Virtual reality: the next step in nursing education?

With the emergence of the COVID-19 pandemic, the way in which student nurses and other trainee health professionals develop knowledge and skills for practice rapidly changed. There was already a move towards the use of simulation within nursing education, with some arguing that high-quality simulation could replace some elements of practice learning. The Nursing and Midwifery Council (NMC) faced calls to consider a reduction of clinical hours required for nursing registration (Royal College of Nursing, 2017). Supporters of a move towards more simulated methods of learning suggested that the requirements put excessive pressure on already busy clinical areas and could even deter potential applicants (Mitchell, 2019).

In late 2021, the NMC announced that the flexible use of simulated practice would continue to be accepted and encouraged following the implementation of post-COVID-19 recovery standards (NMC, 2021). These allow education providers to use up to 300 hours of practice learning requirement within a simulated learning environment.

With innovative approaches to learning being adopted by educational institutions, in an effort to improve student engagement and preparation for practice, it is clear that technological advances may also have an important role to play. Virtual reality (VR) and VR-type simulation devices have become far more accessible and there is a steadily growing foundation of evidence to support their use in an educational context.

Simulation: the story so far

In the past, simulation in nursing and healthcare curricula often focused on the teaching and development of clinical skills or procedural competencies with little attention paid to ‘soft skills’. Traditional modalities of clinical simulation cater for the more kinaesthetic or ‘hands on’ learner and usually consist of a demonstration followed by the learner practising the skill. Although this approach has proven particularly effective for preparing nursing students for conducting clinical ABCDE assessments through use of patient mannikins, or undertaking catheterisation using model anatomy, these methods are not necessarily helping to coach students in the more human-centred skillsets required to undertake these interventions in the ‘real world’.

Communication, advocacy, cultural awareness, task prioritisation and decision making are all examples of ‘softer skills’ that often cannot be effectively learnt or demonstrated using a simulation mannikin or mock equipment. These types of skills are sometimes presumed to ‘emerge over time’ or be developed in clinical practice, despite being essential to providing safe and person-centred care from day 1 of nursing practice. Where these are taught in a simulated environment, they often use ‘role playing’ with peers which, for many, lacks realism, does little in the way of engaging students with their learning, and often fails to provide meaningful feedback.

How can these competencies be successfully taught and mastered, while maintaining a sense of ‘realism’ and engagement? The answer may lie with technology that allows students to safely consolidate their skills in an environment that is as close as possible to ‘real life’.

What is virtual reality?

VR is a specialist type of technology that aims to give users an immersive simulation of an artificial environment. It was originally developed mostly for entertainment purposes, where individuals could become absorbed in a different world and experience activities (such as driving a vehicle or skydiving) in a 360° simulation of the real event or a computerised version (Kardong-Edgren et al, 2019).

As the technology has improved, the widespread applications of VR in industry and its potential benefits have slowly been realised.

The engineering and construction sectors have invested heavily in the use of VR to help train future workers in design, site safety and operation of complex machinery. Research conducted by Wang et al (2018) suggested that the use of VR, in an educational context, led to increased student participation, more accessible learning and allowed students to evaluate their practical application of theoretical learning. Similarly, healthcare education providers have started to take an interest in VR technology, with some universities developing their own software to enhance patient care simulations.

VR simulation is a sensory experience, so requires specific equipment such as headsets, earphones and handheld remotes to achieve a multidimensional perception that is as close to reality as possible. Previously considered an extremely costly activity (given the prices of equipment required), an average full-immersion VR setup is now a financially viable option for most education organisations. However, the development of appropriate software for these devices often requires significant investment in terms of both time and finances (Marks and Thomas, 2022).

Although teaching approaches that involve VR technology show real potential in a variety of areas, careful attention must also be paid to the ethical considerations of using such methods (Table 1). Immersive VR use has been shown to elicit physical adverse effects in some individuals such as headache, motion sickness, nausea and migraine. These symptoms could impact on a user's ability to fully engage with learning scenarios and may be totally unacceptable for some, such as those prone to seizures following visual stimuli. Another significant drawback of VR-oriented learning is the potentially isolating nature of the technology. Students who engage in VR learning from home (ie through a mobile device) may experience emotional distress from being immersed in certain manufactured situations and struggle to access support or ask questions about the experience. It could be argued that VR simulation, embedded within a curriculum, should be facilitated by teaching staff or those who can offer both emotional support, reflective discussion and further explain scenarios (Saab et al, 2021).

VR in nursing education

Recently, the renewed interest in the use of VR for clinical simulation in nursing education has led to some novel approaches to learning. The emergence of fully immersive simulations for the teaching and consolidation of both clinical skills and communication-related competencies has been hailed as a possible realistic alternative to traditional placement-based learning.

One example of where VR-type technology has been successfully implemented in a nursing curriculum was a program simulating management of an acutely deteriorating patient (Singleton et al, 2021). Students were given the opportunity to engage in clinical decision making to ensure the correct and timely treatment of an individual's worsening condition. The expectation was that those participating in the experience would be able to gain confidence in making time-critical decisions and escalating care accordingly, all within a ‘safe’ and learning-focused environment. While completing the scenario students would be given ‘real time’ feedback through the program to help guide future development and reflection on skills. The authors reported that many of the participants interviewed felt that the realistic nature of the VR simulation could support preparedness for clinical practice and help to apply theoretical learning to a ‘real life’ scenario. Those involved also found the technology considerably more engaging than traditional teaching methods.

Other simulation experiences using VR have focused more heavily on portrayal of patient perspectives of receiving care. An immersive dementia experience was recently developed in an Irish university to aid awareness in healthcare workers of the types of cognitive, perceptual and physical challenges people living with dementia can often face. The learning experience allowed participants to feel fully immersed in what it may feel like to live with the condition and how small adaptations could make a real difference to an individual's daily functioning. Following engagement with the resource, many health professionals reported feeling significantly better prepared to care for someone living with dementia and believed that the experience helped to illustrate the need for empathetic and person-centred care provision for these patients (Slater et al, 2021).

VR simulation programmes have also provided students with opportunities to develop their communication skills, with Stuart et al (2021) evaluating VR approaches to building confidence with SBAR (Situation, Background, Assessment, Recommendation) clinical handovers. The software provided a fictitious patient scenario in which an avatar of a nurse would provide the user with appropriate clinical information in an SBAR format. Students appraise the quality of the artificial nurse's handover and answer a series of questions to test their knowledge of constructing an effective handover. Although the authors reported that those engaging with the VR resource scored well in a post-experience questionnaire, it was also reported that students felt that the simulation lacked realism and tailored feedback on performance.

Future use

VR in education has been yielding promising learner outcomes, but there is still potential for further innovation. Some educators may want to employ VR immersion to aid teaching of complex anatomical structures and physiological mechanisms or even simulate the undertaking of intricate clinical procedures.

VR could also change the way in which softer skills, such as empathy and communication, are developed. Recently, a Scottish university co-designed and trialled VR software to simulate difficult conversations at the end of life, in a project that seeks to improve the confidence of novice nurses caring for those with palliative care needs (Ross, 2022). The use of VR simulation as a potential substitute for some aspects of placement learning is certainly a hot topic, with evidence suggesting that virtual simulation can facilitate the enhancement of both theoretical knowledge and skill confidence when access to clinical placement opportunities may be in short supply (Kean, 2022).

Conclusion

Simulation and digital learning methods are becoming commonplace in nursing education. It seems clear that education providers must carefully consider the use of innovative approaches to further enhance their programme delivery but also remain aware of the possible ethical and financial implications that may arise with the use of such technologies.