Vital Views

Joe Gaccione 0:01
Greetings, and welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joe Gaccione, Communications Director for the School of Nursing. We created this podcast to help share tales from our hard working fantastic nurses out there, whether they're students, faculty, staff, alumni or donors. These stories focus on work on the front lines, in the classrooms, in the lab, wherever our nurses are making a difference. But we don't just talk about nursing, we dive into broader healthcare topics to bring attention to bigger issues that impact everybody. We also talk about ways to keep you, your family, and your community healthier both physically and mentally. From electronic charting to smart beds to mobile video conferencing robots and even stethoscope apps, the technology available to nurses these days has come a long way. Ideally, the digital age is supposed to make nursing easier and offset increased responsibilities and patient ratios. Truly, there are some impressive new ways to enhance patient care, but how do nurses balance that reliance on technology while never forgetting that interpersonal training? Here in the booth with me today is Dr. Rocky Rockstraw, Professor in Residence at UNLV Nursing. His expertise includes clinical simulation, which features extensive technological devices and skill sets. Specifically, he focuses on resource allocation for technology and how to apply it to nurse education and practice. His work in simulation stretches both nationally and internationally. Dr. Rockstraw, thanks for coming by.

Rocky Rockstraw 1:23
Thanks for inviting me, Joe.

Joe Gaccione 1:24
For those unaware, how do simulation centers, like the one here in Las Vegas, utilize technology to enhance a health student's education?

Rocky Rockstraw 1:31
Well, Joe, when I think about the technology in simulation, I think of it as the platform as you, you said. It's what we utilize to help the students to practice what they're learning. Number one, it provides a standardized experience. Actual patient-care patients change by the hour, what you're taking care of today may be very different tomorrow and the students don't have a standardized patient. Within simulation, whether you're dealing with five students or 500 students, with computerized scenarios or standardized patients they all have that same standardized experience. So, it's controlled by the instructor to help aid the student learning. It also, simulation, places, in a non-technical way, places healthcare equipment, supplies, furniture, and the simulated patients in one area in the novice's hand to be able to practice in a safe environment. When I talk about safe, it's clinically safe, as well as psychologically safe. Clinically, in that we're not caring for real patients. We're caring for computerized manikins or we're caring for trained actors, trained standardized patients, who will help guide that learning. So, it's clinically safe. It's psychologically safe because many times it's a practice environment where feedback is provided to the student and by them just showing up, it's a pass, it's not a, it's not a fail. But there are times, especially in our graduate students, where they're working with OSCEs and it can be psychologically unsafe because there's a potential for, for not passing the exam or not passing the course as well.

Joe Gaccione 2:54
Can you clarify what an OSCE is?

Rocky Rockstraw 2:55
So Joe, an OSCE is a structured clinical examination where students practice and actually measure how they would treat a patient clinically, introduction, diagnostic reasoning, interviewing skills, as well as physical assessment, and there are certain things that the faculty look for, for the student to be able to safely provide that assessment and exam and pass the, the actual OSCE.

Joe Gaccione 3:17
And you talked about those computerized manikins. Those manikins, by themselves, are incredibly sophisticated. There are low fidelity manikins and high fidelity manikins. Can you explain the difference between those two?

Rocky Rockstraw 3:29
Sure, let me start with the high fidelity. The high fidelity manikins pretty much does everything but get up and walk out of the bed. They, they can talk, they have breath sounds, lung sounds, bowel sounds, they have pulses. There's different procedures that you can do on them from IV therapy, central lines, chest tubes, intubation, things like that. And they're on the upwards to $80,000 to $100,000. Those are high fidelity. And a lot of times I think that the use of those are for our graduate students or nurse practitioners and physicians. Our low fidelity have breath sounds and lung sounds, but they don't have the ability to do a lot of those treatments like central lines and chest tubes and what have you. Some of them have pulses and you can start IVs on them and what have you, but they’re a lower technology and the cost is much less as well.

Joe Gaccione 4:15
And those manikins, even though they are computerized, students have told me, in previous interviews, that it can get emotional too. Students and faculty, I should say, that even though you're not actually failing, you're not failing by killing a patient in a, in a clinical simulation setting, you might quote unquote, “kill the manikin,” it can still produce an emotional response within the students.

