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Online learning has taken a firm hold in several areas and levels of nursing education. However, there are educational elements that still seem to be strictly a campus-based opportunity, notably the use of high-fidelity human patient simulation (HFHPS). Commonplace in undergraduate nursing programs, “simulation replicates key aspects of a clinical situation to facilitate student learning . . . to promote critical thinking and self-efficacy” (Richardson, Goldsamt, Simmons, Gilmartin, & Jeffries, 2014, p. 309). Therefore, someway, somehow this learning strategy should become an equal opportunity for face-to-face and distance students alike.
A resolution to this problem aligns with a directive from the NLN Vision (2012) priority for research in nursing education to study “the use and cost-effectiveness of technologies (e.g., online, simulation, tele-health) to expand capacity in nursing education” (NLN Board, 2012, p. 3). As a fully online undergraduate nursing program with a direct tie to a brick and mortar campus and simulation lab, the missing component was telepresence. Thus, a mobile remote presence (MRP) would provide the link between distance students, distance faculty, and the campus simulation lab. An MRP is “characterized by a video conferencing system mounted on a mobile robotic base” (Kristoffersson, Coradeschi, & Loutfi, 2013, p. 1). Thus, the MRP allows the user (distant student) to move about in the robot’s environment, the campus simulation lab. As such, the MRP allows for flexibility, mobility and an engaging, immersive operator experience (Lewis, Drury, & Beltz, 2014).
Methods:
In order to begin this process, a simplistic mobile robot was identified as the optimal tool to “bring” the distance student into the simulated environment. The pilot user (distance student), embodied in the MRP, is allowed a full immersion experience to engage with local users; those “situated at the same physical location as the robot [who] . . . are free to move around while interacting with the pilot user” (Kristoffersson et al., 2013, p. 2). The chosen robot was selected for its cost, capability, and ease of use and care on both sides of the equation (use by distance students/faculty and care by the simulation lab staff). Simplistic in design, essentially a Segway type base and a mounted iPad, the robot was quite suitable to roam around the simulation center.
To prepare distance students for their high-acuity, fully online course, there was a desire to 1) observe and assess their clinical preparedness, 2) offer high-acuity simulation experiences, 3) offer simulated teaching on high-acuity patient care technologies, and 4) offer intensive care unit (ICU) field trips. Thus, the MRP offered a solution to this problem by providing the direct connection between the distance students, distance faculty, and the available resources at the campus based simulation lab.
The use of telepresence robots has increased in the medical arena to allow distanced physicians/providers to be placed at the point of need instantaneously (Grifantini, 2015). Thus, it was not much of a stretch to imagine telepresence robots bringing distance students to the point of learning, the simulation lab. Although, this process seems to run effectively and efficiently in the patient care setting, it was necessary to determine how well the MRP would be received by the local users. Likewise, it was imperative to determine centricity of presence from the distance student perspective. Both, endocentric presence, “a state of immersion (sensory-perceptual envelopment) and involvement (focus/attention/action) in the simulated situation” and exocentric presence, “a dominant state of being in and interacting with the natural environment where the meaning of the simulated environment is perceived strongly as artificial” (Dunnington, 2014, pp. 160-161) were assessed.
Results:
Both modes of presence were beneficial to learning. Endocentric presence occurred when the distance student, via MRP, was an active participant in a simulation “enacting the self as if in a role in the real patient care situation represented by the simulation” (Dunnington, 2014, p. 160). Likewise, exocentric presence became more of an observational experience. According to Kaplan, Abraham, and Gary (2012), “observational experiences during simulation may provide a valuable learning opportunity for undergraduate nursing students” (pp. 12-13).
Learning through observation via an exocentric presence deemed a meaningful opportunity and a request was made of the mobile robot manufacturer to create a means to have more than one student on the robot simultaneously. This request was granted through the use of a cost effective software subscription that allowed up to five participants on a robot at one time. As such, only one student had the opportunity to be the operator (pilot) while four others could “ride” along (co-pilots). The face of the pilot was visible on the iPad robot component although the voices of all co-pilots could be heard if and when they spoke amongst themselves or to others physically present in the simulation lab. Thus, this capability made it possible for the pilot to be present and participatory (endocentric presence) in a simulation while the co-pilots observed as immersed in the pilot’s perspective. As such, co-pilots enter into bicentricity “characterized by a salience of presence in which either endocentricity or exocentricity was dominant” (Dunnington, 2014, p. 162).
Components of a simulation experience also include access to the patient chart and information, orientation to a simulation area, conversation with other participating students, and debriefing. All of these elements were easily addressed for the distance student and distance faculty via email (patient chart), by operating the MRP, and by interacting with the simulation environment, local students, and co-pilots. In a study by Kelly, Hager, and Gallagher (2014), students ranked facilitated debriefing and post simulation reflection as the top two simulation components for applying clinical judgement while actual participation in the simulation was ranked fifth. Through the use of MRP, students are easily able to participate in the two highest ranked components of simulation. Based on feedback from pilots and co-pilots, presence and participation in a simulation was also ranked very high but this is likely due to the novelty of the situation and less of a sound reflection on the process of a simulated patient event.
Conclusion:
Through this pilot study, distance students were able to 1) participate in an actual simulation with campus based students, 2) take an ICU field trip, and 3) learn about ICU technologies through demonstration. Through these experiences there was an immense amount of learning, laughter, and pleasant surprises. Many learning needs were addressed and new ideas were conjured for future implementation of simulation for distance students via MRP. The interaction of the MRP with live simulation lab based students required the development of basic robot etiquette, or robotiquette. Likewise, dysfunctional aspects of the robot were identified as embodied health concerns to be addressed and minimized; these included transition ataxia, robotic internet attack, and virtual vertigo. Although this effort was directed towards the enhancement of distance learning, there was a great interest among local users to be given opportunities to “work with the robot.” Certainly, this dual perspective will be addressed going forward.
As the integration of the MRP into land-based simulation evolves, a shift continues in the way distance faculty and distance students are perceived by others and themselves. More importantly, the array of learning opportunities available for the distance nursing student via MRP are only limited by creativity and a willingness to implement change.