An NFC Approach for Nursing Care Training

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1 An Approach for Nursing Care Training Jesús Fontecha, Ramón Hervás, José Bravo MAmI Research Lab, University of Castilla-La Mancha Ciudad Real, Spain {jesus.fontecha, ramon.hlucas, Vladimir Villarreal Technological University of Panama Panama, Republic of Panama Abstract Nowadays there is a need to improve the life quality of people in different social environments. One of the main fields to propose new improvements is healthcare. In this kind of scenario, health workers are doing a very important job because they are responsible for providing appropriate care to their patients. However, they are complaining about the complicated use of healthcare applications. In this paper, we describe a developed system based on technology and touching interaction (as a complement) to help nursing students to perform patient care tasks with simple interactions, including medication administration, clinical tests, and vital signs supervision among other. This goal is achieved through services deployment in the environment. Moreover, we have evaluated the developed prototype in two Nursing Schools obtaining interesting results. Keywords Ambient Intelligence, Nursing education, Near Field Communication, Natural Interaction, Touching Interfaces. I. INTRODUCTION Ambient Intelligence is a paradigm based on Ubiquitous Computing initiated by Mark Weiser [1] that presents a new interaction model where information is integrated strongly in activities and everyday objects. In an Ambient Intelligence environment, devices work to support people carrying out their activities in a natural way. In healthcare, the Weiser vision is not being played out successfully. The complexity of information management in a health scenario makes difficult the application of this approach. However, a proper user technological adaptability and the use of new pervasive technologies provide us reasonable solutions to this problematic. Moreover, thanks to natural interfaces and new interaction mechanisms, we can facilitate the information management to health workers. We have developed a nursing education system to support nursing students in the performing of several tasks related to their future professional work. For that, we have used technology combined with touch interaction and a touch-based services approach. All proposed services have been implemented and then evaluated with nursing students and teachers. They do not need understand the operation of the system but interact with different elements distributed by the environment for getting these services. This interaction is not implicit, but a simple touch is only needed. Also, it is complemented with touch displays for managing and synchronizing clinical records of patients. This paper is organized into five sections. Section 2 analyzes related work about technology integration in healthcare environments, representing our motivation. In Section 3 we present our approach, an application in nursing care and the interaction with distributed tags. Section 4 describes the developed module for nursing education and deployment services through interactions. Also, the behavior of our system is presented. Section 5 describes an evaluation of the module by means of experiments with nursing students. The most relevant results are presented in this section. Finally, Section 6 analyzes the conclusions and contributions of this paper. II. RELATED WORK AND MOTIVATION There are many studies and proposals to support the integration of new technologies in hospitals. There is a wide range of relevant studies such as approaches for telemedicine, patient monitoring, location and identification services, intelligent system for emergencies and clinic information management among others [2]. Incorporation of new technologies in healthcare environments has not been very effective because of the difficulty of its handling and integration in this heterogeneous scenario. In fact, a high percent of clinical staff is reticent to modify their daily way of work even knowing the practical benefits that these technological approaches offer. We have seen the use of PDA or Tablet PC devices has not achieved the expected results. In [3], Roy Want analyzed the gap between computational advances in healthcare and their actual applicability, and he asked if computers work efficiently in hospital. He also argues that the Weiser approach had not expected success. We can speak of a certain frustration degree about it. However, innovative research lines such as Ubiquitous Computing, Context-Awareness and Natural Interaction can reduce that gap and help in the final user acceptance. In these matters, Favela in [4] analyzed the daily workflow of hospital nurses, medical interns and physicians identifying that the time spent by these health workers for information management represents up to 20% of their time. This fact reduces the time that the professional dedicates to their patients in a face-to-face way, causing a loss of contact with these people. By integrating technological solutions that implicitly acquire information of the user activities, it is possible to reduce this problem and, thus, to increase the time dedicated to face-to-face healthcare of patients. Moreover, the use of pervasive technologies can offer an essential support for patient control and monitoring more efficiently. Other researches focus on the use of display devices in healthcare. Adaptive visualization of information in clinical

