A Nurse First

Embrace the unexpected

• Sigma Nursing • Season 5 • Episode 6

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The beauty of embracing uncertainty lies in the potential for serendipitous discoveries. Each step Ronald Hickman took, whether through mentorship conversations or pursuing postgraduate education, opened doors he had not anticipated. The unexpected moments became stepping stones that shaped his career and research, demonstrating that the path to success is rarely linear. Instead, it is often a winding road filled with detours that can lead to even greater achievements—like being inducted into Sigma's International Nurse Researcher Hall of Fame for his avatar-based simulation research to aid decision-making for families of ICU patients. 

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A number of folks who were very instrumental in my life, in my professional life and my personal journey, were already part of the International Nurse Research Hall of Fame. And I remember as a young doctoral student and an early career faculty member looking at that award on their shelves and always thinking, one day, I want to be just like them when I grow up, right? My program of research has largely focused on how to use avatar based technologies or simulations to guide informed decision making among surrogate decision makers or family members. making decisions for cognitively impaired ICU patients, as well as individuals aiming to promote healthier lifestyles and behavior change to manage an illness or their overall health. So, I must admit, when I received the International Nurse Research Hall of Fame, I was ecstatic to be able to say that I've contributed in a meaningful way, both in the United States and internationally. To be able to say that I've done something that's brought in new perspectives into the discipline, but also brought in, I also shared those perspectives outside Welcome to A Nurse First. This is Ronald Hickman telling his own A Nurse First story. I talk about the unexpected. This was an unexpected focus of my research program. When I was beginning my research program as a postdoc, We are all trying to develop or cultivate a program that's innovative, something that's a departure from what is currently existing so that we can positively impact the target populations we're interested in and move the needle forward on some perplexing problem. And for me, my problem was focused on how do we get good information to patients and families in the ICU so that when the patient is unable to make a decision for him or herself or their selves, the family member can step in and provide goal-concordant care. And there has been a lot of work to date that has been done, but a lot of the research in that space has not found truly effective interventions. So early on, I was exploring strategies, interventional approaches that might help to improve this perplexing problem of how do we enhance the quality of shared decision-making in the ICU, improve quality outcomes such as goal-concordant care. But there was an unexpected opportunity that arose with one of my mentors, and he asked me to join his team and write a grant. At the time, it was a challenge grant, and they were looking for really bold, new ideas. So he had proposed to use technology to help inform health behavior change, and he knew that I was steeping in this cross-disciplinary literature on behavior change and decision-making, and he said, Ron, I really think You'd be an excellent addition to our team as we think through this bold new idea. So as a team, we started thinking about what could help people, consumers of health care, make more effective behavior changes around chronic illness behavior, particularly self-management of diabetes, chronic lung disease, and high blood pressure. As you know, three major chronic illnesses that affect most adult Americans in the United States and even worldwide. We thought about an opportunity we use with training healthcare providers, and that is simulations. And so we were thinking about how could we create these experiential learning activities or strategies that would be deployable without having to bring patients or people in. And so we talked about, could we deploy these simulations using technology? And we came up with avatar-based solutions to allow individuals to practice sort of having conversations with their providers and then engaging with avatars, these conversations that sometimes are difficult, so that they could have confidence in sort of negotiating, getting what they needed and wanted from their healthcare providers. At the time, as a young person back then, I didn't know much more about avatars than the James Cameron movie. with the blue characters. I mean, that literally was sort of the time frame, which all of this was coming up. And so I didn't really understand it. And I was probably one of the biggest skeptics on the team was whether or not these 3D, three-dimensional characters that we would build in realistic settings would actually provide benefit for adults. I just thought that it would not work. Lo and behold, we got funded for this particular study that many individuals around us thought was something that was too out there. It was too innovative, too bold, but it got funded. The National Institutes on Minority Health and Health Disparities. And we used a relatively, what I would say, novel design at that time, now almost looking back almost two decades earlier, where we engage people with the lived experience to help us co-create these simulations. and we used actors, we wrote scripts, then we developed a software technology called eSmartHD, which