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The Complete Guide to Immersive VR Simulation for Nursing

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Introduction

The healthcare industry is currently facing a critical challenge: the demand for new nurses is outpacing the supply of clinical sites and preceptors. 

The nursing field is experiencing a wave of retirements, and a national shortage of nursing faculty is leading to a reduction in experienced registered nurses who can act as preceptors to guide and mentor students. Rapidly increasing enrollments in nursing programs are simultaneously straining the capacity of nursing programs to scale up and meet the growing demand for quality clinical placements. The result is a bottleneck in nursing education that threatens the future of high-quality healthcare.

"In the attempt to address nursing and faculty shortages - at the bedside and in the classroom - we have created the conditions where the demand is exceeding and exhausting the supply. To continue to provide the mandated and much needed clinical training for nursing students, clinical education must be redesigned to align with the resources available” - Pamela Jeffries, PhD, RN, FAAN, ANEF, Dean of Nursing, George Washington University (Jeffries, 2015).

Limitations of Traditional Clinical Experiences

Clinical experience serves as the cornerstone of nursing education, playing an indispensable role in shaping competent, compassionate, and effective nursing professionals. It is through clinical experience that students learn to link theory with practice, enhance their problem-solving capabilities, develop empathy, and improve communication skills. It provides a crucial platform where theoretical knowledge can be applied and integrated with practical elements, encompassing affective, cognitive, and psychomotor domains of learning. Through clinical experiences, nursing students acquire and hone essential skills, absorb professional attitudes, and learn to uphold the core values of the nursing profession (Jallad & Işık, 2021). 

However, there are significant limitations in this conventional model that impede the learning process for pre-licensure nursing students:

  • Evidence suggests students frequently miss key learning opportunities in conventional clinical teaching environments and often fail to gain experience across the full scope of their future practice (Jeffries, 2015)
  • Variations among clinical sites and preceptors mean the traditional model falls short in facilitating situation-specific pedagogies that foster clinical learning (McNelis et al, 2014). 
  • Students can waste valuable time waiting for faculty availability. The challenge of securing preceptors is amplified by factors such as burnout, fatigue, and concerns about decreased clinical practice productivity (Barker & Pittman, 2010).

It is essential to recognize and address these shortcomings to optimize the clinical learning experience for nursing students.

Filling in the Gaps with Simulation  

Simulation has emerged as a valuable tool to fill the gaps in nursing education. Nursing schools have increasingly incorporated simulated activities into their curricula, harnessing the potential of this experiential, "learning by doing" approach (NCSBN, 2016; Jeffries, 2015). 

Simulation-based learning bolsters the development of nursing students' competence and confidence and offers a safe environment where students can practice until they attain skill competency, self-reflect, self-correct, and accept feedback. It provides opportunities that are often absent or limited in clinical settings, where students might merely shadow another person and experience suboptimal learning. 

Moreover, simulation is particularly beneficial for students who have not been exposed to a wide range of patient conditions in their clinical experiences, as it provides standardized learning scenarios that ensure comprehensive training (Aebersold, 2018; Goldsworthy et al, 2022). The need for simulation will likely grow as the nursing shortage escalates and the number of faculty and clinical sites dwindle (Aebersold, 2018).

“Reliable evidence exists that simulation is an efficient, safe, and cost-effective means by which students can develop beginning clinical competence, as well as confidence in their clinical practice knowledge and skills. Simulation technology must become an integral part of the teaching-learning process in prelicensure nursing curricula today.” - Pamela Jeffries, PhD, RN, FAAN, ANEF, Dean of Nursing, George Washington University (Jeffries, 2015)

Replacing Up to 50% of Clinical Experience with Simulation 

A landmark study by Hayden et al. (2014) conducted under the auspices of the National Council State Board of Nursing (NCSBN) provides significant guidance for nursing schools regarding the substitution of traditional clinical experiences with simulation-based learning. The study, which spanned 10 different nursing schools, evaluated the potential of integrating simulation across various aspects of the nursing curriculum, including fundamentals, medical-surgical, advanced medical-surgical, maternal-newborn, pediatrics, mental health, and community health.

The findings of this comprehensive study were that up to 50% of traditional clinical experience can be effectively replaced with simulation in all core courses throughout the pre-licensure curriculum. Importantly, the study also found that NCLEX pass rates were unaffected by the substitution of real clinical experience with simulation.  

In light of these findings, the NCSBN proposed key recommendations for pre-licensure nursing programs (Alexander et al, 2015). This guidance underscores the growing recognition of simulation-based learning as a viable, effective, and potentially transformative approach in nursing education.

