Enhancing Nursing Education

Through Affordable and Realistic

Holographic Mixed Reality:
The Virtual Standardized Patient
for Clinical Simulation

Sean W. Hauze, Helina H. Hoyt, James P. Frazee,

Philip A. Greiner, and James M. Marshall

Abstract delivered via mixed reality immersive simula-

Nurses serve a valuable role in the healthcare tion. This chapter also discusses the research
industry. Nurses are trained with the skills and initiative currently underway to assess student
knowledge to thrive in a fast-paced, evolving perceptions to this modality of health training
environment. In order to meet the complex simulation.
and diverse needs of patients, nurses must be
able to assess and prioritize care to produce Keywords
safe and high-quality outcomes. Simulation is Nursing education · Technology · Mixed
an established method of educating nursing reality · Immersive simulation · Assessment
students and preparing nurses to respond
appropriately to situations they are likely to
encounter in practice. Traditional nursing sim-
ulation devices are prohibitively expensive for 1 Introduction
many nursing education institutions. The
development of augmented, mixed, and vir- Simulation is an important aspect of training
tual reality simulation delivery offers a new nursing students. Once education is complete and
platform for simulation, known as immersive licensure is obtained, professional nurses func-
simulation. Immersive simulation can virtu- tion in an industry that is high-stakes, rapidly
ally place nursing students in situations that changing, and technology-driven (American
are difficult to arrange in actual clinical practi- Association of Colleges of Nursing 2016;
cums or that occur rarely but for which nurses National League for Nursing 2015). Pre-licensure
need to be prepared. Additionally, the hard- nursing education encompasses both theoretical
ware required to deliver immersive simulation and clinical development. A debate exists about
is much cheaper than that of traditional nurs- the best method for helping nursing students
ing simulation devices. This chapter describes transition from a novice to a professional role
the virtual standardized patient application that is safe for students and produces quality out-
comes for students and future employers alike
S. W. Hauze (*) · H. H. Hoyt · J. P. Frazee (American Association of Colleges of Nursing
P. A. Greiner · J. M. Marshall 2016; Benner et  al. 2010; National League for
San Diego State University, San Diego, CA, USA Nursing 2015).
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1

P. M. Rea (ed.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1120,
https://doi.org/10.1007/978-3-030-06070-1_1
2 S. W. Hauze et al.

Nursing educators have embraced simulation nursing workforce is expected to have more than
as a safe and realistic teaching methodology to one million job openings as 2020 approaches.
help support the clinical development of nursing The nursing faculty shortage is attributed as one
students for over a decade (National League for of two critical reasons for the looming shortage
Nursing 2015). A study was conducted in the (American Association of Colleges of Nursing
United States by the National Council of State 2016). The faculty shortage is complex and per-
Boards of Nursing (NCSBN) to explore the role petuated by multiple factors. These include an
and outcomes of simulation in pre-licensure aging faculty, looming retirements, non-­
nursing education. This landmark research pro- competitive faculty salaries, burdensome work-
vided substantial evidence to support simulation loads, and insufficient educational pathways for
being used as a substitute for up to 50% of tradi- nurses to obtain the appropriate credentials to
tional clinical experiences when delivered serve as nursing faculty (American Association
through evidence-based methods (Hayden et  al. of Colleges of Nursing 2016; National League
2014a; National League for Nursing 2015). for Nursing 2015).
Guidelines by the National League for Nursing Strategies to overcome the nursing faculty
(2015) articulated that technology alone does not shortage have centered around both short- and
provide a realistic simulation experience. long-term approaches to the problem. Short-term
Evidence-based methods surrounding simulation strategies involve the use of academic innovation
should include a situation that is purposeful, that could increase the effectiveness of under-
requires student preparation, involves debriefing, graduate nursing education through immersive
and is related to student learning outcomes and standardized simulation experiences
(National League for Nursing 2015). Well-­ (American Association of Colleges of Nursing
designed simulation experiences are built upon 2016). The use of simulation to enhance teaching
concepts of active learning and student mastery. and clinical experiences despite a shortage of fac-
These concepts have repeatedly demonstrated the ulty could prove beneficial for regions that are
importance of aligning what is learned in theory especially hit hard by the shortage, such as rural
to authentic, real-world scenarios (Bandura 1977; communities.
Benner et  al. 2010; Bloom 1968; Dewey 1938;
Ericsson et  al. 1993; Freeman et  al. 2014;
Knowles 1973). A vast array of nursing and non-­ 1.2 Lack of Clinical Placements
nursing educational research has shown that sim-
ulation can engage students in authentic active A lack of undergraduate student nursing clinical
learning that is motivating, relevant, and builds placements is the second critical constraint to
confidence (Keller 1987; Larue et  al. 2015; increasing student enrollment for nursing schools
Vaughn et al. 2016; Weaver 2011). across the United States (National League for
Nursing 2015). The National League for Nursing
(NLN) and the American Association of Colleges
1.1 Shortage of Nursing Faculty of Nursing (AACN) are the two professional
organizations that monitor pre-licensure nurse
Multiple competing forces are creating a need to training programs and provide data about the
transform the nursing educational system in the obstacles to expanding educational capacity
United States (American Association of Colleges within the United States. A study among various
of Nursing 2016; Benner et al. 2010). A current types of pre-licensure nursing programs from
shortage of nurses is being compounded by an 2012 to 2014 indicated 49% of Associate Degree
insufficient number of faculty (American Nursing programs and 41% of Bachelors of
Association of Colleges of Nursing 2016, 2017). Science in Nursing programs have turned quali-
According to the American Association of fied applicants away because of the inability to
Colleges of Nursing (2017), the professional provide appropriate clinical placements within
Enhancing Nursing Education Through Affordable and Realistic Holographic Mixed Reality: The Virtual… 3

