Differences in Brain Activity of Skilled and Novice Nurses during

Blood Collection

Naoki Taira

, Yukie Majima

, Seiko Masuda

, Tsuneo Kawano

, Masanori Akiyoshi

Kenji Adachi

, Kazuma Mihara

and Ryoma Namba

Graduate School of Humanities and Sustainable System Sciences, Osaka Prefecture University, Japan

Graduate School of Science and Engineering, Setsunan University, Japan

Department of Information Systems Creation, Faculty of Engineering, Kanagawa University, Japan

Department of Computer Science and Intelligent Systems, Graduate School of Engineering,

Osaka Prefecture University, Japan

College of Sustainable System Sciences, Osaka Prefecture University, Japan

Keywords: Blood Collection, Cerebral Blood Flow, FNIRS, Nursing Skills, Tacit Knowledge.

Abstract: Nursing skills are highly implicit. No effective method has been established for passing them on to the next

generation of nursing workers. This research represented an attempt to formalize the skills of skilled nurses.

To evaluate human mental state and emotions objectively, we clarified differences in brain activity between

skilled and novice nurses at the time of collecting blood from a patient. As a result, many skilled nurses tried

to use their own knowledge for the blood vessels they faced for the first time, irrespective of the blood

collection success or failure. However, some novice nurses face subsequent blood collection without

reflecting on the clear factors leading to success or failure.

1 INTRODUCTION

In recent years, the population of Japan has been

decreasing and rapidly aging. Concomitantly, demand

for workers in the medical and nursing fields is

increasing. Moreover, the sophistication and

complexity of medical and nursing technologies are

accelerating (Japan Cabinet Office, 2016). Therefore,

developing human resources and improving skills in

medical and nursing fields is important. The high

turnover rate of nurses, especially the early retirement

of new graduate nurses, has been a long-standing issue

(Japan Nursing Association, 2018). According to a

survey conducted by the Japan Nursing Association

cites take many factors that are related to nursing skills,

a gap between abilities at the end of basic nursing

education and abilities required at nursing sites and to

be required higher nursing skills than before, as one

cause of turnover(Japan Nursing Association, 2004).

For this reason, review of the education contents and

the mode of education in basic nursing education is

necessary. However, in the acquisition of nursing skills,

a need exists to formalize tacit knowledge because it is

difficult to transfer and pass on tacit skills such as

“skills” and “knacks” possessed by skilled nurses to the

next generation of workers (Naohisa, K. et al., 2004).

Thus, we attempt to clarify and formalize the skills

(tacit knowledge) possessed by skilled nurses.

In this paper, we especially focused on the blood

collection and aim to clarify the difference in brain

activity between skilled nurses and novice nurses

during blood collection.

2 RELATED RESEARCH

2.1 Tacit Knowledge of Nursing Skills

There are two types of tacit knowledge: "cognitive

aspect" and "technical aspect"(Yujiro, N. et al., 1996).

In the case of nursing skills, it is necessary to formalize

both of them. Most of the research on the cognitive

aspect is that there are subjective and qualitative

approaches such as interviews with nurses. In the

research on the technical aspect, we focused on skin

development and pressure, which are the movements

of auxiliary fingers during blood collecting, and tried

to clarify tacit knowledge by comparing the skills of

Taira, N., Majima, Y., Masuda, S., Kawano, T., Akiyoshi, M., Adachi, K., Mihara, K. and Namba, R.

Differences in Brain Activity of Skilled and Novice Nurses during Blood Collection.

DOI: 10.5220/0009165506990704

In Proceedings of the 13th Inter national Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 699-704

ISBN: 978-989-758-398-8; ISSN: 2184-4305

699

nurses and nursing students (Takeshi, M. et al., 2018),

(Naoki, U. et al., 2018).

2.2 Biological Information

Biological information is generated during activities

controlled by human autonomic nerves without human

consciousness. Such information is related to the

person’s mental and physical state. Examples of

biological information include pulse, respiratory rate,

and brain waves.

2.2.1 Biological Information:

Electroencephalogram

We especially examined brain waves in biological

information and conducted a study measuring brain

waves during nursing skills implementation. The

electroencephalogram expresses a person's mental

state and emotions more prominently than other

biological information. The study suggested that the

voice of a skilled nurse while performing intravenous

injection leads the patient to a relaxed state (Tsuneo, K.

et. al., 2016).

