Integration of Extended Reality and a High-delity Simulator in Team-based Simulations for Arrhythmia Scenarios Among Undergraduate Nursing Students

Objective: The purpose of this study was to evaluate the usability and feasibility of smart glasses for team-based simulations constructed using a high-delity simulator. Methods: Two scenarios of patients with arrhythmia were developed to establish the process for interprofessional interaction via smart-glass in 15 hour simulation training. Three to four participants made a team and took roles of either remote supporter and bad-side trainee with smart-glass. Usability, attitudes towards interprofessional health care team and learning satisfaction were assessed. A scale for software evaluation was used to obtain quantitative data and essay questionnaire were used to assess usability and feasibility of current program. Using SPSS (version 25.0), statistical analysis was conducted. Results: Data were obtained from 31 participants. The current program was given an easy to use (3.61±0.95) rating, and the users reported feeling condent during use (3.90±0.87). Participants responded positively to long-term use (3.26±0.89) and low levels of physical discomfort (1.96±1.06). The likability of the smart glasses-based simulation was high, with a high rating for satisfaction (4.65±0.55). The majority (84%) of subjects provided favorable responses to their overall experience with high expectations for improving safety in future clinical practice. Key barriers and challenges of the current program include unstable internet connection, poor resolution and display, and physical discomfort of the smart glasses with accessories. Conclusion: We determined the feasibility and acceptability of smart glasses for interprofessional interaction within a team-based simulation environment. Participants responded favorably toward a smart glasses-based simulation learning environment that would be applicable in clinical settings. in interprofessional interactions.


Introduction
Patients with arrhythmia are in critical condition, and nurses should be prepared for emergency [1]. In an emergency, health providers must have adequate skills to establish and share common knowledge to make informed decisions. Multiple health professionals would have numerous factors in priority; hence, training for optimal interprofessional interactions would ensure the best patient outcome by providing fast but accurate care in a cooperative manner [2]. Knowing the importance of such issues, organizations such as the American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology [3,4] have provided guidelines for optimal care. These guidelines are best used when patient data are well collected and analyzed comprehensively, enabling care teams to arrive at an optimal decision [5].
Findings from meta-analyses indicate that simulation-based learning is far more effective than traditional theory-based learning, improving competency and problem-solving 7ability [3,6]. Currently, high-delity simulators have been widely used in nursing schools which focuses on reproducing symptoms of illnesses so that students can learn how to care for individual patients [3]. High delity alone, however, does not su ciently build a clinical situation where diverse health professionals collaborate in a large range of hospital environments.
'Team-based simulation (TBS)' has been introduced to foster collaborative teamwork and mimic possible challenges that may be encountered while working together with colleagues [7][8][9]. TBS is an approach aimed at establishing a collaborative learning environment in which students become pro cient and actively participate in learning team care for complex health problems [9]. Although the bene ts of TBS have been well recognized, current nursing simulation-based education is subject to potential limitations and questions concerning the full engagement of all students involved. Due to a high teacher-student ratio and spatial de cit, 4-5 students comprise a group which is unlikely to go through the decision making with proper interaction between members [10].
With the advent of new technology, methodologies for interprofessional interaction have undergone rapid transformation. At present, with the outbreak of COVID-19, interest in virtual communication has never been higher [11]. Wearable devices, such as smart glasses, have been considered as promising, affordable, and easy-to-setup assistive devices for information exchange in healthcare settings owing to its intuitive design, unobtrusiveness, minimal training requirement, and ability to facilitate telemedical consultation [12] as well as general-purpose in-view recognition [13]. Smart glasses display interactive images on the visual eld of users by overlaying visual information without signi cant hinderance of natural vision [14,15]. Thus, it is time to build a learning environment that incorporates cutting edge technology into education to enable students to quickly adapt to a rapidly changing clinical environment.
Given the increased accessibility and improved affordability, there is empirical evidence suggesting the use of smart glasses could result in promising results by enhancing the learning process. The educational application of smart glasses in simulation training has shown strong potential in the acquisition of clinical skills and knowledge [16][17][18]. Provision of supportive information via smart glasses allows students to con dently make decisions during simulations. Furthermore, the availability for realtime discussion and consultation would increase students' willingness to participate in clinical situations and reduce the burden of uncertainty in their abilities. This study aimed to examine whether adaptation to smart glasses would produce bene cial effects on learning outcomes with TBS by improving team dynamics and learning engagement.

