty, operated the manufactured RP-7 via a laptop, joystick, and headset (Fig. 1) remotely. This study used student and faculty questionnaires from the study of Sampsel et al.14 In addition, other segments of the research were added to expand the body of nursing knowledge in the area of testing the efficiencies derived from the faculty extender. An embedded, single-case design
REMOTE TELEPRESENCE ROBOTIC SYSTEM IN NURSING EDUCATION
was used to examine the usefulness, effectiveness, and impact of the RPR for the RLTFM in oversight of a newly created home-based simulation for a required undergraduate simulation experience. This design is useful when investigating current real-life phenomena with unclear contextual boundaries and the opportunity to collect data from multiple sources. The units of analysis ranged from the largest (impact on faculty oversight of simulation) to the smallest (individual student, clinical faculty, and the remote presence device). During this study, sources of evidence included (a) participant observations, (b) research investigator’s observations through the RPR, (c) surveys from students and clinical faculty, (d) simulation staff, and (e) data collected in the Co-Principal Investigator’s field notes.
Clinical faculty were full-time, experienced Master’s degree–prepared nurses with a variety of specialty backgrounds, including medical– surgical, pediatric, community health, and psychiatric nursing. All faculty members had previous experience in the gerontological course and previous experience with mid- and high-fidelity simulation, but only one had previous experience with the RPR. All nine clinical groups in the course of 70 students participated in the simulation and were invited to participate in the study during debriefing, with 56 completing the surveys (80%). No attempt was made to differentiate those who participated from those or did not. Most student participants (89%) had no prior experience with the RPR.
SETTING AND SAMPLE
MEASUREMENT TOOLS
The study was conducted in the Living Laboratory (LL) smart house (Dayton, OH), which was designed to reflect a home of an integrated multigenerational family. The RPR was operated in a technologyladen single family home, composed of several types of human patient simulators, which are capable of mimicking many of the human body functions. The house, which is populated with three generations of simulated family members, creates a microcosmic view of life at home. This is a perfect backdrop for testing and evaluating RPRs. Nursing and other healthcare students from surrounding schools and universities utilized the LL for a wide variety of simulated and technology experiences. The sample for this study included one RLTFM using the RPR, five clinical faculty members, and 70 undergraduate nursing students who participated in the simulation at the LL. The RLTFM served as course coordinator for an undergraduate clinical course in gerontological nursing (a required course for a Bachelors Degree in Nursing). Relocation of the course coordinator presented unique opportunities to explore the use of the RPR beyond the clinical teaching role explored previously.14 The course coordinator was responsible for general course administration, content, learning experiences, quality control, and evaluation of any changes to the course. As part of the quality improvement responsibility of the RLTFP, three simulation experiences set in the main campus laboratory had been used with good outcomes. A fourth simulation was created to provide all students the experience of caring for an older adult living at home with a family member. This simulation differed from the community health home visit by focusing more on the impact of agerelated changes to the initial assessment, response to changes in condition, impact of the home environment, and interaction with the adult son as well as the older adult. This simulation represented an opportunity to observe students in a complex but controlled clinical situation that brought together much of the course content and skills. The RPR was made available to the RLTFM through an existing agreement among the Nursing Institute of West Central Ohio, Wright State University, and InTouch Health. A previous study found the RPR easy to use by clinical faculty supervising a simulated experience, acceptable to students, and with minimal technical issues.14 The five clinical faculty members routinely supervise and evaluate a maximum of 10 students with responsibility for up to three groups.
The measurement tools were adapted from surveys described elsewhere and found to have face validity.14 Adaptation avoided multiple versions of the survey and provided greater depth to participant responses regarding usefulness and effectiveness of the RPR. The adapted survey included two demographic items to distinguish student from faculty/staff members and previous exposure to the RPR followed by five open-ended questions addressing usefulness and effectiveness (Fig. 2). Usefulness was determined through survey items 4 and 5; effectiveness was determined through items 6 and 7.
PROCEDURE The study was approved by the university-affiliated Institutional Review Board prior to the start of data collection. The RLTFM and clinical faculty were invited by the Principal Investigator to
Fig. 2. Field note themes. RPD, remote presence device (remote presence robot from InTouch Health).
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participate during one regular course team meeting and again with the undergraduate students during one regular class session. An email invitation was also sent to the students, faculty, and the RLTFM after the initial live invitations to ensure all potential participants were reached. The RLTFM was consented and trained on the RPR prior to the first simulation experience, and all clinical faculty and students were consented the day of their simulation experience prior to the debriefing session. Clinical faculty completed one consent and one survey regardless of how many clinical groups they supervised. The LL is a four-bedroom home; thus the number of clinical groups permitted is limited to one or two groups depending on the total count in the house. For this study, one clinical group was scheduled for a 3-h session, with one-half doing the actual simulation and the other half performing the whole house safety evaluation. When both halves had completed the simulation, debriefing took place with time at the end for consenting and completion of the surveys. A schedule was set to bring two clinical groups to the LL over a 2-week period toward the end of the course. On the assigned day, all clinical groups participated in the simulation at the LL. The RLTFM used the RPR to oversee each session. The Principal Investigator or designee was present in person for each clinical session. As course coordinator, the RLTFM moved around the LL interacting with the students and/or clinical faculty members, the simulated older adult, or others present in the LL. During, and at the conclusion of, each session, the RLTFM recorded events, feelings, and thoughts about using the robot, student and/or faculty reactions, or other pertinent information about the robot during that session. The RLTFM completed one survey at the conclusion of the first session.