2.2.2 Biological Information: Cerebral Blood

Flow

In this research, we newly focused on cerebral blood

flow, which is one of biological information. It has

been reported that the activate parts on the left and right

sides of the brain reportedly differ and table 1 presents

the respective brain characteristics. Cerebral blood

flow is used as an objective index to evaluate

technology and content in various fields (Lei, H. et. al.,

2012), (Shinsuke, M. et. al., 2012). For this research,

we estimate brain activity based on changes in

oxygenated hemoglobin concentration in the cerebral

blood flow. In earlier study, we measured cerebral

blood flow during five consecutive blood collecting

sessions, and qualitatively considered the state of brain

activity flow during each blood collecting by skilled

nurses and novice nurses (Takahito, T., 2018).

Table 1: Brain functions and features.

Right

brain

Called “image brain,” it is activated

when thinking according to the image

and emotion

Left

brain

Called “Language Brain,” it is activated

when you think about things logically

and understand the lan

Therefore, this research further expanded the field

of view, we particularly focused on the success and

failure of blood collecting through five sessions.

We aimed to elucidate the state of brain activity

flow when nurses succeeded or led from failure to

success of blood collecting.

3 EXPERIMENT

3.1 Outline of Experiment

For the present research, we specifically examine the

“blood collection technique” that is frequently used in

nurse’s daily work and measure the brain activity

during puncture. Blood collection was performed using

arm models for blood collection simulation. A patient

role-player was set in front of subjects to give a sense

of realism of blood collection. The nurse was able to

collect blood while talking with the patient. Table 2

shows the experimental location and period. Fig. 1

portrays the experimental environment.

This research was conducted with the approval of

the Ethics Committee of the Graduate School of

Sustainable System Sciences, Osaka Prefecture

University.

Table 2: Experiment place and period.

Implementation period

4 days from November to

December 2018

Implementation location

practice room in Hospital

Figure 1: Experiment environment.

3.2 Subject of Experiment

Subjects were 19 active nurses working at a hospital

who agreeded to collaborate. Table 3 shows the ladder

levels and the number of nurses. The ladder level is a

nurse development and evaluation system and axis

established by the Japan Nursing Association. It

includes five levels of competence and career, ranging

from a novice to an experienced practitioner: higher

numbers denote higher nursing practice capabilities.

HEALTHINF 2020 - 13th International Conference on Health Informatics

700

For the present research, we referred to the ladder level

set by the hospital at which the target nurses work and

divided them into two groups: novice nurses and

skilled nurses.

Table 3: Nurse ladder lebel.

Implementation

category

Ladder

level

Number of

people

Total

Novice nurse

Ⅰ 9

Ⅱ 0

Skilled nurse

Ⅲ 4

Ⅳ 4

Ⅴ

Total 19

3.3 Used Equipment

3.3.1 Cerebral Blood Flow Meter

For analyzing brain activity, we used a wearable

optical topograph (NIRS WOT-220; Hitachi Ltd.), a

cerebral blood flow meter, to measure changes in

oxygenated hemoglobin concentrations in cerebral

cortical blood flow. This cerebral blood flow meter has

10 channels, each of which measures oxygenated

hemoglobin in the cerebral blood flow.

Figure 2: Wearing a cerebral blood flow meter.

3.3.2 Arm Model for Blood Collecting

Simulation

For the blood collecting simulation, we used an arm

model (LM-086; Koken Co. Ltd.), from which a nurse

can select blood vessels to collect blood. Several types

of blood vessel models can be used. Fig. 3 shows the

arm model. Fig. 4 shows the type and difficulty of

blood vessel models.

Figure 3: The arm model with the blood vessel model.

We explained in advance that exchanging multiple

simulation model. However, participants did not know

from which blood vessel model they will collect blood.

Figure 4: The type and difficulty of the blood vessel model.

4 ANALYTICAL METHOD

We examined the brain activity of nurses based on

changes in hemoglobin concentrations in the cerebral

blood flow obtained from experiments. The data are

graphed. Features are extracted from the graph. The

analytical procedure is presented below.