Simulation Intervention
The smart glass based TBS consisted of four parts of 1) lecture, 2) students developing algorithm for patient care, 3) team based training and 4) evaluation. Participants had a lecture for EKG analysis, medication and nursing care for patients with arrhythmia (Table 1). Two scenarios of arrhythmia were introduced, and task was given to build step by step algorithm including decision making process. For each scenario, four students in one group, two students take the role of remote supporters who are in charge of sharing information with bedside workers for optimal decision makings. Students were given opportunities to have repetitive training using AR with chances to x their algorithm. The nal test was video recorded for expert evaluation. Since the majority students had only little no previous experience of smart glass, a short instruction of this cooperation system was made prior to simulation education. The framework of the 15-hour simulation program was developed based on a previous study [19] that included seven nursing skills and 4-5 incidents where students were required to perform nursing practice and make clinical decisions (Appendix 1). The smart glasses-based TBS consisted of three parts; 1)participants attended a lecture on EKG analysis, medication, and nursing care for patients with arrhythmia. 2)Two scenarios of arrhythmia (a-b and PSVT) were introduced, and 3) a task was given to build a step-by-step algorithm. For each scenario, four students formed a group and two students took the role of remote supporters who were in charge of sharing information with bedside workers for optimal decision making. The control group attended traditional TBS, in which all students participated in the simulation as bedside trainees without smart glasses.

Development
Our system is composed of a trainee-side wearable system, supporter-side desktop system, and network server ( Figure 1). The trainee-side wearable system consists of Google Glass (GG), Bluetooth earphones, and a small mirror attached to the GG. GG has a front camera, Bluetooth audio, and a touchpad. The supporter-side desktop system consists of a desktop computer and headset, video conferencing application program to monitor the trainee, and image transmission program for sharing image les.
The trainee-side wearable system transmits real-time video and audio captured from the trainee's eld of view through GG and receives audio and image transmitted from the supporter-side system. We used Google Glass Enterprise Edition 2 (Glass EE2; Android Oreo8.1). The supporter-side desktop system receives the trainee's video and enables voice communication. We also developed software that can transmit images and text required for training by accessing the web RTC server using Google Chrome.
Our system was installed in two simulation rooms: the emergency intensive care unit and emergency support unit ( Figure 2). In the emergency intensive care unit, there were two trainees wearing a traineeside wearable system and high-delity patient simulator. In the emergency support unit, there were two remote supporters sitting the supporter-side desktop system. The supporters can use two desktop application programs: Option1 -Image guide and Option2 -Monitoring system. The image guide delivers selected images to the corresponding trainees and transmits real-time video from the smart glasses to the supporter monitor.

High delity simulator
The METIman is a life-like human simulator that physically represents patients. With clinical features including breathing, pulse, heart and lung sounds, various scenarios of adults with heart disease can be simulated. Not only does the simulator show physical symptoms, but the monitor connected to the simulator displays associated signs (e.g., vital signs).

Sample
The study population included nursing students who attended a baccalaureate nursing program at a university located in J district, Korea. A total of 32 participants were recruited and data from 31 participants. The purpose of this study was explained to all study participants and written informed consent was obtained.

Usability
Developed by Ingrassia et al. [20], we revised the questionnaire according to the design and purpose of this study. The survey consisted of 54 questions spanning six categories: user input (12 items), system output (6 items), system usability (17 items), delity (8 items), immersivity (4 items), and likability (7 items). Using a 5-point Likert scale, the study participants provided ratings from 1 (strongly disagree) to 5 (strongly agree). There were four additional questions in which study participants rated their overall level of satisfaction from 1 (very dissatis ed) to 4 (very satis ed) regarding the smart glasses device, ease of use, system output, and smart glasses-based simulation.
Attitudes towards the interprofessional health care team The Attitudes towards Interprofessional Health Care Teams scale was developed by Heinemann et al. [21] and modi ed by Curran et al. [22]. This scale consists of 14 items that include the quality of care, time constraints, and teamwork of health professionals. This scale uses a 5-point Likert scale with values ranging from 'strongly disagree' (1) to 'strongly agree' ( 5).

Learning satisfaction
Satisfaction with the education program was measured using the questionnaire used by Ji and Chung [23]. The 5-point Likert scores were used, randing from "not at all satis ed" (1) to "very satis ed" (5). The higher the score, the higher the satisfaction with the education program.