Results Data from survey items 1, 2, and 3 were summarized using percentages. Data from open-ended questions 4, 5, and 6 were coded into categories that emerged from the data and were then categorized into the major study variables of usefulness and effectiveness in terms of positive or negative statements.18 The RLTFM’s field notes of the nine sessions (over 4 days) were analyzed for major themes of usefulness, acceptability, and impact through the procedure described by Krippendorf.18 Categories emerged from the data and, like the survey, were further grouped into usefulness and effectiveness, but an additional theme of impact emerged. Data from the RPR were considered proprietary and was not made available to the researchers. However, the RLFTM kept notes on connect time and interruptions or downtime to gain some estimate of these parameters as they affect usefulness, effectiveness, and impact. Sixty-nine questionnaires were returned: 56 of 70 students (80% response rate), five clinical faculty (100%), three LL staff (100%), and one from the RLFTM. Three student surveys lacked sufficient data and were eliminated from the analysis (Table 1). Most students had no previous experience with the RPR, whereas most faculty/staff did. Initial response to the robot was mixed for both students and faculty/staff, that is, responses were almost evenly distributed as positive, negative, and unsure/mixed. Most students
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Table 1. Student and Faculty/Staff Responses to Survey Items by Item Category STUDENTS (N = 56)
FACULTY/ STAFF (N = 9)
Usefulness Prior robot interaction Yes
6 (11%)
5 (56%)
No
50 (89%)
4 (44%)
Positive
16 (29%)
4 (44%)
Negative
20 (36%)
2 (22%)
Mixed or unsure
20 (36%)
3 (33%)
42 (75%)
5 (56%)
Initial reaction
Robot as faculty extender Yes No In some situations
2 (4%) 12 (21%)
4 (44%)
Education source
14 (25%)
5 (56%)
Immediate interaction
15 (27%)
2 (22%)
9 (16%)
1 (11%)
19 (34%)
4 (44%)
Effectiveness Uses of robot
Healthcare collaboration Faculty extender Build confidence/independence
5 (9%)
Economical
1 (2%)
Simulated real life
1 (2%)
Not useful No answer
1 (2%)
How improve for faculty Improve technical difficulties
18 (32%)
Improve structure, function, mobility
13 (23%)
Educate faculty
2 (22%)
3 (5%)
5 (56%)
No improvements needed
7 (13%)
2 (22%)
Unsure
1 (2%)
No answer
17 (30%)
How improve for students Improve technical difficulties
15 (27%)
Improve structure, function, mobility
10 (18%)
1 (11%)
Educate faculty
6 (11%)
5 (56%)
No improvements needed
9 (16%)
1 (11%)
Unsure
1 (2%)
1 (11%)
15 (27%)
1 (11%)
No answer
Data are number (%).
REMOTE TELEPRESENCE ROBOTIC SYSTEM IN NURSING EDUCATION
(75%) and faculty/staff (56%) thought the RPR was useful as a faculty extender, but more faculty/staff perceived that usefulness was situational. The most common category of effectiveness identified by students was as a faculty extender, with educational source and immediate interaction/communication as the next most common categories. Faculty/staff identified the RPR most commonly as an effective educational source, with faculty extender the second most common category. No student or faculty/staff member stated the RPR was ‘‘not useful.’’ Categories for improving the effectiveness for faculty and students also displayed some differences between the perceptions of students and faculty/staff respondents. Students clearly felt technical difficulties needed improvement for both themselves and their faculty, whereas faculty/staff felt faculty education was the greatest area of needed improvement for both faculty and students. Data from the RLFTM logs revealed three major themes: (1) usefulness, (2) acceptability, and (3) impact of the RPR (Fig. 2). Usefulness emerged in the areas of productivity, function, technology, and observation. Productivity was the ability to multitask, for example, ‘‘ . talked over technical issues and sent e-mail to the PI [Principal Investigator] while introduction to simulation begins.’’ Function related to how the RLTFM used the RPR: ‘‘ . getting better at driving’’ and ‘‘ . room too small to maneuver easily.’’ Technology was the RPR as a tool: ‘‘ . if [student] not in the way, been able to zoom in and see skin changes and student techniques’’ and ‘‘ . robot can hear [simulator].’’ Observation of students and the unfolding simulation enabled the RLFTM to follow students communication skills (‘‘ . students interact better when patient responds’’), their critical thinking (‘‘ . [one group of] students disorganized in approach’’), and their reaction to the simulation and RPR itself (‘‘ . this group is having trouble interacting with simulation and robot/me’’). Acceptability emerged in terms of positive or negative statements of how the students and faculty interacted with the RPR. Positive comments ranged from ‘‘ . jokes, came and ‘touched’ robot/me’’ to ‘‘ . students look at me when I speak.’’ Negative comments were more frequent and included commentary on the students discomfort such as ‘‘ . lots of giggling as I move around students’’ and ‘‘ . student froze when I started asking about pressure ulcer.’’ The RPR made a positive impact on the quality assurance role of the core coordinator through enhancing evaluation of student skills in physical assessment, home assessment, and communication, the use of technology in the course, the learning experiences, the simulation experience, and educator preparedness. Direct evaluation of the students is evident in statements such as ‘‘ . putting it all together,’’ ‘‘ . foot assessment [completed],’’ ‘‘ . working with son,’’ and ‘‘ . home assessment.’’ Impact on the use of technology in the course is demonstrated through statements and questions posed such as ‘‘ . make a list of technology available [in the LL] for distribution’’ and ‘‘ . coloring . how true?’’ Impact on the learning experience itself was evident in statements such as ‘‘students set roles for themselves’’ and ‘‘ . good transfer of learning.’’ Finally, impact on simulation evaluation evident through statements on what is needed
to improve the simulation experience: ‘‘ . may practice heart and lung sounds on [simulator] before simulation.’’ Educator preparedness was the final theme and included subthemes of lesson planning (‘‘ . list of what students need to bring’’), educator training (‘‘ . orient to bag contents’’), simulation training (‘‘ . learning how to debrief’’), and simulation planning (‘‘ . the importance of props cues, crutches, clipboard, roadmap, and stethoscope’’). Data were not available directly from the RPR but, based on notes from the RLFTM connect time, was approximately 6 contiguous h for 4 days spread over 2 weeks. Connectivity was lost more frequently the first day but gradually improved over the total time. Approximately 4 h of downtime resulted from three sources: (1) connectivity issues for the RLFTM or LL, (2) short battery life, or (3) update issues with the RPR main service center. Connectivity issues resulted in the loss of either or both audio and visual but typically did not last more than 2–3 min. The short battery life resulted in 1 day of staying ‘‘tethered’’ to the power outlet, but once the battery was replaced, the RPR lasted the full 6 h of continuous use. On the final day, the RLFTM could not log-on because of an update that resulted in removal of the needed RPR from the list of available devices until updated by the responsible central service center. This delayed the start of the session by less than 30 min.
Discussion and Conclusions The results of this study support the use of a RPR as a faculty extender to facilitate course quality assurance when the lead faculty is not on site. Both faculty and students perceive this type of technology as a potential faculty extender, but both faculty and students need preparation for the experience. Faculty and students suggested improvements for the capabilities of the RPR, including adding ‘‘arms,’’ enhancements to the camera (i.e., a superimposed grid, focused lights), and a way to move it between floors. Signal stability was consistently a major complaint and identified as an improvement much needed. This study has several limitations that impact internal and external validity. Internal validity is threatened by the use of the RPR simultaneously with a complex simulation experience involving two high-fidelity simulators in a home setting not previously experienced by the students or the clinical faculty. External validity is threatened by the small convenience sample and a survey tool not further examined for psychometric properties in this sample. Despite these limitations there are some important implications. The RPR represents a unique means to access nursing faculty in real time from anywhere in the world. The RPR has the potential to extend the ‘‘work life’’ of experienced faculty with disabilities or who relocate but do not desire to change work places. The RPR could provide access to nursing experts around the world to supplement the critical faculty shortage in higher education nursing programs.
Acknowledgments The robot and human patient simulator technology and operational funding were provided by the Nursing Institute of West Central Ohio’s sustainability partnership of Wright State University, Premier Health Partners, and Sinclair Community College. The authors thank
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Graceworks Services, Wright State University, and the Nursing Institute of West Central Ohio for allowing this research to be conducted in the Living Laboratory Smart Technology House on the campus of Bethany Village Campus in Centerville, OH. They further would like to thank Stephanie Gilardi, Diane Mehling, and Marie Bashaw who provided assistance that made the study possible.
Disclosure Statement No competing financial interests exist.
tele-intensive care unit to grow and understand it. Telemed J E Health 2011;17:773–783. 9. Reynolds EM, Grujovski A, Wright T, Foster M, Reynolds HN. Utilization of robotic ‘‘remote presence’’ technology within North American intensive care units. Telemed J E Health 2012;18:507–515. 10. Lamb GS. Nursing care in telehealth. J Telemed Telecare 2006;12:55–56. 11. Glaser G. Telethinking with Yulun Wang, PhD. Telemed J E Health 2005;11:629–632. 12. Nehring WM. U.S. boards of nursing and the use of high-fidelity patient simulators in nursing education. J Prof Nurs 2008;24:109–117. 13. Kilmon CA, Brown L, Ghosh S, Mikitiuk A. Immersive virtual reality simulations in nursing education. Nurs Educ Perspect 2010;31:314–317.