2 environments can make easier the performed activities and also, reduce the time spent in access to clinical records. Munoz et al. [5], propose the use of public displays for access to patient history, facilitating collaboration between doctors and nurses. A similar approach that includes contextawareness was described in [6, 7]. Bardram in [8], proposes an interactive visualization collaboration with remote users in a radiology area by means of dedicated displays. All these proposals focus on making decisions and need the collaboration among health workers. The use of mobile devices as support in hospital care is suitable because of the mobility and dispersion of these environments, and the low cost of deployment. For instance, Benelli and Pozzebon [9] propose the use of mobile phones with technology to exchange patient data between doctors and nurses. Also, Marcus et al. [10] have developed a system using -enabled mobile phones to facilitate the tracking and care of patients in a low-resource environment. Focusing on our case of study, the nursing care learning and training, there are also several remarkable works. In a research at the University Hospital La Paz, from Spain, Monzón [11] developed a study in these matters identifying two key troubles: mobile devices have not suitable visualization and data input capabilities, and tablet-pcs are not enough lightweights to be used to this kind of activities. Huffstutlerand and Wright [12] developed a prototype that was tested in the Virginia School of Nursing to train nurses using handheld devices. In [13], Alemán et al., make a review on the use of computer tools to perform several tasks in nursing education. Nowadays, more and more resources appear for nursing training. Also, we have proposed a clinical data management by technology [14], and the use of tagging context as a method of awareness for nursing care [15]. We believe that the integration of transparent and accessible technology to users, without requiring an extra interactive effort or previous knowledge, facilitates data management, reducing time and the volumes of paperwork, and minimizing errors. This is achieved through new interaction ways such as touching interaction, provided by technology. In general and in contract to the most of previous works, our proposal integrates the use of -enabled mobile devices and touching displays to make easier the training of nurses. This approach reduces the problems of mobile devices to input information because these actions are performed by a simple touch through and, also, we solve the limitation of information visualization combining the mobile device with dedicated displays. III. APPLYING IN NURSING CARE The need to achieve an improvement in health care poses a new challenge in the education of future nurses. In terms of interaction, technology is appropriate to support users with certain technological inexperience. With mobile devices, nurses can perform different tasks related to patient care through simple interactions. An example of this is when a nurse has to administrate a medicine to a patient, nurse approximate his mobile device to a medicine tag and then she/he touch the patient bracelet. Providing natural interaction mechanisms to meet the patient needs is possible nowadays thanks to this kind of technologies. We have developed an education module to support nursing students in several patient care tasks. The aim of this system is to reduce the information management from the environment and the implementation of this system in a hospital plant would increase the time that nurses spend with their patients. For this, each nurse has associated a phone. Turn, the mobile phone can interact with RFID tags (known as tags) distributed by the environment. The necessary process is launched automatically when the interaction happens. It is possible thanks to the internal mechanisms of MIDP Push Registry 1 on the phone by the programming language. IV. NURSING EDUCATION MODULE In this section, we are going to detail the developed module. Using an application implemented in JavaME 2, the nurse will get different services whenever she/he interacts with the proper tag. As consequence, a touch application in a computer provides the necessary support for updating data from deployed services and performing other complex tasks. A. Touch-based services approach When the user interacts with a tag through his mobile phone, one or more services will be launched. In our case, a service is an internal JavaME process that runs when interaction occurs. The aim of these services is to update the patient clinical history or record. Different elements of the environment have associated tags for hospital routines. Information inside these tags is read and interpreted by mobile phone before deploying the appropriate service. 1) Service Taxonomy We have identified different types of services depending on its purpose. In Table 1 we have described all these identified and developed services, including the kind of interaction and the elements involved in each service. Identification services are used to identify the elements of the environment. These elements are: nurses, patients and objects. When a nurse, through the phone, interacts with her/his identification tag, the JavaME application links the phone to nurse. When a nurse interacts with a patient tag or bracelet, all done tasks and pending tasks are displayed on the phone. Also it displays patient information. Typical tasks of a hospital routine are: Medication administration. A nurse has to administer some medicaments to patients. Clinical tests and samples. For example an X-ray test, blood test and others. Taking vital signs. For example, taking blood pressure or temperature, among others

3 Type Service Description Interaction Involved Elements Identification Nurse Identification The nurse is identified when she/he interacts with her/his tag. mobile device is associated to nurse. Nurse phone and nurse identification tag Patient Identification Access & Management Object Identification Touch Display Access Clinical History Navigation Nursing Shift Change The patient information is showed when the nurse interacts with a patient tag. The object information is showed when the nurse interacts with an object tag. The nurse is identified in the touch display system. The nurse can review patients clinical history and pending tasks. The nurse takes a shift change to another nurse interacting with the identification tag, reader and the touch display. Synchronization Upload of Clinical History The nurse updates the record of the treated patients when she/he touches the reader with her/his phone. Download of Clinical History The nurse interacts with the reader for downloading the clinical histories of their patients. Control & Monitoring Medication Administration Clinical Tests and Samples Vital Signs The nurse interacts with the medication panel tags (or medicament tag) and the patient bracelet to control his/her administration. The nurse interacts with the tags of a tests panel and the patient bracelet to control his/her completion. The nurse interacts with the tags of vital sign panel and the patient bracelet to store the measured values. Table 1. Service Description & Touch Touch & Touch & Touch & Touch Nurse phone and patient identification tag (or bracelet) Nurse phone and object identification tag Nurse phone, touch display and reader Touch display Nurse phone, nurse identification tag, reader and touch display Nurse phone, reader and touch display Nurse phone, object identification tag (or tag panel), patient identification tag (or bracelet) Control and monitoring services are used to update the task list of a patient in run time, and storing results of this. Access and management services are launched when a nurse interacts with the touch screen for identifying, navigating and shift changing between two nurses. In this case, we have used an reader to transfer data (relating to access or data of shift change) from phone to the central system (Fig. 1). Figure 1. Touch Display and Reader Interaction require that the phone interacts with the reader. 