Margie Molloy, DNP, RN, CNE, CHSE, Assistant Professor and Director, The Center for Nursing Discovery (CND), Duke University School of Nursing

Transcription

1 2017 NCSBN Annual Meeting - The Future of Nursing: Mobile Technology, Robotics and More Video Transcript 2017 National Council of State Boards of Nursing, Inc. Event 2017 NCSBN Annual Meeting More info: Presenter Ryan Jeffrey Shaw, PhD, RN, Director, Duke Health Innovation Lab; Associate Professor Duke University School of Nursing, Center for Health Informatics School of Medicine; Center for Applied Genomics & Precision Medicine, Duke University Margie Molloy, DNP, RN, CNE, CHSE, Assistant Professor and Director, The Center for Nursing Discovery (CND), Duke University School of Nursing - [Ryan] So I'm going to start by talking about some of these emerging technologies, I'm going to talk a little bit about why things are happening. I'm going to talk a little bit also about science, not too much, but to just really lay the overview and then we're going to have Margie, for the most part, bring us back down to earth and talk about regulations, talk about education in a nursing practice too. Okay, so health care as we currently know it, is really delivered in a series of phases. In other words, it's really like a Polaroid picture. Over our lifetime, we collect information on our patients at specific points in time either as a checkup or as when a certain event happens or if you are hospitalized. We tend to only collect health information at periods of time over our lifetime. That is health care but health itself is completely different. It is from birth till death, it is ongoing, it is dynamic, it's constantly flowing, we have vital signs that are always changing. My blood pressure right now is probably really high but that information is not being captured anywhere. And so, we have this big discrepancy between what is health care and what is actually health. I would argue that we really only capture health in, say, in ICU when we are able to collect most information about an individual at a point in time in their life and so this discrepancy is actually quite profound. And we can think about this from a fairly simple example, is if we're going to fit someone with a new running shoe, we can either look at them at that point in time and make a guess but if you were to get a video of them actually running, you would have a much better idea of their foot pronation and you could really give them a shoe that is tailored to them because we have more information on their behaviors. We call this precision health and this is really the next generation of what health care is going to be. And by far the most part, today medical care and also health care is really tailored to an individual based upon science that is about the average...based upon the average, it's based upon populations. And by far, that's how we deliver care but no one in this room is a population, we're all individuals. Tomorrow, we will truly tailor care based upon you as an individual, based upon your DNA, what you do in your life, your behaviors, the environment that you're in, the air that you breathe, the resources that you have. We do this to some extent, but not really. And that is where we are 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 1

2 trying to move to. This is not entirely new, there are some instances where we truly do tailor things to people like, say, eyeglasses. For the most part, we can get that specifically towards you and also blood type as a couple examples there. But by far, health care is not like this and I'm going to show you. This came out in 2015 in the journal <i>nature</i> and these are the top 10 grossing medications in the U.S. and they work for the person in blue. When I first saw this, I was like, "What? No." But then I thought about it, say you have hypertension, the drug that you get, the dose that you get, the frequency is kind of a guess. We don't really know the drug for you because we don't have...we can't take your DNA, we don't know what your behaviors are like to really know if this is the right drug, the right dose, the right frequency. When you look at the consequences of it, the symptoms of it, we do this in nursing care too. Sorry. And so, the next generation of health care will be on precision health. And not to give too much jargon but that's called a "phenotype." All that means is that's everything about you, from your DNA all the way to the food that you eat, how you exercise, if you adhere to, you know, your different care recommendations, your family, if you're stressed and so forth. So eventually, we will tailor care to individuals on the phenotype, we just aren't there yet but we are making advances in science and I'll also briefly talk about a largely economic reason why too. Okay, and the ultimate goal here is to better be able to assess disease risks, to customize disease monitoring, to also prevent disease and eventually one day be able to know the point in time when someone actually gets something. So a bacteria, a virus, a chronic illness, for the most part, those get diagnosed based upon symptoms, not at the point in time when that actually happens. Not for everything but by far. Okay, another big reason why this is going to happen is the changing payment models in health care, we are shifting away from fee-for-service where for the most part, the whole system gets paid upon encounter a nursing care visit or a clinic visit to where those payments are going to be bundled. You get paid so much for a primary care a year or you go through surgery and you only get paid so much. The challenge with this is that health systems are going to get paid a fixed amount no matter what happens. And thus, there is this need to know what's going on with people in between office visits or post discharge and for the most part, we don't know what goes on with people. And I would wager that most people in here, a health system doesn't know about your health in this moment in time. Maybe someone does and I'd be interested in speaking about you...or not about you, but to you. Sorry. I'm still a little bit nervous. So I'm here to mostly talk to you about emerging technologies that will allow us to shift to a closer model of what health is like versus our health care system. And I'd like to talk to you about mobile health technologies and to think of these