Jonathan Letourneau, MDesMDes: Master of Design Studies
I build and optimize UX capabilities for agile innovation teams within large organizations, leveraging UX research methodologies
to inform service delivery decisions for generative AI and emerging technologies.
Innovation Analyst | Mass General Brigham Emerging Technologies and Solutions (MGBETS)
UX Researcher | Dana-Farber Cancer Institute
Information Designer | Self-employed
Metaverse Curation and Relations Strategist | American Medical Extended Reality Association (AMXRA)
03. Developing a Web-Based Digital Twin of a Nursing Code Cart
BWH 234—34/2
Role
Product Owner,
UX Researcher Duration
Eight MonthsDevelopment Team TwoProject TeamEight
AudienceCenter for Nursing Excellence (CNE) Objective
Reduce training costs for on-boarding new nurses with immersive technologies Approach
Leverage immersive web technologies to reduce development costs and maximize scalability Challenges
Limited budget. No existing process to develop immersive applications. Limited feedback mechanisms.
Project Initiation
Connected with Center for Nursing Excellence (CNE) to explore ways to augment nurse education
User Research
Observed nurse skills day – an eight hour educational day for new nurses
Data Synthesis
Translated research notes to visual artifacts to communicate lessons learned to nursing staff
Design & Prototyping
Facilitated sessions with CNE to define and iterate the solution
Evaluation & Refinement
Tested solution during subsequent nurse skills day to direct solution iteration
Reporting & Implementation
Integration to nurse education course.
Fielded follow-up organic interest for this solution from other teams
User Research & Problem Identification
Nurse Skills Day
Nurse Skills Day is an eight-hour educational session for nurses joining the hospital. This hands-on learning helps nurses learn BWH-specific equipment, policies, procedures, and expectations. It is particularly useful for new nurses who received a remote education during the COVID-19 pandemic.
Nurse skills day is
labor-, cost-, and material-intensive.
The material baskets, (img. 2 below) take 1-2 people 2+ hours to create while the room takes 1.5 hours to set up with 3 people
1) Nurse Skills Day Room Setup2) Skills Day Requires Numerous Materials3) Learners Group up for Specific Equipment Training4) Learners Group up for Specific Equipment Training We discovered a key challenge for nurse educators is the time and material costs to create immersive, interactive trainings.
Outcomes
Quick Adoption by Nurses
Following the launch of the MVP, there was a significance uptick in the usage of this solution. Most notably, there is continued usage on non-training days.
Requests from Departments Across the Enterprise
Following the delivery of our MVP, we have been approached three separate times by teams who heard of our solution from nurses who used this solution. From this, we are currently developing three new code carts for clinical teams across the Mass General Brigham system. Reduction in Training Costs and TimeEach use of the code cart directly saves the costs of re-certifying the code carts. Quantifying the time and monetary savings are still in progress.
Standardization of New Service Offering
Due to development approach and desire from other departments to create similar code carts, a formal process for intaking and developing these code carts has been created.
Concept Ideation
Following nursing skills day, the project team explored several solution directions. The focus was to reduce material and labor costs with limited to no resources. Ideally, the solution would be digital, leveraging immersive technologies (AR/VR). This type of education would allow learning to engage with the solution independently with the benefit of immersion.
1) Create Virtual Insulin Pens
There could be an opportunity to create virtual insulin pens to train people on the different dosages, etc. and how to make sure the correct dose is administered.
Why is this important? Wrong pen = wrong dose, this may be more of a protocol training.
Considerations: Are there are critical tactile components? | Could this be co-developed with manufacturer(s)? 2) Interactive Component to Drawing Medicine into a Syringe
Why is this important? The students practiced this right after a video explainer was shown, and it was clear many had not absorbed all the instructions from the video.
Considerations: Tactile components | Process practice3) Central Line Dressing Change
Why is this important? Nurse educators consistently reinforced the importance of keeping a sterile vs. clean hand that could maybe be a fit.
Considerations: Tactile components | Dexterous task | Process practice
4) Process Improvement: Self-Service Room
One idea would be to set up a self-service room with AR/VR devices set up to get practice with some of the trickier tasks that require less tactile feedback (these may be tasks not included in the training we observed). Students will schedule a time and go there and practice, potentially in groups.
Why is this important? Processes and protocols are difficult to learn when the learning is not repetitive.
Considerations: Scheduling | Inciting people to use service | Location and inventory management 5) Insulin administration, Chest Tubes, and Pressure injuries and skin assessment
Why is this important? These tasks have many process-oriented steps (Ex. Insulin administration: timing of patient’s fingerstick test, meal, insulin administration. Prime the needle, hold the needle in place after injection, specific type of syringe to use, different types of insulin)
Considerations: Tactile components | Process practice
Solution Ideation
Leveraging Immersive Technologies for Nurse Education
Many key components to nurse education require tactile feedback – such as administering a central line and administering medication. With current immersive technologies, tactile feedback is not possible, especially at the level of fidelity needed to accurately simulate these tasks.
Since digitizing tactile educational material would be too technically and financially expensive, the project team returned to the research to explore alternatives. The Activity Analysis graph parsed key information about skills day, such as content delivery type and level of interaction.
Activity Analysis Graph
Following the insights from the Activity Analysis graph, the team identified passive activities with limited immersion as the focus area. These training materials were primary videos, PowerPoint presentations, or a show-and-tell demo. We realized these materials had the highest potential to be improved with an immersive technology solution.