was our first avatar-based solution, and pilot tested that in three groups, folks living with high blood pressure, individuals with diabetes, and individuals with chronic lung disease, particularly asthma and COPD. and we've seen positive changes with that work. That led into some spinoff opportunities where we started to look at young adults who were suffering with anxiety and depressive symptoms and whether or not that platform would be a good platform for young adults who needed to better manage their self, their mental health. And we went in that population because we thought younger adults would be receptive to the technology and they were. And in a similar fashion, there was positive results where we saw substantial reductions in depression and depressive symptoms in those in young adults who received our interventions. And in 2014, our intervention focused on mental health. eSmart MH was highlighted by the White House as one of the most innovative behavioral These highly realistic 3D virtual environments for healthcare training use photo assets from local hospitals to design immersive spaces where learners navigate as first-person avatars. In these virtual worlds, individuals interact with healthcare providers and patients, practicing effective communication skills in a controlled setting. With the data showing such success, Ronald began to wonder how he could apply it to make an impact in his area of passion, And that led me to think about how could we apply this technology to help with informed decision making in the ICU, because it hadn't been done. As I'm evolving and trying to develop my research program, I said, you know what, I've been involved with this project. It's been shown to have effectiveness across different target populations, why don't I apply it to my own context with family members in the ICU? And we weren't quite ready to take it to the ICU, but one of my first federally funded projects was to do a clinical trial that looked at how can family members better be supported with an avatar-based solution to support long-term care decisions, placements in nursing home, feeding tube decisions, DNRs, and so forth. and we saw some positive signals there, which led to additional research funding, another R01 from the National Institute of Nursing Research, which also proved to us that we were making some positive effects on improving decision-making in the context of end-of-life decision-making for ICU patients, which again was where I wanted to go with it. But this work started to pick up, and what we learned was it wasn't just the platform. It was about this experiential learning aspect, which we think is the secret sauce. This platform allowed the deployment of simulations that allowed individuals, patients, families, and even health care providers to practice whatever it is that we were teaching them in a safe virtual environment so that they could go off in the real world and actually do these things. We take a lot of care to make sure that the virtual environments are realistic. If anyone's ever played a role-playing game in their life where that means you're a first person, where you're navigating the scenes, and that there are digital avatars, healthcare providers, other patients wandering around, But we teach them a set of ways to be effective in their behaviors, how to mostly communicate with providers using a mnemonic called SBAR3, share your story, bring your background, ask for what's right for me, review the plan, repeat the plan, and if need be, repeat the conversation if it's not going the way that needed. And so that is a strategy, a cognitive behavioral strategy. that has been fundamental to all of our avatar-based solutions. Even the personalities of our avatars vary. You don't get a static platform. You may have a very moody receptionist. We've never, ever encountered that, right? Like, you know, the quick, snippy receptionist versus the one that we always want, which is that nice, pleasant, smiling receptionist, to a doctor or a health care provider who is also, maybe does not have the best bedside manner, but you got to navigate all these contacts. Other aspects that we pay attention to is that we know that in certain groups of people, racial concordance matters between a patient and their provider. People tend to feel more comfortable with people who look like them. But we also have tried to create mismatches in that so that those individuals can practice still getting what they want or need through their health care encounter, even when folks don't look like them or behave in a way that they think would help them the most. Another feature that we think also provides support is that embedded into this feature is a digital coach. And this is something that our participants told us early on, that even having the presence of someone in there that could be empathetic and that could help them navigate some of this and provide them a little bit of behavioral reinforcement was critical. And we took a lot of time to really create our coaches. Coaches are racially ambiguous. We took a lot of social psychology and thought about gender, gender and comfort. Our coaches are mostly female, but you can choose the gender identity of your coach. But more importantly, the coach is someone that helps to, I think, really provide some emotional support that helps to, what I call, extinguish some of the hotness of the moment. When we think about social psychology or psychology pieces, We know that emotion is a big trigger for most folks. And so when you're in stressful situations in a doctor's office or making difficult decisions about a loved one, or even making decisions about