Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study

BACKGROUND

Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited.

OBJECTIVE

This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level.

METHODS

This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants' experiences.

RESULTS

The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing.

CONCLUSIONS

It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54180.

Development and Implementation of a Stress Monitoring Paradigm Using Virtual Reality Simulation During the COVID-19 Pandemic

Healthcare providers, particularly during the COVID-19 crisis, have been forced to make difficult decisions and have reported acting in ways that are contrary to their moral values, integrity, and professional commitments, given the constraints in their work environments. Those actions and decisions may lead to healthcare providers' moral suffering and distress. This work outlines the development of the Moral Distress Virtual Reality Simulator (Moral Distress VRS) to research stress and moral distress among healthcare workers during the COVID-19 pandemic. The Moral Distress VRS was developed based on the agile methodology framework, with three simultaneous development streams. It followed a two-week sprint cycle, ending with meetings with stakeholders and subject matter experts, whereby the project requirements, scope, and features were revised, and feedback was provided on the prototypes until reaching the final prototype that was deployed for in-person study sessions. The final prototype had two user interfaces (UIs), one for the participant and one for the researcher, with voice narration and customizable character models wearing medical personal protective equipment, and followed a tree-based dialogue scenario, outputting a video recording of the session. The virtual environment replicated an ICU nursing station and a fully equipped patient room. We present the development process that guided this project, how different teams worked together and in parallel, and detail the decisions and outcomes in creating each major component within a limited deadline. Finally, we list the most significant challenges and difficulties faced and recommendations on how to solve them.

Digital Interventions for Stress Among Frontline Health Care Workers: Results From a Pilot Feasibility Cohort Trial

BACKGROUND

The COVID-19 pandemic has challenged the mental health of health care workers, increasing the rates of stress, moral distress (MD), and moral injury (MI). Virtual reality (VR) is a useful tool for studying MD and MI because it can effectively elicit psychophysiological responses, is customizable, and permits the controlled study of participants in real time.

OBJECTIVE

This study aims to investigate the feasibility of using an intervention comprising a VR scenario and an educational video to examine MD among health care workers during the COVID-19 pandemic and to use our mobile app for longitudinal monitoring of stress, MD, and MI after the intervention.

METHODS

We recruited 15 participants for a compound intervention consisting of a VR scenario followed by an educational video and a repetition of the VR scenario. The scenario portrayed a morally challenging situation related to a shortage of life-saving equipment. Physiological signals and scores of the Moral Injury Outcome Scale (MIOS) and Perceived Stress Scale (PSS) were collected. Participants underwent a debriefing session to provide their impressions of the intervention, and content analysis was performed on the sessions. Participants were also instructed to use a mobile app for 8 weeks after the intervention to monitor stress, MD, and mental health symptoms. We conducted Wilcoxon signed rank tests on the PSS and MIOS scores to investigate whether the VR scenario could induce stress and MD. We also evaluated user experience and the sense of presence after the intervention through semi-open-ended feedback and the Igroup Presence Questionnaire, respectively. Qualitative feedback was summarized and categorized to offer an experiential perspective.

RESULTS

All participants completed the intervention. Mean pre- and postintervention scores were respectively 10.4 (SD 9.9) and 13.5 (SD 9.1) for the MIOS and 17.3 (SD 7.5) and 19.1 (SD 8.1) for the PSS. Statistical analyses revealed no significant pre- to postintervention difference in the MIOS and PSS scores (P=.11 and P=.22, respectively), suggesting that the experiment did not acutely induce significant levels of stress or MD. However, content analysis revealed feelings of guilt, shame, and betrayal, which relate to the experience of MD. On the basis of the Igroup Presence Questionnaire results, the VR scenario achieved an above-average degree of overall presence, spatial presence, and involvement, and slightly below-average realism. Of the 15 participants, 8 (53%) did not answer symptom surveys on the mobile app.

CONCLUSIONS

Our study demonstrated VR to be a feasible method to simulate morally challenging situations and elicit genuine responses associated with MD with high acceptability and tolerability. Future research could better define the efficacy of VR in examining stress, MD, and MI both acutely and in the longer term. An improved participant strategy for mobile data capture is needed for future studies.

TRIAL REGISTRATION

ClinicalTrails.gov NCT05001542; https://clinicaltrials.gov/study/NCT05001542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32240.

Updating the Foodbot Factory serious game with new interactive engaging features and enhanced educational content

Serious games (i.e., digital games designed for educational purposes) can foster positive learning attitudes and are increasingly used as educational tools. Foodbot Factory is a serious game application (app) that helps children learn about healthy eating based on Canada's Food Guide principles and has demonstrated to increase nutrition knowledge among this group. This paper describes the process followed to expand Foodbot Factory's educational content and integrate immersive technologies and innovative features into the app. The revision process, which was guided by the Obesity-Related Behavioral Intervention Trials model, included the following phases: first, an interdisciplinary team of nutrition scientists, education experts, and computer scientists analyzed data from the original pilot study, recently published literature, and feedback from stakeholders to define areas to improve Foodbot Factory. The five original Foodbot Factory modules were evaluated by the team during weekly meetings, where the educational content, interactive features, and other elements that required updates (e.g., aesthetics and accessibility) were identified. Second, prototypes were created and refined until a final version of Foodbot Factory was approved. Nineteen children tested the updated Foodbot Factory and found it "easy to use" (89%) and "fun" (95%). The new version of Foodbot Factory contains 19 learning objectives, including 13 original and six new objectives. Interactive engagement features in the updated Foodbot Factory included augmented reality incorporated into two learning modules; new mini-games were created, including a memory game; an overhaul of the aesthetics; (e.g., new food images); and accessibility features were included to support users with cognitive and vision disabilities.