less as about devices and really about different kinds of sensors that can capture health information almost anywhere in the entire world at any time. So we mostly think about these as, say, a cell phone and the reason why I bring this up is that you can think of your smartphone as a bunch of sensors that are in this device that for the most part you carry on you throughout your life. And there's actually more power in these devices than when they sent people to the moon, which is kind of crazy that there's more computing power in your pocket than it took to send Buzz Aldrin off to the moon. But it's also more than that, it's perhaps wearables, it might be also something like a wireless scale that you can put pretty much anywhere and I'll talk a bit more about that too. So just out of curiosity, who here has like a Fitbit or some other type of wearable? Okay. So quite a few. This is a biased sample, just so you know. That's not most people. I'm curious, who here doesn't have a smartphone? There's always...one, two, three, four, so just a few. So every year, this number goes down. This number goes down. When I started all of this almost 10 years ago, almost nobody had one and it's just been interesting to see how this changes. For the people who did raise their hand, I assume you at least have a basic cell phone. Okay? All right, okay, that's what I thought. So we can still get health data from this thing in your pocket. So it's also more than that, it could be sensors that we put in your home, in your car, the idea that we could capture health data not just from something that we might be able to put on you but in your immediate 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 2

3 environment too. And this is a lot of things and I don't even know all of the different devices. It could be a blood pressure cuff, it could be a device that you put on your phone to capture a remote EKG and you're just like, "I'm going to click it on," and it takes an EKG and that information can be sent off, it could be a portable ultrasound, it could be text messages, it could be a lot of different things. And this also is a giant market, it's a huge market, it's a multi-billion dollar market and this was from 2015, so I would say this is actually quite old, but there's a lot of investment in this area too because of the potential. So the biggest thing though is this. Is that for the most part, there is now a device on the majority of the people in our country where we can technically collect health information and also send or also deliver care to someone's pocket, almost no matter where they are at any time. So this is kind of a paradigm shift where for the most part across socioeconomic lines, across geographies, we can directly reach people in near-real-time about their health. And that's not how health care is structured. Healthcare is episodic, right? It's for the most part fixated or maybe a nurse might go out to deliver care but it's still within this episodic, I would say, nature but tools like this allow us to shift to better match this idea about what health is. So the biggest thing is that...our thoughts are that this can really help us improve chronic illness care which happens over often a lifetime or perhaps, I mean, years, it might start to build up because of years or perhaps the behavior or you start to have a certain exposure to something. But the thing is that we still only deliver care for these based upon episode, say, like diabetes, a patient might go to a clinic every six months but for the most part, we still don't know what is going on with other people since that last visit. And we can get labs and stuff but we don't really have great data to be able to prevent care before that visit. This is also extremely expensive, it's the majority of health care costs. So from a health system structure standpoint, there is a lot of interest in trying to enact change. Okay. And so the goal is to be able to collect health information over time where we can better deliver nursing care and all sorts of care, even physical therapy, social work and so forth. And from a system standpoint, we can technically pull this information into an electronic health record, thus, this is actually quite real and we are already doing this in some different instances. So what can we do right now? We can use these tools to help people lose weight, we can use these tools to help people stop smoking, we can use these tools to help people monitor diabetes care. I'll just very briefly talk to you about this, this is a current nursing care study where we enroll primary care patients who have Type 2 diabetes and we give them several different devices to monitor their health data over six months. They're not monitoring anything that they aren't already supposed to, they monitor physical activity, they monitor weight, they monitor glucose and we bring this information in real-time back to our health system with really three goals in mind: that the patient is able to see their own health information and they will hopefully better selfmanage when they come to that next clinic visit that a provider can better deliver care because they actually know what's going on on a day-to-day basis. And eventually from a nursing care standpoint, we will be able to deliver care at the point at time when health actually happens, not based upon a clinic visit but when people start to have swings up in their, say, blood sugar or their weight which might be three months before that actual visit. I'm sorry. So the thing is that this isn't that...it's not that easy, when we start getting this much health information, we run into all different kinds of issues and I'll just give you one. So we give our patients actual cellular scale and they just step on it like they do for really any scale, it takes their weight and it almost magically transmits it off. And so, we can monitor weight gain and also weight loss, but do you know what is the biggest problem that we have with these? People love to weigh their pets on this, so they'll pick up their dog, they'll step on the scale and they'll put it down. So we are able to know if someone gains too much weight within a day or even a week, and so we can create algorithms to throw different values out but the biggest problem is, really, that people love to weigh their little dogs. The dogs that weigh like two pounds, three pounds, so they will like, "I'm going to pick up this dog," they're like, "I'm going to step on this scale," and then they will put it down but we 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 3