their respective region (National League for nology devices, such as Google Glass, showed
Nursing 2015). Similarly, AACN conducts an positive effects on nursing student confidence
annual survey of pre-licensure baccalaureate (Vaughn et al. 2016).
nursing programs. In their 2016 Report on Traditional simulation falls short in address-
Enrollment and Graduations in Baccalaureate ing the lack of available clinical placements due
and Graduate programs in Nursing, a majority to the cost-prohibitive nature of high-fidelity
(72.9%) of pre-licensure baccalaureate nursing manikin simulators, space and maintenance
programs reported insufficient clinical sites as a costs, and costs related to staffing. Innovation in
reason for not admitting more students (AACN the field of immersive technology provides a
2016). Without alternative solutions to the clini- promising new alternative for high quality simu-
cal placement constraint, the impact will be lation at an affordable price. While this approach
potentially catastrophic (National League for is attractive in terms of portability and afford-
Nursing 2015). ability, the effectiveness of this immersive tech-
Simulation may provide a solution to this nology simulation to provide a motivating
shortage in clinical placements. In a study by learning experience has not been thoroughly
(Hayden et  al. 2014b), findings concluded that investigated.
simulation can be a successful substitute for tra-
ditional clinical experiences. This landmark
study provided the basis for the National Council 2 Background
of State Boards of Nursing (NCSBN) to allow
state boards and schools of nursing within the 2.1 History of Simulation
United States to substitute up to 50% of tradi- in Nursing Education
tional clinical experiences when delivered
through an evidence-based framework. The NLN There is a rich history of simulation being used in
has further developed a simulation framework nursing education. “Mrs. Chase” was the first
that is widely used as the theoretical foundation patient simulator on record being used in the
for nursing simulation development and conduct- Hartford Hospital Training School for Nurses in
ing research in the field around simulation use 1911 (National League for Nursing 2015). Mrs.
and its effectiveness (Jeffries 2005; Jeffries 2012; Chase was a life-sized adult doll with movable
National League for Nursing 2015). joints. Nurse educators used the doll to allow
nursing students the ability to practice safely
turning patients within a hospital bed. There was
1.3 Potential for Immersive no interaction or realistic-feel to the original
Simulation “Mrs. Chase.”
Several advances have been made in technol-
Recent advances in immersive technologies ogy and the use of simulation since Mrs. Chase.
makes possible a new kind of simulation, with Nurse educators built upon previous simulation
potential to transform health education simula- research that centers on student satisfaction and
tion. Virtual reality (VR), augmented reality confidence to continually improve simulation so
(AR), and mixed reality (MR) technologies that it is more realistic and interactive (Hayden
enable the user to interact with and control et  al. 2014a). New methods provide not only
virtually-­
displayed components within virtual learning opportunities for students but evaluation
and physical environments. The combination of opportunities as well. There is a call for educators
both physical and virtual components enables the to continue to measure student satisfaction and
user to practice low-frequency, high-risk scenar- confidence with simulation, as well as develop
ios within the safety of the classroom or clinical methods to measure knowledge and skill acquisi-
skills lab. While the research on such technolo- tion (Hyaden et  al. 2014a; National League for
gies is limited, early studies of immersive tech- Nursing 2015).
4 S. W. Hauze et al.

Currently, nurse educators utilize multiple ficulty, and design based on student learning
modalities of simulation to enhance student outcomes.
learning and encourage skill mastery. A robust • Clinical thinking is a disciplined process that
body of evidence exists surrounding use of tradi- allows an individual to be purposeful, goal-­
tional methods of simulation in nursing educa- oriented, and scientific in methodology.
tion. It showcases the rich learning opportunity • Evaluation is the appraisal of data and involves
for students to enhance assessment skills, develop a judgment that is based upon quality mea-
the ability to become adept at clinical reasoning, sures versus a standard measure.
work in teams, and receive immediate feedback • Fidelity is the degree to which a simulation
on care provided during the simulation (National experience is authentic. Creating fidelity that
League for Nursing 2015). is realistic involves several dimensions (envi-
Nursing simulation has helped bridge the gap ronment, equipment, psychological factors,
between theory and real-time clinical decisions social factors, culture) and an element of trust
in an environment that is risk-free to patients and between participants.
students. Evidence based methods of delivering • High-fidelity simulation involves large scale
simulation in an effective manner are rapidly computer driven experiences such as patient
changing. Not all schools have faculty who are simulators, virtual reality, or standardized
experts in simulation or the ability to benefit from patients. These experiences seem realistic and
the latest equipment that offers better integration are highly interactive.
of simulation into the curriculum and to substi- • Low-fidelity simulation involves experiences
tute for real-world clinical experiences (American that are naturally static like manikins, use of
Association of Colleges of Nursing 2016; case studies and role-playing.
National League for Nursing 2015). • Mixed reality (MR) devices provide an ability
The International Nursing Association for to combine both the physical and virtual
Clinical Simulation and Learning (INACSL) worlds and create a realistic and immersive
identified key concepts that guide simulation in experience.
nursing education. According to INACSL (2016), • Pedagogy is the art and/or science of teaching.
a consistent terminology is important to guide • Simulated-based learning experience involves
simulation experiences, research, and literature. a combination of strategic activities that re-­
The following definitions from INACSL (2016) create real-world situations in a pretend envi-
are commonly used: ronment with a case study that unfolds.
• A standardized patient is a person trained to
• AR technologies overlay digital objects into act as a patient with a scripted scenario.
the real-world physical environment. • Virtual reality (VR) is a term that can be
• Clinical relates to learning in a real or simu- used for virtual, augmented, and mixed real-
lated environment and provides opportunities ity. This technology is unique in that it trans-
for students to apply knowledge, skills, and ports the user into a constructed reality
attitudes. environment outside of the current physical
• Clinical judgement involves a process of mak- environment.
ing decisions and taking action.
• Clinical reasoning is identified as the capabil-
ity of a person to gather and understand data 2.2 Nursing Simulation Modalities
while remembering certain knowledge, skills,
and attitudes, about the situation as it Nursing education relies heavily on simulation as
develops. a proven method for nursing students to master
• A clinical scenario gives the context for a par- objectives to achieve safe, high quality care prac-
ticular simulation and can vary in length, dif- tices (McGaghie et al. 2011). These nursing sim-
Enhancing Nursing Education Through Affordable and Realistic Holographic Mixed Reality: The Virtual… 5