Development of a data-driven digital phenotype profile of distress experience of healthcare workers during COVID-19 pandemic

BACKGROUND AND OBJECTIVE

Due to the constraints of the COVID-19 pandemic, healthcare workers have reported acting in ways that are contrary to their moral values, and this may result in moral distress. This paper proposes the novel digital phenotype profile (DPP) tool, developed specifically to evaluate stress experiences within participants. The DPP tool was evaluated using the COVID-19 VR Healthcare Simulation of Stress Experience (HSSE) dataset (NCT05001542), which is composed of passive physiological signals and active mental health questionnaires. The DPP tool focuses on correlating electrocardiogram, respiration, photoplethysmography, and galvanic skin response with moral injury outcome scale (Brief MIOS).

METHODS

Data-driven techniques are encompassed to develop a tool for robust evaluation of distress among participants. To accomplish this, we applied pre-processing techniques which involved normalization, data sanitation, segmentation, and windowing. During feature analysis, we extracted domain-specific features, followed by feature selection techniques to rank the importance of the feature set. Prior to classification, we employed k-means clustering to group the Brief MIOS scores to low, moderate, and high moral distress as the Brief MIOS lacks established severity cut-off scores. Support vector machine and decision tree models were used to create machine learning models to predict moral distress severities.

RESULTS

Weighted support vector machine with leave-one-subject-out-cross-validation evaluated the separation of the Brief MIOS scores and achieved an average accuracy, precision, sensitivity, and F1 of 98.67%, 98.83%, 99.44%, and 99.13%, respectively. Various machine learning ablation tests were performed to support our results and further enhance the understanding of the predictive model.

CONCLUSION

Our findings demonstrate the feasibility to develop a DPP tool to predict distress experiences using a combination of mental health questionnaires and passive signals. The DPP tool is the first of its kind developed from the analysis of the HSSE dataset. Additional validation is needed for the DPP tool through replication in larger sample sizes.

Hand Sewn Anastomosis Skill Acquisition and In Vivo Transfer Using 3D-Printed Small Bowel Simulator

INTRODUCTION

General surgery residents need to master the hand-sewn bowel anastomosis (HSBA) technique. However, practice opportunities outside of the operating room are rare, and commercial simulators are often costly. The objective of this study is to assess the efficacy of a new, affordable silicone small bowel simulator, made with a three-dimensional (3D) printed mold, as a training tool to learn this technique.

METHODS

This was a single-blinded pilot randomized controlled trial comparing two groups of eight junior surgical residents. All participants completed a pretest using an inexpensive, custom developed 3D-printed simulator. Next, participants randomized to the experimental group practiced the HSBA skill at home (eight sessions), while those randomized to the control group did not receive any hands-on practice opportunities. A posttest was done using the same simulator as for the pretest and practice sessions, and the retention-transfer test was performed on an anesthetized porcine model. Pretests, posttests and retention-transfer tests were filmed and graded by a blinded evaluator using assessments of technical skills, quality of final product, and tests of procedural knowledge.

RESULTS

The experimental group significantly improved after practicing with the model (P = 0.01), while an equivalent improvement was not noted in the control group (P = 0.07). Moreover, the experimental group's performance remained stable between the posttest and the retention-transfer test (P = 0.95).

CONCLUSIONS

Our 3D-printed simulator is an affordable and efficacious tool to teach residents the HSBA technique. It allows development of surgical skills that are transferable to an in vivo model.

The exploration of remote simulation strategies for the acquisition of psychomotor skills in medicine: a pilot randomized controlled trial

Background

Progress in remote educational strategies was fueled by the advent of the COVID-19 pandemic. This pilot RCT explored the efficacy of a decentralized model of simulation based on principles of observational and peer-to-peer learning for the acquisition of surgical skills.

Methods

Sixty medical students from the University of Montreal learned the running subcuticular suture in four different conditions: (1) Control group (2) Self-learning (3) Peer-learning (4) Peer-learning with expert feedback. The control group learned with error-free videos, while the others, through videos illustrating strategic sub-optimal performances to be identified and discussed by students. Performance on a simulator at the end of the learning period, was assessed by an expert using a global rating scale (GRS) and checklist (CL).

Results

Students engaging in peer-to-peer learning strategies outperformed students who learned alone. The presence of an expert, and passive vs active observational learning strategies did not impact performance.

Conclusion

This study supports the efficacy of a remote learning strategy and demonstrates how collaborative discourse optimizes the students' acquisition of surgical skills. These remote simulation strategies create the potential for implantation in future medical curriculum design.Trial Registration: NCT04425499 2020-05-06.