REFERENCES 1. Finkelman AW, Kenner C. Teaching IOM: Implications of the Institute of Medicine reports for nursing. Washington, DC: IOM Press, 2009. 2. Bleich MR, Hewlett PO, Santos SR, Rice RB, Cox KS, Richmeier S. Analysis of the nursing workforce crisis: A call to action: Despite the urgent need, we still lack a national strategy designed to avert the nursing shortage. This review may provide a foundation for such a plan. Am J Nurs 2003;103:66–74. 3. Sampsel D, Dockery J. Data Informed Planning in West Central Ohio. Nursing Institute of West Central Ohio, Dayton, OH and Center for Urban and Public Affairs, Wright State University, Dayton, OH. Presentation at the 39th Biennial Sigma Theta Tau International Honor Society for Nursing Convention, November 3, 2007, Boston. 4. Nursing Faculty Shortage Fact Sheet. Volume 30, pp. 14–16. StuNurse.com. November 2013. Available at www.digitaleditionsonline.com/publication/ index.php?i=0&m=6623&l=1&p=3&pre&ver=swf (last accessed February 9, 2014). 5. Rosseter R. Shortage of Faculty and Resource Constraints Hinder Growth in U.S. Nursing Schools Constraints Hinder Growth in U.S. Nursing Schools. American Association of Colleges of Nursing (AACN) Shortage of Faculty and Resource. 2010. Available at https://www.aacn.nche.edu/news/articles/2010/facultyshortage (last accessed February 9, 2014). 6. Simpson R. Patient and nurse safety: How information technology makes a difference. Nurs Admin Q 2005;29:97–101. 7. Ball MJ, Weaver C, Abbott PA. Enabling technologies promise to revitalize the role of nursing in an era of patient safety. Int J Med Inform 2003;69:29–38. 8. Reynolds HN, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M. A working lexicon for the tele-intensive care unit: We need to define
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14. Sampsel D, Bharwani G, Mehling D, Smith S. Robots as faculty: Student and faculty perceptions. Clin Simul Nurs 2011;7:e209–e218. 15. Lai F. Robotic telepresence for collalborative clinical outreach. Stud Health Technol Inform 2008;132:233–235. 16. Lai F. Stroke networks based on robotic telepresence. J Telemed Telecare 2009;15:135–136. 17. Lai F. Robotic telepresence for medical training and education. Stud Health Technol Inform 2009;141:151–152. 18. Krippendorff K. Measuring the reliability of qualitative text analysis data. Qual Quant 2004;38:787–800.
Address correspondence to: Debi Sampsel, DNP, MSN, RN College of Nursing University of Cincinnati 3110 Vine Street Cincinnati, OH 45221
E-mail: [email protected] Received: February 18, 2014 Revised: February 25, 2014 Accepted: February 25, 2014
Debi Sampsel, DNP, MSN, RN,1 Patricia Vermeersch, PhD, GNP,2 and Charles R. Doarn, MBA3 1
College of Nursing, University of Cincinnati, Cincinnati, Ohio. Kent State University, Kent, Ohio. 3 Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio. 2
Abstract Background: There is a growing shortage of nursing graduates and faculty to prepare students for careers in nursing. One way to ameliorate this paradigm is to integrate technology such as a remote presence robot (RPR) in both clinical and educational settings. Materials and Methods: The InTouch Health (Santa Barbara, CA) RP-7, an RPR, was deployed in a simulated, multigenerational home where nursing students and faculty interact in a variety of activities. Seventy students and five faculty members were instructed by a remotely located instructor who controlled the RP-7 from a distant site. Students and faculty, using questionnaires, provided feedback on the didactic interaction. Results: Of the 70 student participants, 56 (80%) responded, and faculty and clinical staff were 100% compliant, resulting in 69 total respondents. Using Krippendorf’s themes of (1) usefulness, (2) acceptability, and (3) impact, the data indicated the following. The majority of the students (89%) had no previous experience with the RPR, but the majority (75%) felt that the RPR was a good faculty extender. The students were initially evenly split on first exposure in (a) a positive experience, (b) a negative experience, or (c) a mixed experience. Although there were some technical challenges in operations, these were not deemed significant; nevertheless, they must be addressed. Conclusions: The results of this study support the use of RPRs as faculty extenders to facilitate course quality assurance when the lead faculty is not on site. Both faculty and students perceive this type of technology as a potential faculty extender, but both faculty and students need preparation for the experience. Key words: telenursing, robotics, e-health, pedagogy, simulation
growing needs. There is a concomitant growing shortage of doctors, nurses, and allied health workers nationwide. This is a challenge not only in clinical practice at all levels in the continuum of care but also in the education of future practitioners as well. This is especially profound in nursing education. At the national level, the Institute of Medicine has reported a growing shortage of skilled nurses and qualified faculty to teach future nurses. As Finkleman and Kenner1 reported, this will have a significant impact on the quality of healthcare in the United States and therefore broaden the current chasm. Bleich et al.2 also provide a summary of the nursing workforce crisis and how a strategy needs to be developed to ameliorate the growing gap. This shortage is not only in graduates but also in faculty who guide future nurses through their training. This gap has been observed nationwide. The Nursing Institute of West Central Ohio commissioned a regional workforce study in 2004 and in 2006. They reported on a workforce profile that depicted a steady shortage of faculty.3 Over half of the faculty completing the survey indicated that they would enter retirement within the next few years. The age of the faculty and the reported predictions set this particular region 2 years ahead of the national average. More recent workforce projection studies indicate that the nursing workforce will affect not only direct care staff but also faculty positions. According to the National League of Nurses, the faculty shortage is expected to climb 6.9% or more per year.4,5 This shortage will be compounded by the current aging of the faculty and faculty freedom to work either at home or another location due to the rapid growth of proven online programs of nursing.5 This makes recruiting seasoned staff a greater challenge for nursing schools that are not located in the most ideal geographical areas, and thus pedagogy will be impacted. As online programs continue to flourish, the use of technology will continue to be integrated into nursing and healthcare as well. One of the most desirable technologies that may assist nursing schools is the use of telepresence robotics in the classroom as well as in the clinical setting. The remote presence robot (RPR) offers a great alternative solution for faculty who want to work from desired locations across the United States. These devices serve as the physical presence that can emulate faculty members who can now be present virtually.