4 don't have a way to actually know if they are weighing their pets or not, so these little dogs are impeding science, just saying. That is actually true, I'm not making that up. Okay, all right, enough jokes. So we can do a lot more than that, there are apps on your phone that you can monitor all sorts of things, like say, asthma, there are the next generation where we can use different artificial intelligence to do things like being able to pre-screen children for potentially having autism. This is a current study where you download an app on your phone, you consent right there and you take a video of your child and with the eventual goal that an algorithm can see changes in facial structure to give a recommendation to go get screened. So you can imagine from a nursing standpoint, from a public health standpoint, a nurse could go out and screen thousands of kids to see if they potentially have autism among many other things. It's not a diagnostic tool, it's just a recommendation that this person might be at risk, so we can take that idea and apply it to many different things. You can imagine in very rural places, things like this could be quite useful because you could even empower family members to do this too. So the other thing is that we are also now to the point where there are wearables that are about to come out where it's almost like an ICU on your wrist. This is called the E4 Band, it's been used by an astronaut, it's been used by also others too and we're able to get so much data on people that we can almost know what they're doing in their daily lives, if they're standing, sitting, if they're exercising, if they're eating or not. And I realize that's a little bit scary, but if we can take that ICU model and apply it to a public health standpoint, we can potentially change the way in which we are able to capture changes in health when it actually happens versus based upon symptom management, when it's likely already too late or not. And this is just to show you that...oh, we can get information on people every 2 hours, every 10 seconds and so forth and this is just to show that we can get information on temperature, on heart rate, on blood pressure and different skin excretions to really be able to make health inferences almost no matter where somebody is. And the near future will also involve 3D printing to, say, where a nurse is able to actually print something out that is tailored towards an individual whether it's a splint, a cast or also something else. It could be an actual shoe that you print out that is tailored to that person based upon a photo that you take on your phone. This will all be the future of nursing care. So just real quick, what I think is going to be the biggest change for the profession is that we are going to take what we often think about as...on a telemetry unit where we might monitor patients with a...to look at their cardiac rhythms with a device that goes back to a central station on a nursing unit where that software is able to monitor for, say, tachycardia and so forth. And if it goes off, it notifies, say, a teletech and then they try to intervene, and if they can't help, they will notify a nurse and so forth. That inpatient model can now be taken to the outpatient one, to where we can monitor not only, say, dozens of people but thousands, if not a millions of people where the majority of that work is done by software that just monitors health and we will have nurses that will eventually monitor populations to hopefully recognize when trends happen upon an individual and upon communities too. And it's a similar model to this where we can use these tools to get a better understanding of health... I'm sorry, not just from an individual but from entire communities. And we know that as...and we also know that this inpatient model can be safely taken to an outpatient one too and we have data on this. And I'm not trying to present too much data but we have proven that it is just as safe for a nurse to titrate medications or to make different small changes based upon data in the outpatient model just like in perhaps the inpatient one where you say you might titrate an insulin drug. So the future doesn't stop, it's really moving faster in...faster. They're trying to make contact lenses that are able to monitor blood sugar, they are putting sensors that will be embedded in people that you can also take a pill that it might send an actual signal that you took it when it hits your stomach acid. There's going to be wearable tattoos that will be able to...that are able to detect at the point in time when you are exposed to a virus. And I'm not making this up, we have engineers at Duke that have already made these things. They just don't know what to do with them and they have no idea how to put them into health 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 4

5 care, so they need a nurse. I mean, they don't understand how to take things like this and actually help people. So what we're trying to do at Duke is to bridge the divide and show people how important is to have nursing at the table and even if we knock on the door 10 times, when they eventually hear us, they become really interested in us and I'll just show you one more thing before I pass this off. So we have the future here but it doesn't stop, so I met this engineer who told me that he was building a nursing robot and I was like, "What? You're building a nursing robot?" And I was like, "Have you ever talked to a nurse about this?" "No." I was like, "Okay." So I went by there and they built something which looks kind of scary right now, but what they said is during the recent Ebola outbreak is that they don't want nurses going into these rooms that are dangerous for them, so why don't we create like a remotecontrolled robot where a nurse could drive it in to care for people in very high-risk areas? So I met them and we taught them basic nursing care and it blew their mind and we were able to advance science and I'm going to show you a very brief video on this. So this is TRINA, this is the Tele-Robotic Intelligent Nursing Assistant and we taught engineers how to deliver patient care which kind of made me laugh because I