Digital Interventions to Reduce Distress Among Frontline Health Care Providers: Analysis of Self-Perceived Stress

Due to the constraints of the COVID-19 pandemic, healthcare workers have reported behaving in ways that are contrary to their values, which may result in distress and injury. This work is the first of its kind to evaluate the presence of stress in the COVID-19 VR Healthcare Simulation for Distress dataset. The dataset collected passive physiological signals and active mental health questionnaires. This paper focuses on correlating electrocardiogram, respiration, photoplethysmography, and galvanic skin response with the Perceived Stress Scale (PSS)-10 questionnaire. The analysis involved data-driven techniques for a robust evaluation of stress among participants. Low-complexity pre-processing and feature extraction techniques were applied and support vector machine and decision tree models were created to predict the PSS-10 scores of users. Imbalanced data classification techniques were used to further enhance our understanding of the results. Decision tree with oversampling through Synthetic Minority Oversampling Technique achieved an accuracy, precision, recall, and F1 of 93.50%, 93.41%, 93.31%, and 93.35%, respectively. Our findings offer novel results and clinically valuable insights for stress detection and potential for translation to edge computing applications to enhance privacy, longitudinal monitoring, and simplify device requirements.

Optimizing the Learner's Role in Feedback: Development of a Feedback-Preparedness Online Application for Medical Students in the Clinical Setting

Feedback is an essential component of medical education, especially during clinical rotations. There is growing interest in learner-related factors that can optimize feedback's efficiency, including goal orientation, reflection, self-assessment, and emotional response. However, no mobile application or curriculum currently exists to specifically address those factors. This technical report describes the concept, design, and learner-based feedback of an innovative online application, available on mobile phones, developed to bridge this gap. Eighteen students in their third or fourth year of medical school provided comments on a pilot version of the application. The majority of learners deemed the module relevant, interesting, and helpful to guide reflection and self-assessment, therefore fostering better preparation before an upcoming feedback session. Minor improvements were suggested in terms of content and format. The learners' initial positive response supports further efforts to engage in validity and evaluation research. Future steps include modifying the mobile application based on learners' comments, evaluating its efficacy in a real clinical setting, and clarifying whether it is most beneficial for mid-rotation or end-of-rotation feedback sessions.

The Role of Collaborative Observational Practice and Feedback-Discourse to Promote Remote Acquisition of Technical Surgical Skills

INTRODUCTION

Acquisition of technical skills remotely in a decentralized model requires an efficacious way of providing feedback. The primary objective was to test the efficacy of various forms of feedback on the acquisition of surgical skills by medical students.

METHODS

Forty volunteers were randomized to four experimental groups, differing from the nature of feedback (free text versus structured) and who provided the feedback (expert versus peer learners). They had to perform sutures and upload attempts on a learning management system to receive interactive feedback. The pretest and retention test performances were assessed.

RESULTS

All groups significantly improved from pretests to retention tests; however, participants using checklist showed statistically lower improvements than the other groups, which did not differ from each other.

CONCLUSIONS

Remote learners can acquire surgical skills, and most importantly, peers who provide feedback, are as effective as experts if they use open-ended comments and not checklists.

Development of Content for a Virtual Reality Simulation to Understand and Mitigate Moral Distress in Healthcare Workers

Background In high-stakes situations, healthcare workers are prone to suffer moral injury, the psychological, social, and spiritual impact of events involving betrayal or transgression of one's own deeply held moral beliefs and values. As a result, this may negatively impact their capacity to provide adequate levels of care to patients. There is a lack of educational resources catered to help healthcare workers navigate ethical situations in clinical settings that may lead to or worsen moral distress. The aim of this report is to describe the methodology of development and resulting outcomes in the form of an educational resource that includes a virtual reality (VR) simulation to help healthcare workers understand and mitigate moral distress as a result of internal and external constraints at their workplaces. Methodology A study using a method outlining a set of constraint parameters, followed by ideation utilizing design thinking (DT), and concluding with a consensus-building exercise using Delphi methodology (DM) with a group of 13 experts in healthcare simulation, VR, psychiatry, psychology, and nursing. The constraints parameters included technology use (VR), use of experiential learning theory, and duration of the intervention (15 minutes). A DT process was performed to generate and expand on ideas on the scenario and intervention of a possible VR simulation which were funneled into a three-round DM to define the foundations of the VR simulation. Average, standard deviations, and free-text comments in the DM were used to assess the inclusion of the produced requirements. Finally, a focus group interview was conducted with the same experts to draft the VR simulation. Results Within the specified constraints, the DT process produced 33 ideas for the VR simulation scenario and intervention that served as a starting point to short-list the requirements in Round 1. In Rounds 1 to 2, 25 items were removed, needed revising, and/or were retained for the subsequent rounds, which resulted in eight items at the end of Round 2. Round 2 also required specialists to provide descriptions of potential scenarios and interventions, in which five were submitted. In Round 3, experts rated the descriptions as somewhat candidate to use in the final VR simulation, and the open feedback in this round proposed combining the elements from each of the descriptions. Using this data, a prototype of the VR simulation was developed by the project team together with VR designers. Conclusions This development demonstrated the feasibility of using the constraints-ideation-consensus approach to define the content of a possible VR simulation to serve as an educational resource for healthcare workers on how to understand and mitigate moral distress in the workplace. The methodology described in this development may be applied to the design of simulation training for other skills, thereby advancing healthcare training and the quality of care delivered to the greater society.