Background
A
s the full effect of the Patient Protection and Affordable Care Act implementation is realized, the healthcare industry in the United States will see a large increase in patient population as more people seek healthcare. This will burden a system that is already maligned as a result of a labor force that is inadequate in numbers and ill equipped to address the
DOI: 10.1089/tmj.2014.0038
STRATEGIES FOR TURNING THE TIDE One way to enhance nursing practice and nursing education is to further introduce, adapt, and integrate technology. The integration of technology into nursing education and practice has been presented by several individuals. Simpson6 reported on how the integration of technology can enhance safety for patient and practitioner. Ball
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et al.7 also discussed how technology can transform healthcare delivery by impacting cost-effectiveness, productivity, and patient safety, and thereby revitalize nursing practice. In the practice of medicine, RPR systems, where a clinician can drive a robotic system from room to room while wirelessly tethered from a distant site, has shown promise. Reynolds et al.8 developed a lexicon for telehealth that is integrated into the intensive care unit. Furthermore, Reynolds et al.9 reported effective utilization of such remote systems in this setting. Lamb10 discussed how telehealth has been used in nursing care. In an interview of Dr. Yulun Wang in 2005 concerning his efforts in developing telepresence robotic systems, he commented on the utility of such systems in healthcare.11 In addition, the integration of simulation has been of great value in medicine and in nursing. High-fidelity simulators provide students and faculty alike unique opportunities to learn skill sets and then rehearse them repeatedly prior to actual practice.12,13 In the academic setting, the RPR has been used only in limited situations as the technology of choice for faculty extender nursing research. A research study by Sampsel et al.14 was one of the first in the world to test the use of this technology in an academic setting. Since that time, there have been other studies conducted within the academic setting where the use of RPRs and other two-way communication devices have been used to attempt to extend the reach of faculty.
REMOTE ROBOTIC SYSTEMS The RPR (InTouch Health, Santa Barbara, CA) is a remote-controlled device that permits synchronous communication between two different locations (Fig. 1). The device is controlled from a distant site via a communication link. The RPR has been approved by the Food
and Drug Administration and meets all the patient safety and Health Insurance Portability and Accountability Act compliance rules. The RPR is equipped with a ‘‘bionic’’ eye that is 10 times more powerful than the human eye. The user can zoom the camera to assess pupils and skin eruptions, as well as throat infections and other behaviors of a person that would indicate some sort of health deviation. The attachment of a stethoscope, telephone receiver, printer, and links to medical imaging files creates very extensive capabilities for completing a health physical, creating teaching images, and being able to communicate in real time with very little delay in timing. This system has been used in clinical settings as well as for education and training.15–17 The RPR in operational settings can also be monitored 24/7 by InTouch. The sophistication of the technology and the broadband transmission creates a reliable communication flow between the sender and the receiver. The real-time capability of the transmissions makes the sender seem virtually present. The other feature of the RPR is that the sender can drive the RPR all over the educational and healthcare setting with ease. A joystick is used to remotely control the robot. The computer keyboard allows the sender to zoom up close to the receiver and have complete privacy as needed through the use of the headphone sets. The sender has a panoramic view of the room, all participants, and the room furnishings. The sender also has the capability to obtain and store photographs as well as video capabilities. These two features are added bonuses for faculty and clinical adjunct personnel as the faculty sender can use photographs and DVDs to help illustrate case studies, to draw on them to emphasis certain lesson plan objectives, and to incorporate various disease processes into the educational experience.
