Keywords

1 Background

Nursing practice at hospitals by nursing students is the most important opportunity to connect nursing theories and skills implementation for nursing students in nursing education [1]. However, as nursing work diversifies and becomes more complicated due to the highly developed modern medical care, changes in disease structure, increased age of patients, and reduction in average number of days of hospitalization, nursing students are experiencing the problem of being able to experience fewer nursing skills in nursing practice. According to a survey by the Japanese Nursing Association in 2002 [2], more than 70% of new nurses only identify the 4 items “bed making”, “linen changing”, “vital sign measurement”, and “height and weight measurement” out of 103 items as “skills they recognize they can perform alone when starting employment”, creating a situation where nurses are working who have not acquired sufficient nursing skills while studying at educational institutions. Due to the gap between the skills required by new nurses at the time of hiring and the skills learned at the time of graduation, unfortunately 9.7% of new nurses lose or leave their jobs within 1 year of starting employment [4]. For this reason, it can be said that the creation of a structure which allows nurses to acquire a certain level of nursing skills by graduation is a social need demanded to the field of nursing education.

In addition to nursing practice, nursing students also spend time engaging in in-school training to acquire the skills required as nurses. Normally, after acquiring knowledge in classes on nursing skills, nursing students undergo in-school training under the instruction of teachers to acquire nursing skills. One-on-one practice between students and teachers is the most effective learning method for nursing skills [5], but for example of the our university, instruction is conducted by 4 teachers for 60 students, making it difficult for all students to receive sufficient instruction due to a lack of teacher personnel resources. Furthermore, there is also a study showing that the amount of time a teacher spends directly instructing a student in in-school training is 9.4 min [6], resulting in difficulty for nursing students to acquire skills due to limited time resources as well.

In order to solve these various problems, our research team is continuously conducting research into the automation of nursing skill acquisition.

Nursing students aim to acquire nursing skills which they cannot sufficiently acquire in classes and training by repeating self-study outside of class hours, but there are many cases where repeated self-study only results in them acquiring skills incorrectly. This is because the nursing students execute actions based on their own judgment in self-study, and although they need to notice what is wrong with their actions and correct the problems, their ability to objectively perceive their own actions is insufficient, causing them to not notice what is wrong with their actions and believe they are correct [7]. In other words, in order to acquire nursing skills it is essential for there to be a third party who can objectively evaluate the actions of nursing students and provide feedback. However, the lack of human and time resources makes it impossible for teachers to evaluate the self-study of students. And so our research team, believing that an automated system which can appropriately evaluate and provide feedback on the nursing skills conducted by students could solve these problems, has been conducting research necessary for the construction of such a system.

First of all, we examined whether nursing students can acquire nursing skills not through teaching methods which provide feedback depending on the problem points and learning characteristics of students which are normally used by teachers to teach students to acquire nursing skills, but rather through simple feedback which does not indicate specific methods for improvement but simply whether or not the actions are correct. The results showed that nursing students can acquire nursing skills only with simple feedback indicated whether “correct” or “incorrect” and without indicated specific methods for improvement, and furthermore that simple feedback has even more effective learning results than self-study via audio-visual teaching materials and textbooks which have been traditionally utilized [8, 9]. This experiment suggested the possibility that the presence of teachers, which had previously been thought essential for acquiring nursing skills, can be replaced by an automated simple feedback system.

Next we developed a nursing skill evaluation system utilizing the KINECT sensor by Microsoft [10] (Fig. 1).

Fig. 1.
figure 1

Room used in experiment by KINECT.

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This system automatically evaluates the wheelchair transfer skill wherein a patient is transferred from a bed to a wheelchair by digitizing the movements of the nursing students using the KINECT sensor and provides feedback (Fig. 2) for each check item to the nursing students. This system is designed to enable students to use it alone without involvement by teachers or system engineers.

Fig. 2.
figure 2

Feedback screen of nursing skill evaluation system by KINECT.

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We conducted an experiment on 5 nursing students to evaluate the effectiveness of this system. In the experiment we had the students use the system for self-study after taking a test on wheelchair transfer skills before using the system. Lastly, we conducted a wheelchair transfer skill test again and had a teacher score the test. The results confirmed a statistically significant improvement in score after using the system compared to before using the system [11, 12] (Fig. 3).

Fig. 3.
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Score by self-learning system.

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This experiment proved that the automated self-study system was effective in acquiring nursing skills compared to traditional self-study conducted by nursing students alone. In other words, nursing students can learn correct nursing skills even without a teacher by conducting self-study of nursing skills using this system.