Rocky Rockstraw 4:35
So, you bring up a good point, Joe. There are many people when we say high fidelity, we talk about the technology. I like to believe that when, and there are a few of us that believe that high fidelity is how real the situation feels. So sure, the room, the environment feels real, although it's a computerized patient, a computerized manikin, or what have you, it still gets pretty close to the real thing. So, when you are talking to the manikin and it's talking back to you or when you’re caring for it and potentially the manikin dies, it can, it can provoke real emotional responses and that's how close to reality we get with simulation.

Joe Gaccione 5:09
As an educator, what do you look for in technological tools to help teach? What are those attributes you're looking for, specifically? As an educator, you're looking for tools, technology that helps bring the students up to speed, the nursing students up to speed, what tools do you prefer as far as the most effective ways to teach? Are there certain characteristics or traits from a device, maybe a program that are better than others?

Rocky Rockstraw 5:33
Sure, if I could, I'd like to divide that into two areas: one specific to simulation and then one in general education, classroom and/or clinical as well. So, in simulation, the great thing that the technology offers is the ability to record and playback for the learner’s performance, their conversations, other healthcare professional actions, and patient interaction so that they can see that after the fact and be able to sit back down with the faculty and walk through it and process through that. So, it's really kind of playback of the 20 minute scenario that they just conducted. So, that technology allows them to kind of sit back and see themselves in action, in practice, what did they do well, and what can they do better next time? And a lot of that heavy lifting and work is done by the SIM staff and the technology so that the teacher as well as the student can just focus on the practicing of nursing care. As an educator, when I think about technology, I think about the interaction between students, that's student-to-student, student with teachers, and students with content, and what does that really mean? The more that you can engage the learner, whether it's in gaming devices, there's apps out there called Kahoot or Poll Everywhere, where it offers competition and you have the ability to answer questions and poll and see what people think, whether it's a general opinions or actually create on-the-spot quizzes so you can see what knowledge they have and if 75% of the class answers it wrong, you know to stop and reteach whatever that is. That technology helps to assess the knowledge level in that one point rather than waiting until the midterm or final exam. Creative styles of encouraging students with creativeness, such as Padlet or Flipgrid, which allows the students to use technology and create a storyboard that they're able to then submit as assignments and engaging them as well. There's apps, there's blogs, there's discussion boards, quizzes, technology contests that the different apps offer, digital whiteboards. They're all interactive online tools. And I guess, bottom line is whatever the technology you use is to encourage the student to learn, engage with each other and the faculty, engage with learning, and to be curious, and, I hope, to have fun in doing it.

Joe Gaccione 7:35
When you talk about Kahoot, it makes me think of gamification, it makes me think of virtual reality, that’s another concept that's become more common in nursing. Now, simulation already puts students in a real life scenario, so how does that differ from VR?

Rocky Rockstraw 7:48
So, virtual reality, in my mind, is a computerized generated environment. They have scenes and objects within that virtual reality visually appear to be real, allowing to be immersed in that virtual experience, but there is no touch and there is no tactile experience with that. So, when I think about student practice, best place, hospital, where you're dealing with real patients and real challenges and what have you. But until we can get there, simulation environments are great and allow us to, to have that practice experience in that safe environment. Simulation environments can be pretty expensive and not all schools of nursing have simulation environments. So, those rural areas or those areas that can't afford the simulations, I think VR is, is immersive, but not quite up there in that rather than touching a manikin in a simulation environment and feeling for a pulse or listening to some lung sounds or what have you, you're using your keyboard and your mouse to interact with those virtual experiences. Yes, you are, in some virtual experiences that you might have locally, you may be using your fingers and moving around, but you're not touching that finger-to-skin contact or that taking a stethoscope and placing it on the actual patient, as well. Not that that's bad, but it does offer a little bit less of that experience. Again, practicing in a skills lab, allowing the interaction of assessment and trial and error, VR does that, simulation does that, promotes basic clinical reasoning, that thought process assessment, “What do I think's going on? What would be my treatments? How's the patient responding to that?” Simulation in VR does allow that, as well, but again, it's that physical assessment part that is a difference between a sim environment and VR.