Table 1  Nursing simulation modalities

Modality Cost Definition Example
Partial task $500–$20,000 Low-tech simulation manikins and models Plastic arm for intravenous
trainer used for specific scenario training procedures
High-Fidelity $10,000–$200,000 Computerized patient simulation manikins SimMan simulation manikin
Manikin used for a wide array of critical medical
scenarios
Standardized $20–$40 per hour A patient actor trained to role-play specific A patient actor with makeup
Patient medical scenarios displaying symptoms of
anaphylaxis

ulation modalities are employed across all levels 2.3 Immersive Technologies:
of nursing education, spanning the continuum of Virtual, Augmented
nursing fundamentals to advanced nursing and Mixed
courses. Along with coursework and clinical
experience, simulation is a key component for Immersive technology exists as a continuum of
transforming nursing students from novice to modalities ranging from fully virtual environ-
expert (Benner et al. 2010). Simulation requires ments that transport the learner in time, space,
nursing students to acquire knowledge, make and scale to holographic overlays on our real
sense of the learning, make use of the learning, environment, enabling users to view digital con-
assimilate learning, and transfer the learning into tent in immersive, real world contexts. Milgram
the patient care setting (Decker et al. 2008). and Kishino (1994) established a taxonomy for
Table 1 outlines costs, definitions, and exam- immersive technologies, defining the “virtuality
ples of commonly utilized nursing simulation continuum” as an array of immersive simulation
modalities, including partial task trainers, high-­ modalities as shown in Fig. 1.
fidelity computerized simulation manikins, and As shown in the diagram, one end of the virtu-
standardized patients (Decker et al. 2008; Jeffries ality continuum exists the real environment with
et al. 2009). the opposite end represented as a fully virtual
The challenges nursing education faces to environment. Within the real environment, AR
meet increasing demand with limited resources simulation can bring anything to you in the form
makes traditional simulation cost-prohibitive for of simulated digital content, typically overlaid
many institutions, particularly those in rural via a camera and digital display. In contrast,
areas (Lapkin and Levett-Jones 2011; National VR—referred to in continuum diagram as aug-
League for Nursing 2015). For example, nursing mented virtuality (AV)—brings the users any-
students at the San Diego State University  – where through immersion in a fully simulated
Imperial Valley campus do not have access to reality that is entirely separate from the real envi-
high-fidelity nursing simulation, with the nearest ronment. In the center of the virtuality continuum
high-fidelity simulation center located over 100 is MR, which blends virtual content with the real
miles away. The recent innovation in the field of environment. Each of these modalities within the
immersive technology may provide a new virtuality continuum relies on external hardware
modality for high quality simulation for institu- in the form of monitor-based displays, transpar-
tions in need of high-quality simulation at an ent head-mounted displays (HMDs), and fully
affordable price. immersive HMDs.
6 S. W. Hauze et al.

Fig. 1  The virtuality

continuum. (Milgram
and Kishino 1994, p. 3)

