Abstract
BACKGROUND:
The in-depth understanding of human anatomy is the foundation for safety in nursing practice. Augmented reality is an emerging technology that can be used for integrative learning in nursing education.
OBJECTIVE:
The study aimed to develop a human anatomy-based skill training system and pilot test its usability and feasibility.
METHODS:
Twenty-seven nursing students participated in 3D anatomy-based skill training for intramuscular injection and Levin tube feeding using HoloLens 2. Various user interfaces including pictures, videos, animation graphics, and annotation boxes assisted users with a comprehensive understanding of the step-by-step procedures for these techniques. A one-group pre-post test was conducted to observe changes in skill performance competency, usability, and learning satisfaction.
RESULTS:
After study participation, a statistically significant improvement in skill performance competency (
CONCLUSION:
The 3D anatomy-based nursing skill training demonstrated good potential to improve learning outcomes and facilitate engagement in self-directed practice. This can be integrated into undergraduate nursing education as an assistant teaching tool, contributing to the combination of knowledge and practice.
Introduction
For human anatomy, which is a prerequisite subject in nursing, a sound knowledge of body structure and functions is vital to become a successful healthcare practitioner after graduation [1]. In particular, nursing students undergo numerous examinations to discern whether they have adequate knowledge of nursing practices. For the discipline of human anatomy, a clear visualization of the spatial relationship between surrounding structures is essential [2]. Traditionally, the educational experience for learning anatomy was mostly through the use of cadavers. Existing barriers to this method are high teaching costs, spatial restrictions, low interest levels, and concern that cadaveric dissection cannot be widely incorporated into nursing education [3].
Schools have tried to replace cadaveric dissection and augmented reality (AR) has recently proven its potential. AR may be defined as “the concept of digitally superimposing virtual objectives onto physical objects in real space so individuals can interact with both at the same time” [4]. The findings of previous research have proved the benefits of three-dimensional (3D) visualization of human anatomy [5, 6, 7]. While the wide range of anatomy atlases and textbooks endeavors to provide anatomical illustrations, findings reinforce the value of 3D dynamics of the anatomical structure of the human body [8, 9, 10]. A prior empirical study revealed that AR in anatomical education allows a more extensive interactive learning experience than that of conventional education [11].
3D human anatomy augmentation for nursing education
Diverse efforts are taken to provide optimal anatomical views during nursing training [12]. However, by using low-fidelity mannequins, only human-like physiological representation can be offered and students are unable to capture a clear comprehension of anatomical structure [13]. The use of immersive technologies, such as the application of AR technology in anatomy pedagogy, has been particularly recommended in healthcare education [14, 15]. When provided with extensive visual anatomy information via superimposed 3D graphics, learners can conduct harmless practice, experiencing improved engagement in learning [16]. With recent advancements in AR technology, more sophisticated and detailed anatomical structure configurations can be constructed [17].
Visualization of the internal human body [18] through AR technology allows for the integration of anatomical mechanisms in a clinically relevant context and improves the understanding of individual nursing practices. AR technology can also deliver diverse assistive audiovisual information including text, pictures, video clips, and animation graphics [19]. In addition, previous studies have revealed that technology increases independency, improving an individual’s responsibility for their learning [20].
The study aimed to develop a human anatomy-based skill training system and pilot test its usability and feasibility. To our knowledge, this is the first attempt at 3D AR anatomy educational content for nursing skill training using HoloLens 2. A clear understanding of its potential benefits would lead to active development and application in education. By overlaying mannequins with 3D anatomy, students experienced enriched interaction with digital 3D anatomy and experienced hands-on practice.
Materials and methods
Sample and setting
A total of 29 participants were recruited and 27 completed both pre- and post-testing. The inclusion criteria were: 1) nursing students, 2) previous experience of learning nursing skills, 3) understanding of the study purpose and procedures, and 4) the ability to operate a HoloLens device.
Ethical considerations
In accordance with the Declaration of Helsinki, the study was conducted with written consent from all study participants. Ethical approval was obtained from Mokpo National University in Korea (MNUIRB-220325-SB-001-01).