The Emergence of Virtual Reality Simulation 

Virtual reality (VR) simulation provides opportunities for standardized clinical experiences that improve patient safety and enhance readiness for practice without requiring the large footprint of a traditional skills-type laboratory (Smith et al., 2018). VR simulation gives nurse learners a safe environment for repeatable training and augments the development of their cognitive and psychomotor skills (Smith et al., 2016). Due to its inherent flexibility, the VR modality addresses several challenges in healthcare education. For example, it prepares professionals for rare or critical events that would be difficult, if not impossible, to set up in real life without posing risks to patients (Bracq et al., 2019). 

The Proven Combination of VR and Manikin Simulation 

The choice between VR simulation and manikin simulation is not an 'either-or' proposition but rather a 'both-and' approach. Recent research underscores the effectiveness of a combined approach. A study by Goldsworthy et al. (2022) involving undergraduate nursing students found that integrating a VR simulation with a high-fidelity manikin simulation enhanced students' perception of their own competence and confidence. 

“I think that the high-fidelity manikins can teach them the critical thinking skills and the psychomotor skills. But sometimes I think it lacks the ability for them to learn the clinical judgment that goes along with it. It's so hard for students sometimes because they know the instructors are watching them with the high-fidelity manikins. But in UbiSim with a headset on, they tune everyone else out that's in the room.” - Dr. Tina Barbour-Taylor, Professor, University of West Florida School of Nursing

Introducing the Powerful UbiSim Immersive VR Simulation Platform

UbiSim immersive VR simulation is a scalable solution to the limitations of clinical experience in nursing education. UbiSim reduces cost, time, and logistical challenges, while consistently providing highly impactful, standardized clinical training that rivals the effectiveness of traditional clinical placements and desktop VR simulation modalities. 

“Nothing beats real life, obviously, but we don't have control over real life. We don't know who's going to walk in the door and who's going to be sick on any given day. That's why we do simulation-based training, and we can do that with a live actor or a manikin, and we do that a lot. But it's expensive. You have to schedule it. You have to set aside a room. You have to have staff. The setup takes time. The teardown takes time. So there's only so much of that we can do. With VR, you just switch on the headset, and you're off and running.” - Dr. Jeffrey Jacobson, Senior Manager, Boston Children’s Hospital XR Simulation Lab

The uniqueness of UbiSim lies in its Intuitive Editor. Designed with nurse educators in mind, anyone can edit, customize, or create a UbiSim simulation with the user-friendly editing tool even if they do not have technical expertise. Educators can select from a wide range of environments, patients, supplies, and assessment findings. Additionally, UbiSim hosts a "By the Community" library, which includes scenarios written and shared by other programs.

“Within UbiSim, you can design virtually any scenario that you want, not only how the patient presents itself, but also the different things that you'll find within the electronic health record. You can personally program patient orders, patient electronic MARS, the lab results, and all of those things can really help to guide the simulation and how it will evolve.” - Lindsay Jusino, Professor, University of West Florida School of Nursing

All UbiSim scenarios are reviewed annually by expert nurse educators, peer-reviewed, and align with best practice standards to provide a repeatable, realistic learning experience that helps nurse learners improve their clinical judgment, decision-making, team interaction, and patient engagement skills. 

Each UbiSim nursing scenario aligns with the Next Generation NCLEX-RN test plan developed by the NCSBN, the NCSBN Clinical Judgment Measurement Model, and the AACN Essentials Core Competencies for Professional Nursing Education. Structured according to INACSL standards, UbiSim scenarios include pre-briefing, immersive VR sessions, immediate feedback, and robust, multi-tiered debriefing.

Evidence of Efficacy

As the new field of immersive VR simulation has matured, it has garnered substantial evidence of efficacy with significant benefits over traditional training methods. Immersive VR simulation has been found to lead to:

  • Higher performance scores compared to traditional hospital-based training (Cieslowski et al., 2023) 
  • More learner satisfaction with a greater sense of realism, proprioception, presence, and interactivity than desktop VR simulation to help bridge the theory-practice gap (Qiao et al, 2023; King et al., 2018)
  • Enhanced clinical judgment and interpersonal skills among nursing students, including developing non-technical skills such as situational awareness, decision-making, communication, and teamwork (Pardue et al., 2023; Griffin et al., 2020; Sweigart et al., 2016)
  • Rapid acquisition of task-related skills, with strong short-term gains and long-term advantages over traditional teaching methods (Smith et al., 2016)
  • High knowledge transfer to learners (Samosorn et al., 2020)
  • Increased learner confidence (Bracq et al, 2019)
  • Easier tracking and recording of learners, allowing educators to provide objective feedback and adjust their teaching to address skill gaps (Samosorn et al., 2020) 
“I think it was beneficial because it offers that extra hands-on. So even though you're not physically doing it on a manikin in a room, you're still looking at a patient and then doing your step-by-step as if you were in the room,” and “…completely immersed in the scenario. You forgot where you were. The world could be crashing around behind you and you have no idea because you're in the patient room; you're in the hospital.” - Nurse learner reflecting on their experience in immersive VR Simulation (Farra et al, 2018)

