By Suzanne Harrison, RN, MSN, PhD, Director/Professor, School of Nursing, Université de Moncton, NB, Canada

Trevor Gertridge, BSc. Math and Computer Science, DevOps Engineering Lead at Medavie Blue Cross in Moncton, NB, Canada.

Paul-Eric Lagace, Diploma in Fine Craft., IT Technician, Software solutions. Environment and Climate Change Canada

Citation: Harrison, S., Gertridge, T. & Lagace, P.  (2022). Creating Kayla: A low-cost solution for febrile convulsion simulation in nursing. Canadian Journal of Nursing Informatics, 17(2).  https://cjni.net/journal/?p=10084

Abstract

Offering safe and effective care requires the development of informational and communication technology competencies. High-definition technologies and wireless devices used in simulation support the development of informational skills required in clinical settings. High-fidelity simulation in nursing education can be used as a replacement for, or an enhancement to clinical experience. Intervening with children and their families can be stressful. To address the challenges encountered in pediatric settings, a low-cost doll imitating febrile seizures was integrated into a high-fidelity simulation. This article describes the creation, implementation, and evaluation of Kayla. Three field tests helped refine Kayla before her use in pediatric clinical settings. Participant tension was palpable when she began convulsing, as was the collective relief when she stopped, thus confirming the doll’s increased realism. Realism was also ensured by the remote control of seizures via a smartphone app, and the use of remote-controlled diagnostic equipment. By presenting the development and evolution of this unique teaching tool, the hope is to inspire other nursing schools to adopt low-cost technological solutions instead of always using expensive equipment, especially when the same learning goals can be achieved.

Introduction/Background

Despite being at ease with the use of informational and communication technology (ICT), baccalaureate of nursing students must enhance ICT competencies in order to deliver safe and effective patient/client care (Canadian Association of Schools of Nursing, 2014). Participating in high-fidelity simulations which require the use of wireless technology can help students meet provincial and national ICT entry-to-practice competencies. In fact, the New Brunswick Nurses Association (2017) sees the use of ICT as a teaching tool for students and faculty.

The integration of simulation in nursing education has grown exponentially over the last two decades (Cleaver and al., 2021, Deschênes and al., 2016). When offered in a safe learning environment that poses no risk to clients, the use of simulation as a techno-pedagogical tool can produce significant benefits such as improved clinical judgment and critical thinking (Cleaver and al. 2021, Goldsworthy and al., 2019, Kim and al. 2016). Competition for clinical placement settings, particularly in specialized areas, have unwittingly contributed to the replacement of some clinical hours with simulation hours, thus offering more standardized training in highly specialized care settings, such as pediatrics. Because child hospitalization rates have steadily declined over the years in regional health centres, nursing schools have been forced to become more creative regarding clinical placements. Several studies have shown that up to 50% of clinical hours can be safely replaced by intermediate to high-fidelity simulation (Oermann and al., 2018, Larue and al., 2015, Hayden and al., 2014). However, nursing students often say, and studies confirm, that reality is key regarding the success of high-fidelity simulation use. Small et al., (2018) recently concluded that “high-fidelity simulation can help nursing students step into the real world of nursing and, as such, can help bridge the gap between theory and practice” (p. 153).

For their part, Darcy Mahoney and al. (2013) noted that the availability of high-fidelity patient simulators can be an obstacle and their use can be intimidating to instructors who are unfamiliar with their utilization. However, they believe the learning curve can be easily overcome if the computer programs are straightforward and simplified. Despite the popularity of simulation use in nursing education, these same authors indicate that few studies have examined its use in pediatric settings. In their scoping review and narrative analysis, Cleaver and al. (2021) closely examined 32 research papers looking at the use of pediatric nursing simulation in areas such as end-life care, acute care (sepsis, meningitis, sickle cell crisis, croup, and cardiac arrest), chronic care (asthma, congenital heart disease) and generalized care (pediatric assessment, child safety, medication administration, and fever management). Even though febrile seizures occur in 2-5% of all children between the ages of six months and five years (Canadian Pediatric Society, 2018) and status epilepticus is the most common pediatric neurological emergency (Stredny and al., 2018), only two of the 32 studies used simulation to help nursing students prepare for dealing with seizures in a timely manner (Kim, 2014, using a high-fidelity patient simulator and Goldsworthy, 2019, simulation device not mentioned).

In fact, for Stredny and al. (2018), time management is essential in the proper management of seizures in children, yet barriers can occur from preventative care and education to acute in-hospital management. School nurses and teachers, along with parents, and caregivers need training programs to increase their confidence and competency in administering anticonvulsants. Although not mentioned in their article, the use of pediatric convulsion simulation could help decrease some of the barriers and be an integral part of training programs.