OBJECTIVES The purpose of this study was to explore the application of the RPR in the role of course coordinator in oversight of a newly created simulation experience in a required undergraduate gerontological nursing course. The study was focused on evaluating the utility and effectiveness of the RPR and to evaluate the use of this technology as an extender for faculty who may not be in residence and must work remotely. The RPR has been demonstrated to be effective in the acute care environments for physicians and advanced practice nurses providing mental health services, stroke network interventions, and critical care rounds.12–14
Materials and Methods
Fig. 1. Remote presence robot from InTouch Health (courtesy of InTouch).
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The InTouch Health RP-7 was deployed in this study. A remotely located tenured faculty member (RLTFM) member, who served as the remote operator, was the instructor for the students and other adjunct clinical faculty. The RLTFM, located approximately 250 miles from the students and other faculty, operated the manufactured RP-7 via a laptop, joystick, and headset (Fig. 1) remotely. This study used student and faculty questionnaires from the study of Sampsel et al.14 In addition, other segments of the research were added to expand the body of nursing knowledge in the area of testing the efficiencies derived from the faculty extender. An embedded, single-case design
REMOTE TELEPRESENCE ROBOTIC SYSTEM IN NURSING EDUCATION
was used to examine the usefulness, effectiveness, and impact of the RPR for the RLTFM in oversight of a newly created home-based simulation for a required undergraduate simulation experience. This design is useful when investigating current real-life phenomena with unclear contextual boundaries and the opportunity to collect data from multiple sources. The units of analysis ranged from the largest (impact on faculty oversight of simulation) to the smallest (individual student, clinical faculty, and the remote presence device). During this study, sources of evidence included (a) participant observations, (b) research investigator’s observations through the RPR, (c) surveys from students and clinical faculty, (d) simulation staff, and (e) data collected in the Co-Principal Investigator’s field notes.
Clinical faculty were full-time, experienced Master’s degree–prepared nurses with a variety of specialty backgrounds, including medical– surgical, pediatric, community health, and psychiatric nursing. All faculty members had previous experience in the gerontological course and previous experience with mid- and high-fidelity simulation, but only one had previous experience with the RPR. All nine clinical groups in the course of 70 students participated in the simulation and were invited to participate in the study during debriefing, with 56 completing the surveys (80%). No attempt was made to differentiate those who participated from those or did not. Most student participants (89%) had no prior experience with the RPR.
SETTING AND SAMPLE
MEASUREMENT TOOLS
The study was conducted in the Living Laboratory (LL) smart house (Dayton, OH), which was designed to reflect a home of an integrated multigenerational family. The RPR was operated in a technologyladen single family home, composed of several types of human patient simulators, which are capable of mimicking many of the human body functions. The house, which is populated with three generations of simulated family members, creates a microcosmic view of life at home. This is a perfect backdrop for testing and evaluating RPRs. Nursing and other healthcare students from surrounding schools and universities utilized the LL for a wide variety of simulated and technology experiences. The sample for this study included one RLTFM using the RPR, five clinical faculty members, and 70 undergraduate nursing students who participated in the simulation at the LL. The RLTFM served as course coordinator for an undergraduate clinical course in gerontological nursing (a required course for a Bachelors Degree in Nursing). Relocation of the course coordinator presented unique opportunities to explore the use of the RPR beyond the clinical teaching role explored previously.14 The course coordinator was responsible for general course administration, content, learning experiences, quality control, and evaluation of any changes to the course. As part of the quality improvement responsibility of the RLTFP, three simulation experiences set in the main campus laboratory had been used with good outcomes. A fourth simulation was created to provide all students the experience of caring for an older adult living at home with a family member. This simulation differed from the community health home visit by focusing more on the impact of agerelated changes to the initial assessment, response to changes in condition, impact of the home environment, and interaction with the adult son as well as the older adult. This simulation represented an opportunity to observe students in a complex but controlled clinical situation that brought together much of the course content and skills. The RPR was made available to the RLTFM through an existing agreement among the Nursing Institute of West Central Ohio, Wright State University, and InTouch Health. A previous study found the RPR easy to use by clinical faculty supervising a simulated experience, acceptable to students, and with minimal technical issues.14 The five clinical faculty members routinely supervise and evaluate a maximum of 10 students with responsibility for up to three groups.
The measurement tools were adapted from surveys described elsewhere and found to have face validity.14 Adaptation avoided multiple versions of the survey and provided greater depth to participant responses regarding usefulness and effectiveness of the RPR. The adapted survey included two demographic items to distinguish student from faculty/staff members and previous exposure to the RPR followed by five open-ended questions addressing usefulness and effectiveness (Fig. 2). Usefulness was determined through survey items 4 and 5; effectiveness was determined through items 6 and 7.
PROCEDURE The study was approved by the university-affiliated Institutional Review Board prior to the start of data collection. The RLTFM and clinical faculty were invited by the Principal Investigator to
Fig. 2. Field note themes. RPD, remote presence device (remote presence robot from InTouch Health).