Focus Group Findings to Support the Preliminary Development of the Augmented Reality Education Experience (AREduX)

Dementia is considered a global health priority with projections of the disease set to increase dramatically across the world. Current support for persons living with dementia (PLWD) relies on long-term care and local service centers to provide education and support. Augmented reality-based programs continue to gain momentum across health sectors, becoming an innovative approach that provides an opportunity to have a visceral experience, which can deepen understanding and provide an embodied perspective of other groups within a relatively short time frame. There is increasing interest in developing approaches to aid patient care outcomes for PLWD and their caregivers. Hence, healthcare providers (HCPs) who are appropriately trained and equipped to provide quality care to PLWD are essential and of international concern. The purpose of this research program is to develop an augmented reality (AR) education experience (AREduX), a proof of concept prototype in the form of a digital resource that uses AR to simulate the physical and cognitive symptoms that PLWD experience. The findings from a stakeholder focus group will allow for the preliminary development of the AREduX.

Development and Learner-Based Assessment of a Novel, Customized, 3D Printed Small Bowel Simulator for Hand-Sewn Anastomosis Training

Hand-sewn bowel anastomosis (HSBA) is an essential skill for surgical residents to learn, as it is used in numerous surgical procedures. However, the opportunities to practice this skill before attempting it on patients are limited. Practice on simulators can help improve this technique, but there is a paucity of realistic, cost-efficient simulators for the acquisition of HSBA skills.

This technical report describes the development of our simulator that consists of a small bowel manufactured from silicone and a 3D-printed clamp system to hold the bowel in place. Our simulator was co-designed by a clinical team of surgeons and then assessed for perceived acceptability and effectiveness by 16 junior residents in various surgical specialties at our faculty. A majority of the learners rated our simulator to be a good or very good learning tool for HSBA, although they suggested some minor improvements.

Overall, our silicone small bowel model appears to be an effective and inexpensive way to acquire this surgical skill.

Effective Collaboration Through Activity Theory and Knotworking in Clinical Settings

Healthcare professionals must be able to work in multidisciplinary teams (MDTs). The purpose of this editorial is to explain how healthcare professionals (can) contribute to the effectiveness of MDT, through the use of activity theory (collective work activity shared by others who are motivated by a purpose mediated by tools in order to achieve a specific goal) and the associated idea of knotworking (method of tying, untying, and retying together seemingly separate threads of activity). The leading thesis here is that MDTs benefit from health professionals with well-established leadership skills, and also strong collaborative skills that enable them to transition fluidly between leadership roles as needed to advance patient care. Within activity theory, knotworking is the process of tying and untying various threads of activity and knowledge from across the MDT in order to accomplish specific objectives over time. Knotworking exemplifies the dynamic nature of MDT collaboration, which requires professionals to be productive in their environment. The viewpoints offered in this editorial contribute to a new perspective on MDTs, one that acknowledges distributed leadership and the importance of co-producing a successful partnership in a clinical setting.

Digital Interventions to Reduce Distress Among Health Care Providers at the Frontline: Protocol for a Feasibility Trial

Background

Stress, anxiety, distress, and depression are high among health care workers during the COVID-19 pandemic, and they have reported acting in ways that are contrary to their moral values and professional commitments that degrade their integrity. This creates moral distress and injury due to constraints they have encountered, such as limited resources.

Objective

The purpose of this study is to develop and show the feasibility of digital platforms (a virtual reality and a mobile platform) to understand the causes and ultimately reduce the moral distress of health care providers during the COVID-19 pandemic.

Methods

This will be a prospective, single cohort, pre- and posttest study examining the effect of a brief informative video describing moral distress on perceptual, psychological, and physiological indicators of stress and decision-making during a scenario known to potentially elicit moral distress. To accomplish this, we have developed a virtual reality simulation that will be used before and after the digital intervention for monitoring short-term impacts. The simulation involves an intensive care unit setting during the COVID-19 pandemic, and participants will be placed in morally challenging situations. The participants will be engaged in an educational intervention at the individual, team, and organizational levels. During each test, data will be collected for (1) physiological measures of stress and after each test, data will be collected regarding (2) thoughts, feelings and behaviors during a morally challenging situation, and (3) perceptual estimates of psychological stress. In addition, participants will continue to be monitored for moral distress and other psychological stresses for 8 weeks through our Digital intervention/intelligence Group mobile platform. Finally, a comparison will be conducted using machine learning and biostatistical techniques to analyze the short- and long-term impacts of the virtual reality intervention.

Results

The study was funded in November 2020 and received research ethics board approval in March 2021. The study is ongoing.

Conclusions

This project is a proof-of-concept integration to demonstrate viability over 6 months and guide future studies to develop these state-of-the-art technologies to help frontline health care workers work in complex moral contexts. In addition, the project will develop innovations that can be used for future pandemics and in other contexts prone to producing moral distress and injury. This project aims to demonstrate the feasibility of using digital platforms to understand the continuum of moral distress that can lead to moral injury. Demonstration of feasibility will lead to future studies to examine the efficacy of digital platforms to reduce moral distress.