What Nurses Say About Immersive VR Simulation

Recent research (Saab, et al, 2021) finds that nursing students believed that immersive virtual reality is a novel, fun, memorable, inclusive, and engaging means of learning. Many said that virtual reality would complement current teaching and learning approaches, help build learners' confidence, and provide nursing students with a safe space for trial, error, and problem-solving. Students recommended the use of immersive virtual reality to practice various nursing skills and learn about human anatomy, physiology, problem-solving, and clinical decision-making.

Quotes from nursing students who participated in focus groups in the Saab, et al (2021) qualitative study:

Full Body, Multisense Engagement/Virtual Presence

I was paying attention to everything and I was really interested. I didnt find myself zoning out, because you couldnt. You saw something you had to do it…youre definitely going to remember what was said.

Exposure to rare and critical events 

On placement, I might never see a grade four pressure sore, but then someone else might see one. This might be putting me at a disadvantage, whereas if I was able to see that on VR, it kind of puts everyone on the same playing field.

Safe Environment for practice and exploration

When Im in clinical practice, I can get quite shaky, especially if its the first time Im doing something. Thats where VR would come in. It would give me that space to practice literally hands-on without actually being on clinical placement.

In VR, its just yourself with the goggles. Nobody is going to observe you. You can feel free to make errors and increase your confidence. You can fail, you can do things wrong, you can learn from the mistakes.

Acquiring “soft skills”

“If you were able to go into it [VR] and interact with a patient and if there was a random mode and their vitals change and you need to recognize them. So, you’re kept on your toes.”

Conclusion

VR simulation technologies have grown in sophistication and immersion and are now more accessible and affordable than ever before (Farra et al, 2018; Scerbo, 2016). The use of immersive VR simulation is rapidly gaining acceptance in nursing education due to its evidence-backed efficacy in enhancing knowledge transfer, clinical judgment, and confidence among nursing students. Immersive VR provides a safe and standardized environment for the training of rare and critical events that traditional clinical settings cannot easily replicate. As immersive VR simulation continues to become increasingly accepted for use in nursing education, accelerating its full adoption will help promote positive outcomes for nurse learners and the patients they serve.

Interested in trying immersive VR for your nursing students? Request a demo of UbiSim today!

Glossary

  • Simulation: A technique to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. It is not defined by technology, but rather by an educational approach grounded in learning theories (Gaba, 2004). Simulations provide nurse educators with an innovative way to teach students about real-world nursing in an experiential, immersive, and non-threatening environment (Jeffries et al, n.d.). Simulation enables students to repeat and master training in competencies that build confidence in their practice. 
  • Traditional Clinical Experience: Practice in an inpatient, ambulatory care, or community setting where the student provides care to patients under the guidance of an instructor or preceptor.
  • Virtual Reality Simulation: Places learners in a key role through the exercise of their complex cognitive thinking abilities, decision-making, effective, psychomotor control, performance, and communication skills (Jallad & Işık, 2021). 
  • Desktop Virtual Reality Simulation - Users interact with a 2D virtual environment that is displayed on a computer screen and navigated with a keyboard and mouse. 
  • Immersive Virtual Reality Simulation - Users interact in a 3D virtual world that replicates real-life situations; typically incorporating interfaces such as a head-mounted display, motion sensors, or haptic devices. Immersive VR is a multisensory experience that leads to a high degree of proprioception (the learner is able to feel their position and movement within the virtual space) and sense of presence, ultimately supporting the suspension of disbelief. 

References

Abulfaraj, M. M., Jeffers, J. M., Tackett, S., & Chang, T. (2021). Virtual reality vs. high-fidelity mannequin-based simulation: A pilot randomized trial evaluating learner performance. Cureus, 13(8), e17091. https://doi.org/10.7759/cureus.17091

Aebersold, M., (April 3, 2018) "Simulation-Based Learning: No Longer a Novelty in Undergraduate Education" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 2.

Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kesten, K. S., ... & Tillman, C. (2015). NCSBN simulation guidelines for prelicensure nursing programs. Journal of Nursing Regulation, 6(3), 39-42.

American Association of Colleges of Nursing. (2017). Fact sheet: Nursing shortage. Retrieved from http://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet-2017.pdf?ver=2017-10-18-144118-163

Bracq MS, Michinov E, Jannin P. (2019). Virtual reality simulation in nontechnical skills training for healthcare professionals: a systematic review. Simulation in Healthcare, 14:188-94.

