A scoping review of augmented reality in nursing

To answer our research question, we carried out a scoping review using a systematic search of the databases PubMed, CINAHL, PsycINFO, Web of Science Core Collection, Cochrane, ACM and AISEL. We chose databases from the fields of healthcare and technology as well as interdisciplinary databases to provide relevance for our research question.

We also checked the bibliographies of each study and used existing networks and organizations to identify additional relevant studies [24]. These networks consisted of experts in the fields of Business Computer Science and Nursing. Due to resource limitations, we did not perform a hand-search of key journals. Hits in English or German were considered. Any date of publication was acceptable. The reference manager tool EndNote was used to compile relevant literature and to identify duplicates.

This study used the PRISMA-ScR Checklist which consist a flow diagram. The flow diagram (Fig. 1) allows a transparent reporting of the literature findings based on conceptual and practical advances in the science of systematic reviews [26]. Author one (HW, nursing scientist; M.Sc. Public Health, B.Sc. Business Computer Science) and author two (JB, student of nursing science) reviewed the titles and abstracts using the inclusion criteria (Table 1). Only articles written in English and German were included because of the authors linguistic background. Articles chosen by both reviewers were automatically included. Articles chosen by one reviewer were audited by a third independent reviewer (MG, gerontologist in the field of nursing in technology; M.A. Health Care Management, B.A. Gerontology). The full text of the remaining publications was then reviewed.

A majority of the studies did not describe the methods used for case identification, but three studies described them in detail. One publication used qualitative methods to identify relevant use cases [27], and one publication used quantitative methods [28]. One study mentions the combination of a literature review and interviews for use case identification [29]; however, the remaining twenty publications do not describe any methods used for use case identification.

The use case studies included here can be separated into the fields of nursing education [28, 30‐39] and clinical settings [27, 29, 31, 40‐47].

After use case identification, the process of requirements elicitation followed. Among the identified studies, the requirements elicitation was described with varying levels of detail. These varying levels are as follows: methods used for software development, the use of less standardized methods and no explicit methods used for requirements elicitation. In regards to software development, user-centred design [29, 44] and design science research methods [39, 47] are mentioned. In regards to less standardized methods, interviews and shadowing [27], the inclusion of an experienced nurse [42], iterative design and working ground [45], and analysing training sessions [32] were used.

Many of the studies without a method of requirements elicitation did not require one as no new applications were developed. The innovative aspect was the usage of an existing application in a new field [30, 31, 33, 40, 43]. Furthermore, eight studies did not describe their performed requirements elicitation [28, 34‐38, 41, 46, 48, 49].

Sixteen of the publications reviewed here performed evaluations with different aims. Most of them were broadly defined, e.g., Schneidereith states that the aim of her evaluation was describing errors in medication and administration, whereas Grünerbl et al. listed a range of questions to evaluate. Some studies focus on evaluating one specific application, task or device [30, 31, 36, 37, 40, 43, 46, 47], while others aim to get evidence of the type of task or device suitable for applications [29, 32, 34, 35, 41, 42]. In addition, two publications focus on providing general insights by evaluating specific applications [27, 33].

Conversely, seven studies did not conduct any evaluations. Two of them describe only the design process of an application [39, 44], whereas the other focuses on the development of a guideline instead of an application [45]. Additionally, some articles focus on a broad overview regarding the use of AR [48, 49]. One study refers to another publication describing the evaluation [28], while one article describes its prototype without an evaluation [38].

A variety of evaluation methods are described in these publications. Both qualitative [29, 30, 47] and quantitative methods [28, 32, 35, 40, 43, 46] were used separately, but the majority of studies relied on a mixed methods approach [27, 31, 33, 34, 36, 37, 41, 42].

Each of the included publications describes the potential use of AR in nursing. Different advantages of using AR are mentioned including hands-free usage of a device [27], reduction in the anxiety of patients [40, 48], time savings [33, 46], individual visualization [28], easy information retrieval [29, 32, 33, 41, 42], observation from different perspectives [30, 37, 43], increased accuracy of documentation [47], and support of simulations [31, 34, 36, 39].

There are possible negative effects including the need for attention on the device [29]. This may be critical as it takes away focus from the patient [33]. Furthermore, communication with the patient may become challenging [47]. In addition, due to concentration on the system, other hints may be missed [31].

Table 3 the devices used to identify technical challenges. Most of the studies used a Smart Glass, but some used a Smart Watch, a Head Mounted Display, a Helmet Mounted Display, a Smartphone or a Tablet. Some combined different devices, and one did not specify the device used. Technical challenges were identified during the use of each device.

Identified use cases focus on specific fields of use, and use case identification and requirements elicitation are often not described in detail. In addition, we determined that the results of studies evaluating AR in nursing were predominantly positive; however, several technical challenges are described for most of these devices. Moreover, most applications could be identified as prototypes in an early stage of implementation. The settings in which the studies operated are noteworthy. While twelve studies can be grouped into a broad clinical setting with the variation in use cases, eleven studies are set in the field of nursing education.

We found that many studies focused on obtaining knowledge on the applications developed instead of the effects of technology inclusion on nursing. No studies questioned the clinical relevance of their results. Considering context while evaluating applications would be another goal for future research. This could be achieved through performing field trials for longer periods of time.

For future development trends we infer that further technological advances will lead to new use cases for AR in nursing. Which may be developed rapidly and need to be investigated in question of added value and impact, afterwards.

Although the inclusion of values into technology development [50] and the design of technologies in nursing are needed and the “unreflective handling” of technology in nursing is occasionally criticized [51, 52], our review shows that values are only barely recognized for designing and evaluating AR in nursing. Methods such as Value sensitive design may integrate values to shape the design of technology [50]. According to the literature, these methods are not currently being used in the development of AR in nursing.

Implementing technology into a new field when there is not a demand for it is called the technology-push approach. This approach is criticized as it introduces technology without any real need and may not solve problems [53]. Therefore, we argue that careful evaluation is especially reasonable in these cases.

Furthermore, our results show that the evaluation methods used in the literature did not include the whole context of technical implementation. Some authors claim that the context of technological implementation is important [54], but most publications did not agree or take the effects of these evaluated technologies into account.

For these reasons, we conclude that future publications should focus on performing long-term evaluations to take framing conditions and the long-term consequences of AR use into account. It is to mention that AR is still in a process of various technical improvements which can only be predicted to some extent. We argue though, that long-term evaluations of newly implemented or soon to be implemented applications and devices will be beneficial to further works. As some of the emerging findings will be transferable onto technical improvements yet to come, it might also prove useful to explore a broader range of evaluations of AR applications in different contexts. On the one hand this could be additional studies from the field of healthcare with and without mentioning nursing. On the other hand it could be useful to take different fields without any direct link to the healthcare sector such as design and manufacturing [6] or maintenance and logistics [2] into account. This could allow to learn from possibly made mistakes in other areas as well as to get a more differentiated view on problems specific to the field of nursing.

This review provides information for future research regarding AR in nursing; however, our findings are limited and must be interpreted with caution. First, we identified a relatively small number of studies that focused on AR in nursing. Second, we did not assess the quality of the studies included because this is a scoping review [24]; thus, studies with varying quality are included, and the results may have limited reliability. Third, negative results regarding AR in nursing may have been missed due to publication bias. Forth, studies did not focus on specific elements of nursing and did not focus on long-term implementations.