In response to the COVID-19 pandemic, emergency education standards from the Nursing and Midwifery Council (NMC) allowed approved education institutions (AEIs) greater flexibility in providing learning experiences that contribute towards the practice component of pre-registration programmes (NMC, 2020). These changes in standards have contributed to increased use of approaches that involve simulated practice learning. The new NMC definition of simulated practice learning requires the AEIs to ensure that simulation authentically replicates practice using technology effectively and proportionately across the pre-registration nursing curriculum to support supervision, learning and assessment (NMC, 2023a).
The rapid development of information technology and shortages in the nursing workforce have highlighted the need for the transformation of nursing education to prepare nursing students for evolving and complex healthcare environments (Chen et al, 2020). Virtual reality (VR) is the use of computer technology to create an interactive three-dimensional (3D) world in which users have a sense of spatial presence. It provides a first-person active learning experience through different degrees of immersion, or, in other words, the real perception of the digital world and the ability to interact with objects and/or perform a series of actions in that digital world (Cao and Cerfolio, 2019). VR simulation refers to the use of a variety of immersive, highly visual, 3D characteristics to replicate real-life situations and healthcare procedures, incorporating physical or other interfaces such as a computer keyboard, a mouse, speech/voice recognition, motion sensors, or haptic devices (Shin et al, 2019). In general, VR in simulation is an effective supplemental tool for teaching. VR has potential as a means of evaluating student performance and identifying areas for improvement, as well as an opportunity to practise required skills.
Recent studies have found that VR supported participants in achieving learning outcomes and professional attitudes, and increased their knowledge and self-confidence; it also highlighted gaps in knowledge and areas of bias (Kleinert et al, 2015; Foronda et al, 2016; Logeswaran et al, 2021; Jallad and Isik, 2022).
This project evaluation used the VR problem-based learning approach, and its purpose was to evaluate pre-registration nursing students' experiences of carrying out holistic patient assessments using two different methods of artificial intelligence (AI) interaction within VR technology: menu-based and voice-controlled.
For this project evaluation, participants were exposed to two different clinical scenarios developed by the same VR simulation platform. Both clinical scenarios were characterised by patient behaviours that were driven by AI, incorporating adaptive dialogues and a dynamic physiology and wellness systems.
For the menu-based interaction scenario, participants used a hand-controller to select a task (such as clinical procedures, assessment tools, dialogue options) from a pre-set menu to complete their holistic assessment of a virtual patient named Deepak with hypertension.
In the voice-controlled interaction scenario, students used their voice to interact with and initiate tasks on a patient with a cluster headache. This second interaction method used voice recognition technology, allowing users to interact with the virtual patient named Ray by talking through a microphone, instead of using a pre-set menu.
In both scenarios, once the question had been formulated by the user, the AI-led back-end algorithm provided a response that the AI-led patient verbalised. In both scenarios, users received immediate personalised feedback through an autogenerated report. The feedback report indicated correct and incorrect decisions in three categories of critical, important or additional aspects; this categorisation depended on how the user's actions or omissions could potentially impact the patient's outcomes. From that feedback report, users were also able to identify technical and non-technical skills related to nursing assessment and management of that particular clinical case that required improvement.
Methods
Student nurses in parts 1 and 2 of pre-registration nursing programmes were invited to participate in two VR scenarios, comprising different AI interaction methods (menu-based and voice-controlled). All participants invited had access to a participant information sheet and consent form prior to the VR sessions. Eleven participants were selected through purposeful sampling, and each signed a consent form, demonstrating their informed and voluntary participation in the evaluation. The participants were from two UK universities, all on adult nursing pre-registration programmes. Ethical and institutional approvals for the execution of this project evaluation were obtained from both institutions. The scenarios were appropriate for the level of knowledge and skills of those participating. The participant information sheet and consent form clearly indicated that audio recordings were necessary for data collection and analysis. For participants who did not wish to be audio-recorded, the option to stop recording during their participation was provided, and the option to edit out their voice input was offered.