Choi, J., Thompson, C. E., Choi, J., Waddill, C. B., & Choi, S. (2022). Effectiveness of immersive virtual reality in nursing education: systematic review. Nurse Educator, 47(3), E57-E61.

Cieslowski, B., Haas, T., Oh, K. M., Chang, K., & Oetjen, C. A. (2023). The Development and Pilot Testing of Immersive Virtual Reality Simulation Training for Prelicensure Nursing Students: A Quasi-Experimental Study. Clinical Simulation in Nursing, 77, 6-12.

Farra, S. L., Smith, S. J., & Ulrich, D. L. (2018). The student experience with varying immersion levels of virtual reality simulation. Nursing education perspectives, 39(2), 99-101.

Fogg, N., Kubin, L., Wilson, C. E., & Trinka, M. (2020). Using virtual simulation to develop clinical judgment in undergraduate nursing students. Clinical Simulation in Nursing, 48, 55-58.

Gaba, D. M. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13(suppl 1), i2-i10.

Goldsworthy, S., Ferreira, C., Shajani, Z., Snell, D., & Perez, G. (2022). Combining virtual and high-fidelity simulation to foster confidence and competency in postpartum assessment complications among undergraduate nursing students. Clinical Simulation in Nursing, 66, 18-24.

Griffin, C., Aydın, A., Brunckhorst, O., Raison, N., Khan, M. S., Dasgupta, P., & Ahmed, K. (2020). Non-technical skills: a review of training and evaluation in urology. World Journal of Urology, 38, 1653-1661.

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). Supplement: The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), C1-S64.

Jallad, S. T., & Işık, B. (2021). The effectiveness of virtual reality simulation as learning strategy in the acquisition of medical skills in nursing education: a systematic review. Irish Journal of Medical Science (1971-), 1-20.

Jeffries, P. R., Beroz, S., Slaven-Lee, P., Farina, C.,  Lewis, K., Dreifuerst, K.T., and Kardong-Edgren, S. (n.d.). Essentials in Clinical Simulations Across the Health Professions [MOOC]. Coursera. https://www.coursera.org/learn/clinicalsimulations/ 

Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing education perspectives, 36(5), 292-293.

King, D., Tee, S., Falconer, L., Angell, C., Holley, D., & Mills, A. (2018). Virtual health education: Scaling practice to transform student learning: Using virtual reality learning environments in healthcare education to bridge the theory/practice gap and improve patient safety. Nurse Education Today, 71, 7-9.

Krokos, E., Plaisant, C., & Varshney, A. (2018). Virtual Memory Palaces: Immersion Aids Recall. Virtual Reality, (0123456789) (pp. 1-15). (pp. 1-15.

McNelis, A. M., Ironside, P. M., Ebright, P. R., Dreifuerst, K. T., Zvonar, S. E., & Conner, S. C. (2014). Learning nursing practice: A multisite, multimethod investigation of clinical education. Journal of Nursing Regulation, 4(4), 30-35.

Pardue, K. T., Holt, K., Dunbar, D. M., & Baugh, N. (2023). Exploring the Development of Nursing Clinical Judgment Among Students Using Virtual Reality Simulation. Nurse Educator, 48(2), 71-75.

Qiao, J., Huang, C. R., Liu, Q., Li, S. Y., Xu, J., Li, L., ... & Ouyang, Y. Q. (2023). Effectiveness of Non-Immersive Virtual Reality Simulation in Learning Knowledge and Skills for Nursing Students: Meta-analysis. Clinical Simulation in Nursing, 76, 26-38.

Saab, M. M., Hegarty, J., Murphy, D., & Landers, M. (2021). Incorporating virtual reality in nurse education: A qualitative study of nursing students' perspectives. Nurse Education Today, 105, 105045.

Samosorn, A. B., Gilbert, G. E., Bauman, E. B., Khine, J., & McGonigle, D. (2020). Teaching airway insertion skills to nursing faculty and students using virtual reality: A pilot study. Clinical Simulation in Nursing, 39, 18-26.

Smith, S. J., Farra, S., Ulrich, D. L., Hodgson, E., Nicely, S., & Matcham, W. (2016). Learning and retention using virtual reality in a decontamination simulation. Nursing education perspectives, 37(4), 210-214.

Smith, S. J., Farra, S. L., Ulrich, D. L., Hodgson, E., Nicely, S., & Mickle, A. (2018). Effectiveness of two varying levels of virtual reality simulation. Nursing education perspectives, 39(6), E10-E15. 

Sweigart, L. I., Umoren, R. A. , Scott, P. J. , Carlton, K. H. , Jones, J. A., Truman, B. & Gossett, E. J. (2016). Journal of Nursing Education, 55 (1), 31-35. 

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