4.1 Channel Selection

Ten channels of the cerebral blood flow meter were

divided into two areas, the left brain and the right brain.

Then the average values of channels operating

normally from each area were calculated. Normal

operation required that to satisfy the two conditions:

(1) the device is in the “Normal” state during

calibration, and (2) the measured value does not detect

an extreme abnormal value.

4.2 Graph Smoothing

It is difficult to interpret the overall characteristics even

when graphed because the raw data obtained from the

cerebral blood flow meter are noisy. Therefore, it

might be necessary to smooth the graph by applying

some processing in order to make it easy to ascertain

the graph characteristics.

4.2.1 Graph Smoothing in Earlier Study

Earlier study removed noise on the raw data using the

moving average method in order to facilitate

interpretation of the characteristics of the graph.

Subsequently, smoothing was performed by reducing

the number of data by calculating root mean square

(RMS) values. However, if RMS is applied to raw data

that might be negative, then the output would be a

positive value, which cannot represent brain activity

accurately. Therefore, for this research, data smoothing

was attempted by the following procedure.

Differences in Brain Activity of Skilled and Novice Nurses during Blood Collection

701

4.2.2 Graph Smoothing in This Research

High frequencies above a certain threshold are often

noise generated by the experimental environment and

the life activity of the subject because cerebral blood

flow gradually reflects changes in neural activity over

time. Therefore, this time, noise was removed by

application of Low Pass Filter.

4.3 Normalization

Analyses of Cerebral blood flow were made based on

the amount of hemoglobin concentration change in

each nurse because individual differences exist in the

absolute amount of hemoglobin concentration change

in the cerebral blood flow. The amount of change was

expressed as a value of 0-1.

5 RESULTS AND DISCUSSION

One graph shows the transition of oxygenated

hemoglobin concentration during five blood

collections. The vertical blue line mark in the graph

shows the following time points during one blood

collection: (1) start of blood collection, (2) needle

insertion, (3) needle removal, and (4) end of blood

collection. In addition, the nurse ID and type of blood

vessel model are shown in the graph. Each trial is

separated by a red bold vertical line. The success (○)

and failure (×) of blood collection are shown at the top

of the graph.

5.1 Patterns of Skilled Nurse Success

The pattern monitored in Figure 7 is often seen by

skilled nurse who completely succeeded in all blood

collections. The transition of oxygenated hemoglobin

concentration in both of right brain and left brain were

highest at the first time and gradually decreased from

the second to the fifth blood collection. In addition, the

time required for blood collection was the longest at

the first time and gradually decreased.

Figure 7: Example of a pattern of skilled nurse success.

Accordingly, it is considered that a skilled nurse

who has high ladder level and high blood collection

technique is gradually able to succeed in blood

collection without considering because deep

considering about success factor when succeed for the

first time, they can grasp the knack.

5.2 Patterns of Novice Nurse Success

The pattern monitored in Figure 8 is often seen by

novice nurse who completely succeeded in all blood

collections showed the different graph from that of

skilled nurse success pattern. The transition of

oxygenated hemoglobin concentration did not

gradually decreased from the second to the fifth like a

skilled nurse. The transition of oxygenated hemoglobin,

especially in the left brain, was flat from the first to the

fifth blood collection.

Accordingly, it is considered that someone of

novice nurses who has low ladder level and low blood

collection technique was not able to succeed blood

collection without deep considering from the second

time on too because they could not understand the

success factor even when succeeded.

Figure 8: Example of a pattern of novice nurse success.

5.3 Patterns Leading to Success from

Failure of Skilled Nurse

The pattern monitored in Fig. 9 is often seen by skilled

nurse who failed once the first or second blood

collection and succeeded more than three times

thereafter. The pattern was similar to the pattern of

skilled nurse success. The transition of oxygenated

hemoglobin concentration was the highest at the first

time and gradually decreased from the second to the

fifth blood collection.

Figure 9: Example of a pattern leading to success from failure

of skilled nurse.

Accordingly, it is considered that a skilled nurse

who has high ladder level and high blood collection

technique is thereafter able to success blood collection

because they finded and improved the cause of failure

by deep considering about it when failed.