Qualitative data were collected following participation in the virtual scenarios in the form of focus groups. Three focus group sessions were carried out using a list of four open-ended questions with prompts to encourage participants to share their thoughts about their experience on using both interaction methods in the VR scenarios (Table 1). The participants were required to attend one of the focus group sessions that were facilitated on the same day and at the same venue as their VR scenarios. Each session comprised four or five participants and lasted approximately 45 minutes. The sessions were audio recorded and the verbatim transcriptions were thematically analysed and interpreted by the project team.
| Questions | Prompts |
|---|---|
| 1. Explain your experience of holistically assessing a patient using virtual reality (VR) | None – proceed to next question |
| 2. Did you experience any differences between assessing Deepak and Ray using the VR tools? | 2.1. What were the strengths and limitations of the artificial intelligence (AI) voice-controlled tool (Ray)? |
| 3. Which knowledge and skills do you feel you have developed using the VR tools while undertaking a holistic assessment? | 3.1. Which skills and knowledge do you feel you have practised/developed using the AI voice-controlled VR tool (Ray) that you could not develop using the VR hand-controller tool (Deepak)? |
| 4. How did this workshop prepare you in carrying out a holistic assessment in clinical practice? | 4.1. How did the use of the VR hand-controller tool (Deepak) prepare you in carrying out a holistic assessment in clinical practice? |
Individual data were kept anonymous and were not disclosed to any other individual or organisation. The data collected were used solely for the purpose of this evaluation and were accessible only to the project team at the participating universities. In accordance with the General Data Protection Regulation as outlined by the Data Protection Act 2018, participant data were securely stored.
Data were analysed using verbatim transcriptions of each participant's voice and narrative feedback. Thematic analysis is a widely used method of qualitative data analysis that involves identifying patterns, themes, and meanings within data (Braun and Clarke, 2006). The process of thematic analysis typically involves six steps: familiarising oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing a report (Braun and Clarke 2006; Nowell et al, 2017).
The project leaders followed the six-step framework independently and then met for a discussion to establish agreed key themes, review whether these accurately represented the data, define key themes and subthemes, and create an agreed coherent description. Finally, in the sixth step, a report was produced that presented the themes and the analysis clearly and concisely (Nowell et al, 2017). By following these six steps, the project leaders were able to analyse qualitative data and identify important themes and patterns effectively and systematically. Additionally, the project leaders considered and used the ‘hermeneutic circle’ as this helped to continuously review the identified themes emerging from the data (Gadamer, 1986; Alsaigh and Coyne, 2021).
Findings
Results were obtained from the three focus group sessions facilitated with the student participants. Four key themes emerged from these discussions, which are intricately connected with different stages of their educational and professional progression. They revolve around:
Table 2 summarises the evidence compiled for each key theme and subthemes in the form of quotes from the student nurses (Q1 to Q39), which have been numbered for clear linkage throughout the analysis.
| Quote | Key theme | Sub-theme | Evidence: quotes (Q); Deepak = menu-based interaction scenario; Ray = voice-controlled interaction scenario | Student participant |
|---|---|---|---|---|
| Q1 | Technological literacy | Ease of use | ‘It was actually very intuitive and it was very easy to pick up and get on with it. And once you knew where the buttons were and the way it was laid out was very good.’ | 5 |
| Q2 | Technological literacy | Ease of use | ‘I found it easier to speak myself, to just ask questions and then if I needed some prompts or if I kind of ran out of things to say, then just go to the guidelines.’ | 6 |
| Q3 | Technological literacy | Ease of use | ‘I found it [Ray], easy to use, like technologically. Actually didn't feel like it got in the way for me to work up like that. I got that quite quickly and I was thinking more about my assessment.’ | 8 |
| Q4 | Technological literacy | Ease of use | ‘I liked the second one [Ray], because it's easy and then allows you to think.’ | 6 |
| Q5 | Technological literacy | Ease of use | ‘I found it easier to just speak to him.’ | 11 |
| Q6 | Technological literacy | Ease of use | ‘I think there was some kind of communication barrier.’ | 4 |
| Q7 | Technological literacy | Ease of use | ‘He didn't always understand me or answer correctly.’ | 8 |
| Q8 | Technological literacy | Familiarity with the platform | ‘I'm not really familiar with these things. I mean, the most technology that I really use is like my mobile phone and a computer. So when I did the first scenario, it was a bit difficult for me to kind of manoeuvre. I found that it's just a slight problem with that. But having said that, I think it's really something that I would appreciate. If it's something that I can really familiarise myself with, then I know that it would be helpful for me.’ | 7 |