2) Tagging Objects We have grouped the previous tasks in panels of tags. There are two types of panels: the actions panel and the medication panel. Each of them has a number of tags with icons to represent an action or task. Also, tags can be stuck to objects such as medicaments boxes, measuring devices and clothes. Any object in the environment can be tagged. In our case, nursing students interact with tag panels to simulate the assigned tasks. B. A specific service: Medication Administration Looking for a better understanding of a care service, we present the next example: when a nurse has to administer a medicine to a patient. So, the nurse, in this case nursing student, must follow the steps in Fig. 2. While, the synchronization services is used to upload the work done to patients to the system (known as mobile clinical record), and also, download the remaining tasks from the central system to the nurse mobile phone. Both methods

4 Figure 2. Medication Administrationn Service First, nurse through device, interaccts with an patient bracelet or tag for displaying innformation about pending tasks of this patient (1, 2). Next steep corresponds to administer medication to the patient. This coontrol is easy, and nurse only has to interact with the appropriatte medication tag on the panel (3). Finally, and in order to conffirm the action (4) nurse interacts with patient tag. Automatically, his/her clinical record is updated on the phone. Then, wheen nurse interacts with the reader, the system updates thee patient s history with the performed tasks. Fig. 4 shows a simple sequence diagram for task synchronization from a singlle patient with the central system. After attending to patients, nuurse interacts with reader to start a new sync (TaskSynchrronization). Now, device sends a request to the system throough reader bridge. It is a software module to transfer datta between device and touch system. It launches the uploadd and download services (Records_Update & Records Download) for synchronizing patient records in both (systtem and phone). Thus, new tasks are going to be available on tthe device. V. EVALUATION After development of the prototype basedd on the proposed approach, the educational module was evaluaated by means of an experiment in Nursing Schools from C Ciudad Real and Albacete, in Spain. A. Experiment We intend to evaluate the integration of NF FC technology in nursing care environments. For this experim ment, we selected 62 nursing students and 8 teachers. In it, ssome participants assumed the roles of nurses and patients, and others were spectators. The participant nurses have to pperform different tasks to simulated patients. We propose an experiment model divided iinto stages. Fig. 3 shows each of these stages. Figure 3. Experimeent Stages In the initialization stage, studen nt is identified as a nurse when she/he interacts with her/hiss identification tag. In the second one, nurse interacts with the touch screen to familiarize with touch interaction methods. In itt, nurse displays the patient history and perform tasks associateed to their patients. In the next stage, nurse interacts witth an reader for downloading all tasks, that is, mob bile clinical record. In the tasks stage, nurse interactss with the environments elements (tagging panels and patien nt bracelets) to complete all tasks. Then, the nurse sends the information i to the system through interaction with the reader. Finally, the nurse checks the updating of clinical record in the system. Furthermore, in the last stage, wee propose a shift change between two participants with the ro ole of nurse. At the end of the experiment, alll participants completed a questionnaire to analyze different isssues of this experience. In the following table (Table 2), we desscribe these issues. Block B0. The mobile phone B1. and touch technology B2. Interactions B3. Usability of the system B4. Relationship with nursing tasks B5. General rating Description Queestions about this device Kno owledge of both technologies Tou uch and interaction For measuring the usability Any y relationship between the systtem and nursing education Finaal assessment of participants Table 2. Blocks of questions

5 Figure 4. Sequence Diagram of Sync Example 1) Additional interaction based on touch displays We have used a touch screen to interact with the central system. However, the interaction for care patients is done with mobile phones. This touch screen is suitable for displaying the clinical history of patients. Also, a nurse may perform other complex tasks such as phone-system data transfer thanks to reader, without losing the naturalness in the interaction. As with technology, touch interaction is natural and is an ideal complement to the interaction. Thus, we have the advantages of both interaction mechanisms, ncluding mobility and visualization. B. Results After analysis of the experiment, we obtained numerous results. The most relevant are presented below. All participants have used a mobile phone regularly. A total of 85% of them did not known technology before the experiment. On the one hand, 73% believe that the management and visualization of information through touch interfaces is faster and more efficient. While 56% of students think the proposed solution would integrate properly in a real hospital environment. Concerning the system operation, 90% said they would remember it. This fact is manifested in 66% admitting an easy comprehension of the system. 71% believed that the integration of these technologies and systems will improve different aspects, including time, productivity, etc. related to existing systems. The proposed system would be used frequently by 57% of the participants.