Trial Registration

ClinicalTrials.gov NCT05001542; https://clinicaltrials.gov/ct2/show/NCT05001542

International Registered Report Identifier (IRRID)

DERR1-10.2196/32240

Using Simulation-Based Methods to Support Demonstration of Competencies Required by Micro-Credential Courses

The rise of the digital revolution has disrupted entire industries and job markets, leading individuals to either upgrade or transfer their skills in order to continue within their designated fields or transition to new workplace contexts. Employers expect their employees to apply their knowledge to real-world settings, analyze and solve problems, connect choices to actions, and innovate and create. Moreover, the COVID-19 pandemic has exacerbated changes to the educational landscape by forcing online and remote contexts; physical distancing and other preventive measures have necessitated a shift towards increasing the use of disruptive digital technologies- extended reality (e.g., virtual and augmented reality), gaming, and additive manufacturing-in simulation delivery. Yet Canada’s economic and demographic data suggests that many new graduates struggle to transition from school to working life. The confluence of these factors has led to a need for both individuals and higher education institutions to upgrade and adapt to new digital techniques and modalities. As these needs grow, simulation-based education (SBE) techniques and technologies-already an integral part of training for some professions, including nursing, medicine, and various other health professions-are increasingly being used in digital contexts.

In this editorial, we provide our perspective of the socio-technological movement associated with health-professions education (HPE) within the SBE context and examine the application and implementation of micro-credentialing within this field. We also discuss the various levels of expertise that learners may acquire. From this vantage point, we address how SBE can complement the assessment of competencies that learners must demonstrate to attain micro-credentials and explore micro-credentialing’s advantages for, and use in, HPE.

A Model for an Online Learning Management System for Simulation-Based Acquisition of Psychomotor Skills in Health Professions Education

The current coronavirus disease (COVID-19) pandemic has shifted traditional educational approaches in health professions education (HPE) from in-person to remote learning. Although pedagogical strategies have been developed and implemented rapidly to support cognitive and affective domains of learning in HPE, less progress has occurred in psychomotor skills acquisition. Psychomotor skills, referred to as technical skills training, are underpinned by educational theories and conceptual frameworks. Considering the widening gap in learning domains, this editorial provides an overview and recommendations for developing and implementing remote training supported by educational theories, such as deliberate practice, and conceptual frameworks in technical skills acquisition in HPE. We begin by discussing the unique curricular needs for remote psychomotor skills in medical teaching-learning contexts and subsequently present a theory-driven and evidence-based model for remote psychomotor skills acquisition.

Development of Unity Simulator for Epidural Insertion Training for Replacing Current Lumbar Puncture Simulators

We have recently developed the Unity Simulator for Epidural Insertion Training (USEIT) system that provides an innovative and relatively inexpensive virtual simulation approach for epidural training. This report describes the design and development process to produce the USEIT system.

The Effectiveness of the Foodbot Factory Mobile Serious Game on Increasing Nutrition Knowledge in Children

The interactive and engaging nature of serious games (i.e., video games designed for educational purposes) enables deeper learning and facilitates behavior change; however, most do not specifically support the dissemination of national dietary guidelines, and there are limited data on their impact on child nutrition knowledge. The Foodbot Factory serious game mobile application was developed to support school children in learning about Canada's Food Guide; however, its impacts on nutrition knowledge have not been evaluated. The objective of this study was to determine if Foodbot Factory effectively improves children's knowledge of Canada's Food Guide, compared to a control group (control app). This study was a single-blinded, parallel, randomized controlled pilot study conducted among children ages 8-10 years attending Ontario Tech University day camps. Compared to the control group (n = 34), children who used Foodbot Factory (n = 39) had significant increases in overall nutrition knowledge (10.3 ± 2.9 to 13.5 ± 3.8 versus 10.2 ± 3.1 to 10.4 ± 3.2, p < 0.001), and in Vegetables and Fruits (p < 0.001), Protein Foods (p < 0.001), and Whole Grain Foods (p = 0.040) sub-scores. No significant difference in knowledge was observed in the Drinks sub-score. Foodbot Factory has the potential to be an effective educational tool to support children in learning about nutrition.

Optimizing Child Nutrition Education With the Foodbot Factory Mobile Health App: Formative Evaluation and Analysis

BACKGROUND

Early nutrition interventions to improve food knowledge and skills are critical in enhancing the diet quality of children and reducing the lifelong risk of chronic disease. Despite the rise of mobile health (mHealth) apps and their known effectiveness for improving health behaviors, few evidence-based apps exist to help engage children in learning about nutrition and healthy eating.

OBJECTIVE

This study aimed to describe the iterative development and user testing of Foodbot Factory, a novel nutrition education gamified app for children to use at home or in the classroom and to present data from user testing experiments conducted to evaluate the app.

METHODS

An interdisciplinary team of experts in nutrition, education (pedagogy), and game design led to the creation of Foodbot Factory. First, a literature review and an environmental scan of the app marketplace were conducted, and stakeholders were consulted to define the key objectives and content of Foodbot Factory. Dietitian and teacher stakeholders identified priority age groups and learning objectives. Using a quasi-experimental mixed method design guided by the Iterative Convergent Design for Mobile Health Usability Testing approach, five app user testing sessions were conducted among students (ages 9-12 years). During gameplay, engagement and usability were assessed via direct observations with a semistructured form. After gameplay, qualitative interviews and questionnaires were used to assess user satisfaction, engagement, usability, and knowledge gained.