cancer care, we know that emotions sometimes hijack a particular part of our brain called the prefrontal cortex, where a lot of our executive function is. And a lot of what we've done in the past in this area of supporting behavior change and informed decision making has focused on just supporting individuals getting lots of information, but we haven't done a really good job of emotional supports. And so our coach helps us tend to the emotional piece, helping to decrease some of that emotionality so that There is resources available to the prefrontal cortex to allow people to take in that information and then maybe make good judgments, including around health care or behavior. We use a lot of things to enhance the realism, voiceovers, coaching to help address some of the emotionality that does occur in these fairly high stress, uncertain situations that we deal with in health care. And I think those elements plus some behavioral cueing, really has made this to be an effective platform for both informed decision making and behavior change. Looking back, we were literally at the forefront. We leaned into the journey. We knew we were venturing into something where it hadn't been done before, but that was also very exciting in and of itself. And we made some mistakes along the way, and we continued to learn and stayed open. I think it was something that We didn't necessarily want it to sought out to be the first. We just wanted to see if this technology indeed could lead to effective behavior change. And it does. I think it was to be at the early stages of anything, let me tell you, but there was a lot of uncertainty. Oftentimes the research in terms of developing effective program research doesn't happen overnight. And I think that's what's one of the biggest challenges, or even deterrent, that there's a lot of invisible work, a lot of work that doesn't always end with any form of gratification. Most often you get a lot of rejection in terms of manuscripts and grant submissions. And it's not always easy, but the rewards are great. And I think the impact is greater at the macro level. And with the research that most of us will do and carry out, it can create an evidence base that can impact systems of care, policy, if one stays the course. Now we're probably one of the foremost teams to do this type of work in a very systematic way, in a very thoughtful way, a very theoretically driven way as well. And we have the evidence to support how certain features will aid in the effectiveness of these types of platforms. I think the future could be quite bright for this area. And there's just so many applications from chronic disease management, cancer care conversations. Gosh, I think we're only bound by our creativity now. I think the technology used to be a limiting factor. Now more Americans have access to the technology, whether through their smartphones, laptops, or even technologies such as a lot of the goggles and Most of us struggle with the discomfort of uncertainty. We want to see a clear path forward. But you found your path almost in reverse, by leaning into the unexpected. Why is it important to embrace what Because as you go through it, there could be something extremely wonderful and more than you could envision if you just stay the course. And I see a lot of young people in my current role uncertain about what lies ahead, which can sometimes, that fear can sometimes serve as a form of paralysis and not allow them to get through some of the challenges or just to just live through the uncertainty to come out of it and really enjoy what have lied ahead of them. Continue to lean into those unexpected opportunities that not knowing and having some uncertainty is par for the course and that these things will oftentimes work out. And in our case, it's worked out for the best. And when I look back on this entire journey, whether the transition from thinking about being a doctor versus becoming a nurse to getting a PhD to postgraduate education and that all the conversations it took with mentors. who got me into becoming a faculty member and lo and behold being an endowed chair and associate dean for research and all of those things really at the beginning of all this was not an input an end point that I would have ever envisioned and along the way became first of many things along the way. first African-American man to graduate in our PhD program, which is one of the third oldest programs in the United States, first African-American male to earn tenure in the School of Nursing to hold endowed professorship, as well as a leadership position. And I don't wear those first as always badges of honor. I wear that as a reminder of the work that we have to continue to do to ensure that nursing and other health professions remain to be diverse, diverse in multiple ways, as a gender diversity and racial diversity, diversity in sexual orientation, and even in thought. And so the journey was unexpected, but I have leaned into those unexpected moments and opportunities, and hopefully have had a small impact on this field called nursing. I'm appreciative of the designation to be known as an international nurse researcher inducted into the Hall of Fame. And so it's actually given me the freedom to sort of pause and think, you know, avatar-based simulations are great, but now I'm at a point of a career where I can lift my head up and not look so focused on each step forward, but to look at the horizon and think through, how do I get to wherever I want to go and each step make it more impactful? But I got a lot left Thank you for listening to A Nurse First from Sigma. 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