Joe Gaccione 9:27
And I feel like that tactile, the physical response, is so underrated because, and this is what makes a nurse a nurse, is that physical contact, that hand-to-hand touch or hand-to-shoulder, that almost like a sense of comfort that you can't simulate until you actually do it. And despite the advantages of VR, it sounds like that's still a critical piece that, while cost effective, might be too important to miss.

Rocky Rockstraw 9:49
I would agree with that. In the simulation environment, when you're dealing with a computerized manikin, although that you're touching plastic, you still can feel that pulse whether it's weak and thready or strong and bounding. When you’re working with standardized patients, you do have that touch of another human being. I can't alter a human being's pulse rate or what have you in the standardized patient, but it does offer that near-to-real experience in the simulation environment.

Joe Gaccione 10:13
Artificial Intelligence is an increasingly common tool in all fields, including nursing. Despite it not being that new, when I think of artificial intelligence, I'm gonna admit, I think of science fiction, I think of the Terminator, think of Skynet, but in reality, when it comes to nursing, it's more about the algorithms and machine learning that helps nurses make better decisions for patients. What are your thoughts on AI?

Rocky Rockstraw 10:34
When I think about AI, and as you kind of mentioned it, Google is a form of AI or an algorithm. Facebook, Waze, or maps for different things, Google Maps, Amazon uses types of AI to improve the visitor’s experience and what have you. You know, any machine that makes decisions is an AI, Artificial Intelligence. As I was preparing to come and talk with you here, I did a little homework on this, because I'm still excited about and learning a lot about AI. There's three areas of different types of AI. It's artificial narrow intelligence, artificial general intelligence, and artificial super intelligence. The ANI, or the Narrow Intelligence, is computers performing a single task. There's no IQ, the IQ of that is zero, they’re just performing one task. Artificial general intelligence are machine’s ability to learn and match and learn from their experience. That's kind of that futuristic, HAL-2000 is one example of that. That super intelligence that we're maybe moving towards, is the machine's ability to learn everything about the human race and passing that cognitive ability, like you mentioned in Terminator or The Matrix. I did, I just recently, about a month ago, started subscribing to a medical futurist, and I read an article by Dr. Mesco, the, he's the director of the Medical Futurist Institute, and I'll give you an example about AI and what it can do for us in healthcare. Looking at X-rays, you're looking at an x-ray film and a physician or a nurse would look at it and look for pneumonias, look for tumors, and different things as well. What a provider would look at over their lifetime, AI would be able to look at that information in maybe a morning, and what they're able to do, the AI, is able to collect data, match it, separate data, so that they could very quickly look at a film and identify abnormalities. It can combine previous images from that person's previous experience very quickly or the other person's individual and match them and give the provider that suggested, where to look, what to look for. Other areas that AI is, can be very helpful is mining EMRs or electronic medical records. Being able to very quickly look at the vital signs, look at the different lab values and what have you. AI is able to help design treatment plans, reviewing many treatment plans, and providing a specific plan for that patient with a specific lab values and film results and what have you. Other areas, potentially for growth in AI would be to create precision medicine, rather than one treatment fits all patients, AI would tailor this specific care targeted to the individual drug creation. Think about what we're just coming out of with COVID, with drug creation, drug approvals take sometimes 10 plus years for approval. AI could greatly reduce this time from months or even less than that and that would have really impacted us with COVID-19. Instead of waiting six to nine months, we may have had immunizations in weeks.

Joe Gaccione 13:23
Can you provide an example of that? Like how AI would actually reduce that time?

Rocky Rockstraw 13:27
Um, well, what it does is again, it collects that information, it looks at the efficacy, the safeness, the dosages for all persons and all ages and all health conditions and what it would take, again, for me to read over months and years our clinical trials, it would take some basic clinical trials, apply the computerized rationale and what have you, and come up with safe, we're not there yet, but, but we're heading towards that, to provide safe clinical outcomes for the different drugs, not just, “How does this drug affect the person who may be affected by a disease and/or a virus like this?” but also, “What is the ramifications, genetics that they may pass on to a family member during the birthing process?” or what have you. So, AI is not here to replace healthcare providers, some of us may believe that, but rather it's the 21st century of a stethoscope to help us in the assessment and diagnosis of patient care. But what we need to do is be ready for when AI gets here or when we start the approach and preparing by preparing regulations, a guidance that we all should follow at a local, state, national, and even a global level, as well as getting the education out there so we can understand what the possibilities are.