| Q9 | Technological literacy | Familiarity with the platform | ‘I thought it was pretty interesting. So I'm like relatively technological we use [virtual reality] (VR) stuff before including VR medical stuff and I quite enjoy it.’ | 8 |
| Q10 | Technological literacy | Familiarity with the platform | ‘And I think in the first scenario it was more like learn. I think I was learning about the system, like learning about the software more. If I played it several times, I'd figure out where the questions are.’ | 8 |
| Q11 | Technological literacy | Familiarity with the platform | ‘I was a bit confused, like, whether they wanted us to go through a whole head to toe examination or whether they just wanted us to focus on the cardiovascular stuff.’ | 9 |
| Q12 | Technological literacy | Limitations in the methods | ‘I couldn't really think what else to do. So to be honest, I think it was probably a little bit to do with the system and then probably a bit also partly to do with me and not being very familiar with using the tool.’ | 7 |
| Q13 | Technological literacy | Limitations in the methods | ‘What if you wanted to say something that wasn't in the options, whereas you could do that with Ray.’ | 9 |
| Q14 | VR as a learning tool | Authenticity and realism | ‘I was really impressed personally on how well he picked up my questions and gave the right answer.’ | 5 |
| Q15 | VR as a learning tool | Authenticity and realism | ‘It was great initially getting all these questions out and I did the examinations but then I was like “well, where do I kind of go from here?”.’ | 5 |
| Q16 | VR as a learning tool | Authenticity and realism | ‘The ability to construct and have that flow of consultation.’ | 4 |
| Q17 | VR as a learning tool | Authenticity and realism | ‘It helped me to think about [the] assessment and how to structure it.’ | 8 |
| Q18 | VR as a learning tool | Authenticity and realism | ‘Gaining confidence and getting slickness in a consultation manner.’ | 5 |
| Q19 | VR as a learning tool | Authenticity and realism | ‘He told me he didn't understand me.’ | 4 |
| Q20 | VR as a learning tool | Intuitive ‘It was really good because you are asking questions, developing communication skills and listening or changing and adapting.’ | 3 | |
| Q21 | VR as a learning tool | Intuitive | ‘It helped me to develop my communication skills as a student nurse.’ | 1 |
| Q22 | VR as a learning tool | Intuitive | ‘Prepared me to get more knowledge of assessing, how to assess a patient and what to do after the assessment based on what he or she will tell me.’ | 5 |
| Q23 | VR as a learning tool | Intuitive | ‘I think, in my head, I am able to categorise what I want to ask and I didn't have to waste time thinking about where to find the question.’ | 8 |
| Q24 | The road of learning: learning in action | Critical thinking and knowledge | ‘I feel like it pushes your knowledge, doesn't it? Like what were the next steps I would take? And just being forced to think by yourself without being able to ask your assessor.’ | 9 |
| Q25 | The road of learning: learning in action | Critical thinking and knowledge | ‘Ray today challenged my critical thinking skills.’ | 1 |
| Q26 | The road of learning: learning in action | Critical thinking and knowledge | ‘I agree. Yeah. It really does bring up your critical thinking.’ | 3 |
| Q27 | The road of learning: learning in action | Communication skills | ‘I feel about Ray, the strength was like I can develop as a student nurse, I can develop my communication skills with the patient.’ | 1 |
| Q28 | The road of learning: learning in action | Communication skills | ‘It's really good because you are asking questions. It's just developing your communication skills.’ | 3 |
| Q29 | The road of learning: learning in action | Communication skills | ‘I think listening skills, because it's not about only you talking, you have to listen to the patient.’ | 4 |
| Q30 | The road of learning: learning in action | Communication skills | ‘He didn't always understand me or answer correctly.’ | 8 |
| Q31 | The road of learning: learning from action | Opportunity for self-reflection | ‘When you come out of it, obviously you can see. […] I missed a bit on describing where the pain was radiating, to which I probably would ask if someone had a headache now and I was seeing them on placement.’ | 10 |
| Q32 | The road of learning: learning from action | Opportunity for self-reflection | ‘The feedback was really good, because whatever, I didn't ask properly […] I can think about it and probably develop more skills.’ | 1 |
| Q33 | Transitioning to independence | Confidence | ‘I think I preferred it to the in person [simulation] ones. It's nice to have a slightly different scenario, a different way of working, and different… It was interesting and it was nice to have all the different options up there. (…) It was also quite nice to be doing it on your own… I definitely felt like I learned something that's more ingrained because it was just me doing it rather than in a group.’ | 10 |
| Q34 | Transitioning to independence | Listening | ‘And also, I think listening skills because it's not about only you talking, you have to listen to the patient.’ | 4 |
| Q35 | Transitioning to independence | Listening | ‘The patient side is the most important. What he's telling you will help you to get a clearer assessment for him or her.’ | 4 |