While some educators have limited access to high-end costly equipment, forcing the need for low-cost alternatives (Mücke and al., 2020), some nursing schools can spend hundreds of thousands of dollars to develop a fully equipped simulation lab. In such cases, the focus is often placed on preparing students for the most frequent cases they will meet in health care settings. As a result, a nursing school will spend a high percentage of its budget on adult medical-surgical equipment including high-fidelity adult mannequins. According to Darcy Mahoney and al. (2013), pediatrics is a particularly challenging field to prepare nursing students for practice and few studies have offered insight into high-fidelity patient simulation use in those settings. Pediatric clinical experiences can be stressful for nursing students due to the vulnerability of the population and the myriad of challenges that accompany a pediatric patient including non-verbal patients, fear of healthcare settings, and parental anxiety (Oermann and Lukomski, 2001). Because of the numerous benefits of high-fidelity simulation, our nursing school decided to create Kayla, a low-cost doll that mimics febrile seizures. Because of the lack of informational and technical skills among nursing faculty and members of the simulation lab, help was sought out in her creation. Here is the story of her evolution.

One school of nursing’s experience

In 2010, the School of Nursing Science of the participating University implemented a competency-based baccalaureate of nursing degree containing 39 problem-based nursing learning units, five of which are pediatric related. Although febrile seizures are discussed in one case study, the integration of simulation-based learning associated with this condition happened because of a research project that implemented three evolving simulation scenarios with second- and third-year nursing students. Students were quite satisfied with all three simulation scenarios. They felt the experience helped them put theory into practice in a safe environment and better prepared them for dealing with similar situations in healthcare settings. Students also provided feedback to increase the realism of the scenarios.

Creating Kayla: Version 1.0

Prior to creating Kayla, the school of nursing only presented theoretical information regarding febrile seizure as part of a bigger lecture exploring common neurological disorders in children. A review of the literature uncovered Rideout and Raska’s 2016 article describing a simulation case study dealing with fever and seizures in a young infant. Permission was obtained to translate and adapt their scenario into French.

A generic store-bought doll, used to teach first year students how to bathe and take care of a newborn, served as the first Kayla. The doll lacked realism, it was barely life-like and the student playing the role of the nervous mom, was also asked to shake the stretcher to mimic the seizures that the doll could not produce. Student feedback and faculty observations in the Spring of 2019 strongly demonstrated the urgent need for more realism in the febrile convulsion simulation.

Creating Kayla: Version 2.0

To increase realism, a life-like Toddler Reborn Doll, was purchased from Amazon at a cost of approximately 300$ (CDN).  To mimic febrile convulsions, two wireless programmable articulated Crescendo vibrators (200$ each CDN) were purchased and attached to each arm. A long-sleeved shirt was added to hide the vibrators. Wireless vibrators were chosen to permit the start and stop of convulsions remotely behind a two-way mirror. Obstacles faced in this phase of development (Fall of 2019) included the need for two smartphones, each device linked via a downloaded app. Despite being described and rated as the best and most powerful vibrators on the market, they could not simulate a strong enough febrile seizure (little arm movement).

Creating Kayla: Version 3.0

The third attempt at turning Kayla into a proper seizure simulator happened in January 2021 when the primary author noticed the results of a relatively low-cost embedded control creation for scale models done by her husband and an extended family member under the guise of their hobby group Maudlin Modellers (both co-authors of this paper). They created a custom special effects system for a scale model of the Millennium Falcon spaceship from Star Wars (see video 1).

Video 1: Special Effects for Millennium Falcon Model from Star Wars

The model was built, but then a work colleague suggested adding an inexpensive Raspberry Pi Linux microprocessor to the model to produce sound and light effects.  The custom electronics inside the Falcon were created over the span of 1.5 years and a Creality Ender3 Pro 3D printer was used to print custom plastic parts for the interior of the model.  Lagace handled soldering and 3D part design, while Gertridge did custom software development to drive the effects. Based on the success of the Falcon special effects controller, a new seizure control system was requested for Kayla.

From January to September 2021, research and development for a seizure simulator was conducted by looking into data sheets for analogue and digital electronics, DC motors, motor control boards, as well as 3D design and printing. Parts such as a case for the Raspberry Pi computer, and cases for the vibrating motors were designed, each being iterated to ensure durability, feature function, and cost effectiveness. The free modelling application TinkerCAD was used to create the designs that were 3D printed.

Given the relatively low cost of the Kayla base doll and the fact that she had no rigid internal structures, experimentation was done to find the best way to make the doll move.  Effort was made to reduce noise production caused by the vibrating motors thus reducing student and instructor distraction during the simulation (realism distortion). Experiments were also performed to determine the best possible way to maximize the vibrations given the simplistic nature of the doll. Various types of springs, rubber stems, and balls (to name a few) were used to try to amplify arm movement.