The care-recipients in the series of experiments were healthy persons with nursing qualifications and work experience. If the person playing the role of patient knows what actual patients are like they can behave “like patients”, but it is difficult for nursing students to behave “like patients”, because nursing students don’t know patient due to do not have experience of nursing practice at hospitals. Using the example of the wheelchair transfer, not only do the legs of patients with paralysis feel heavier than the legs of a healthy person, it is difficult for nurses to move them. Furthermore, when moving the arms of patients with joint pain in their arms, patients will intentionally restrict their arm movement to avoid the pain, so nurses must be more cautious when passively moving their arms. It is difficult for nursing students who have had little opportunity to actual interact with patients to reproduce these patient behaviors. It is difficult to say that nursing students playing the role of patients in training are reproducing the paralysis and pain of actual patients, and furthermore they may move the same as healthy persons due to feeling bad for the students playing the role of nurse and wanting to make it as easy as possible for them. The result is that training proceeds without students being able to truly learn the important points to know when assisting patients with pain and paralysis. It is difficult for nursing students to acquire nursing skills under these circumstances. In order to solve this issue it is necessary for nursing students to understand how paralysis and pain manifest in patients by actually interacting with them, but the nursing practice time, which is the only time when nursing students can interact with patients, is limited and it is difficult to increase the nursing practice time in the curriculum. In recent years there are vigorous efforts being made to train members of the public to be simulated patients (Simulated or Standardized Patients; hereinafter “SP”) able to realistically play the roles of patients considering their physical, mental, and social conditions not only for nursing education but also medical education. However, SP training is said to require about 4 months of time, and furthermore continuous training and support is essential for mastering SP, resulting in a situation where the number of SPs cannot be said to be keeping with the demand for SPs [13]. Therefore, this research team concluded that a robot patient which can reproduce the restricted movements of limbs caused by paralysis and pain caused by load on joints would be a solution for a variety of problems and developed a robot patient [14, 15]. We equipped the robot with functions to reproduce paralysis and express pain due to excessive load on joints.

In this research we conducted experiments for the purpose of clarifying the learning effectiveness of self-study by nursing students using the robot patient and the effect of more “patient-like” robot on the self-study of nursing students.

2 Purpose

The purpose of this research is to clarify the following 2 points.

  1. (1)

    Clarify the effectiveness of self-study by nursing students by using our robot patient.

  2. (2)

    Clarify the effect of more “patient-like” robot patient on the self-study of nursing students.

3 Methods

We conducted an experiment according to the following procedures targeting 12 nursing students (9 3rd-year students and 3 4th-year students) at a nursing university.

  1. (1)

    View a wheelchair transfer instructional video created by nursing teachers.

  2. (2)

    Conduct self-study of wheelchair transfer 6 times using the robot patient.

  3. (3)

    Conduct questionnaire survey regarding self-study using the robot patient. The questionnaire asked the students’ impressions regarding the robot, points of improvement, etc., in a free description format.

In (2) above we graded the students’ skills using a wheelchair transfer scoring checklist drafted in advance by nursing teachers.

Below is a summary of the specifications of the robot patient developed in this research.

160 cm height, 40 kg weight. A motor is installed into the shoulder and elbow joints of both upper limbs, and a thermo-brake is installed in both knee joints. Triggered by the vocal greeting of the nurse, the motor and thermo-brake can be respectively controlled and can reproduce the paralysis of the upper and lower limbs and express pain via audio (Fig. 4).

Fig. 4.
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Scene of experiment

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This research was conducted after an ethical review by the Tokyo Ariake University of Medical and Health Sciences (No. 138-2, approved July 26, 2016).

4 Results

The score transition of self-study using the robot patient is shown in the following table (Table 1). The highest score was 23, the lowest score was 7. The most difference between the highest score and the lowest score was 14.

Table 1. Scores of the subjects
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In the free description of the questionnaire survey, the following kinds of answers were received.

“When students are playing the role of patients they provide unnecessary assistance to avoid burdening the person playing the role of nurse with their body weight, but the robot does not, making it feel likely an actual patient.”

“I think the robot was good because the body weight was heavy.”

“The robot was too heavy for me to lift. Are actual patients this heavy?”

“With other students it feels like practicing with friends, but a robot doesn’t feel like a friend so I was nervous.”

“The robot seemed heavy, which made me worried about whether I can transfer actual patients who are heavier than the robot when I start nursing practice.”

“It is hard to practice again and again when a friend is playing the role of patient, but with a robot I can.”

“I was rude, because the robot felt strongly like “a thing” rather than a human.”

“It felt like I was practicing with an actual patient.”

“The robot is paralyzed and can’t move, so it felt more like a patient.”

5 Discussion

Because the score clearly rises, showing that the robot patient is effective for self-studying wheelchair transfer. These results are the same as the results of the other experiments regarding nursing skills conducted by this research team in the past, and further support the usefulness of automated nursing skill acquisition systems for self-study. However, in our previous experiments we used systems which partially reproduced the symptoms and conditions of patients, but did not reproduce the entire body of a patient. Therefore, it was useful to focus on only a certain nursing skill and master it. However, nursing students do not care part of the patient’s body in nursing practice at hospitals. Nursing students care for the whole-patient approach. So, It is important that the robot patient must reproduce the whole, not a part. Nursing education simulators currently on sale in Japan are also simulators which reproduce only parts of patients to specialize in subjects of study, while in this research we were able to confirm the effectiveness of robot patient which reproduce the entire body of a patient.

Also, by conducting self-study using robots which reproduce the entire human body of patients, students who had never interacted with patients were able to be cognizant of patients closer to reality. It was clarified in our questionnaire survey that the students felt the weight of patients, the difficulty of assisting the limbs of patients with paralysis and pain, the difficulty of keeping the patients safe, etc. Until then, nursing students were practicing between students, but nursing students were making new discoveries about patients. It shows the difficulty of nursing students playing the role of patients.

Furthermore, it was suggested that it is impossible to acquire nursing skills provided to actual patients with patients played by nursing students.

This research confirms that students can acquire wheelchair transfer skills via self-study using the robot patient and suggests that several problems inherent to self-study for acquiring nursing skills conducted with fellow students can be solved by using the robot patient.

6 Conclusion

It was clarified that nursing students can acquire wheelchair transfer skills through self-study using the robot patient. By studying with the robot patient that reproduces the entire body of a patient, students felt the difficulty of providing care caused by patients’ body weight, paralysis, and pain.