| Q36 | Transitioning to independence | Preparation for independence practice | ‘I think it just prepared me for uncertainty… I developed a system for knowing what to ask and also not missing things and investigating further some particular things.’ | 8 |
| Q37 | Transitioning to independence | Preparation for independence practice | ‘I feel it's good because we are moving toward technology and when going to practice we miss on so many things, but this one allows you to go back and see what you have done but need more practice.’ | 6 |
| Q38 | Transitioning to independence | Communication | ‘It gives me more communication skills, sort of, and to know the kind of question to ask, to get a better response back from Ray, and again, to know the next step to take and how to assess a patient.’ | 4 |
| Q39 | Transitioning to independence | Critical thinking and reasoning | ‘It helped me with communication skills and how to investigate. It helped me […] to be more curious, what's going on there, and then think about and reflect what I did well or what could have happened better.’ | 6 |
Technological literacy
Within the context of this project, technological literacy refers to the ability to use, understand, and evaluate technology and the importance of platform readiness. This key theme encompasses a range of subthemes such as ease of use, familiarity with the platform, and limitations of interaction methods.
When participants were asked about their overall experience of using the VR platform, generally students reported that they found the platform to be intuitively navigable (Table 2, Q1). To interact with the ‘patient’ in the first scenario, participants used the VR hand controller to select a question from a menu-based interface. During the second scenario, participants directly talked to the AI-led ‘patient’, which required them to formulate the questions, verbalising key words programmed in the system to receive an adequate response. Although the majority of participants preferred the voice-controlled mechanism as their method of interaction due to ease of use and authenticity (Table 2, Q2-Q5) some stated that they had to repeat and reformulate questions to be able to communicate with the AI-led patient more effectively (Table 2, Q6-Q7).
Some students commented that the exposure to the new technologies across both scenarios was one of the factors potentially affecting their experience, and familiarising themselves with the tool would help them to adapt more easily and perform better using these technologies (Table 2, Q8-Q9). This subtheme was linked with the previous subtheme because students stated that exposure to the software during the first scenario helped them to have a better performance during the second scenario (Table 2, Q10). The familiarity factor was not only limited to VR as a tool – some students mentioned that it had affected the patient management and flow of the scenario (Table 2, Q11).
Limitations around the technology being used and highlighted by participants pertained to constraints regarding the types of questions that could be posed in both scenarios. One student stated that the question not being programmed into the system for the menu-based scenario was one of the limitations whereas they could ask any questions using the voice-controlled scenario (Table 2, Q12). In contrast, some students stated that in the voice-controlled scenario, even though they had the freedom to formulate any question (Table 2, Q13), the system did not have answers to them at times.
VR as a learning tool
The student participants identified the importance of being able to see the patient in a recognisable clinical environment and that it felt like a more natural way to carry out an assessment. They commented that further VR sessions in the future would be useful to prepare them for practice and gain experience in different clinical environments. The interactions with voice-controlled scenarios were perceived as more authentic experiences and closer to real-life experiences that the students had had previously in clinical practice (Table 2, Q14).
Moreover, the student participants commented that it felt more natural to communicate with the voice-controlled interaction scenario. Indeed, with the menu-based interaction scenario, the students felt that they got lost in all the questions, that there were too many options, and that it was difficult to understand the flow. Some commented that once they had completed all the tests and examinations for this scenario, they were unsure what to do next (Table 2, Q15).
Some students said that communicating in the voice-controlled interaction scenario was more like having a conversation with a real patient and provided the opportunity to practise consultation techniques, history-taking, and assessment skills (Table 2, Q16-Q18). In contrast, some students commented that they found assessing the AI-led patient more difficult as it was harder to work out how to frame questions and at times, the AI-led patient did not understand the questions (Table 2, Q19). This challenged the students to think differently about how to ask different questions and change and adapt their approach. Other students found it easier to categorise what they wanted to ask in the voice-controlled interaction scenario and found it less time-consuming than searching the automated list in the menu-based interaction scenario to find the question (Table 2, Q20-Q21).