Table 2  Immersive technology modalities there are many important and distinct functional-
Modality Cost Definition Example ities that that differentiate each modality.
Virtual $5– A fully rendered Oculus
reality $800 representation of Go Virtual Reality  The modality of VR transports
a virtual
the user into an entirely virtual environment out-
environment
Augmented $100– An overlay of Apple side of physical reality through a digitally con-
reality $1400 virtual content iPhone structed rendering (Barsom et  al. 2016). The
onto the real HMDs used for VR fully immerse users in the
environment virtual environment. The leading VR HMDs are
Mixed $1000– A blend of a Microsoft
HTC Vive and Oculus Rift, both of which were
reality $3000 virtual HoloLens
environment released in the spring of 2016. Both HTC Vive
with the real and Oculus Rift require the processing power of
environment, in a computer equipped with advanced graphics
which virtual
functionality and the Windows 10 operating sys-
objects interact
with the physical tem. Additionally, external infrared tracking sys-
environment tems devices are required to physically move
within the virtual space. Since the release of
Oculus Rift and HTC Vive, several standalone
VR HMDs were made available at a fraction of
2.4 Recent Advances the cost. Oculus Go and Lenovo Mirage Solo
in Affordable Immersive were released in the spring of 2018 for $199 and
Simulation $399 respectively. Both the Oculus Go and
Lenovo Mirage Solo operate without the need for
Innovation in the field of immersive technology external computing or tracking hardware. Other
has increased both the affordability and fidelity VR hardware includes smartphone auxiliary
of commercially available devices. Recently HMD devices, including Google Cardboard and
released headsets include the Oculus Go, Lenovo Samsung Gear, that utilize existing computing
Mirage Solo, Magic Leap One, and Microsoft power and display of smartphones.
HoloLens. Each of these devices enables realistic
simulation in one or more of the following The VR modality enables users to interact
modalities, compared in Table 2. with simulations within a location or scale appro-
priate to the content. For example, The Body VR
application enables the learner to travel virtually
3 Immersive Technology through a three-dimensional representation of the
Modalities human body at the micro scale. Through the VR
hardware functionality, the software enables the
Immersive technologies can be categorized into learner to navigate within the simulated human
VR, AR, and MR depending on the degree to body to explore human biological systems.
which the simulation environment is real versus
digital. While VR is widely considered the Augmented Reality  The AR modality overlays
generic term for all immersive technologies, digital objects within the context of the learner’s
Enhancing Nursing Education Through Affordable and Realistic Holographic Mixed Reality: The Virtual… 7

physical environment. This overlay of virtual 4 Economic Projections

content within the physical environment allows for Immersive Technology
learners to visualize relationships between physi-
cal and virtual content, as well as simulate low-­ The innovation in immersive technology is pro-
frequency, high-risk events (Akçayır and Akçayır jected to generate major economic activity, with
2016). AR software utilizes the location tracking, Business Insider projecting the immersive tech-
accelerometer, and camera hardware standard in nology market to reach $162 billion by the end of
smartphone and tablet devices to deliver immer- 2019 (Blodget 2016). International educational
sive simulation through hardware many students content publishers recognize immersive technol-
already own. ogy is poised to become a dominant mode of infor-
mation and knowledge transfer and are therefore
One example of the use of AR simulation is investing in the development of educational con-
the SkyView mobile application, which utilizes tent. Pearson and other publishers are currently
the user’s location combined with the accelerom- investing heavily in these new technologies, with
eter and front-facing camera built into modern the potential to impact millions of students glob-
mobile devices to overlay planets, stars, and con- ally (Meyer 2016). The technological innovation
stellations over the night sky. SkyView provides in hardware, combined with the investment in
graphical representations of celestial bodies, ­educational immersive simulation software devel-
along with descriptive annotations. opment, creates the potential for immersive simu-
lation to transform education. There is therefore a
Mixed Reality  The MR modality combines the strong need to empirically assess the efficacy of
ability to use physical interactions to control immersive technology through the scholarship of
and interact with virtual components (Chiu et al. teaching and learning.
2015). As the term mixed reality implies, MR
combines physical and virtual manipulates
resulting in a mixed digital and physical experi- 4.1  he NLN Simulation
T
ence. Commercially available MR HMDs Framework
include Microsoft HoloLens, Meta 2, and Magic
Leap One, each of which enables the user to The National League for Nursing/Jeffries
integrate holographic content within the physi- Simulation Theory (Jeffries 2005, 2012) is widely
cal components of the real environment through used as the theoretical foundation for implemen-
hand gestures. The hand gestures, as well as tation and evaluation of nursing simulation use
objects in the physical space, are mapped and and efficiency within the United States and
recognized through infrared sensors on the front beyond (Jeffries and Rogers 2007; Young and
of the HMD.  Simulation delivered via the MR Shellenbarger 2012). The model blends experien-
modality enables learners to interact with vir- tial learning and technology as a method to
tual content integrated into the physical envi- enhance learning and skill performance for stu-
ronment. This combination of virtual and dents. The framework helps articulate the unique
physical elements enables MR to be particularly experiences that exist within clinical simulation
effective for scenarios in which the physical and offers a way to disseminate best practices.
environment is important to the learning task, The framework builds upon perspectives of
such as a clinical setting in which nursing stu- expert simulation researchers and is the founda-
dents practice. tion for future discoveries.
8 S. W. Hauze et al.