Participants
Using convenience sampling, nursing students were invited to experience a smart glass-based skill training program and evaluate its usability. All students experienced the training program.
The inclusion criteria were: 1) undergraduate nursing students with previous experience of nursing skill education within their curriculum, 2) the ability to use smart glass, and 3) an understanding of AR technology with minimum proficiency required to operate the system.
Development of a 3D human anatomy-based skill training system
Augmented reality-based nursing skill training was developed which focused on enabling nurse-simulator interaction for improving skills in a realistic manner. The training included 3D models to provide a comprehensive configuration of human anatomy including muscles, nerves, vessels, and bones that are required to provide safe nursing practice. The visualization contents and user interface were constructed using VIRNECT Make [21] and was demonstrated via VIRNECT View [22].
The 3D human anatomy images were adopted from the Unity asset store. These 3D models were of good quality and suitable for the experimental purposes, in consideration of the computational performance of the AR mobile device (HoloLens 2) and its storage capacity. The user interaction for training purposes was also considered by reducing the 3D model file size and separating each part so that the users could interact with individual parts.
Microsoft HoloLens 2 has suitable features for an AR-based training system, which include see-through holographic lenses (waveguides) and a 2k resolution display. For head and hand tracking, it has four-visible light cameras, two-IR cameras, 1 ToF depth sensor, an IMU sensor, and a 1080p video camera. Therefore, it is possible to use hand-tracking, eye-tracking, and voice recognition. In addition, the virtual pad raised the propriety of the study as a previous study that used Vuzix [23] as an AR-supported image guide revealed that the use of a touchpad was perceived as inadequate due to the importance of keeping an aseptic technique.
The Mixed Reality Toolkit (MRTK) was applied with unity3D for developing the applications. MRTK is a Microsoft-drive open source project to accelerate cross-platform mixed reality development in Unity. It provides the cross-platform input system and building blocks for spatial interactions and the user interface. It supports developers with various features for implementing high-level augmented reality applications.
Implementation
When a user wearing HoloLens 2 runs the study application, the user sees two available 2D menus at eye level. As the user chooses one of the menus, the HoloLens 2 shows 3D anatomy models in the space where the user is. At the beginning of the individual process, 3D human anatomy models are visible, enabling the participants to observe bones, muscles, blood vessels, and nerves. To examine the model more closely, the skin and muscles can be peeled off in order. Depending on the visual angle, the movement of blood vessels and nerves can be seen.
Where necessary, the following items were added: 1) related landmarks were displayed using graphical indicators (e.g. arrows, lines, and circles with text), 2) video clips were placed where movement required demonstrating (e.g. opening the L-tube cap) and was located at the right side of the 3D anatomy model, 3) at the same location as the video clips, additional visual aids were provided (e.g. a chest X-ray), and 4) to the left of the 3D anatomy, 3D annotation boxes were placed for the textual description of individual procedures. Within the description box, icons were placed to move to the before and next procedures (Fig. 1).
Procedure
A 3D human augmentation-based nursing training system was used as a tool to promote self-directed learning. Beside the mannequins, HoloLens 2 and a big screen monitor (mirroring view) were placed so that students were able to freely access and view the human anatomy and knowledge related to each nursing skill. A one-group pre-post test was conducted to evaluate usability and feasibility. A 3-hour training program on two different nursing skills was designed, as shown in Table 1.
The 3D human augmentation-based nursing training system
The 3D human augmentation-based nursing training system
Screen capture of the UI of the current training system.
Grouping three to four students at a time, two students shared one device for 3D human anatomy augmentation-based training. After running one hour of open lab training, self-directed learning was supervised by research assistants with experience in teaching nursing skills.
Usability test
After completion of the training program, the participants completed a 16-item usability survey with regard to the ease of use (8 items), usefulness (5 items), and intention to use (3 items). Using a 10-point Likert scale, usability was scored from 1 (not at all) to 10 (very much). The survey was developed by Kim et al. and the items were modified to fit the purpose of the study.