was like, "This is simple," but from a scientific standpoint, this is extremely complex. And so this is just to show that everything that I talked about, these different wearables and all of this different data, things like this are happening too and it's a lot sooner than we probably think. The goal isn't to take away people's jobs here, it's to augment care in times when it might be needed. You can imagine that eventually, a robot might go around and just turn patients and it'll be controlled by a nurse. That's me doing stuff. But we take these same sensors that we put on people and we just put them on a robot like this and the reason why... I'm not here to show this to actually scare people but this is to say that it is really important that nursing is here as these things get built because we need them to be built to actually improve health, to actually improve care delivery. So we have to be bold in who we speak to and also how we might be able to advance science forward. The most difficult thing for them is actually to open up drawers. And so, it's not that robots are anything new, they do this in the operating room on, say, a brain surgery, but it only operates in an actual window that is about this big. So they can do very fine things but from an engineering standpoint, nursing is extremely complex because we work in an environment that is really unstructured. Okay, all right. So now I'm going to pass this off to Margie Molloy who's going to bring this back to, let's say the real world if you will. So, thank you. - [Margie] Good Ryan, thank you. Good morning, everyone. I have to say Ryan was so instrumental in connecting us with our School of Engineering students and they have all brilliant minds but they were lacking the nursing knowledge. And our nursing students, our pre-licensure students, were able to go to the School of Engineering and they were actually paid a little bit of money to partake in helping the engineer students understand what nurses do. So another plus out of this is it became a good interprofessional education which we ask the engineering students all the time now to come over the School of Nursing and just as an aside, one of the things I was mentioning one day to them was, "Our mannequins are great but they can't do everything and one of the things about a newborn being born is they naturally creep and find the mother's breast to feed and so we have to move the baby mannequin up to the mannequin's breast." And the engineering student says, "Oh, we should put magnets that will get the baby up to them," and I said, "Wow-wee." So we're always looking for that connection with them. A report that I think a lot of you will be very familiar with is the <i>collaborative</i> <i>future of Nursing</i> report that really put on paper lots of things that I think we've been thinking about. We have a rapidly changing knowledge base. I mean, who would have thought Ryan's topics would have been talked about 5 or 10 years ago would have been really like in the future, like <i>the Jetsons,</i> right? We have new technologies throughout our nursing careers. You know, my generation of nurses, we learn things and we thought that was it but we are lifelong learners, all of us now, we have to commit ourselves to that. Care is shifting out of the acute care setting, especially with the care of the elderly. A lot of movement 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 5

6 now to keep patients...to keep elders at home with their loved ones where they think it's better for them mentally, so we have to think about that. And also the use of high fidelity simulation is really opening up lots of doors for us in, not only education in the school setting but also in the hospital setting as well. Let's see, we're talking about new jobs. Ryan mentioned about nurses now looking at populations of people whereas we would have somebody sit in front of telemetry monitors, maybe now a nurse would be responsible for sitting in front of lots of monitors and watching for population health. We want to explore nursing students to new models as well. I don't know about you but in my experience, we send most of our students to the hospital setting for their preceptorships. We're breaking that mold now, we're starting to send them to primary care. We have a collaboration now with our health system and they told us that operating room nurses are aging out and there's going to be a massive shortage. So in our prelicensure curriculum, we created a perioperative elective course that will be direct entry into a job as an operating room nurse and we had 25 slots open, we'll start it in the fall, I think 47 out of 70 of our students signed up for it, so we had to, you know, backtrack. It was new and exciting but I think also the students felt secure in knowing that they would have a job almost immediately because if they do a good job through this elective course, then they do have a full-time job when they graduate. This is what we're looking at now, our environments of learning look different. So if you look at the top picture, these are our nurse anesthetist learning in the simulated operating room. We went through pains of creating a space that was realistic, it has the booms, it has the monitors, everything is real. In the lower left-hand side, you see the instructor working with the experiential learning, letting the students do hands-on suturing, anything, we still use pigs' feets, we moved on from oranges but we use pigs' feet. And on the right, you see what our simulated environment looks like, we are able to look through a window and see what the students are doing in the simulated environment, capture it with video, play it back, debrief with the students. These are projects that I'm going to talk about. Ryan already showed you the robot, the one on the left. First, I'll talk about the RQI which is actually a CPR study that we are doing with Marilyn Oermann is our PI, with Suzan Kardong-Edgren is another project manager and we're doing it with 10 schools across the nation to look at how best can we teach CPR skills to people because how many in here think that we have it after going every two years? Right? There is definitely a decay and we have to figure out what's the best way to teach this skill set. So what the study does is we look at prescribing doses of coming back and doing CPR practice, but it's based on your