Contemporary Nurse

ISSN: 1037-6178 (Print) 1839-3535 (Online) Journal homepage: http://www.tandfonline.com/loi/rcnj20

Augmented reality, virtual reality and gaming: An

integral part of nursing

Dr Caleb Ferguson RN, BScN, MHlth, PhD, Prof Patricia M. Davidson RN, PhD,
FAHA, Prof Peter J. Scott, Prof Debra Jackson RN, PhD & A/Prof Louise D.
Hickman RN, MPH, PhD

To cite this article: Dr Caleb Ferguson RN, BScN, MHlth, PhD, Prof Patricia M. Davidson RN,
PhD, FAHA, Prof Peter J. Scott, Prof Debra Jackson RN, PhD & A/Prof Louise D. Hickman RN,
MPH, PhD (2015): Augmented reality, virtual reality and gaming: An integral part of nursing,
Contemporary Nurse, DOI: 10.1080/10376178.2015.1130360

To link to this article: http://dx.doi.org/10.1080/10376178.2015.1130360

Accepted author version posted online: 17

Dec 2015.

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 Publisher: Taylor & Francis
Journal: Contemporary Nurse
DOI: 10.1080/10376178.2015.1130360

Augmented reality, virtual reality and gaming:

An integral part of nursing.

1) Dr Caleb Ferguson  RN, BScN, MHlth, PhD  Faculty of Health, University

of Technology Sydney, Australia

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2) Prof Patricia M. Davidson  RN, PhD, FAHA School of Nursing, Johns
Hopkins University, Baltimore, USA
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3) Prof Peter J. Scott  Assistant Deputy Vice Chancellor (Education),
University of Technology Sydney, Australia.

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4) Prof Debra Jackson  RN, PhD, School of Nursing, Oxford Brookes
University, & School of Health, University of New England, Australia.
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5) A/Prof Louise D. Hickman  RN, MPH, PhD  Faculty of Health, University
of Technology Sydney, Australia.
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Corresponding Author:
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Dr Caleb Ferguson, RN, PhD

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Faculty of Health, University of Technology Sydney, Australia

PO Box 123, Ultimo, Sydney, NSW, 2007.
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Tel +61 2 9514 4576

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E: Caleb.ferguson@uts.edu.au
Twitter: @calebferg
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Introduction
A powerful quote by Michael J. Fox beautifully illustrates that ‘we should teach
the way people learn’. Academics and nurses have to adapt their teaching
approaches to accommodate the learner, as people learn in many different
ways. Augmented reality (AR), virtual reality (VR) and gaming provide an
immersive learner experience, more than ever before new ways of learning
are needed and this applies to academics, students, nurses and patients.
These technologies can be utilized in many settings to assist in health
 behavior change interventions, optimize care, and improve health outcomes
of individuals across all care settings.

Drawing on the ubiquitous influence of technology that is cost-effective, and

the pervasive nature of smart phone technology to enhance how we learn and
how we can access education is essential for keeping up with the latest
research and practice issues. When used appropriately these technologies
provide tools for nurse educationalists to enhance teaching and learning in all
on-campus, off-campus and clinical settings. The current ranges of

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technologies literally transform any context or situation into a learning
opportunity. These technologies can mean that expert help is at hand for
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nurses in the clinical environment, and that information and learning support

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can be accessed as needed. Academics with responsibility for curriculum

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renewal should integrate AR and VR as contemporary teaching and learning
strategies for students. Further, health facilities should ensure the upskilling of
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their existing nursing workforce to best apply AR and VR technologies across
all types of care settings.
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Technological innovation and the World Wide Web have heralded a new era
in healthcare. AR, VR and gaming applications are set to be the next big wave
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in the technological revolution in practice and education for both patients and
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health professions. Gaming, AR and VR interventions have broad applicability

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in practice, examples may include; using a virtual classroom as a component

of patient education, supplementing a cardiac rehab program with an AR
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iPhone game, or incorporating videogames as part of a stroke rehab program.

In this editorial, we explore the impact and potential these technologies may
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have on healthcare innovation, nursing teaching and education.

Gaming is the act of playing games. Games range from table top, puzzle, to
video games, and role-playing games. Whereas gamification is an umbrella
term used to describe the process of using gaming to engage individuals in
non-game environments, including healthcare settings.1 There is increasing
interest in gaming and its potential to contribute to teaching and learning in
healthcare, and there is a broad range of opportunities for nurses to leverage
 the benefits of gaming and gamification to assist in health behaviour change
interventions, optimise care, and improve health outcomes of individuals
across all care settings. Gaming has the appeal if being fun, socially
captivating, interactive, whilst being challenging, yet relaxing.2
Gaming can be used in conjunction with other technologies to (re)create a
range of clinical scenarios and, importantly, allows the user to follow a range
of pathways. Virtual reality, defined as an immersive multimedia, or computer
simulated realities, is one such example. Virtual reality can artificially recreate

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experiences for the user, including all of the senses, including sight, hearing,

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touch and smell. Augmented reality bridges ‘virtual and real worlds’,
supplementing, rather than replacing, reality.3 Augmented reality supplements
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the real world environment and augments the user experience with computer

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sensory input, such as sound, video or Global Positioning System (GPS) data.