6 distributed by the environment, a nurse can get services in a natural way. We have combined these processes with an reader and touch interaction mechanisms to perform more complex tasks and need to transfer data referent to patient histories to a computer. Therefore, the need to anticipate an improvement in health care poses a new challenge in the education of future nurses. From this approach, we can include mechanisms for awareness in healthcare, for example in a hospital plant. In this case, the environment, through technology, could provide different needed services according to health workers. These services are not sued directly by the user, but awareness mechanisms are going to facilitate its deployment. Figure 5. Some pics of the experiment In Fig. 5 we present some pictures of the experiment with the nursing students. To finish this section, Fig. 6 shows a chart with the final assessment of the system according to the participants. There are five satisfaction levels: 1 is the worst score and 5 the best. It means, we observe that 57% of participants valued this & Touch interaction system very positively, and only 5% did not believe in its possibilities. Figure 6. Final Assessment Chart According to the results, integrationn of the news technologies in healthcare environments is necessary, but we must consider the final user. The use of non-intrusive systems, through simple interactions, encourages the technological adaptability among users. and touch interaction is a good alternative as we can seen in this paper. VI. CONCLUSIONS In recent years, proposals for including news technologies in healthcare environments have contributed to improve patient care. However, integration of computing systems is not simple, and in many cases has been a failure. Users of these environments do not need to learn new ways for doing their jobs. But, the effective integration of new technologies in these places will be required soon. In this paper, we have presented a system based on technology to perform several nursing tasks. Through the interaction of an mobile device with tags ACKNOWLEDGMENT This work has been financed by PII1I project from Junta de Comunidades de Castilla-La Mancha (Spain). REFERENCES [1] Weiser, M., The Computer for the 21st. Century. Scientific American, 1991: p [2] Varshney, U., Pervasive Healthcare n12: p [3] Want, R. People First, Computers Second. in IEEE Pervasive Computing [4] J. Favela, M.T., L. Castro, V. Gonzalez, E. Moran, and A.I. Martinez. EstimatingHospital Workers' Activities and its use in Context-Aware Hospital Applications. in First Conference in Pervasive Healthcare Innsbruck, Austria. [5] M. Munoz, M.D.R., J. Favela, A.I. Martinez-Garcia, and V.M. Gonzalez. Context-Aware Mobile Communication in Hospitals. in IEEE Computer [6] Hervás, R.N., Salvador W.; Chavira, Gabriel; Sánchez, Carlos; Martín, Sergio; Castro, José; Bravo, José. Visualization Mosaic Carrying Out Cooperative Tasks: An Interactivee Experience. in IADIS Multi Conference on Computer Science and Information Systems (MCCSIS) Lisboa, Portugal. [7] Hervás, R.B., José; Nava, Salvador W.; Chavira, Gabriel. Interacción Natural en Ambientes Inteligentes a travás de Roles en Mosaicos de Visualización. in VII Congreso Internacional de Interacción Persona- Real. Spain Ordenador Puertollano, Ciudadd [8] Bardram, J. Hospitals of the Future Ubiquitous Computing support for Medical Work in Hospitals. in 2nd International Workshop on Ubiquitous Computing for Pervasive Healthcare Applications [9] Benelli, G., Pozzebon, A., Near Field Communication and health: Turning a mobile phone into an interactive multipurpose assistant in healthcare scenarios. Communications in Computer and Information Science, 2010(52): p [10] Marcus, G., Law, D., Verma, N., Fletcher, R., Khan, A., Sarmenta, L., Using -Enabled Mobile Phones for f Public Health in Developing Countries in First International Workshop on Hagenberg, Austria. [11] Monzón, A.Z. Las PDA en el entorno hospitalario. Mitos y realidades [cited; Available from: [12] Huffstutler S, W.T., Wright CP., The use of handheld technology in nursing education [13] J. L. Fernández Alemán, J.M.C.d.G., Una revisión de la enseñanza de la enfermería basada en las TIC. RevistaeSalud.com, n22. [14] J. Bravo, G.C., M. Vergara, C. Fuentes, R. Peña, R. Hervás and V. Villarreal. Supporting clinical information management by technology in 4th European Conference of the International Federation for Medical and Biological Engineering, ECIFMBE Antwerp, Belgium: Springer. [15] José Bravo, R.H., Carmen Fuentes, Salvador Nava, Gabriel Chavira. Tagging for NursingCare. in 2nd International Conference on Pervasive Computing Technologies for Healthcare (Pervasive Health) Tampere, Finland.