In general, the student participants commented that they found the voice-controlled interaction scenario to be more ‘personable’ and that they could engage more with it by listening to its answers. They felt more connected, and assessing in this case scenario felt like spending time with a real patient. The intuitive responses from this AI-led patient empowered the students to be more creative with their questioning and develop their critical thinking skills. This helped to prepare them to plan what steps they would take after the assessment, based on the responses the AI-led patient had given (Table 2, Q22-Q23).
The road of learning
Another key theme identified in this evaluation was referred to as the ‘road of learning’, which was subdivided into two distinct subthemes. The first subtheme, ‘learning in action’, encapsulated students' knowledge and skills acquired during active engagement with the VR tool. The most common skills developed were communication skills, assessment techniques, and thinking processes, particularly within the context of clinical reasoning. This last one, was more evident with the AI voice-controlled interaction method. Students did not have prompting or software mechanisms that could guide them in formulating pertinent assessment queries and conducting a comprehensive patient history assessment (Table 2, Q24-Q26).
Communication skills – how to gather and listen to patient information – were developed using both scenarios. However, students said these skills were demonstrated more easily when students used the AI voice-controlled scenario (Table 2, Q27-Q29). It is also worth noting that, on certain occasions, students encountered frustration when using the voice-controlled scenario, as the AI patient exhibited difficulty in comprehending lengthy or poorly formulated questions. Consequently, students endeavoured to rephrase their inquiries to effectively collect patient information (Table 2, Q30).
The second subtheme was labelled ‘learning from action’. This subtheme emerged due to students placing significant emphasis on the value derived from autogenerated feedback and the opportunity for self-reflection on their performance. The students highly valued the ability to recognise previously missed crucial interventions and connect them with evidence-based sources. This procedure, which was equally present in both scenarios and interaction methods, aided in identifying their knowledge deficits and enhanced their curiosity and eagerness to delve deeper into specific subjects (Table 2, Q31-Q32).
Transitioning to independence
The findings from the focus groups emphasise the valuable role of VR technology in nursing education, shaping students into competent and self-assured practitioners as they transition into professional autonomy. A central theme, ‘transitioning to independence’, emerged prominently, highlighting the significant gains for students' professional growth through gaining VR-based holistic assessment skills. The gains associated with this transition encompassed increased confidence; improved listening skills; enhanced preparation for independent practice; advanced communication skills; sharper critical thinking; and the development of essential clinical reasoning skills.
In terms of confidence, students reported augmented self-assurance in clinical skills and decision-making, a direct outcome of immersive VR simulations with both interaction methods, providing a secure space for practise and learning (Table 2, Q33). The emphasis on effective listening in nursing care surfaced as a key outcome with voice-controlled AI patient engagement when compared with menu-based interaction, compelling active listening, empathy expression, and clear communication (Table 2, Q34). This, in turn, translated to improved listening skills, enabling a deeper understanding of patients' needs and more meaningful interactions in real-world settings (Table 2, Q35).
The VR simulations, particularly those with voice-controlled interaction, not only enhanced preparation for independent practice (Table 2, Q36-Q37) but also honed students' communication skills, allowing experimentation with different approaches. It equipped them with augmented abilities to build rapport, convey empathy, and perform a systematic person-centred assessment (Table 2, Q38). The exposure to diverse patient conditions within both interaction methods prompted critical thinking, refining the students' capacity to analyse and respond to complex patient needs. Moreover, the VR experiences facilitated the repeated practise of relevant clinical procedures in a safe setting, enhancing memory processes and technical skills (Table 2, Q39). Students expressed how this experience contributed to a smoother transition into their professional nursing careers, reducing the learning curve typically associated with the early stages of autonomous and independent practice.
Discussion
Most higher education institutions are striving to implement digital and immersive learning tools into pedagogical programmes (Health Education England (HEE), 2020) and expect students to become ‘digital scholars’ through the use of technology in diverse forms across their academic studies (Weller, 2011; Quintas-Mendes and Paiva, 2023). This project evaluation strengthens the knowledge about the benefits of VR nursing simulations as a pedagogical strategy to enhance the practical application of non-technical clinical skills. VR can better prepare students for specific clinical situations, challenging and consolidating ideas on the support for individual patients with varying needs (Arveklev et al, 2015). This adds to the body of knowledge that demonstrates that the interactive and operational attributes of VR outperform 3D videos in enhancing students' comprehension and assimilation of knowledge (Jang et al, 2017).