NLN Jeffries Simulation Theory identifies tion across the medical field. Several recent stud-
multiple variables that exist to produce desirable ies have explored the use of immersive simulation
outcomes for the system, patient, and participant in medical education, particularly in the anatomy
(Jeffries and Rogers 2007; National League for curriculum. Anatomy education presents chal-
Nursing 2015). The framework identifies the lenges due to financial, ethical, and supervisory
importance of a process that begins with back- restraints with using human cadavers. Immersive
ground and design leading to the simulation technology provides an alternative through simu-
experience. The success of the simulation experi- lation of interactive, photorealistic anatomical
ence depends upon an environment of trust, lead- representations of human anatomical systems.
ing to a learner centered experience that is Immersive simulation also provides safe, realis-
collaborative, interactive, and experiential tic, and meaningful practice complex scenarios
(National League for Nursing 2015). The such as disaster relief, medication administration,
dynamic interaction between the facilitator and and psychiatric care (Smith and Hamilton 2015;
student must be directed by strong educational Ulrich et al. 2014; Vottero 2014).
strategies (National League for Nursing 2015). The use cases for immersive simulation in
education extend beyond the field of medicine.
Studies across astronomy, chemistry, mathemat-
4.2 Student Motivation ics, and social sciences indicate immersive tech-
and the ARCS Model nology promotes both affective and cognitive
student gains. This research includes the use of
Several recent studies of augmented reality immersive simulation to promote science learn-
devices, such as Google Glass, showed positive ing through hands-on interaction, virtual intro-
effects on student confidence, satisfaction, and duction to chemistry concepts, and increased
motivation (Akçayır and Akçayır 2016; Vaughn astronomical knowledge retention (Cai et  al.
et al. 2016). One of the educational frameworks 2014; Chiu et al. 2015; Salmi et al. 2016; Zhang
most used to evaluate student motivation to learn et al. 2014). As previously discussed, immersive
is John Keller’s ARCS model (Keller 1987, 1999, technology is also shown to be effective in
2010). The ARCS model asserts that motivation increasing student motivation (Vaughn et  al.
to learn is comprised of the degree to which the 2016; Akçayır and Akçayır 2016).
learner becomes engaged in the learning experi-
ence through elements of attention, relevance,
confidence, and satisfaction. To measure the four 4.4 Use Cases Within Nursing
constructs of the ARCS model, Keller (1993) Education
developed the Instructional Materials Motivation
Survey (IMMS). This instrument was created to There are many opportunities for the use of virtual
measure and identify issues related to student standardized patient simulations within under-
motivation to learn with the use of self-directed graduate nursing education. According to Skiba
learning materials, therefore the IMMS is an (2016), the classroom lecture of today is waning as
appropriate research instrument to measure nurs- the primary teaching method in undergraduate
ing motivational attitudes toward the use a self-­ nursing education. Interactive technologies pro-
directed immersive simulation. vide more project-based, inquiry-driven learning
experiences. Virtual simulation shows great prom-
ise when used in cases that deal with high-risk to
4.3 Educational Potential patients involved (Skiba 2016). According to
of Immersive Simulation Decker et  al. (2008), learning with simulation
requires gaining knowledge, making sense of the
Immersive technologies offer a new simulation knowledge, and then making use of the knowl-
modality with the potential to transform educa- edge. Ultimately, the goal is for the assimilated
Enhancing Nursing Education Through Affordable and Realistic Holographic Mixed Reality: The Virtual… 9

learning to transfer into clinical readiness skills in a patient with psychiatric signs and symptoms
a real-world setting. Best practices in simulation (Smith and Hamilton 2015). Additionally, virtual
have been identified when it is integrated through- technologies have been shown to be effective for
out the entire undergraduate ­nursing curriculum, technical skill acquisition for invasive procedures
increases in difficulty, aligns with student learning such as urinary catheter insertion (Smith and
outcomes, and uses the appropriate tools for both Hamilton 2015), hazardous chemical decontami-
teaching and measurement (Decker et  al. 2008; nation (Ulrich et  al. 2014), and communicating
National League for Nursing 2015). with mentally ill patients (Kidd et al. 2012).
The New Media Consortium (NMC) (2017), Discussion from individual studies within
identified ten big picture themes that are posi- undergraduate nursing have identified four posi-
tioned to impact teaching, learning, and innova- tive concepts regarding use of virtual simulation:
tion in higher education. The themes are a result (1) Virtual simulation is promising for knowl-
of seventy-eight experts partnering with the edge and skill acquisition, (2) the technology cre-
EDUCAUSE Learning Initiative (ELI) to outline ates an opportunity for student centered learning
the 5-year impact of higher education innovation experiences, (3) the technology can be a safe and
across the globe. The NMC Horizon Project is realistic evaluation method, and (4) the technol-
seen as education’s longest-running exploration ogy is user friendly and able to help save vital
of new technology practices. The following ten academic space. The main concern articulated by
themes outline what institutions should know the initial researchers surrounds early coordina-
about the use of technology to improve, support tion in the planning phase with instructional
or extend teaching, learning, and creative inquiry: designers to ensure that the simulation experi-
(1) Student success should be at the center of ence is related to student learning outcomes, real-
institutional learning approaches, (2) real-world istic, and not a distraction to the particular
skills are needed to ensure students are prepared scenario or skill that should be the focus of the
for the workplace, (3) collaboration is key for experience (Berndt 2014; De Gagne et al. 2013;
scaling effective solutions, (4) inequity regarding Fisher and King 2013).
student access to technology in education must Immersive simulation is a new theme that
be addressed, (5) educators must develop new shows promise for low-frequency, high-stakes
ways to evaluate acquisition of individualized scenarios that are difficult to replicate with cur-
vocational skill, competencies, creativity, and rent nursing simulation modalities. These modal-
critical thinking, (6) digital fluency is critical, (7) ities are sparking interest among nurse educators
multiple strategies for integrating blended learn- because they are less expensive and able to pro-
ing must showcase enriched learning outcomes, vide a standardized patient within a more immer-
(8) learning ecosystems must be flexible enough sive environment. The use of virtual simulation is
to embrace the future practices, (9) higher educa- changing rapidly and there is a need for research
tion must be a developer of intuitive technology to assess this evolution (Doolen et al. 2016).
that responds to human interaction, and (10) life-
long learning must be fostered by higher educa-
tion (Becker et al. 2017). 5 The Virtual Standardized
Recent undergraduate nursing studies show- Patient
case concepts of the EDUCAUSE movement and
lay the foundation for immersive technologies to 5.1 Meeting the Need
be safe, realistic, and meaningful. Limited stud- for Affordable, Realistic
ies exist, but there is promise for situations where Nursing Simulation
teaching complex assessments are difficult to
simulate such as a disaster (Ulrich et  al. 2014), In October of 2016, SDSU’s Instructional
for administering medication within a busy envi- Technology Services and School of Nursing part-
ronment (Vottero 2014), and when encountering nered with Texas Tech University, Microsoft, and
10 S. W. Hauze et al.

