Virtual Simulation to Enhance Clinical Reasoning in Nursing: A Systematic Review and Meta-analysis

Benefits and Barriers of Using Virtual Reality in Teaching Undergraduate Nursing Students: A Scoping Review

BACKGROUND

Although studies have been conducted using virtual reality (VR) in nursing education, evidence distinguishing the benefits and barriers of adopting VR pedagogical methods to teach undergraduate nursing students is not well-defined in nursing literature.

PURPOSE

To identify current evidence on the benefits and barriers of adopting VR as a pedagogical method in nursing education.

METHODS

A scoping review of 6 databases using PRISMA-ScR reporting guidelines. Data were managed using Covidence® software. Table of Evidence illustrates the themes.

RESULTS

Seventeen articles identified 5 thematic benefits of VR (knowledge acquisition, student engagement, improved self-confidence, teaching strategy, and cost factors) and 4 barriers (physical discomfort, learning outcome challenges, challenges to integrating into curricula, and technology challenges).

CONCLUSIONS

VR is an effective teaching-learning strategy to reinforce nursing concepts and build competencies. It is not a substitute for clinical education.

An evaluation of a Transition to Foundations curriculum for first year pediatric residents in Competency Based Medical Education

A Transition to Foundations (TTF) curriculum that includes didactic and simulation components prepares first-year pediatric residents for increased roles and responsibilities in the Foundations of Discipline stage of Competency Based Medical Education, including junior night float rotations. Simulations of acute presentations improve resident comfort before overnight on-call experiences.

Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial

BACKGROUND

History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents.

METHODS

Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time.

RESULTS

The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group.

CONCLUSION

VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

Clinical virtual simulation: predictors of user acceptance in nursing education

BACKGROUND

Using virtual patients integrated in simulators expands students' training opportunities in healthcare. However, little is known about the usability perceived by students and the factors/determinants that predict the acceptance and use of clinical virtual simulation in nursing education.

OBJECTIVES

To identify the factors/determinants that predict the acceptance and use of clinical virtual simulation in learning in nursing education.

METHODS

Observational, cross-sectional, analytical study of the use of clinical virtual simulation in nursing to answer the research question: What factors/determinants predict the acceptance and use of a clinical virtual simulator in nursing education? We used a non-probabilistic sampling, more specifically a convenience sample of nursing degree students. The data were collected through a questionnaire adapted from the Technology Acceptance Model 3. In technology and education, the Technology Acceptance Model is a theoretical model that predicts the acceptance of the use of technology by users.

RESULTS

The sample comprised 619 nursing students, who revealed mean values of perceived usefulness (M = 5.34; SD = 1.19), ease of use (M = 4.74; SD = 1.07), and intention to use the CVS (M = 5.21; SD = 1.18), in a Likert scale of seven points (1-the worst and 7 the best possible opinion). This study validated the use of Technology Acceptance Model 3 adapted and tested the related hypotheses, showing that the model explains 62% of perceived utility, 32% of ease of use, and 54% of intention to use the clinical virtual simulation in nursing by nursing students. The adequacy of the model was tested by analysis of the direct effects of the relationships between the internal constructs (PU-BI, β = 0.11, p = 0.012; PEOU-BI, β = -0.11, p = 0.002) and the direct relations between some of the constructs internal to the Technology Acceptance Model 3 and the external determinants Relevance for learning and Enjoyability. In the proposed model, the external constructs that best predicted perceived usefulness, ease of use, and behaviour intention to use the clinical virtual simulation in nursing were Relevance for learning and Enjoyability.

CONCLUSIONS

These study results allowed us to identify relevance for learning and enjoyability as the main factors/determinants that predict the acceptance and use of clinical virtual simulation in learning in nursing.

Integrative virtual nursing simulation in teaching cardiopulmonary resuscitation: A blended learning approach

BACKGROUND

Online learning resources facilitated educational development during the COVID-19 pandemic. This study focuses on the integration of online virtual simulation with interactive exercises and offline low-fidelity simulation for the first time to explore the impact on CPR skills.

METHODS

First year nursing students from a medical college participated as volunteers in this study. They were divided randomly into two groups with both having a cardiopulmonary resuscitation (CPR) lesson with the same timings and objectives. The experimental group (n = 36) adopted a blended learning method, with virtual simulation and low-fidelity simulation as resources; the control group (n = 36) used the same method without virtual simulation. The same lecturers taught both classes. Students' self-directed learning (SDL) and critical thinking skills were assessed before and after the intervention and their CPR skills were examined afterward.

RESULTS

The experimental group exhibited significantly greater improvement in their SDL abilities and CPR skills. By contrast, we found no statistical differences in their critical thinking abilities.

CONCLUSIONS

During CPR training, blended learning method was used to integrate virtual nursing simulation in teaching, which effectively improved students' SDL and CPR skills.