HEALTHINF 2020 - 13th International Conference on Health Informatics

702

5.4 Patterns Leading to Success from

Failure of Novice Nurse

The pattern monitored in Fig. 10 is often seen by

novice nurse who failed once the first or second blood

collection and succeeded more than three times

thereafter. The pattern was similar to the pattern of

leading to success from failure by skilled nurse but the

transition of oxygenated hemoglobin concentration

was different from that when skilled nurses failed in

blood collection.

Accordingly, it is considered that a skilled nurse

who has low ladder level and low blood collection

technique collected blood at the first time without deep

considering because not finding success factor, they

could not understand what should do when they

collected blood.

Figure 10: Example of a pattern leading to success from

failure of novice nurse.

6 CONSIDERATION

This research clarified differences in brain activity

between skilled nurses and novice nurses during blood

collecting from the viewpoint of changes in

oxygenated hemoglobin concentration in the cerebral

blood flow. Results indicate that many skilled nurses

tried to use their own knowledge for the blood vessels

they faced for the first time, irrespective of the blood

collection success or failure. However, some novice

nurses face subsequent blood collection without

reflecting on the clear factors leading to success or

failure. Therefore, the brain continues to be active

every time, even if the failure continues or succeeds.

From the above, one can infer that, at the time when

the first blood collection is completed in the future, the

nurses are encouraged to reflect on their performance.

From that point forward, the skilled nurse and the

novice nurse will specifically examine what points to

connect to the next blood collection analyses and will

verify the difference. Results demonstrate such

reflection and subsequent success are necessary

experiences to clarify the tacit knowledge of skilled

nurses in nursing techniques that are difficult to

verbalize.

7 FUTURE WORK

We think to use another biological information like

gaze and pressure and develop index that can measure

nursing skills proficiency based on all of biological

information.

ACKNOWLEDGMENTS

This research was supported by JSPS KAKENHI

16H05571, 17H04433, 17K19845, 19K22774. We

deeply appreciate the nurses, including those of

Hospital A, for their cooperation with this research.

REFERENCES

Japan Cabinet Office., 2016. 2016 White Paper on Aging

Society.

Japan Nursing Association., 2018. Survey of hospital nursing.

Naohisa Kishida, Atsushi Ishigame, Yukie Majima., 2004.

Examination about the system which induces the

synchronization of the brain wave by music stimulation

and dialogue in the injection skills, Ergonomics. Vol.50,

Supplement, pp.294-295.

Yujiro Nonaka, Takeuchi Hirotaka., 1996. Knowledge

creation industry, Toyo Keizai Shimbun.

Takeshi Matsuda, Yukie Majima, Kouske Ootani., 2018.

Pressure data analysis for vascular fixation in

venipuncture, The Institute of Electronics, Information

and Communication Engineers, IEICE technical report.

Vol.117, No.419, pp.1-3.

Naoki Ueda, Masao Izumi, Yukie Majima, et al., 2018.

Correlation between left hand contact force and skin

development in injection technique, The Institute of

Electronics, Information and Communication Engineers,

IEICE technical report. Vol.117, No.419, pp.11-16.

Tsuneo Kawano, Yukie Majima, Yasuko Maekawa, et al.,

2016. Inter-brain Synchronization between Nurse and

Patient During Drawing Blood, Proceedings of the 9

International Joint Conference on Biomedical

Engineering Systems and Techologies. Vol.5, pp.507-

511.

Lei Hou, Keiichi Watanuki., 2012. Measurement of Brain

Activity during Lathe Operation Using Near-Infrared

Spectroscopy, The Japan Society of Mechanical

Engineers, Transactions of the JSME, Vol.79, No.800,

pp.228-237.

Shinsuke Mitsui, Toshikazu Kato., 2012. Approach for

Objective Evaluation Method of video Content using

Physiological Parameters, The Institute of Image

Information and Television Engineers, ITE Technical

Report. Vol.36, No.19, pp15-17.

Takahito Tamai, Yukie Majima, Tsuneo Kawano, 2019. A

Study on Brain Activities during Blood Draw Technique

-Viewpoint from cerebral blood flow-, The Institute of

Differences in Brain Activity of Skilled and Novice Nurses during Blood Collection

703

Electronics, Information and Communication Engineers,

IEICE technical report. Vol.118, No.509, pp.11-15.

HEALTHINF 2020 - 13th International Conference on Health Informatics

704