own individual level of competence. So if I go to this machine which can measure how I'm doing with compressions and ventilations, it might tell me that because of my skill set, I have to come back every three months and get practice whereas maybe Ryan comes and you know what? He's really good at this, maybe he can come every two years and do just as good. But we have to have that frequent assessment of what students are able to do. I do have to say that you will be reading a lot about this. Dr. Oermann and Dr. Kardong-Edgren are going to be starting writing this with us and it is going to change the way that CPR re-certification is done, so keep your ears open for that one. Another project that we did is we love our mannequins, you know, we get very sensitive about our mannequins, we don't like to call them dummies and we realize the limitations that they have, even though they can do lots of things. There you have breath sounds, lung sounds, we can give medicines and know if we've given too much or too little, it doesn't have the ability to show the symptoms that we need. So in this example, we had a young girl that we hired as a standardized patient who was an asthmatic and the student went into the room and was going to take care of the mannequin but in the Google Glass, they were able to see augmented reality where the mannequin...where the person actually looked like the mannequin but she would go through like, "I'm having trouble," because that's different than looking at a mannequin in a bed. And even though vital signs and things reflect changes, you can't see somebody who's gasping for air and perhaps saying, "I think I'm going to die." That's different. So that's what we tried to do through this project. One 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 6

7 of our projects that's actually got a lot of legs that we now when we go to conferences, we see it all over that people are initiating this technology...and we're not here to promote any one particular product, but we just happen to stumble upon looking at this product. Ryan is great because he really keeps me as the Simulation Lab Director really up on what's out there and I'm not a particularly tech person but I have become really interested in what is out there. We had seen a video of a principal from a school in...well, from multiple schools in Alaska. One principal service is probably five or six schools and they have to fly into the schools but the weather sometimes is so bad in Alaska that the principal cannot get to these particular schools, so he goes to the school remotely through this Double Robotic telepresence monitor and he engages with the children, really like as if he's right there with them. And then we thought to ourselves, "Gosh, we used to have nurse practitioners in our building and when we did sims with our pre-licensure students, we used to beep the instructor in the classroom and say our pre-licensure students are doing a simulation and they need a health care provider at this point and the instructor would send up two students to the sim lab and they would partake in the simulation. Well, our programs that do...all our masters programs became distance-based and our students come once a semester for about four or five days to campus but we no longer had the nice thing of having them in the building but this really bridged the gap for us and I'll show you a brief video of how this worked. As educators, we're always looking for innovative ways to use technology and I think the use of the robot has certainly met our need. - We have been using the Double Robots as an educational tool to engage our nursing students with our advanced practice students. - [Jackie] Actually, using the Double has been kind of fun. We were looking for a way to incorporate our nurse practitioner students into simulation. - [Raymond] We do a couple different types of simulations, we do some with what we call "standardized patients" which are paid live actors that act as patients and then we also do some with what we call "high fidelity simulators," so these are computerized mannequins that they blink and get heart sounds, lung sounds, they also hook up to a monitor so the students get sort of an experience that would be some of what they would see in a hospital. - In the past, the nurse practitioner students would come and join the pre-licensure students, the ABSNs in simulation and the nurse practitioner who would be in the building maybe in class would be told to come, you know, and help the students out. When they became distance-based, they were no longer here to do that. - Once the Advanced Practice Program changed to distance-based, we were faced with the challenge of how can we still keep our nurse practitioner students involved in the simulations with our pre-licensure students, so the robot actually became a great way, a great tool if you will, to have a presence of the nurse practitioners here on campus. - Having a nurse practitioner presence in simulation is just very beneficial for the students, it provides teamwork opportunities, certainly communication opportunities for the students and it goes both ways, the ABSNs are communicating with the advanced practice nurses for nurse practitioners and in return, the nurse practitioner students need to learn how to get the information from the ABSN students. - The telepresence robots allow end user such as our students to have more autonomy over their interaction and engagement in a clinical simulation. By our students having autonomy to actually thrive, they feel like they are more part of our community here. - We like the idea that our students are seeing emerging technologies as well because in health care, they'll likely see the use of that type of technology so we're starting that while they're students. They are all 21st-century learners so they love the infusion of innovative technology. - As healthcare evolves to integrate telehealth into standard clinical practice, our educational offerings also have to evolve to meet those needs. So here at the Duke University School of Nursing, we are integrating telehealth technology into our educational offerings so that as our students graduate, they are comfortable using this 21st-century technology. - It really does add a presence to the simulation even though it is on a stick and an ipad, it actually makes you feel as if that person is present in the room. So it's really interesting because when we did studies on it to see what the students thought about it, the 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 7