Learning satisfaction
As developed by Ji and Chung [24], the level of learning satisfaction was assessed using seven items that were modified according to the purpose of the study. A 10-point Likert scale was used ranging from 1 (not at all) to 10 (very much), where a higher score indicates greater learning satisfaction, with a maximum score of 70.
Competency
The level of competency was assessed using a VAS scale ranging from 1 (not at all) to 10 (very much), where a higher score indicated a greater level of skill competency performance.
User feedback
Eight open-ended essay questionnaires were used to obtain qualitative feedback on the user experiences and included: 1) the overall experience, 2) the ease of operation and need for additional information, 3) any confusion during use, 4) difficulties in device operation, 5) usefulness for future practice, 6) usefulness of 3D augmented human anatomy, 7) requirements for repetitive use, and 8) other improvement requests.
Statistical analysis
Statistical analysis was conducted using SPSS version 27 to calculate the mean
Results
Quantitative findings
The characteristics of the study participants are presented in Table 2. Female students comprised 81.5% of the total subjects. About half of the study participants (51.9%) reported a high level of learning satisfaction. The majority of the participants (88.9%) reported a moderate level of competency in nursing performance and only 14.8% had previous experience in AR or smart glass.
Demographic characteristics of the study participants (
27)
Demographic characteristics of the study participants (
Regarding the self-reported usability of 3D anatomy-based nursing skill training, the highest score was obtained for the item of perceived interest with 9.75
Results of the 16-item usability test (
The average learning satisfaction score was 9.55
Learning satisfaction scores (
A statistically significant improvement was achieved in both skills after intervention (
Changes in nursing skill competency after 3D anatomy-based skill training (
Regarding the overall experience, 92.9% of the participants responded positively and 46.4% reported that the current training program is exciting and interesting. In addition, 85.7% of the participants responded positively to their expectation of improved nursing skill performance due to its engaging (50.0%) and memorable (35.7%) learning methods. Only one out of five (21.4%) participants reported that the current system is easy to operate and 46.5% had difficulties, particularly with the virtual touchpad (42.8%) (Fig. 2).
Perceived difficulties and drawbacks of the current system.
Perceived benefits of the current system.
Recommendations requiring further improvement were on the following two points; content expansion (25.0%) and system improvement (32.1%). Participants wanted diverse content that they were able to choose in areas that needed further practice as part of self-directed learning. The participants also placed value on the system (32.1%) being more intuitive and definite in manner, with clear resolution and simple operation. Eight out of ten participants (82%) reported that they benefited from using the current learning system. Appreciation was mostly towards visualization of human anatomy (67.8%) (Fig. 3).
The current study aimed to develop and pilot test a 3D anatomy-based nursing skill training system using HoloLens 2. Diverse user interfaces were used to ensure the learning engagement and interest of nursing students. At the completion of training, the study participants showed improvement in their nursing performance competency and found substantial levels of usability and learning satisfaction with the training program. The study results suggest that AR technology has the potential to become well-integrated into nursing education.
In accordance with prior investigations on the use of immersive technology in healthcare education [25, 26, 27], the findings of the current study demonstrated successful learning using AR technology. The results of the current study showed a statistically significant improvement in nursing skill competency. Interestingly, there was greater improvement in L-tube feeding when compared with intramuscular injection, which had much lower pre-test scores. This result was similar to previous studies [28, 29] which showed that along with the opportunity for repeated use, the system enabled an enriched user experience through various user interfaces with differing audiovisual content. In addition, self-directed practice may assure students’ performance competency, even for nursing skills that are unfamiliar and complex.
In terms of overall usability, the study findings support a favorable student learning experience in 3D anatomy-based nursing skill training. HoloLens 2 offered visual guidance, presenting 3D human anatomy and associated information in such a way that the study participants reported an “impressive experience with high engagement in learning”. The students mostly appreciated the visualization of human anatomy in a 3D manner. In addition, this method of learning was perceived as “interesting” and “exciting”, which are known to be key factors for engagement in learning. This study revealed the good potential of 3D anatomy-based skill training for both anatomical and nursing pedagogy.