Essay questionnaire
An essay questionnaire was used that asked seven qualitative questions: 1) "How did you nd the smart glasses-based emergency simulation in general?"; 2) "Was this program easy to use? What are the points that you thought needed further improvement?"; 3) "Were there any di culties or constraints when operating the system?"; 4) "Do you think this smart glass-based simulation education would be useful for your future practice?"; 5) "Do you think the smart glass would be useful in the clinical environment?"; 6) "What are the components that require additional technical efforts for active application and continuous use of these smart glasses?"; and 7) "Please add any other comment on this program."

Statistical analysis
Statistical analyses were performed using SPSS (version 25.0). For demographic data, the frequency, percentage, mean, and standard deviation were calculated. Independent t-tests and chi-squared tests were used to examine the homogeneity between the intervention and control groups. Independent t-tests were used to compared group differences, and statistical signi cance was set at p<.05. Once a month 0 (0) 0 (0)

Results
Once a week 0 (0) 0 (0) Data are presented as the mean ± standard deviation or number (%).
The mean age of study participants were 23.9 and 23.7 respectively and the intervention group had higher proportion of male participants (p=.044) ( Table 2)   Table 3. User input and system output The participants reported good level of control over the system overall (mean 3.77, SD 0.67). Some expressed lack of controllability (22.6%) and preference to alternative interaction methods (38.7%). Majority of participants (87.1%) reported appropriateness of display of system. In terms of contents provided via screen of smart-glass, 58.1% of participants experienced some degree of limitations for seamless performance of tasks.   The study participants reported good usability of information provided via smart-glass (mean 4.13, SD 0.67) and usefulness for problem solving within simulation scenarios. Four participants (13%) reported lack of realism of the current smart-glass based TBS.
Except for one study (3.2%), the most participants expressed that they could well engaged to the simulation.  Participants' level of satisfaction that highest scores were obtained on smart-glass based TBS (mean 3.26, SD 0.68) and system output were reported as lowest satisfaction (mean 2.68, SD 0.94). Overall, the attitude towards interprofessional health care team was scored 4.23 (SD 0.59) and participants scored 'quality of care 'subscale relatively higher than other subscales ( Table 8). The table 9 showed the learning satisfaction of current smart-glass based TBS. In terms of learning satisfaction, the item "I actively engaged in learning activities" scored the highest (mean 9.19, SD 1.08) and the item "It is effective way to achieve learning goal" scored the lowest (mean 8.58, SD 1.46).

Qualitative response
Overall experience About eight out of ten (84%) participants responded positively. Users reported that smart glasses-based team simulation was new, exciting, and interesting (40%) and experienced practical assistance while using the smart glasses during the simulation (44%). Some participants (16%) felt frustrated, reporting that the system needed further improvement.

Perceived bene ts
Thirty participants stated that they expected that smart glasses would improve the accuracy of nursing skill performance using image and voice guidance (96.8%). Seventeen users (54.8%) reported that fast and accurate information exchange using smart glasses could assist interprofessional teamwork.
Twenty-six participants (83.9%) reported the system could prevent the occurrence of errors saying, "The remote supporter found me using the wrong dose of medication." Six participants (19.4%) reported they felt con dent using medical devices saying, "Although I used EKG device for the rst time, image guidance and voice assistance from the remote supporter was really helpful."