Virtual simulation in healthcare education: a multi-professional, pan-Canadian evaluation

BACKGROUND

As we experience a shortage of healthcare providers in Canada, it has become increasingly challenging for healthcare educators to secure quality clinical placements. We evaluated the impact of virtual simulations created for the virtual work-integrated learning (Virtu-WIL) program, a pan-Canadian project designed to develop, test, and offer virtual simulations to enrich healthcare clinical education in Canada. Evaluation was important since the virtual simulations are freely available through creative commons licensing, to the global healthcare community.

METHODS

Students self-reported their experiences with the virtual simulations and the impact on their readiness for practice using a survey that included validated subscales. Open-ended items were included to provide insight into the students' experiences.

RESULTS

The evaluation included 1715 Nursing, Paramedicine and Medical Laboratory students enrolled in the Virtu-WIL program from 18 post-secondary universities, colleges, and institutions. Results showed most students found the virtual simulations engaging helped them learn and prepare for clinical practice. A key finding was that it is not sufficient to simply add virtual simulations to curriculum, careful planning and applying simulation pedagogy are essential.

CONCLUSION

Virtual simulation experiences are increasingly being used in healthcare education. Results from this rigorous, large-scale evaluation identified ways to enhance the quality of these experiences to increase learning and to potentially decrease the number of hours healthcare students need in clinical practice to meet professional competencies. Further research is needed regarding many aspects of virtual simulations and, in particular, curriculum integration and the timing or sequencing of virtual simulations to best prepare students for practice.

The impact of virtual clinical simulation on nursing students' palliative care knowledge, ability, and attitudes: A mixed methods study

BACKGROUND

Palliative care is fraught with numerous challenges when it comes to conducting practical teaching as it involves caring for people facing the complexities of end-of-life and death. Insufficient clinical practice hinders nursing students from mastering knowledge, attitude and ability of hospice care. Virtual clinical simulation has demonstrated its effectiveness as a valuable educational tool in nursing. However, there is a dearth of evidence supporting its utilization in the context of palliative care practice education.

OBJECTIVE

To develop a virtual clinical simulation education system and assess its impact on enhancing nursing students' knowledge, ability, and attitudes toward palliative care.

DESIGN

A single-group pretest-posttest design and focus group interviews were employed.

SETTING

The study was conducted at a medical university in southwest China.

PARTICIPANTS

A total of 76 third-year nursing students participated.

METHODS

Participants underwent a 1-hour learning session using the virtual clinical simulation education system. Pre-test and post-test evaluations were conducted to assess the participants' knowledge, ability, and attitudes toward palliative care. Survey questionnaire was administered to gauge the students' acceptance and perception of virtual clinical simulation. Focus group interviews were integrated to gain insight into students' subjective perceptions and feedback on the virtual clinical simulation.

RESULTS

There were notable enhancements in the students' overall scores of palliative care knowledge, ability, and attitudes after the learning session. Students positively evaluated the usefulness and usability of virtual clinical simulation. Students' feedback regarding virtual clinical simulation can be categorized into four themes: the value of virtual clinical simulation education system, its role as a complement to clinical practice teaching, the enjoyment and accessibility of learning, and the technological challenges encountered.

CONCLUSION

Virtual clinical simulation is an effective learning tool in palliative care practice education, which has the potential to enhance students' knowledge, ability, and attitudes toward palliative care.

Virtual reality simulation for nursing education: effectiveness and feasibility

Virtual Reality simulation (VRS) is an innovative and emerging technology that has the potential to offer increased numbers of pre-registration students authentic learning experiences compared to traditional simulation- based education (SBE) with simulated participants. The aim was to evaluate learner outcomes of SBE compared to 4 fully immersive VRS scenarios, for vocational and higher education nursing students at a training and further education institute in Melbourne, Australia. A mixed methods quasi-experimental design study was conducted over two semesters from 2019 to 2020. Participants were 675 pre-registration nursing students. The intervention group (VRS n = 393) received 4 three-dimensional, immersive VRS modules. The control group (SBE n = 282) received 4 face-to-face large group immersive simulations. In the VRS group 95% of students actively participated, compared to SBE (on average 15%). Knowledge test scores were initially significantly greater (p < 0.01) for VRS versus SBE students, but not maintained post clinical placement. Intervention students found VRS to be realistic and prepared them for clinical practice. Some technical difficulties were identified with VRS. VRS was found to be more cost effective than SBE. VRS fostered critical thinking and provided an efficient and sustainable platform for learning about complex clinical situations.

"Learning a Way of Thinking"-World Café on Clinical Reasoning in Nursing and Midwifery Education and Practice across Five European Union Countries

Clinical reasoning is a key attribute of nursing and midwifery professionals. As a part of the Erasmus plus project, we designed a study with the aim of exploring the understanding of clinical reasoning as a concept, experiences of teaching clinical reasoning and practices related to using clinical reasoning in nursing and midwifery. A qualitative study was carried out using the World Café method, involving 44 participants from five European countries. The participants represented diverse professional backgrounds, including nurses, midwives and lecturers. Our analytical approach was based on a thematic analysis. We categorized the data into three main categories, namely, "Spiral of thinking", "The learning and teaching of a way of thinking" and "Clinical reasoning in real life", all under an overarching theme, "Learning a way of thinking". This study highlighted areas of learning and teaching which can be improved in current nursing and midwifery education. Furthermore, it identified barriers, facilitators and practices from five European countries which can be used in the further development of nursing and midwifery curricula and courses with the aim of enhancing clinical reasoning competence and ultimately improving patient care.