Pearson to develop the virtual standardized students with extensive clinical experience. The
patient (VSP) simulation. Our research is focused research questions guiding the study include:
on the use of the Microsoft HoloLens as a
­simulation tool for nursing students to deliber- 1. Does baccalaureate nursing student motiva-
ately practice addressing such low-frequency, tion to learn differ as a result of the modality
high-­risk scenarios. A nursing student rarely wit- of instruction employed among (a) a written
nesses a patient exhibiting the full array of symp- case study; (b) a written case study plus two-­
toms related to anaphylactic shock, thus this dimensional video; and, (c) a written case
clinical experience is currently supplemented study plus three-dimensional, mixed reality
using written case studies. In order to simulate anaphylaxis simulation delivered via the
anaphylaxis, a holographic video for the VSP Microsoft HoloLens?
captured a standardized patient actor portraying 2. What factors predict nursing student motiva-
symptoms of anaphylaxis. The holographic video tion to learn through mixed reality anaphy-
was recorded using an array of 25 infrared cam- laxis simulation delivered via the Microsoft
eras and 100 video cameras. The holographic HoloLens?
video was then built into a Microsoft HoloLens 3. Does baccalaureate nursing student knowl-

application using the Unity game development edge, of anaphylaxis, differ as a result of the
engine. modality of instruction employed among (a) a
The VSP interactive functionality allows a written case study; (b) a written case study
nursing student to view the holographic video of plus two-dimensional video; and (c) a written
the standardized patient exhibiting symptoms of case study plus three-dimensional, mixed
anaphylaxis overlaid onto a physical hospital bed reality anaphylaxis simulation delivered via
in a clinical teaching facility. The student can the Microsoft HoloLens?
walk around the patient and observe the symp- 4. Does baccalaureate nursing student interven-
toms as they advance the application through the tion, for anaphylaxis, differ as a result of the
three stages of anaphylaxis. The development of modality of instruction employed among (a) a
simulation similar to the VSP provides a much written case study; (b) a written case study
more affordable and transportable simulation plus two-dimensional video; and (c) a written
modality compared with traditional nursing sim- case study plus three-dimensional, mixed
ulation, however research is needed to determine reality anaphylaxis simulation delivered via
the outcomes on nursing student skills, knowl- the Microsoft HoloLens?
edge, and motivation to learn. 5. What variables predict nursing student knowl-
edge and/or skill when the modality of instruc-
tion employed is mixed reality anaphylaxis
5.2 Description of the Study simulation delivered via the Microsoft
in Progress HoloLens?

The study currently in progress included bacca- All students enrolled in the three levels of
laureate nursing students (n  =  161) enrolled in courses during the Fall 2017 semester were
three levels of nursing courses at San Diego State invited to participate. Participating students
University, both at the main campus and at the were stratified and randomly assigned to one of
Imperial Valley satellite campus located 115 the following groups: Research group 1, which
miles east of San Diego in Calexico, California. provided students with an anaphylaxis written
The three levels are defined as level 1 (n = 65), case study containing two-dimensional still
consisting of students familiar with reading case images (n  =  54); research group 2, which pro-
studies with no formal clinical experience; level vided students with an two-dimensional video
2 (n = 60), consisting of students with basic clini- VSP anaphylaxis simulation via a computer
cal experience; and level 3 (n = 36), consisting of monitor plus a written case study (n = 54); and
Enhancing Nursing Education Through Affordable and Realistic Holographic Mixed Reality: The Virtual… 11