Identifying the Problem
Following iteration sessions with the Center for Nursing Excellence (CNE) and other nurse educators, a virtual code cart, developed on a web augmented reality (AR) platform was selected. Improving code cart education is a high priority item for the CNE because the self-reported outcomes for new nurses is low. Following the longitudinal research conducted through the Nora McDonough Nurse Resident Self Reported Survey Response to Comfort with Code Emergencies, after 12 months of education and experience, nurses are still not comfortable with code emergencies. While there is improvement after six months, comfortability plateaus as they reach the 12 month mark.
Note:
While this graph includes data after the launch of the code cart, we do not have enough information to make and observations yet.
Existing Education
Aside from an introduction to the code cart during Nursing Skills Day, new nurses have one other opportunity for formal code cart training – six months after their initial training. They participate in the nurse residency at the Simulation, Training, Research And Technology Utilization System (STRATUS) Simulation Center. At STRATUS, nurses receive emergency response training and practice interacting with the code cart.
For most nurses, learning the code cart happens during real code emergencies, where they are exposed to high-pressure situations, sometimes even before visiting STRATUS for their final training session.
Occasionally, an experienced nurse will work with a new nurse during their shift, opening the code cart and giving them a walkthrough. However, there is a negative stigma surrounding this practice as any opened code cart must return to the central code cart team for processing and recertification. With few code carts and limited resources, this is a very uncommon practice.
Augmented Reality (AR) Code Cart.
The project team collaboratively selected the code cart as the ideal solution to digitize with immersive technologies. The code cart met three key criteria that aligned with the priorities of both the CNE and the development team.
1) Key Training Topic
Knowledge of code carts is a critical topic for new nurses.
Existing educational content did not provide enough hands-on time with the medications.
2) Minimal Technical Requirements
The development team leveraged a web AR platform, enabling development with a two-person team.
The two-person development team leveraged the nursing team to help collect, define, and maintain assets.
3) Wide Accessibility
Web AR is a highly effective solution for teams getting started with AR or VR because it has minimal technical requirements.
Web AR does not require headsets or specialized devices. It works on virtually any phone or desktop.
What is a Code Cart?
A code cart, or crash cart, is a mobile unit with essential medical supplies and equipment used in emergencies like cardiac arrest. It’s vital for healthcare professionals to know how to use it quickly and efficiently, as this knowledge can significantly impact patient survival in critical situations.
Prototyping Methods
2D
2D prototyping was the most efficient method for brainstorming as text and drawings were the easiest communication method for all stakeholders. The team primarily used Figma, Microsoft Word, and PowerPoint.
3D
3D prototyping tools were attempted, but since contents and layout were prioritized in the MVP, the project did not benefit from the creation of higher fidelity models.Virtual (VR)
Immersive technologies were attempted during the prototyping phase, but since a limited number of participants had headsets, communicating the immersive designs were difficult.
Solution Delivery
The digital code cart is a reference artifact for nurses who need quick and reliable information about the BWH code cart. To achieve this, identification, search, and item details were prioritized. Identification
During a high-pressure scenario like cardiac arrest, rapid identification of items within the code cart is critical to saving a life. To aid nurses’ spatial reasoning and identification skills, the virtual code cart is designed to be inspectable from multiple angles and interactive – mimicking real-world interactions.
Search
To aid in nurses’ knowledge of the items within a code cart and how to use them, a search feature was developed to quickly locate items and learn how and when to use them.Item Details
For each item, a detail window was created to provide highly specific, relevant content to nurses on when and how to use each item. These descriptions were thoughtfully written by the Center for Nursing Excellence. IdentificationSearchItem Details
Implementation Strategy
This solution was implemented with two touchpoints.
Adopted by nurse educators as a core component in their curriculum. The AR Code Cart is now a standard part of Nurse Skills Day and an integral part of the specialized code cart training day at the Brigham and Women’s simulation center.
QR Code Badge. The Center for Nursing Excellence printed over 500 QR code badges and is distributing them to new and experienced nurses.
Scan this QR code to interact with the BWH Digital Code Cart
Future Work
Due to the extreme resource and financial limitations, many features are on hold until funding or additional resources can be committed to the project. Below is a short list of key planned feature updates.
High Fidelity Assets. To expedite development, photos were used to represent items within the code cart. The development team is currently working to create 3D assets for each item.
Detailed Analytics. Due to institutional policies, the embedded Google Analytics are unavailable for use.
Scenario Creation. To further integrate the code cart into nurse education, scenarios will be created within the solution. These scenarios will assess nurses’ abilities to respond to common codes and test their ability to identify the correct medication within a set time limit.
Family of Code Carts – Standardizing Development
Currently there are three digital twins in production with one more in development. Following the eight month development cycle of the initial code cart, subsequent code carts take about one month to develop. This is for two reasons: first, the model and core interactions have been developed and can be transferred to the next code cart within a week. Secondly, The code carts are co-developed with the requesting nursing team. They source the key content details and create and fill the layout of each cart. This shifts the burden of work from the two person development team to the highly motivated nursing team.
This development approach also enables the digitization of other key equipment, such as the MGH Rapid Response Box.
BWH Code CartBWFH Code CartMGH Rapid Response BoxBWH ED Code Cart (Coming Soon)
Note (while these applications work on desktop computers, the experience has not been optimized)