RESULTS

The environmental scan data revealed that few evidence-based nutrition education apps existed for children. A literature search identified key nutrients of concern for Canadian children and techniques that could be incorporated into the app to engage users in learning. Foodbot Factory included characters (2 scientists and Foodbots) who initiate fun and engaging dialogue and challenges (minigames), with storylines incorporating healthy eating messages that align with the established learning objectives. A total of five modules were developed: drinks, vegetables and fruit, grain foods, animal protein foods, and plant protein foods. Seven behavior change techniques and three unique gamified components were integrated into the app. Data from each user testing session were used to inform and optimize the next app iteration. The final user testing session demonstrated that participants agreed that they wanted to play Foodbot Factory again (12/17, 71%), that the app is easy to use (12/17, 71%) and fun (14/17, 88%), and that the app goals were clearly presented (15/17, 94%).

CONCLUSIONS

Foodbot Factory is an engaging and educational mHealth intervention for the Canadian public that is grounded in evidence and developed by an interdisciplinary team of experts. The use of an iterative development approach is a demonstrated method to improve engagement, satisfaction, and usability with each iteration. Children find Foodbot Factory to be fun and easy to use, and can engage children in learning about nutrition.

Constructing a Multidisciplinary Network That Relies on Disruptive Technologies to Design, Test, and Implement Simulation Training

MaxSIMhealth is a multidisciplinary network of manufacturing, design, and simulation labs at Ontario Tech University combining expertise in health sciences, business and information technology (IT), and engineering while building community partnerships to advance simulation training. It discovers existing simulation gaps, provides innovative solutions that change systems, and leads to improved healthcare outcomes. Specifically, it utilizes disruptive technologies, including 3D printing, gaming, and extended reality, as innovative solutions that deliver cost-effective, portable, and realistic simulation, which is currently lacking. MaxSIMhealth is a novel collaborative innovation with aims to develop future cohorts of scholars with strong competencies ranging from technology application, to collaborating in new environments, communicating professionally, and problem-solving. Its work will transform current health professional education landscapes by providing novel, flexible, and inexpensive simulation environments. This editorial aims to showcase maxSIMhealth's innovative strategy focusing on collaborations of expertise in order to develop new simulation solutions that advance the health industry.

A low-fidelity serious game for medical-based cultural competence education

Research has shown that the quality of care is compromised when healthcare providers respond inappropriately to patient language and cultural factors. However, research indicates that medical education is not keeping pace with the changing composition of the patient population in culturally diverse societies such as Canada and the United States, and many healthcare providers do not possess the attitudes or skills required to be effective within a culturally diverse healthcare setting. Here, we present Fydlyty, a web-based, low-fidelity serious game for medical-based cultural competence education. Fydlyty includes both a scenario and dialogue editor providing the ability to develop conversations, interpret responses, and respond to questions/answers from the game player. These responses are based on predefined cultural characteristics of the virtual patient and on different moods that the virtual patient may express depending on the situation. The results of a usability experiment conducted with medical professionals and trainees revealed that the game is easy to use, intuitive, and engaging.

Hand VR Exergame for Occupational Health Care

The widespread use and ubiquity of mobile computing technologies such as smartphones, tablets, laptops and portable gaming consoles has led to an increase in musculoskeletal disorders due to overuse, bad posture, repetitive movements, fixed postures and physical de-conditioning caused by low muscular demands while using (and over-using) these devices. In this paper we present the development of a hand motion-based virtual reality-based exergame for occupational health purposes that allows the user to perform simple exercises using a cost-effective non-invasive motion capture device to help overcome and prevent some of the muskoloskeletal problems associated with the over-use of keyboards and mobile devices.

The Role of Game Elements in Online Learning within Health Professions Education

Given the highly competitive and motivating nature of today's students, gamification, when properly implemented, can be an effective learning tool. Here we studied which gamification (gaming) elements that medical students would be interested in having when using an online learning system to acquire clinical skills. Focus groups sessions were held with medical students, game developers, and game designers to develop an understanding about their perception and preferences regarding gamification. Overall it was determined that gamification will lead to increased engagement and motivation and should include both competitive and social elements.

Improving the Acquisition of Basic Technical Surgical Skills with VR-Based Simulation Coupled with Computer-Based Video Instruction

Next to practice, feedback is the most important variable in skill acquisition. Feedback can vary in content and the way that it is used for delivery. Health professions education research has extensively examined the different effects provided by the different feedback methodologies. In this paper we compared two different types of knowledge of performance (KP) feedback. The first type was video-based KP feedback while the second type consisted of computer generated KP feedback. Results of this study showed that computer generated performance feedback is more effective than video based performance feedback. The combination of the two feedback methodologies provides trainees with a better understanding.

The effect of contextual sound cues on visual fidelity perception

Previous work has shown that sound can affect the perception of visual fidelity. Here we build upon this previous work by examining the effect of contextual sound cues (i.e., sounds that are related to the visuals) on visual fidelity perception. Results suggest that contextual sound cues do influence visual fidelity perception and, more specifically, our perception of visual fidelity increases with contextual sound cues. These results have implications for designers of multimodal virtual worlds and serious games that, with the appropriate use of contextual sounds, can reduce visual rendering requirements without a corresponding decrease in the perception of visual fidelity.