Unexpectedly, the scores for satisfaction were relatively and slightly low, indicating a preference for lecturer-led training. Previous studies identified the strengthened effectiveness of educational training when blended with educator-led learning to some degree [30, 31]. For the participants without sufficient background knowledge and experience, the effects of self-directed learning are limited, as they are likely refrained [31, 32]. At the undergraduate level, self-directed learning has some limitations, thus strategies for the right amount of lecturer involvement seem to be a critical factor for educational effectiveness.
The study findings revealed that the scores for ease of use, particularly convenience, were lower than other indicators of usefulness and the intention to use in the usability assessment. Some users responded that there were issues with the operating system because they had trouble with the virtual touchpad. This result could be related to those of a previous review which raised the issue of hardware problems with HoloLens 2. This is in line with previous studies that reported on the drawbacks of the user interface of HoloLens 2, which required improved accuracy for its manipulations. When compared to the UI of VR, the user feedback involves relatively higher levels of tiredness [33]. The lack of intuitiveness with respect to grasping the virtual pad has also been a concern [34, 35, 36], and a more sophisticatedly designed UI would improve user adaptation. Thus, revision is needed according to the user feedback.
Further concerns were in regard to the relatively low satisfactory scores on resolution. These were the same concerns addressed in other studies about the inability to find optical see-through materials to overlay the 3D graphics on top of the mannequin [33, 37]. Although efforts were made to adjust the fine optical visualization of the 3D anatomy, a number of participants reported the inadequacy of the level of transparency, which requires more vivid graphics. Apart from the degree of transparency, various factors seem to be involved. As the experiment proceeded, several strategies were added in order to reduce the effects of the background environment. Future revision to find the best resolution and spatial setting would foster its active application in education.
Previous studies have reported that the insufficient accuracy of AR technology for high-precision manual tasks confines its applicability to highly detailed and complex medical training [38, 39, 40]. It often generates unintended bias, interrupting the vision of the internal organ structure of the human body. These issues could also be related to the lack of clear standards and guidelines for the construction of 3D structures for healthcare use [38, 41]. The 3D models are supplied by graphic designers who are not medically oriented (e.g. the UNITY asset store), which makes optimization difficult. A projector-based augmentation of human anatomy might be simpler and a more physically comfortable application for skill practice [42, 43].
This study has several limitations. Firstly, the students were volunteers who may be more likely to be accepting in nature and have a greater preference for new technologies. This could have a positive impact on the usability and satisfaction scores, therefore, caution is required when interpreting the study results. Furthermore, by using a one-group pre-post test design and self-reported competency outcomes, the impact on improvement in nursing practice without actual performance evaluations is questionable. Suggestions for the future application of AR in nursing education should focus on practical applications and use a more robust study design in a randomized controlled trial. To fully understand the relationship between anatomy and skill practice, the ultimate goal for future development should consider a precise program that involves hands-on practice, not just viewing overlaid 3D images.
Conclusion
The application of HoloLens-based AR technology presents a new opportunity in nursing education. The current study evidenced the potential of augmentation technology as educational material, optimizing interest with comprehensive understanding by incorporating 3D anatomy and nursing skills. The current training system attempted to integrate 3D human anatomy learning and nursing skill practice by using advanced technology to foster student participation and engagement. The participants’ perceived benefits resulted in improved competency in skill performance with feedback that this program well assisted their learning process. Although several hardware and software limitations remain, efforts to sophisticate the technology may expand its application for diverse healthcare education as well as practice.
Footnotes
Acknowledgments
We express sincere gratitude to the study participants.
Conflict of interest
The authors declare that they have no conflict of interest.
Funding
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (No. NRF-2021R1I1A3044547), the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2022R1A5A8033794), and the Regional Customized Disaster-Safety R&D Program funded by the Ministry of Interior and Safety (MOIS, Korea) (No. 20012234).