8 connection that you have by using this as really as if the person is in the room. Another use that we did with it is in this particular picture, we took it one step further. We had our pre-licensure students do home visits in the simulation lab where we had a standardized patient who had a family member with them, who had to be taught how to do a wound dressing. The nursing students are on the left-hand side of the screen looking remotely from a room in the Sim lab but it would be like a center that they would be at monitoring this home visit and they would ask the family member to expose the wound so that they could see it, ask the family member to describe what the wound looks like and the nursing students could see the wound and then would give instructions to the family member on how to redress this wound. So we're exposing our students also to telemedicine because I think that's not too far in the distant future of what they're going to be doing. So what is the value? We want to be sure that our students are emerged in these technologies and they love it. The students, of course, are from that generation where this is really comfortable for them. We have shown in studies by using these technologies that we are improving teamwork, communication, role development and that we are ultimately promoting safe clinical practice. And also another benefit that I didn't list here is the use of it in interprofessional education because at Duke, we have an IPE clinic that is staffed multi-disciplines, there is an intake in the ED, in the emergency department, and the person comes over to the IPE clinic instead of waiting for hours in the emergency room. Now, mind you, they have so much care at the IPE clinic that probably their length of stay is as long but they like the attention that they do get there. But sometimes students for whatever reason or maybe instructors cannot be physically located in the IPE clinic, so they dial in remotely and come in via the telepresence robot and they take part in it, so we're mitigating distance as a barrier for providing health care. This room is probably very familiar with the national study, the landmark study on use of simulation in nursing education that was done with prelicensure programs throughout the country. And what it did show is that we can replace 50% simulation with the inpatient clinical experience, but I think that we have to really highlight the word "quality" when we do this because the study really showed that if we have properly trained faculty who know what they're doing, that we used theory-based debriefing, not just, you know, a whim that somebody has but it has to be really grounded in theory, and that we have the appropriate faculty to do this work and that our environments are as realistic as possible, so we have really immersed ourselves in all our clinical courses. We, of course, are not near 50%. I think that we're probably lingering around up to 20% at this point but I think the potential with how clinical site placements are becoming more and more difficult, it's just something that we have to think about the benefits. But again, we really have to emphasize that it's done with the right quality. The National League for Nursing, they published their vision for simulation and again, it actually repeats a lot of the 2010 report that we looked at, that it's a way to teach more than just psychomotor skills. We can actually get to the effective domain too, the thoughts and feelings, by having students interact with standardized patients. We are very creative in all of the different things that we do with hearing voices where they put on mp3 players on their head and they hear a schizophrenic patient and have to do all these annoying little tasks while they're doing it because it puts them in the shoes of a person who's going through a psychiatric illness. We want to be sure that the things that I mentioned such as understanding that we have to be prepared for technology changes, the complexity of the cares of an inpatient is really...and even without patients, people are sicker even at home now. The implications for your State Boards of Nursing is how are we going to assure that faculty is properly trained to be able to use this pedagogy effectively? In our School of Nursing, we really emphasize our faculty who are simulated faculty to get certified as Certified Healthcare Simulation Educators because that assures that they have the experience needed, that they understand the pedagogy, the theory behind simulation and also there is a certification that use labs in academic institutions or even in other types of labs can get to accredit the center as a center of 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 8

9 excellence in simulation. And we really have to emphasize also that we're spending time and orienting our students to what we're doing and that's effectively through pre-briefing the student, that we bring them in and we don't just throw them into the room and say, "You can start your simulation now." But we have to orient them to what the mannequin is capable of, what is real in the room to use, if they have to phone a health care provider, is the telephone set up so that they can dial out? So those little things that I think, you know, maybe five years ago, that we just kind of threw them into simulation, we're really being more purposeful in what we're doing now with the pre-brief. I think a lot of people focused on the after Sim debrief and we didn't really look at what the preparation needs to be beforehand. So now, we do a lot with our students with TeamSTEPPS where we teach them SBAR and some of the TeamSTEPPS techniques pre-simulation so that they have more tools available to them as well. So, there are so many emerging technologies between what we hear with virtual worlds, computer simulations...they put the word "serious" in front of gaming because I think they didn't want educators to think our students were playing, so the word "serious" got there, ways to augment reality, how can we make it look real for this student and this whole world of HoloLens which now...there are even... Microsoft has combined with a university and is doing great works in using