Research on the learning experience of virtual simulation class experimental teaching and learning based on the perspective of nursing students

BACKGROUND

The enrichment of information technology has impacted traditional teaching modes. The emergence of virtual simulation class experimental teaching software has effectively improved the quality of nursing experiment teaching. The learning experience of virtual simulation class experiment teaching and learning based on the perspective of nursing students is explored to provide a basis for improving related learning effects in the future.

METHODS

Fourteen undergraduate nursing students were selected using the purposive sampling method for semi-structured interviews. The Colaizzi seven-step analysis method was used to collate and analyse the interview data.

RESULTS

Two themes and six sub-themes were considered during the data analysis. The two themes were positive experiences and negative experiences. In the positive learning experience, undergraduate nursing students showed a deep memory of authentic and diverse scenes, which presented knowledge in a clearly logical, visualised and stereoscopic manner. Negative experiences are manifested as significantly different learning efficiencies in different grades and subjects, and timing the delivery of teaching feedback is difficult.

CONCLUSION

Virtual simulation experimental teaching can promote the subjective initiative of nursing students' learning and promote better coordination and unity in their image and theoretical thinking. Some advantages can be augmented by following the national educational policy, strengthening the information construction, combining the construction of virtual simulation experiments with the discipline's characteristics and optimising the resources. This paper provides a reference for the future exploration of nursing education and further improving the construction of virtual simulation experimental teaching tools and resources.

The effect of virtual reality on cognitive, affective, and psychomotor outcomes in nursing staffs: systematic review and meta-analysis

BACKGROUND

In the healthcare systems of the world, reinforcing the competence and professionalism of nurses has become a concern. Gaining clinical nursing competence in the healthcare system requires more effort, and additional training is required. Medical education and training have begun using digital technologies, such as virtual reality (VR). The purpose of this research was to examine the efficacy of VR in terms of cognitive, emotional, and psychomotor outcomes and learning satisfaction in nurses.

METHOD

The study searched eight databases (Cochrane library, EBSCOHost, Embase, OVID MEDLINE, ProQuest, PubMed, Scopus, and Web of Science) for articles that met these criteria: (i) nursing staff, (ii) any virtual reality technology intervention for education, all levels of immersion, [1] randomized control trial and quasi-experiment study, and (iv) published articles and unpublished theses. The standardized mean difference was measured. The random effect model was applied to measure the main outcome of the study with a significance level of p < .05. The I² statistic assessment was applied to identify the level of heterogeneity of the study.

RESULTS

A total of 6740 studies were identified, of which 12 studies with 1470 participants met the criteria for inclusion. The meta-analysis showed a significant improvement in the cognitive aspect (standardized mean difference [SMD] = 1.48; 95% CI = 0.33-2.63; p = .011, I² = 94.88%), the affective aspect (SMD = 0.59; 95% CI = 0.34-0.86; p < .001, I² = 34.33%), the psychomotor aspect (SMD = 0.901; 95% CI = 0.49-1.31; p < .001, I² = 80.33%), and learning satisfaction (SMD = 0.47; 95% CI = 0.17-0.77; p = .002, I² = 0%) aspects of the groups that received the VR intervention compared to the control groups. Subgroup analysis found that dependent variables (e.g., level of immersion) did not improve study outcomes. The quality of evidence was low which is affected by major methodological issues.

CONCLUSIONS

VR may favorable as alternative method to increase nurse competencies. Randomized controlled trials (RCTs) on larger samples are needed to strengthen the evidence for the effect of VR in various clinical nurse settings. ROSPERO registration number: CRD42022301260.

Nursing Students Reported More Positive Emotions about Training during COVID-19 After Using a Virtual Simulation Paired with an In-person Simulation

Background

Virtual simulations (VS) are educational tools that can help overcome the limitations of in-person learning highlighted during the COVID-19 pandemic. Research has illustrated that VS can support learning, but little is known about the usability of VS as a distance learning tool. Research on students' emotions about VS is also scarce, despite the influence of emotions on learning.

Methods

A quantitative longitudinal study was conducted with undergraduate nursing students. 18 students participated in a hybrid learning experience involving a virtual simulation (VS) followed by an in-person simulation. Students completed questionnaires about their emotions, perceived success, and usability and received a performance score from the VS.

Results

Nursing students reported statistically significant improvements in their emotions about completing their program after completing both VS and in-person simulations compared to their emotions before the pair of simulations. Emotions directed toward the VS were weak-to-moderate in strength, but predominantly positive. Positive emotions were positively associated with nursing students' performance. Findings replicated "okay" approaching "good" usability ratings from a recent study with key methodological differences that used the same software.

Conclusions

VS can be an emotionally positive, effective, efficient, and satisfying distance learning supplement to traditional simulations.