Innovation is the development of new thoughts and solutions that meet new needs or needs not yet articulated (Knol & van Linge, 2009). In the context of nursing, the word is most often linked to positive changes in quality, safety, and efficiency in both nursing education and practice. The use of eye-tracking technology to evaluate visual scanning patterns (VSPs) represents an innovation that can provide important information about nurses' safety behaviors during simulation sessions of high-risk and/or complex clinical activities (Amster, Marquard, Henneman, & Fisher, 2015; Henneman et al., 2010, 2014; Marquard et al., 2011).
The purpose of this article is to discuss the use of eye-tracking technology as an innovative teaching-learning approach to evaluate and improve safety behaviors during simulation sessions. We describe the innovation, discuss current research, demonstrate its use during nursing students' simulation sessions, and discuss implications for use in nursing education and practice.
EYE-TRACKING TECHNOLOGY
Eye-tracking technology is a method for measuring and recording an individual's eye movements while performing a process (e.g., confirming patient identifiers on a wristband or medication record; Poole & Ball, 2006). A number of different models of eye trackers are commercially available. The types of eye trackers being used in patient safety research are typically the mobile, head-mounted models that allow the participant to move about freely in the simulated or naturalistic setting. These mobile eye trackers include both a camera that records the scene in front of the participant and optics to measure the location within the scene where the participant is looking. A crosshair or other marker is used to indicate the specific location where the participant is looking during the simulation. (A photograph of the apparatus is available as supplemental digital content, http://links.lww.com/NEP/A3.)
The goggle/glasses apparatus is connected to a small computer that can be carried in a small pack or pocket. The reader is referred to excellent reviews by Duchowski (2007) and Poole and Ball (2006) for more information regarding technical considerations and device limitations of the different models.
The premise underlying the use of eye tracking is that there is a relationship between where an individual looks (termed point-of-regard) and what the individual is attending to, thinking about, or concerned about at that point in time (Poole & Ball, 2006). For example, if a nurse's eye movements involve fixations on the patient's name and date of birth (DOB) while the patient (real or simulated) verbally states her name and DOB, it could be concluded that the nurse's primary concern of interest at that moment is establishing that the two sets of patient identifiers match.
Eye-tracking data include, but are not limited to, the order in which objects are fixated on, the length of time of each fixation, and the number of transitions between objects of interest. Data obtained with the eye tracker are objective and quantitative, though as with any technology, precision and accuracy must be taken into account (Applied Science Laboratories, 2012).
RESEARCH IN NURSING AND HEALTH CARE
Although eye tracking has been used for many decades in other disciplines such as psychology and industries such as aviation (Duchowski, 2007), its application to nursing education and practice represents a new and innovative approach. Eye-tracking research has provided insight into the perceptual mechanisms underlying a health care clinician's performance (Gegenfurtnet, Lehtinen, & Saljo, 2011). In a recent meta-analysis of studies evaluating VSPs of experts and novices in the professional domains of medicine, transportation, and sports, Gegenfurtnet et al. (2011) reported differences between experts and novices. Experts had a) shorter fixation durations on artifacts (items), b) more fixations on relevant artifacts, and c) shorter times to first fixate on relevant material.
Researchers in nursing, medicine, and engineering have used eye trackers to evaluate common, error-prone health care processes such as verifying patient identification (ID) (Henneman et al., 2008, 2010; Marquard et al., 2011). Furthermore, it has been used to identify differences in the VSPs of nurses who do and do not identify errors. Marquard and colleagues found that nurses who successfully identified errors while administering a medication had different VSPs than those who did not identify errors. For example, nurses who identified errors completed more process steps, had many more fixation points, and had shorter transition times in similar amounts of time than those nurses who did not identify errors.
Eye tracking has also been used to study the effects of interruptions on nurses' behaviors during routine care processes, such as administering a medication in a simulated emergency department setting. Marquard et al. (2011) conducted a study to determine whether differences in nurses' behaviors and VSPs during the medication administration process (with and without interruptions) influenced the nurse's ability to identify patient ID errors. The researchers found that subjects who did not engage in off-topic discussions (i.e., not respond to the interruption) initiated by the simulated patient tended to identify errors more frequently (p < 0.05) than subjects who did engage in off-topic discussions.
Eye tracking has also been used in medicine to evaluate the frequency with which emergency medical providers in a simulated setting correctly verified patient ID during computerized provider order entry. Findings suggested that a high number of medical providers missed patient ID errors during computerized provider order entry because they did not look at information needed to identify the error (Henneman et al., 2008). Another study, using both eye-tracking data and direct observation, lent further support for the existence of patient ID errors in a simulated emergency department setting (Henneman et al., 2010). In this study, one third of subjects (n = 61), who included clerks, nurses, and technicians, failed to detect an embedded patient ID error.
Recently, videos of an individual's eye-tracking behaviors were used as a debriefing approach following participation in a clinical simulation (Henneman et al., 2014). Eye-tracking technology was found to be useful in improving certain patient safety practices, such as those related to patient ID, but did not influence other behaviors, such as those related to knowledge of medications or treatments. This finding is logical in that eye tracking allows the student to visualize artifacts but does not necessarily impart nursing knowledge.
IMPLICATIONS FOR NURSING EDUCATION AND PRACTICE
Implications of using innovative eye-tracking technology to evaluate and improve nursing student and practicing nurses' safety behaviors are demonstrated in the following scenario. At a large east coast university, a senior nursing student was evaluated using eye-tracker technology during a clinical simulation that focused on patient safety behaviors during the administration of medications. Before administering medications, the student asked the patient to state his name, DOB, and presence of allergies. The student, being observed by a nursing instructor via a one-way mirror, appeared to look at the patient ID wristband as the simulated patient responded and then administered medications. The nursing instructor marked the evaluation criteria of "confirms patient ID" as being "met."
When the instructor and student reviewed the simulation medication administration video containing eye-tracking data, it was clear that the student did not look at the wristband as the patient stated his name and DOB. Rather, the student looked at the patient's intravenous (IV) catheter, which was located 6 inches above the patient's wristband in the antecubital area.
In this scenario, eye-tracking data showed that the nursing student did not assess the patient's ID wristband but was assessing the IV site. Despite the instructor's expertise and attention, the instructor was initially mistaken about the student's checking the wristband for the patient's name and DOB. The student and instructor were both surprised when eye-tracking data demonstrated that only the IV insertion site, and not the patient's wristband, was assessed. The student then acknowledged looking at the IV site and not at the patient's wristband. Had this simulation not used innovative eye-tracking technology, this student would have passed a simulation where, in fact, critical patient safety criteria had not been met.
CONCLUSION
Using innovative eye-tracking technology offers the potential for unprecedented, objective insight into how high-risk and/or complex health care processes are performed. Data derived from eye tracking can be used to teach and evaluate nursing behaviors that improve patient safety.
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