There has been a rapid increase in the uptake of social media and smart
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phone technologies in society and these technologies have also been taken
up in health care.4 Within education, the potential for timely engaged learning
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is endless, whilst for patient care the possibilities presented by these

interactive technologies to improve self-management and enhance patient
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engagement with health care support are exciting and need to be explored.5
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Gaming can positively influence health behaviours

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The possibilities of integrating augmented reality applications, when used with

other existing technologies such as GPS and smart phone technology are
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endless. Combining these technologies with traditional methods of nursing

care, may assist in improving adherence to traditional models and lead to
improved health literacy and better outcomes. These technologies are
developing at a very rapid rate, and so the evidence is still being gathered
about the efficacy to patients with some studies showing a positive influence,
while others unable to demonstrate any changes.6 However, as nurses we
need to consider the potential of these technologies and the innovative uses
to which they could possibly be put. There are opportunities for clinicians to
connect with this technology, not only for educational and learning purposes
 but to enhance professional networking and support, reduce professional
isolation (particularly for lone or remote practitioners), and for integrating
augmented reality applications, which are no or low cost (free to download),
into traditional models of primary and secondary prevention programs.

There is an increasing move to out of hospital care, and to the development of

alternative care models for people with acute and chronic illness. Caregivers
are also predisposed to social isolation and can have changing needs for

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education and support, as well as a need to sometimes spontaneously make

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contact with professional health care support. Again, these technologies could
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represent a cost-effective option for providing the support needed by

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caregivers.

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The subsequent case examples highlight a few of the implications for nursing
practice and education:
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Virtual and Augmented Reality in Nurse Education
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Second Life is a computer-based virtual reality environment that has been

widely adopted by some nursing educators as a valid learning platform. It is
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set up as a 3D virtually simulated environment. Second Life is the world’s

most popular 3D virtual reality platform. Nursing schools have successfully
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adopted this platform to enable and support student learning across a virtual
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reality environment. Students have reported positive learning experiences,

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and found this to be an immersive and interactive learning process.7,8

GhostHands is a novel augmented reality interaction concept, that overlays a

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student’s field of view with the virtual hands of an expert modelled in real time,
from the position of the expert’s remote, real hands.9 This innovation,
provided as real time, distance modelling to students, may help to improve the
quality and safety in the healthcare system, and help to reduce costs of
training. GhostHands could easily be applied to postgraduate nursing
education for peri-operative theatre nurses, for example in learning instrument
set up and handling in the operating theatre environment. Educators would be
able to guide students from a distance, in real time, to pick up surgical
 instruments, and learn how to handle these appropriately. Real hands in real
time are much more expressive and powerful than any icons or videos.
Lecturers could guide in person from afar, however provide augmented reality
‘hands on’ advice to students on instrument selection. As nursing is a very
‘hands on’ and often technical profession, GhostHands has real potential for
innovative solutions to creative learning environments.

Wii Fit for upper limb rehabilitation for stroke survivors.

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The Nintendo Wii Fit is an active technology game used in stroke

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rehabilitation as well as to increase physical activity. This videogame,
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originally released in 2007, challenges the stereotype of videogames

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contributing to physical inactivity, and sedentary lifestyle.1 Traditionally,

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videogames have attracted negative health connotations such as sitting on
the sofa for a long period and consuming unhealthy junk food. However, today
videogames including the Nintendo Wii-Fit can lead to health benefits and
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better health outcomes, particularly for those living with chronic conditions
including stroke and dementia.10-12 Individuals or multiplayers may choose to
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participate in games, such as skiing, indoor ten-pin bowling, or ping pong

using the Wii Fit remote controllers.
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Augmented reality smart phone application games to improve

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cardiovascular health and physical activity goals.

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Applications such as INGRESS and ZOMBIES, RUN! are augmented reality

applications that have the potential to increase physical activity and improve
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cardiovascular health, particularly in the adolescent population. Nurses may

consider this as part of a person-centered care intervention to increase the
physical activity of younger people. Within contemporary practice, due to the
frontline nature and accessibility of nurses, we are often asked for
recommendations of health applications, particularly in the primary care
setting. This example demonstrates the importance of nurses being up-to-
date with health and gaming activities, and being appropriately skilled in
appraising the quality and appropriateness of gaming applications when
recommending these to patients.
 Summary
The emergence of exciting new technologies such as enhanced gaming and
virtual reality technologies provide endless opportunities for nurse innovation
in a range of key areas. We have summarized the potential importance and
possibilities that games and gaming can bring to nursing, as an adjunct to
professional engagement as well as to patient care and nurse education.

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Increasing the use of game-based approaches in health care interventions

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may lead to improved outcomes, particularly in health prevention strategies
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and in chronic care settings. Nurses should consider developing and applying

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game based strategies to care, particularly leveraging the ‘fun’ aspect of

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gaming and the ability to present a range of scenarios and promote
engagement. With all nursing interventions it is important that we consider if
these are ‘fit for purpose’, and carefully examine the efficacy of our
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interventions. Personalisation of gaming interventions that focus on the needs
of individuals may help to provide a greater sense of control and may be
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helpful to motivate individuals to achieve their health goals. Nurses may find it
helpful to identify current games and technologies, and personalize these as
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part of a patient-centered, goal-oriented care planning activity.13 This will

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require engaging a new suite of skills and technological partners to improve

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access to this innovative strategy.

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