Once the arms were moving, a mock-up was demonstrated. Pleased with the results, the team proceeded with adding simulated leg seizures to fully mimic a tonic-clonic febrile seizure. Two more motors and motor housings were created, and control software was extended to control all four vibration motors. The controller software was written on the Debian Linux operating system using Bash in Python, and Node-RED. A bilingual Kayla controller app interface was created for use with any web browser. Most of the parts for the third attempt were bought from vendors such as Amazon and PiShop.ca. Some development was done on a battery-based solution to power the entire Kayla simulator (i.e. power the controller computer as well as all four motors), but this idea was shelved because of time (see Images 1, 2, 3).

Image 1: computer and housing unit

Image 2: App interface

Image 3: Kayla connected to the computer

When ready, Kayla 3.0 was then field tested, along with the evolving febrile convulsion simulation scenarios with nursing faculty at all three campuses of the school of nursing in the fall of 2021. The primary researcher and one member of Maudlin Modellers participated in the first field trial, and it was very successful. Faculty members played different roles in the simulation scenario. The tension among the participants was palpable when Kayla began convulsing and so was the collective relief when she stopped, thus confirming the doll’s increased realism. Seizures controlled remotely via the app on a smart phone along with the use of a remotely controlled thermometer, saturation monitor, and glucometer from the Canadian company Innov2Learn also increased realism. Here is a video of Kayla in action (see Video 2).

Video 2: Demonstration of Kayla having a seizure

Because of the long clothes used to dissimulate the vibration motors, one lesson learned was the need for a slight change to the doll’s clothing so participants could remove her sweater as a non-pharmacological intervention to reduce fever. During the first field test, Maudlin Modellers also recognized that they wanted to alter the way the application connected to wi-fi.  It was changed from local in-building general wi-fi to a hotspot wi-fi to make the simulator more portable. During this second field test, part of the Kayla Controller wiring was found to be disconnected because of a faulty soldering point. Fortunately, the simulation lab coordinator was able to fix the soldering quickly prior to the trial commencing. Learning from this, the Controller design was altered by adding better connectors and colour coding them to ensure proper connections.

Kayla 3.0’s Future

While there was a great deal of interest in Kayla 3.0 as a teaching aid, the question of how often it would be used throughout the year at the school of nursing was raised.  Would Kayla be shipped from one campus to the other when needed? Would two more identical Kayla 3.0 be created so each campus could offer febrile seizure simulation?  Would Kayla 3.0 be marketed to other schools of nursing as a low cost, homegrown alternative to much more expensive simulators that are commercially available? In fact, with today’s budgetary considerations for many universities, the importance of using low-cost alternatives is becoming increasingly important. Currently, Kayla 3.0 is only used at the main campus of the school of nursing as part of a pediatric clinical simulation day with third year nursing students. Like the faculty members in the three trials, students also appreciate the unique learning experience and stated they felt more prepared to deal with convulsions in a real-life setting. The clinical instructor quickly acquired the informational skills required to make Kayla function correctly. However, the team is considering how to create Kayla 4.0, some ideas include even more reliable improved connectors, changing reliance on wi-fi to Bluetooth, and adding infant voice sounds to increase realism in the scripted simulation scenarios.  Infant sounds could be added through the Controller app.

Conclusion

The participating University’s school of nursing provides its nursing students with varied opportunities to develop informational and technological skills, using concept mapping software, e-portfolios, e-modules, and high-fidelity simulation (HFS).  In fact, Darcy Mahoney and al. (2013) found that HFS can be done effectively in pediatric undergraduate nursing education, and it can be a highly effective tool that is enjoyed by students. High-fidelity simulation can not only be used as a teaching strategy, but also as a tool that enhances a students’ clinical preparation without bringing harm to the patient. Students who learn ICT in a safe environment through their Bachelor of Nursing program can transpose their competencies into safe and effective practice. As planned, creating Kayla, a low-cost febrile convulsion doll, was successful in adding realism to the students’ learning experience. In fact, the goals of this project resembled closely those of Mücke and al. (2020) who also were looking for a low-cost simulation alternative that would be easy to use and be customizable to individual needs. One of their goals: independence from wi-fi networks, is something the Maudlin Modellers are exploring. 

References

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Author Bio(s)

Suzanne Harrison

Suzanne Harrison, RN, MSN, PhD is the current director of the school of nursing at the Université de Moncton. Her research interests are pedagogy based, simulation use in nursing is one of her passions along with the concept of resiliency in students and women.

Trevor Gertridge

Trevor Gertridge, BSc. Math and Computer Science, is a DevOps Engineering Lead. He has been at Medavie Blue Cross since 2007. His passions include photography and scale modelling.

Paul-Éric Lagace

Paul-Éric Lagace is an IT Technician offering software solutions with Environment and Climate Change Canada. He used his background in Fine Craft to collaborate and create with Trevor Gertridge in Maudlin Modellers (found on Facebook). It is their creativity and ingenuity that brought Kayla to life and enriched student learning experiences regarding febrile seizure intervention.