The impact of secondary-task type on the sensitivity of reaction-time based measurement of cognitive load for novices learning surgical skills using simulation

Interest in the measurement of cognitive load (CL) in simulation-based education has grown in recent years. In this paper we present two pilot experiments comparing the sensitivity of two reaction time based secondary task measures of CL. The results suggest that simple reaction time measures are sensitive enough to detect changes in CL experienced by novice learners in the initial stages of simulation-based surgical skills training.

The effect of sound on visual fidelity perception in stereoscopic 3-D

Visual and auditory cues are important facilitators of user engagement in virtual environments and video games. Prior research supports the notion that our perception of visual fidelity (quality) is influenced by auditory stimuli. Understanding exactly how our perception of visual fidelity changes in the presence of multimodal stimuli can potentially impact the design of virtual environments, thus creating more engaging virtual worlds and scenarios. Stereoscopic 3-D display technology provides the users with additional visual information (depth into and out of the screen plane). There have been relatively few studies that have investigated the impact that auditory stimuli have on our perception of visual fidelity in the presence of stereoscopic 3-D. Building on previous work, we examine the effect of auditory stimuli on our perception of visual fidelity within a stereoscopic 3-D environment.

Z-DOC: a serious game for Z-plasty procedure training

We present Z-DOC, a (prototype) serious game for training plastic surgery residents the steps comprising the Z-plasty surgical procedure. Z-DOC employs touch-based interactions and promotes competition amongst multiple players/users thus promote engagement and motivation. It is hypothesized that by learning the Z-plasty procedure in an interactive, engaging, and fun gaming environment, trainees will have a much better understanding of the procedure than by traditional learning modalities.

Perceptions of the roles of social networking in simulation augmented medical education and training

Simulation-augmented education and training (SAET) is an expensive educational tool that may be facilitated through social networking technologies or Computer Supported Collaborative Learning (CSCL). This study examined the perceptions of medical undergraduates participating in SAET for knot tying skills to identify perceptions and barriers to implementation of social networking technologies within a broader medical education curriculum. The majority of participants (89%) found CSCL aided their learning of the technical skill and identified privacy and accessibility as major barriers to the tools implementation.

Web-based Learning and Computer Supported Collaborative Learning for psychomotor skill acquisition: perspectives of medical undergraduate students

There is a lack of evidence for the use of Web-based Learning (WBL) and Computer Supported Collaborative Learning (CSCL) for acquiring psychomotor skills in medical education. In this study, we surveyed medical undergraduate students attending a simulation based training session for central line insertion on their perspectives and utilization of WBL and CSCL for acquisition of a complex psychomotor skill.

The use of web-based learning for simulation-based education and training of central venous catheterization in novice learners

Both simulation-based education and training (SBET) and Web-based Learning (WBL) are increasingly used in medical education. We developed a Web-based learning course on "Observational Practice and Educational Networking" (OPEN), to augment SBET for central venous catheterization (CVC), a complex clinical skill, for novice learners. This pilot study aimed to firstly, understand the perspectives of novice learners on using WBL in preparation for SBET for a psychomotor skill and secondly, to observe how learners use the OPEN courseware to learn more about how to perform this skill.

The relative contributions of radial and laminar optic flow to the perception of linear self-motion

When illusory self-motion is induced in a stationary observer by optic flow, the perceived distance traveled is generally overestimated relative to the distance of a remembered target (Redlick, Harris, & Jenkin, 2001): subjects feel they have gone further than the simulated distance and indicate that they have arrived at a target's previously seen location too early. In this article we assess how the radial and laminar components of translational optic flow contribute to the perceived distance traveled. Subjects monocularly viewed a target presented in a virtual hallway wallpapered with stripes that periodically changed color to prevent tracking. The target was then extinguished and the visible area of the hallway shrunk to an oval region 40° (h) × 24° (v). Subjects either continued to look centrally or shifted their gaze eccentrically, thus varying the relative amounts of radial and laminar flow visible. They were then presented with visual motion compatible with moving down the hallway toward the target and pressed a button when they perceived that they had reached the target's remembered position. Data were modeled by the output of a leaky spatial integrator (Lappe, Jenkin, & Harris, 2007). The sensory gain varied systematically with viewing eccentricity while the leak constant was independent of viewing eccentricity. Results were modeled as the linear sum of separate mechanisms sensitive to radial and laminar optic flow. Results are compatible with independent channels for processing the radial and laminar flow components of optic flow that add linearly to produce large but predictable errors in perceived distance traveled.

The role of collaborative interactivity in the observational practice of clinical skills

CONTEXT

  Video-based observational practice can extend simulation-based learning outside the training space. This study explores the value of collaborative feedback provided during observational practice to the acquisition of clinical skills.

METHODS

  Nursing students viewed a video demonstrating the proper ventrogluteal injection technique before performing a videotaped pre-test trial on a simulator. They were then assigned randomly to one of three observational practice groups: a group that observed the expert demonstration (EO group); a group that viewed the expert demonstration, self-assessed their individual pre-test and contrasted their self-assessments with expert feedback (ESO group), and a group that observed the expert demonstration, self-assessed and contrasted their assessments with those of an expert, and formed a community that engaged in peer-to-peer feedback (ESPO group). The observation of all videos, the provision of assessments and all networking occurred via an Internet-mediated network. After 2 weeks, participants returned for post-tests and transfer tests.