HoloLens for anatomy, physiology, we'll see a lot of that being used in the future. So what we need to really explore is how can we bridge the gap between theory and nursing practice? And I think probably one of the things that we're all passionate in this room is about not necessarily using all the newest and the greatest and the really cool bells and whistles that we have but we want to make sure that we're improving our patient outcomes. So that's something that I think we have to fight for as nurses. So, thank you all. - [Peggy] Good morning, thank you very much for the presentation. Even though it is foreign to some of us, we did our first assessment, it took us an hour when we went on the floor and then in a year's time, we walk on the floor and sniff and say, "Oh, there's a GI bleed on the floor." So those pieces are taken away from us. I'm Peggy Leonard from the New York State Nurses Association and what pays the bills is I'm Vice President for Medicaid Managed Care Organization. So I think as we look at all these different opportunities and obviously funding to be able to teach nurses how to do this and to teach the faculty how to be able to instruct in these ways, there's two opportunities: one, with my organization, we're already using the e-visit and reimbursing for that e-visit. What we need to do is make sure that we stay politically active to do two things: make sure there's coding that says we can pay a nurse to do this and the second piece, wouldn't it be nice in hospitals for them now to be able to bill for nursing services rather than it coming under the "hotel charges" and not being, you know, pointed out as a PT visit or a doctor visit. So I think the opportunities are terrific but taking it...you know, Ryan took it one place, you took it into reality, I want to take it to the real reality which is will we get paid by the insurance companies and by Medicare, Medicaid in order to deliver these services as a nurse? - Right. Yeah, I think you make very good points and I think we have a lot of work to do with really charging for what we do. I don't know if Ryan has any particular. - Yeah, I think you bring a great point of why partnerships are really crucial here to where...we might have certain expertise but really we need teams to really advance nursing and to advance the future of really health care that's going to improve patient outcomes. But it's still all inside of a political, you know, spectrum...or I guess a box, so we do need to collaborate with other people like yourself or perhaps other advocates too. I completeley agree with you. - [Mark] Hi, I'm Mark Monson. I'm the Citizen Member from the Virginia Board of Nursing. And I think the technology is wonderous, you know, it's carrying us into, like, you know, Bones in our <i>star Trek</i> kind of thing. We talked a little about it, but it's getting there. My concern though is that... and there are a couple of things that you really didn't talk about during the presentation, one of those was how is this going to get paid for? But there are some unintended consequences that we have to be prepared to deal with before we rush headlong into equipping anybody with a cell phone, start gathering 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 9

10 massive data. And, you know, the more data we get, the more it's going to be a target for people to want to get X. And so that brings up, you know, two additional questions that you didn't talk about is, what are we going to do to ensure the cybersecurity of this and once we start gathering massive amounts of data on individuals that then aggregated then collected, how are we going to keep people away from legitimately getting at it to make money and those are two...again, you didn't talk about that. I'm just, you know, curious of what your thoughts are other than, you know, "We got to have collaboration." - Sure, yeah. So I didn't bring that up mostly because of our time constraints too. I could talk about this stuff all day long because I pretty much believe those questions that you just asked. So the best approach is that we approach privacy and also security if you will from the very beginning, so both in the development of these tools but when we begin to discover how to actually use them in healthcare, we have to involve privacy and also security during that time because you are absolutely right, it's not just about us using these for good but there are people out there who are going to use them for other purposes or even just unintended consequences. So it is collaboration in the sense that we have to team up with people who are security experts. From a research standpoint, that has been a mandatory now, at least in the area that I am working. This is a big challenge and we don't have a great answer right now, so it's a balance between innovation to improve health versus this risk where people might steal data, they might sell data. And I mean I would argue that health systems deal with this every single day, "Should we have an electronic health record? It could risk stealing data which has already happened versus should we stick with the paper," and it's kind of that balance between trying to improve health versus those different risks. And I'm not an expert in this topic but what is needed is that we have people who are experts in that as we develop these new different innovations. - [Geraldine] I think what you're doing at Duke is fabulous and I congratulate you. I'm Geraldine Marrocco and I am a member of the Connecticut State Board. I also am a member of the faculty at Yale University School of Nursing and I think I might have ed you at one point, Dr. Molloy. I have for several years, when Google Glasses came out, we obtained a pair of them...they're off the market now, so I'm using FlyWire and it's really interesting to see the students learning using these devices, they like all this cool stuff. The students actually interviewed standardized patients and the patients actually wore the glasses and they were close to the students and the students actually got a chance to see how they actually looked to the patient and it was...the article is called <i>seeing</i> <i>through the Eyes of the Beholder, </i>and it's in the <i>nursing Education Perspectives</i> and it's really...it was a nice little study that I did. And so I don't think Google Glasses are back on the market yet but we're using