research group 3, which provided students with total of three knowledge questions and two skill
a three-­dimensional, MR VSP anaphylaxis sim- questions in observation period two. There was a
ulation via the Microsoft HoloLens plus a writ- total of three knowledge questions after observa-
ten case study (n = 53). tion period three and a total of four overall knowl-
All participants received written instructions edge questions upon completion of the VSP
accompanied by the anaphylaxis case study. Each scenario. Student responses were written on the
student completed a pre-survey to collect data research instrument scored dichotomously
related to previous clinical and simulation experi- (1  =  correct, 0  =  incorrect) by the researchers.
ence. Upon finishing each anaphylaxis observa- Knowledge and skill questions, with grading cri-
tion, participants completed a knowledge teria created by the School of Nursing Director,
measure to determine understanding of the con- Assistant Director, and the Medical-Surgical I
tent conveyed in the corresponding observation. and II Course Coordinator. Knowledge questions
The data collection instruments are outlined were added together to create a total knowledge
below. score for observation period one, two, three, and
overall. Skill questions were added together to
Pre-survey  The pre-survey portion of the create a total skill score for observation period
research instrument was used to determine demo- one and two.
graphic information (age and nursing level), pre-
vious clinical experience, previous immersive
simulation experience, and previous nursing sim- Post Survey  Upon completion of the scenario
ulation experience. and knowledge measure questions, each student
completed a post-survey related to the simulation
experience, focusing on their opinion of the sim-
Case Study  The case study selected for the VSP ulation and the degree to which they felt it helped
was centered on anaphylaxis. Anaphylaxis is a their confidence and motivation. The post-survey
severe, life-threatening allergic reaction. It can included the National League for Nursing (NLN)
occur within seconds or minutes of exposure to Student Satisfaction and Self-Confidence (SCLS)
an allergen. The VSP scenario for anaphylaxis in Learning instrument and the Instructional
involved three VSP observations. Each VSP Materials Motivation Survey (IMMS).
observation showcased a scenario in which the
patient demonstrated signs and symptoms of ana-
phylaxis and increased in severity rapidly. 5.3 Planned Analysis
Students experienced the VSP observation
through three different methods based upon their The planned quantitative analyses to address the
randomized research group assignment (video, research questions include comparisons of sur-
Microsoft HoloLens, or written case study). vey responses between the three research groups.
Analysis of covariance (ANCOVA) will be used
to determine if differences exist between research
Observation Measures  As the VSP scenario groups in terms of skills, knowledge, or student
unfolded, there were three VSP observation peri- motivation to learn. Covariates will include age,
ods that nursing students were prompted to digital quotient, clinical experience, simulation
respond to. Upon completion of each VSP obser- experience, and course in which the participant
vation period, students were asked to complete a was enrolled at the time of data collection.
set of questions to determine knowledge and skill In addition to the ANCOVA, factor analysis,
regarding assessment and intervention in the low-­ path analysis, and structural equation modeling
frequency, high-stakes scenario. There was a will be used to determine which factors predicted
total of three knowledge questions and two skill increased skills, knowledge, and motivation to
questions in observation period one. There was a learn when the modality of instruction employed
12 S. W. Hauze et al.

was mixed reality anaphylaxis simulation deliv- Blodget H (2016) The virtual and augmented reality
market will reach $162 billion by 2020. http://www.
ered via the Microsoft HoloLens. Confirmatory businessinsider.com/virtual-and-augmented-reality-
factor analysis will be used to determine which markets-will-reach-162-billion-by-2020-2016-8.
variables should be included within the factors. Accessed 1 Oct 2018
Bloom BS (1968) Learning for mastery. Regional
Education Laboratory for the Carolinas and Virginia,
topical papers and reprints 1(2):2
5.4 Planned Discussion Cai S, Wang X, Chiang FK (2014) A case study of aug-
mented reality simulation system application in a
Discussion of our future analysis will provide chemistry course. Comput Hum Behav 37:31–40
Chiu JL, DeJaegher CJ, Chao J (2015) The effects of aug-
quantitative data not currently found in the litera- mented virtual science laboratories on middle school
ture regarding the effectiveness of using mixed students’ understanding of gas properties. Comput
reality simulation experience to address low-­ Educ 85:59–73
frequency, high-risk nursing clinical content. The De Gagne JC, Oh J, Kang J et al (2013) Virtual worlds in
nursing education: a synthesis of the literature. J Nurs
results can be used by policymakers, educators, Educ 52(7):391–396
students, and clinical partners to make evidence-­ Decker S, Sportsman S, Puetz L et al (2008) The evolu-
based decisions when contemplating use of simu- tion of simulation and its contribution to competency.
lation modalities to prepare student nurses and J Contin Educ Nurs 39(2):74–80
Dewey J (1938) Experience and education
licensed nurses for the workforce. Additionally, Doolen J, Mariani B, Atz T et  al (2016) High-fidelity
the potential benefits of the study include deter- simulation in undergraduate nursing education:
mining if mixed reality is a viable means of pro- a review of simulation reviews. Clin Simul Nurs
viding simulation education to nursing students 12(7):290–302
Ericsson KA, Krampe RT, Tesch-Römer C (1993) The
through devices much less expensive than using role of deliberate practice in the acquisition of expert
standardized patient human actors and/or high-­ performance. Psychol Rev 100(3):363
fidelity manikin simulators. Fisher D, King L (2013) An integrative literature review
on preparing nursing students through simulation to
recognize and respond to the deteriorating patient.
J Adv Nurs 69(11):2375–2388
References Freeman S, Eddy SL, McDonough M (2014) Active
learning increases student performance in science,
Akçayır G, Akçayır M (2016) Research trends in social engineering, and mathematics. Proc Natl Acad Sci
network sites’ educational use: a review of publications 111(23):8410–8415
in all SSCI journals to 2015. Rev Educ 4(3):293–319 Hayden JK, Smiley RA, Alexander M (2014a) The
American Association of Colleges of Nursing (2016) NCSBN national simulation study: a longitudinal,
Advancing healthcare transformation: a new era for randomized, controlled study replacing clinical hours
academic nursing. American Association of Colleges with simulation in prelicensure nursing education.
of Nursing J Nurs Regul 5(2):S3–S40
American Association of Colleges of Nursing (2017) Hayden JK, Smiley RA, Gross L (2014b) Simulation in
Fact sheet: nursing shortage. American Association of nursing education: current regulations and practices.
Colleges of Nursing J Nurs Regul 5(2):25–30
Bandura A (1977) Self-efficacy: toward a unifying theory INACSL Standards Committee (2016) INACSL standards
of behavioral change. Psychol Rev 84(2):191 of best practice: simulation SM debriefing. Clin Simul
Barsom EZ, Graafland M, Schijven MP (2016) Nurs 12:S21–S25
Systematic review on the effectiveness of augmented Jeffries PR (2005) A framework for designing, implement-
reality applications in medical training. Surg Endosc ing, and evaluating: simulations used as teaching strat-
30(10):4174–4183 egies in nursing. Nurs Educ Perspect 26(2):96–103
Becker SA, Cummins M, Davis A et al (2017) NMC hori- Jeffries PR (2012) Simulation in nursing education: from
zon report: 2017 higher education edition. The New conceptualization to evaluation. National League for
Media Consortium, Toronto, pp 1–60 Nursing, New York
Benner P, Sutphen M, Leonard V et al (2010) Educating Jeffries PR, Rogers KJ (2007) Theoretical framework for
nurses: A radical call for Transformation. Jossey-Bass, simulation design. In: Simulation in nursing educa-
San Francisco tion: from conceptualization to evaluation. National
Berndt J (2014) Patient safety and simulation in prelicen- League for Nursing, New York, pp 21–33
sure nursing education: an integrative review. Teach Jeffries PR, Bambini D, Hensel D et  al (2009)
Learn Nurs 9(1):16–22 Constructing maternal-child learning experiences
Enhancing Nursing Education Through Affordable and Realistic Holographic Mixed Reality: The Virtual… 13