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participate during one regular course team meeting and again with the undergraduate students during one regular class session. An email invitation was also sent to the students, faculty, and the RLTFM after the initial live invitations to ensure all potential participants were reached. The RLTFM was consented and trained on the RPR prior to the first simulation experience, and all clinical faculty and students were consented the day of their simulation experience prior to the debriefing session. Clinical faculty completed one consent and one survey regardless of how many clinical groups they supervised. The LL is a four-bedroom home; thus the number of clinical groups permitted is limited to one or two groups depending on the total count in the house. For this study, one clinical group was scheduled for a 3-h session, with one-half doing the actual simulation and the other half performing the whole house safety evaluation. When both halves had completed the simulation, debriefing took place with time at the end for consenting and completion of the surveys. A schedule was set to bring two clinical groups to the LL over a 2-week period toward the end of the course. On the assigned day, all clinical groups participated in the simulation at the LL. The RLTFM used the RPR to oversee each session. The Principal Investigator or designee was present in person for each clinical session. As course coordinator, the RLTFM moved around the LL interacting with the students and/or clinical faculty members, the simulated older adult, or others present in the LL. During, and at the conclusion of, each session, the RLTFM recorded events, feelings, and thoughts about using the robot, student and/or faculty reactions, or other pertinent information about the robot during that session. The RLTFM completed one survey at the conclusion of the first session.
Results Data from survey items 1, 2, and 3 were summarized using percentages. Data from open-ended questions 4, 5, and 6 were coded into categories that emerged from the data and were then categorized into the major study variables of usefulness and effectiveness in terms of positive or negative statements.18 The RLTFM’s field notes of the nine sessions (over 4 days) were analyzed for major themes of usefulness, acceptability, and impact through the procedure described by Krippendorf.18 Categories emerged from the data and, like the survey, were further grouped into usefulness and effectiveness, but an additional theme of impact emerged. Data from the RPR were considered proprietary and was not made available to the researchers. However, the RLFTM kept notes on connect time and interruptions or downtime to gain some estimate of these parameters as they affect usefulness, effectiveness, and impact. Sixty-nine questionnaires were returned: 56 of 70 students (80% response rate), five clinical faculty (100%), three LL staff (100%), and one from the RLFTM. Three student surveys lacked sufficient data and were eliminated from the analysis (Table 1). Most students had no previous experience with the RPR, whereas most faculty/staff did. Initial response to the robot was mixed for both students and faculty/staff, that is, responses were almost evenly distributed as positive, negative, and unsure/mixed. Most students
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Table 1. Student and Faculty/Staff Responses to Survey Items by Item Category STUDENTS (N = 56)
FACULTY/ STAFF (N = 9)
Usefulness Prior robot interaction Yes
6 (11%)
5 (56%)
No
50 (89%)
4 (44%)
Positive
16 (29%)
4 (44%)
Negative
20 (36%)
2 (22%)
Mixed or unsure
20 (36%)
3 (33%)
42 (75%)
5 (56%)
Initial reaction
Robot as faculty extender Yes No In some situations
2 (4%) 12 (21%)
4 (44%)
Education source
14 (25%)
5 (56%)
Immediate interaction
15 (27%)
2 (22%)
9 (16%)
1 (11%)
19 (34%)
4 (44%)
Effectiveness Uses of robot
Healthcare collaboration Faculty extender Build confidence/independence
5 (9%)
Economical
1 (2%)
Simulated real life
1 (2%)
Not useful No answer
1 (2%)
How improve for faculty Improve technical difficulties
18 (32%)
Improve structure, function, mobility
13 (23%)
Educate faculty
2 (22%)
3 (5%)
5 (56%)
No improvements needed
7 (13%)
2 (22%)
Unsure
1 (2%)
No answer
17 (30%)
How improve for students Improve technical difficulties
15 (27%)
Improve structure, function, mobility
10 (18%)
1 (11%)
Educate faculty
6 (11%)
5 (56%)
No improvements needed
9 (16%)
1 (11%)
Unsure
1 (2%)
1 (11%)
15 (27%)
1 (11%)
No answer
Data are number (%).