Joe Gaccione 14:36
Do you think that will change nurse education going forward, not just in simulation, but even just textbook lecture-based courses, that now you have to have a section about AI and more or less technology in general and how it's becoming more and more integrated?

Rocky Rockstraw 14:53
I would say it would add to the education of a healthcare provider whether it's nursing or physicians or physical therapists or nutritionists, but it's not going to take away from the basic foundation of who we are as nurses. Just like with technology, we added informatics to the nursing curriculum, we've added cultural awareness and individualism to the curriculum, I think the technology or the AI would be added to it and how we utilize that technology to enhance safe patient care, safe patient outcomes, so I think it would be added to it and like anything else, we all would need to learn and get comfortable with it, but I think it would be a definite plus.

Joe Gaccione 15:29
We know all the benefits, but to play devil's advocate, is there too much of a good thing? Earlier Ireferenced stethoscope apps, and based on what I was reading, it's literally just putting your phone onto a person's chest to listen for their, listen for their heartbeat instead of a regular stethoscope and the logic was, maybe for younger patients, it might be less intimidating than if you had a stethoscope. I'm just curious like, how do you replace a stethoscope with a phone? Can you trust the accuracy of it? I guess, going back to the original question, because I'm rambling, is there too much of a good thing?

Rocky Rockstraw 16:00
I'm gonna say no. Part of my history is critical care, trauma, ICU nurse. And we, in all acute stages, and even in some home, we utilize and rely on technology to monitor our patients. There's bedside heart monitors, there's pulse ox that take vital signs and what have you. I don't think there's too much technology in patient care. It promotes access to information, data collection, mining, and alerts and such. As I mentioned, in critical care, we have monitors that alerts us when there's significant changes, whether it's significant changes in the telemetry or the patient's heart rate, the rate it is or the rhythm that it is changes in the respiratory rate or pulse ox, technology alerts us to major lab value switches or changes or trends and the same thing with vital signs. So, that data mining, comparing Rocky from his admission, acute admission to healing process, versus this hospitalization with three previous hospitalizations, really provides me the information I need to understand how Rocky's doing at any given moment. Is he responding well to the treatment? Is he getting sicker? Is there something that I need to alert the doctor with immediately or is that something that might be able to wait for four to six hours? And that technology gathers that information alerts me where I may be with another patient or even with the same patient, but thinking down a different trail, and saying, “Rocky, I'm at a parameter that I think you need to stop what you're doing, and take a look at what's going on.” The nurse should not rely 100% on technology, but the richness of information that technology brought to me is immeasurable.

Joe Gaccione 17:31
Are there any innovations now, or innovations being researched, that you're most excited about when it comes to nursing technology?

Rocky Rockstraw 17:38
I'm going to say I enjoy and I struggle to keep current with technology, whether it's technology in the classroom with access to books and information, technology in the classroom for presenting in the classroom, how do I present? How do I record? How do I promote local versus distance attendance in the classrooms and what have you? Gaming, gamification, whether the students are using a Mac or PC base, a phone versus an iPad or a computer, just trying to keep current whether it's in the classroom or in simulation is, is more than a full time job. I do think we need to, as nurse educators attend conferences, be curious, see what's going out there, but we also need to slow down to say, “So what?” Is what we're doing, whether it's an education alone or education with technology, if it's making a difference, if it's promoting better student outcomes, if it's promoting safer patient care, then I'm all for it. But I think we do need to slow down a little bit and just because it has bells and whistles, do we add it or not? I think that there needs to definitely be some strong markers that say great outcomes for student learning and or patient care.

Joe Gaccione 18:50
Well, that is all I have. Dr. Rockstraw, thanks for stopping in. For everyone out there, thanks for listening, and I hope you have a great day.

Transcribed by https://otter.ai