Recommendation
The study participants' recommendations for further improvements were largely about the narrow eld of view provided for remote supporters (46%), lack of smoothness in communication between remote supporters and bedside trainees (45%), and discomfort of the smart glasses, especially for those who wear glasses (13%). When taking the role of remote supporter, participants complained that "It was sometimes hard to gure out the patient's condition. I guess it might be easier with real patients, but it was really di cult when a mannequin was the patient." In terms of communication, most problems were caused by incomplete construction of the network and Bluetooth earphones that participants reported as "Wearing glass and earphones at the same time seems too much. It is needed to have something that can replace earphones." In addition, users recommended adding a visual status indicator to con rm whether the right information was sent (n= 2, 6.5%), suggesting "It would be nicer to con rm whether the image and text that I clicked and typed were sent. I had to keep asking what bedside trainees were seeing. " The present study evaluated the usability and feasibility of adopting smart glasses for training of nursing skills and interprofessional interactions in emergency arrhythmia situations. The ndings of this study indicate that participants attempted to use various features of the smart glasses to be actively engaged in team working and clinical decision making to provide the best nursing care. The results of the current study provide evidence of the great potential for the use of smart glasses in clinical settings for interprofessional interactions.
The majority of students perceived TBS using smart glasses as a new, exciting, and interesting method for learning. This is in line with previous studies that the incorporation of high-tech devices into education could promote great interest among this digitally native generation [24]. Given the clear roles within the simulation (either bedside trainees or remote supporters), the chances were greater for participants to take part in team communication, with greater responsibility on the remote supporters.
Although the scores were higher in the smart glasses-based TBS group, the results of this study showed no statistically signi cant group differences in attitude towards interprofessional healthcare teams.
Among the subscales, the scores for time constraints and person-centered care showed relatively greater differences. By being constantly connected to the remote supporters, bedside trainees felt more comfortable seeking external help which users found to be a way to address issues of time constraints within team work. In fact, most features of the smart glasses allow for the seamless ow of teamwork [25], which could be a great advantage in emergency care settings where e cient and accurate interprofessional interactions are key to better patient outcomes.
Generally, the users responded positively regarding the GG itself, expressing good feasibility for long-term use with a low level of physical discomfort experienced. One explanation may be that the weight of the GG EE2 is 46 g, which is relatively lighter than other smart glasses (65-350 g) [26]. However, no previous studies have clearly reported wearability and comfortability of the GG; thus, further comparison studies could contribute to the physical design of wearable devices.
Interestingly, users who experienced discomfort were mostly related to the accessories, and only a few participants from previous studies complained regarding the physical aspects of the GG (short battery life, heavy weight, etc.) [27][28]. We used Bluetooth earphones and mirrors to compensate for the defects of the smart glasses, which users found to be super uous. There was consistent frustration expressed by individuals wearing glasses, reporting discomfort of the double layering of glasses. Although one of the reasons why the GG was chosen was the lens-free design, it would be better to seek other solutions.
The ndings of this study revealed that the participants were least satis ed with the system output asking for better resolution and bigger screens. Indeed, wearable assistive technologies have different intended use, environment, and trade-offs [29][30]. In clinical settings, assistive devices should enable the wearer to seamlessly follow clinical work ows of the main task, bene t from hands-free device potential, and maintain sterile conditions [31]. The GG's small display limits the wearer's peripheral vision and multitasking capabilities [32] to keep them more focused and attentive to clinical tasks and work ows. In this study, the use of inexperienced devices within a tense situation could aggravate the di culties related to the display; thus, it is suggested that su cient time is provided for users to become accustomed to new devices.
Perceived usefulness of smart glass based TBS for future clinical practice was great among study participants. The current system was designed to focus on the exchange of information between remote supporters and bedside trainees and knowing the high risks of medical errors from unskilled care providers [33], the participants of this study found the smart glasses to be of great use for interprofessional teamwork. Previous studies also showed that the risk signs of patients were better detected when sharing patient monitoring via smart glasses [28].
The participants reported low complexity of the simulation program, but some users complained of low compliance. Delayed audio was reported as an important concern that should be resolved. A previous study identi ed the requirements of low-latency applications for virtual reality (latency = 1 ms) and telesurgery (1-10 ms) [34]. Although there were concerns over network issue, this is an area where technology is growing rapidly. Therefore, it is worthwhile for the development additional smart glassesbased interventions for education and clinical use.
Further consideration of user-centered interfaces may be the key to success in future system development. The principles of user-friendly interface design include understanding the intended users and their needs [35]. Users recommended the additional incorporation of visual status indicators due to the degree of uncertainty related to communication that was experienced within the current system. As this system was designed for use in emergency care settings, it is necessary to minimize the cognitive effort of users to verify their actions.

Limitation
This study has some limitations. It was di cult to draw clear conclusions by relying on self-reported questionnaires. In addition, the quasi-experimental design for the two-outcome measures did not su ciently prove the effectiveness of the smart glasses-based TBS in nursing education.