FlyWire which they also work a little bit differently. So from an education point of view, I think there's so much to learn, we have such a good environment with, you know, good funding and good faculty who are willing to learn and try to do things a different way. And it's not really just the young students in the faculty, you know, I'm one of the old battle-axes and I really do enjoy teaching using the technology. So from an education perspective, I totally support what you do, we are going to be getting some robots at Yale. And from a practice perspective, I think we need to think about how we're going to translate what we are teaching the students and what we are learning into the practice setting. So bringing robots into places like assisted living where the patients don't need to come out to go to a visit with their primary care provider but the robot is programmed...i think that that's being done down in Emory in Atlanta, so that these patients who are remote can actually get a visit by the visiting nurse and they can be hinged into the provider and the equipment is programmed to take their vital signs and to listen to their heart rate, examine them remotely. So, you know, we have education, we have practice and we finally have research. And, you know, we all have to embrace more research on this and show that it will work. We do not have enough providers to reach the people of this country and thanks to the Affordable Health Care Act, we will be able to continue to get funding and get reimbursement for those visits to reach those people who cannot 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 10

11 really afford or get to a primary care provider. So I really want to commend you on your work, I want to, you know, see more of it and I think as universities, you really have to plunge forward and get the students involved as well, so thank you very much. - Thank you. Yes. - [Mindy] Morning, thank you for the presentation, that was great. I especially appreciated your emphasis on pre-preparation and post and I think from the regulatory perspective, you know, my fear is that people are going to jump into this thinking that they know what simulation and are not adequately prepared. I'm Mindy Schaffner, I'm from Washington State and my question to you is how much do those robots on a stick cost? - Three thousand dollars to buy one. So, you know, it's a little bit of a cost at the beginning but I also think that we're not finished with figuring out ways to use it that would help us with engaging distance students and things like that, so we're still exploring. So, I mean, in the scheme of things, the cost is not terrible and we've actually had individual people who've been intrigued with it and have offered even to donate one as their part of helping the future of nursing. So, you know? - You all have used avatars also, right? - Yes, yeah. Yes? - [David] Morning, my name is David Benton, I'm the Chief Executive Officer of the National Council of State Boards. Fabulous presentation. I have a very specific question, you were very kind to reference the landmark study that NCSBN funded in relation to simulation. Research takes some time, so what would your advice be to the Board of Directors in terms of how we should invest our research dollars? What is the next regulatory-related project that we should be funding to prepare the way in terms of utilizing some of these technologies? - That's a great question. I have spoken to Dr. Carroll Durham who is from UNC Chapel Hill who is really a mover and shaker in the simulation world and we are actually thinking about starting a consortium to make something that can be used state-tostate for training simulation educators. So I think that we need to almost develop a think-tank, bring the best people into the room and develop a product if you will that would be very minimal cost that other states could tap into and hopefully use it to train simulation educators. Six, yes. Yes? - [Tammy] Good morning again, my name is Tammy Buchholz, I'm from the North Dakota Board of Nursing and I'm the Associate Director for Education, so I work closely with the nursing programs in our state and there was something that you mentioned in your presentation that really stood out to me and you said that simulation must be done with the right quality. Last evening, we had a meeting, all of the ED consultants, and when we gathered, we had some discussion about that quality component. We've had the amount defined for us that is safe, the 50% mark, but I would very much like to hear what you're using as your standard for that right quality. - Right. So you can look at the <i>inacsl Standards of Best Practice Simulation</i> and it outlines anything from developing a simulation template to giving facilitators information about their role to how to create a realistic environment and the list goes on and on, but it is almost like the Bible that simulation people should use. And if we get these best practices built into our simulation scenarios, we can assure that they're done with best practice being used. There's other resources too that are free that the National League for Nursing has some ACE-S cases that can be used for geriatric nursing and for VA scenarios that are auditory cases, that the students listen to the story and then they can finish the story. So some of those tools that are out there and Washington State University also has free modules for sim educators to use. So what we do with our sim educators now, we don't let just anybody pop in and be a facilitator. We have them go through a process of an orientation and almost like a checklist over the course of, you know, say, six months and when they reach a certain milestone, then they're observed running a simulation so that they could get advice too from an experienced simulation educator because I think when I had first started, it was like if you were a nurse and had a pulse, you could run a simulation, right? So I think it's almost same in clinical practice, like, a great nurse in a unit may not be a great nurse preceptor, so we have to really get people that are interested in following best practices and want to invest time to learn the process. - Thank you. - Thanks. Nine. - [Cynthia] Good morning. My name is Cynthia Bienemy, I'm the President of the 2017 National Council of State Boards of Nursing, Inc. All rights reserved. 11