VR enhances the student's audio and visual experiences to evoke authenticity, immersion, and realism by stimulating the participant's senses (International Nursing Association for Clinical Simulation and Learning (INACSL), 2016). This evaluation found that students found it easier to relate to the voice-controlled scenario, which challenged them to think differently and adapt their approach in a similar way to how they would interact with different patients in the clinical environment. This contrasts with previous studies, which found that the nursing skills students learned on a virtual platform were not always transferable to real situations (Chen et al, 2020). This could be attributed to the early stage of development in the VR technology used and highlights the need for further development in AI voice-controlled scenarios.
Earlier research revealed comparable student experiences in the process of learning and development. Chen et al (2020) focused on identifying the development of student knowledge, whereas Liaw et al (2023) and Mayor Silva et al (2023) highlighted skills development, particularly in the fields of communication knowledge and interprofessional communication, when using such tools. The present evaluation also indicated that some participants recognised the enhancement of their clinical reasoning and clinical judgement. Fogg et al (2020) observed similar outcomes. Moreover, additional research employing similar problem-based learning VR software revealed that students predominantly acquired proficiency in understanding the patient's cues and executing nursing interventions based on symptoms (Koivisto et al, 2016). This research showed a significant correlation between the application of nursing knowledge and the aspects of usability, exploration and reflection (INACSL, 2016). The findings from these previous studies combined with this project evaluation support the use of VR tools to develop nursing students' clinical reasoning skills. It is crucial to emphasise that the diversity of VR healthcare software available on the market and the way in which students interact with it might impact on students' perceptions, experience and skills development when using these tools. Therefore, it is important to take into consideration these factors when comparing results.
The use of VR technology in nursing education facilitates the transition of nursing students toward independence (Saab et al, 2021). Moreover, a tailored approach for its use in different stages of their pre-registration education contributes to the development of their knowledge, skills and confidence (Chen et al, 2020; Siah et al, 2022; Park and Yoon 2023). This approach aligns with nursing-related educational frameworks in the UK (HEE, 2020; NMC, 2023b) and recognises the importance of relevant technology throughout the learning journey. In the early stages of their pre-registration nursing education, the menu-based interaction VR scenarios seem to be particularly relevant. It offers students a structured and immersive learning experience, promoting self-confidence and practice preparation by acquainting them with fundamental skills and clinical scenarios. As students progress towards more advanced levels of their education, and as they approach professional registration, the shift towards voice-controlled AI technology becomes pertinent. This transition encourages students to exercise their critical thinking skills and apply their knowledge more independently, mirroring the expectations of real-world clinical practice (Jans et al, 2023). In alignment with the NMC (2023b) standards, this dual approach not only tailors their learning experience but also equips them with the competence and confidence needed to excel in their evolving roles as health professionals.
Conclusion
The use of VR and AI-led patients in nursing education positively contributes to the nursing curriculum by exposing students to immersive problem-based learning situations that are effective in the development of a range of nursing skills in a safe environment. Although this applies to different interaction methods available in the market, it is noted that the recent voice-controlled AI technology has been perceived by the students as more advantageous in the intuitive usage of the tool, comprising a more natural experience with the AI-led patient. The conventional menu-based interaction method gives students more structure and guidance, which was also perceived as positive but more relevant for the early stages of their pre-registration programme and development as a student nurse.
Student participants stated that VR, in general, helps them to develop some skills throughout their learning journey (such as communication, critical thinking, and decision-making), with the voice-controlled interaction method being more relevant to their potential transition to professional registration and autonomous practice. Many students also noted that they built up their confidence as the VR simulations allowed them to repeat the scenario multiple times and reflect on their performance.
Although these results cannot be generalised across all nursing students and programmes from UK AEIs, results obtained from this project evaluation are similar to previous research conducted on this topic, strengthening an evidence-based practice rationale for the use of VR and AI-led patients in nursing education. Further studies and research are required not only to strengthen and consolidate these findings but also to ascertain cost-effective and safe ways of introducing these different methods of interaction in VR across the pre-registration nursing programmes and in postgraduate education.