RESULTS

  The pre-test-post-test analyses revealed significant interactions (global rating scale: F((2,22)) =4.00 [p =0.033]; checklist: F((2,22)) =4.31 [p =0.026]), which indicated that post-test performance in the ESPO group was significantly better than pre-test performance. The transfer analyses revealed main effects for both the global rating scale (F((2,23)) =6.73; p =0.005) and validated checklist (F((2,23)) =7.04; p =0.004) measures. Participants in the ESPO group performed better on the transfer test than those in the EO group.

CONCLUSIONS

  The results suggest that video-based observational practice can be effective in extending simulation-based learning, but its effectiveness is mediated by the amount of time the learner spends engaged in the practice and the type of learning activities the learner performs in the observational practice environment. We speculate that increasing collaborative interactivity supports observational learning by increasing the extent to which the educational environment can accommodate learners' specific needs.

Evaluation of tensiometric assessment as a measure of skill degradation

This pilot study explored the use of tensiometry as a measure of retention of knot tying skills. Medical students learned a one-handed square knot tying technique. Their final performances were video recorded and these videos were uploaded on to a website. Students were divided into two groups: an observational learning group that had access to videos before a retention test, and a control group that did not. After a two-week retention period, all students came back and performed one more trial to test the amount of retention of the skill. Tensiometry was used to measure strengths of the knots before and after the retention period. The scores showed no significant difference between the groups (p&gt;0.308) or tests (p&gt;0.737). We interpret the results to suggest that tensiometry is not sensitive enough to detect degradation in the performance of fundamental clinical skills as they are forgotten after being taught.

An online practice and educational networking system for technical skills: learning experience in expert facilitated vs. independent learning communities

This study explored the activities of trainees learning technical skills using an educational networking tool with and without expert facilitation. Medical students (participants) were video-recorded practicing suturing and knot tying techniques and the resulting videos were uploaded to an educational networking site. Participants were then divided into two groups (one group containing an expert facilitator while the other group did not) and encouraged to comment on the videos within their group. We monitored the number of logins and comments posted and all participants completed an exit survey. There were no differences between the activities the two groups (p = 0.387). We conclude that the presence of an expert within collaborative Internet environments in not necessary to promote interactivity amongst the learners.

Developing effective serious games: the effect of background sound on visual fidelity perception with varying texture resolution

Despite the benefits associated with virtual learning environments and serious games, there are open, fundamental issues regarding simulation fidelity and multi-modal cue interaction and their effect on immersion, transfer of knowledge, and retention. Here we describe the results of a study that examined the effect of ambient (background) sound on the perception of visual fidelity (defined with respect to texture resolution). Results suggest that the perception of visual fidelity is dependent on ambient sound and more specifically, white noise can have detrimental effects on our perception of high quality visuals. The results of this study will guide future studies that will ultimately aid in developing an understanding of the role that fidelity, and multi-modal interactions play with respect to knowledge transfer and retention for users of virtual simulations and serious games.

Serious games in the classroom: gauging student perceptions

Serious games, or video game-based technology applied to training, learning applications, provide a high fidelity simulation of particular environments and situations that focus on high level skills that are required in the field. Given the popularity of video games, particularly with today's generation of learners, and the growing trend of restricted resident work hours and diminished operating room exposure due to limited budgets increased case complexity and medicolegal concerns, serious games provide a cost-effective viable training option. To develop effective serious games, the views and perceptions of both the end users (learners) and educators regarding their use "in the classroom" must be assessed and accounted for. Here we present the results of a survey that was designed to assess students' perceptions of serious games.

A serious game for off-pump coronary artery bypass surgery procedure training

We have begun development of an interactive, multi-player serious game for the purpose of training cardiac surgeons, fellows, and residents the series of steps comprising the Off-Pump Coronary Artery Bypass grafting (OPCAB) surgical procedure. It is hypothesized that by learning the OPCAB procedure in a "first-person-shooter gaming environment", trainees will have a much better understanding of the procedure than by traditional learning modalities. The serious game will allow for simulation parameters related to levels of fidelity to be easily adjusted so that the effect of fidelity on knowledge transfer can be examined.

Sonification of range information for 3-D space perception

We present a device that allows three-dimensional (3-D) space perception by sonification of range information obtained via a point laser range sensor. The laser range sensor is worn by a blindfolded user, who scans space by pointing the laser beam in different directions. The resulting stream of range measurements is then converted to an auditory signal whose frequency or amplitude varies with the range. Our device differs from existing navigation aids for the visually impaired. Such devices use sonar ranging whose primary purpose is to detect obstacles for navigation, a task to which sonar is well suited due to its wide beam width. In contrast, the purpose of our device is to allow users to perceive the details of 3-D space that surrounds them, a task to which sonar is ill suited, due to artifacts generated by multiple reflections and due to its limited range. Preliminary trials demonstrate that the user is able to easily and accurately detect corners and depth discontinuities and to perceive the size of the surrounding space.