REMOTE TELEPRESENCE ROBOTIC SYSTEM IN NURSING EDUCATION
(75%) and faculty/staff (56%) thought the RPR was useful as a faculty extender, but more faculty/staff perceived that usefulness was situational. The most common category of effectiveness identified by students was as a faculty extender, with educational source and immediate interaction/communication as the next most common categories. Faculty/staff identified the RPR most commonly as an effective educational source, with faculty extender the second most common category. No student or faculty/staff member stated the RPR was ‘‘not useful.’’ Categories for improving the effectiveness for faculty and students also displayed some differences between the perceptions of students and faculty/staff respondents. Students clearly felt technical difficulties needed improvement for both themselves and their faculty, whereas faculty/staff felt faculty education was the greatest area of needed improvement for both faculty and students. Data from the RLFTM logs revealed three major themes: (1) usefulness, (2) acceptability, and (3) impact of the RPR (Fig. 2). Usefulness emerged in the areas of productivity, function, technology, and observation. Productivity was the ability to multitask, for example, ‘‘ . talked over technical issues and sent e-mail to the PI [Principal Investigator] while introduction to simulation begins.’’ Function related to how the RLTFM used the RPR: ‘‘ . getting better at driving’’ and ‘‘ . room too small to maneuver easily.’’ Technology was the RPR as a tool: ‘‘ . if [student] not in the way, been able to zoom in and see skin changes and student techniques’’ and ‘‘ . robot can hear [simulator].’’ Observation of students and the unfolding simulation enabled the RLFTM to follow students communication skills (‘‘ . students interact better when patient responds’’), their critical thinking (‘‘ . [one group of] students disorganized in approach’’), and their reaction to the simulation and RPR itself (‘‘ . this group is having trouble interacting with simulation and robot/me’’). Acceptability emerged in terms of positive or negative statements of how the students and faculty interacted with the RPR. Positive comments ranged from ‘‘ . jokes, came and ‘touched’ robot/me’’ to ‘‘ . students look at me when I speak.’’ Negative comments were more frequent and included commentary on the students discomfort such as ‘‘ . lots of giggling as I move around students’’ and ‘‘ . student froze when I started asking about pressure ulcer.’’ The RPR made a positive impact on the quality assurance role of the core coordinator through enhancing evaluation of student skills in physical assessment, home assessment, and communication, the use of technology in the course, the learning experiences, the simulation experience, and educator preparedness. Direct evaluation of the students is evident in statements such as ‘‘ . putting it all together,’’ ‘‘ . foot assessment [completed],’’ ‘‘ . working with son,’’ and ‘‘ . home assessment.’’ Impact on the use of technology in the course is demonstrated through statements and questions posed such as ‘‘ . make a list of technology available [in the LL] for distribution’’ and ‘‘ . coloring . how true?’’ Impact on the learning experience itself was evident in statements such as ‘‘students set roles for themselves’’ and ‘‘ . good transfer of learning.’’ Finally, impact on simulation evaluation evident through statements on what is needed
to improve the simulation experience: ‘‘ . may practice heart and lung sounds on [simulator] before simulation.’’ Educator preparedness was the final theme and included subthemes of lesson planning (‘‘ . list of what students need to bring’’), educator training (‘‘ . orient to bag contents’’), simulation training (‘‘ . learning how to debrief’’), and simulation planning (‘‘ . the importance of props cues, crutches, clipboard, roadmap, and stethoscope’’). Data were not available directly from the RPR but, based on notes from the RLFTM connect time, was approximately 6 contiguous h for 4 days spread over 2 weeks. Connectivity was lost more frequently the first day but gradually improved over the total time. Approximately 4 h of downtime resulted from three sources: (1) connectivity issues for the RLFTM or LL, (2) short battery life, or (3) update issues with the RPR main service center. Connectivity issues resulted in the loss of either or both audio and visual but typically did not last more than 2–3 min. The short battery life resulted in 1 day of staying ‘‘tethered’’ to the power outlet, but once the battery was replaced, the RPR lasted the full 6 h of continuous use. On the final day, the RLFTM could not log-on because of an update that resulted in removal of the needed RPR from the list of available devices until updated by the responsible central service center. This delayed the start of the session by less than 30 min.
Discussion and Conclusions The results of this study support the use of a RPR as a faculty extender to facilitate course quality assurance when the lead faculty is not on site. Both faculty and students perceive this type of technology as a potential faculty extender, but both faculty and students need preparation for the experience. Faculty and students suggested improvements for the capabilities of the RPR, including adding ‘‘arms,’’ enhancements to the camera (i.e., a superimposed grid, focused lights), and a way to move it between floors. Signal stability was consistently a major complaint and identified as an improvement much needed. This study has several limitations that impact internal and external validity. Internal validity is threatened by the use of the RPR simultaneously with a complex simulation experience involving two high-fidelity simulators in a home setting not previously experienced by the students or the clinical faculty. External validity is threatened by the small convenience sample and a survey tool not further examined for psychometric properties in this sample. Despite these limitations there are some important implications. The RPR represents a unique means to access nursing faculty in real time from anywhere in the world. The RPR has the potential to extend the ‘‘work life’’ of experienced faculty with disabilities or who relocate but do not desire to change work places. The RPR could provide access to nursing experts around the world to supplement the critical faculty shortage in higher education nursing programs.
Acknowledgments The robot and human patient simulator technology and operational funding were provided by the Nursing Institute of West Central Ohio’s sustainability partnership of Wright State University, Premier Health Partners, and Sinclair Community College. The authors thank
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Graceworks Services, Wright State University, and the Nursing Institute of West Central Ohio for allowing this research to be conducted in the Living Laboratory Smart Technology House on the campus of Bethany Village Campus in Centerville, OH. They further would like to thank Stephanie Gilardi, Diane Mehling, and Marie Bashaw who provided assistance that made the study possible.
Disclosure Statement No competing financial interests exist.
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Address correspondence to: Debi Sampsel, DNP, MSN, RN College of Nursing University of Cincinnati 3110 Vine Street Cincinnati, OH 45221
E-mail: [email protected] Received: February 18, 2014 Revised: February 25, 2014 Accepted: February 25, 2014