Discussion
The present study evaluated the usability and feasibility of adopting smart glasses for training of nursing skills and interprofessional interactions in emergency arrhythmia situations. The ndings of this study indicate that participants attempted to use various features of the smart glasses to be actively engaged in team working and clinical decision making to provide the best nursing care. The results of the current study provide evidence of the great potential for the use of smart glasses in clinical settings for interprofessional interactions.
The majority of students perceived TBS using smart glasses as a new, exciting, and interesting method for learning. This is in line with previous studies that the incorporation of high-tech devices into education could promote great interest among this digitally native generation [24]. Given the clear roles within the simulation (either bedside trainees or remote supporters), the chances were greater for participants to take part in team communication, with greater responsibility on the remote supporters.
Although the scores were higher in the smart glasses-based TBS group, the results of this study showed no statistically signi cant group differences in attitude towards interprofessional healthcare teams.
Among the subscales, the scores for time constraints and person-centered care showed relatively greater differences. By being constantly connected to the remote supporters, bedside trainees felt more comfortable seeking external help which users found to be a way to address issues of time constraints within team work. In fact, most features of the smart glasses allow for the seamless ow of teamwork [25], which could be a great advantage in emergency care settings where e cient and accurate interprofessional interactions are key to better patient outcomes.
Generally, the users responded positively regarding the GG itself, expressing good feasibility for long-term use with a low level of physical discomfort experienced. One explanation may be that the weight of the GG EE2 is 46 g, which is relatively lighter than other smart glasses (65-350 g) [26]. However, no previous studies have clearly reported wearability and comfortability of the GG; thus, further comparison studies could contribute to the physical design of wearable devices.
Interestingly, users who experienced discomfort were mostly related to the accessories, and only a few participants from previous studies complained regarding the physical aspects of the GG (short battery life, heavy weight, etc.) [27][28]. We used Bluetooth earphones and mirrors to compensate for the defects of the smart glasses, which users found to be super uous. There was consistent frustration expressed by individuals wearing glasses, reporting discomfort of the double layering of glasses. Although one of the reasons why the GG was chosen was the lens-free design, it would be better to seek other solutions.
The ndings of this study revealed that the participants were least satis ed with the system output asking for better resolution and bigger screens. Indeed, wearable assistive technologies have different intended use, environment, and trade-offs [29][30]. In clinical settings, assistive devices should enable the wearer to seamlessly follow clinical work ows of the main task, bene t from hands-free device potential, and maintain sterile conditions [31]. The GG's small display limits the wearer's peripheral vision and multitasking capabilities [32] to keep them more focused and attentive to clinical tasks and work ows. In this study, the use of inexperienced devices within a tense situation could aggravate the di culties related to the display; thus, it is suggested that su cient time is provided for users to become accustomed to new devices.
Perceived usefulness of smart glass based TBS for future clinical practice was great among study participants. The current system was designed to focus on the exchange of information between remote supporters and bedside trainees and knowing the high risks of medical errors from unskilled care providers [33], the participants of this study found the smart glasses to be of great use for interprofessional teamwork. Previous studies also showed that the risk signs of patients were better detected when sharing patient monitoring via smart glasses [28].
The participants reported low complexity of the simulation program, but some users complained of low compliance. Delayed audio was reported as an important concern that should be resolved. A previous study identi ed the requirements of low-latency applications for virtual reality (latency = 1 ms) and telesurgery (1-10 ms) [34]. Although there were concerns over network issue, this is an area where technology is growing rapidly. Therefore, it is worthwhile for the development additional smart glasses-based interventions for education and clinical use.
Further consideration of user-centered interfaces may be the key to success in future system development. The principles of user-friendly interface design include understanding the intended users and their needs [35]. Users recommended the additional incorporation of visual status indicators due to the degree of uncertainty related to communication that was experienced within the current system. As this system was designed for use in emergency care settings, it is necessary to minimize the cognitive effort of users to verify their actions.

Limitation
This study has some limitations. It was di cult to draw clear conclusions by relying on self-reported questionnaires. In addition, the quasi-experimental design for the two-outcome measures did not su ciently prove the effectiveness of the smart glasses-based TBS in nursing education.

Conclusion
Smart glasses were introduced as an effective means of communication in the industry. In this study, we presented a TBS using GG to investigate the usability and feasibility of smart glasses for interprofessional interaction. Using the scenario of patients with arrhythmia, students took the role of bedside trainees and remote supporters and used the GG for knowledge sharing and communication. The ndings of this study indicate that the current program has great potential for simulation environments as well for clinical settings. Some drawbacks were identi ed, which require further consideration and improvement in future testing.

Declarations
Ethics approval and consent to participate The procedures of this study were approved by the review board of M University in Korea (IRB No. MNUIRB-201006-SB-011-02). Written informed consent was obtained from study participants before the commencement of study.
Competing interests Figure 1 The ow of the team-based simulation using smart glasses and a high-delity simulator