using clinical simulations. J Obstet Gynecol Neonatal National League for Nursing (2015) A vision for teaching
Nurs 38(5):613–623 with simulation: a living document from the National
Keller JM (1987) Development and use of the ARCS League for Nursing NLN Board of Governors. http://
model of instructional design. J Instr Dev 10(3):2 www.nln.org/docs/default-source/about/nln-vision-
Keller JM (1993) Manual for instructional materials moti- series-(position-statements)/vision-statement-a-
vational survey (IMMS). Unpublished manuscript, vision-for-teaching-with-simulation.pdf. Accessed 1
Tallahassee, Florida, 1999 Oct 2018
Keller JM (1999) Using the ARCS motivational process Salmi H, Thuneberg H, Vainikainen MP (2016) How do
in computer-based instruction and distance education. engineering attitudes vary by gender and motivation?
New Dir Teach Learn 1999(78):37–47 Attractiveness of outreach science exhibitions in four
Keller JM (2010) The Arcs model of motivational design. countries. Eur J Eng Educ 41(6):638–659
In: Motivational design for learning and performance. Skiba DJ (2016) On the horizon: trends, challenges, and
Springer, Boston, pp 43–74 educational technologies in higher education. Nurs
Kidd LI, Knisley SJ, Morgan KI (2012) Effectiveness Educ Perspect 37(3):183–185
of a second life® simulation as a teaching strategy Smith PC, Hamilton BK (2015) The effects of virtual
for undergraduate mental health nursing students. reality simulation as a teaching strategy for skills
J Psychosoc Nurs Ment Health Serv 50(7):28–37 preparation in nursing students. Clin Simul Nurs
Knowles M (1973) The adult learner: a neglected species. 11(1):52–58
Gulf Publishing Company, Houston Ulrich D, Farra S, Smith S et al (2014) The student expe-
Lapkin S, Levett-Jones T (2011) A cost–utility analy- rience using virtual reality simulation to teach decon-
sis of medium vs. high-fidelity human patient simu- tamination. Clin Simul Nurs 10(11):546–553
lation manikins in nursing education. J  Clin Nurs Vaughn J, Lister M, Shaw RJ (2016) Piloting aug-
20(23–24):3543–3552 mented reality technology to enhance realism in
Larue C, Pepin J, Allard É (2015) Simulation in prepara- clinical simulation. CIN: Comput Inform Nurs
tion or substitution for clinical placement: a systematic 34(9):402–405
review of the literature. J Nurs Educ Pract 5(9):132 Vottero BA (2014) Proof of concept: virtual reality simu-
McGaghie WC, Issenberg SB, Cohen MER et al (2011) lation of a Pyxis machine for medication administra-
Does simulation-based medical education with delib- tion. Clin Simul Nurs 10(6):e325–e331
erate practice yield better results than traditional clini- Weaver A (2011) High-fidelity patient simulation in
cal education? A meta-analytic comparative review of nursing education: an integrative review. Nurs Educ
the evidence. J Assoc Am Med Coll 86(6):706 Perspect 32(1):37–40
Meyer L (2016) Pearson pilots mixed reality educational Young PK, Shellenbarger T (2012) Interpreting the NLN
resources. https://thejournal.com/articles/2016/10/31/ Jeffries framework in the context of nurse educator
pearson-pilots-mixed-reality-educational-content. preparation. J Nurs Educ 51(8):422–428
aspx. Accessed 1 Oct 2018 Zhang J, Sung YT, Hou HT (2014) The development
Milgram P, Kishino F (1994) A taxonomy of mixed real- and evaluation of an augmented reality-based armil-
ity visual displays. IEICE TRANSACTIONS Inf Syst lary sphere for astronomical observation instruction.
77(12):1321–1329 Comput Educ 73:178–188