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Immersive virtual reality simulations in nursing education.

ABSTRACT This article explores immersive virtual reality as a potential educational strategy for nursing education and describes an immersive learning experience now being developed for nurses. This pioneering project is a virtual reality application targeting speed and accuracy of nurse response in emergency situations requiring cardiopulmonary resuscitation. Other potential uses and implications for the development of virtual reality learning programs are discussed.

Key Words Virtual Reality--Simulation--Emerging Educational Technologies--Nursing Education


Contemporary nurse faculty are preparing the next generation of students using methods seen only in science fiction when they were students. Indeed, the use of simulation technology to supplement clinical instruction is becoming necessary as health care agencies reach their capacity to handle an increased number of students, and the nurse preceptors responsible for working with students have little time to spend teaching basic skills.

With insufficient resources to provide lengthy orientation programs for newly graduated nurses, agencies will benefit when graduates move quickly from student to practicing nurse, functioning at a more independent level (Jeffries, 2007). This article explores immersive virtual reality as a potential educational strategy for nursing education and describes a project to develop and pioneer its use.

Theoretical Basis for Nursing Simulations Simulation-based training is commonly used in fields characterized by complex, highly technical environments where conditions change frequently, crises can occur rapidly, and human life may be at risk. Examples include the aerospace industry, the military, and the nuclear power industry. Several theories are relevant to the use of simulation in nursing education. Waldner and Olson (2007) combine Benner's (1984) novice to expert model and Kolb's (1984) theory of experiential learning to explain how clinical simulation experiences can be used to bring nursing students to higher levels of expertise in nursing practice. Nursing students are expected to progress to at least the advanced beginner level of expertise by graduation. The process of reflecting on clinical practice experiences and theoretical knowledge learned in the classroom is ongoing and continues after graduation as the new graduate gains competence and eventually transforms into a highly competent expert (Benner).

Sewchuck (2005) describes four learning styles used in experiential learning theory: a) accommodating learners use active experimentation; b) diverging learners reflect upon their experiences; c) converging learners develop abstract ideas and experiment to test them; and d) assimilating learners reflect upon abstract ideas. Ideally, a simulation should be designed to be useful to students with a variety of learning styles. Kolb (1984) describes how active reflection is used by learners to incorporate new experiences into their existing stores of knowledge and achieve higher levels of knowledge in their fields. Both accommodating and assimilating learners benefit from active experimentation in combination with active reflection to help internalize knowledge. Learners may want to experiment with different responses, some of which may be incorrect, in order to learn what would happen and why certain responses are contraindicated in some types of emergencies. Such experimentation would be unthinkable in an actual clinical setting, but could provide a valuable learning experience in a virtual reality setting where there is no risk of patient injury.

The learning theory of deliberative practice is also applicable to virtual reality clinical simulations (Ericsson, 2004).This set of instructional principles has been demonstrated by instructional science research to be effective in helping students gain expertise in clinical medicine, aviation, professional sports, musical performance, and other fields. The principles relate the development of proficiency to the learner's engagement in the deliberate practice of desired outcome goals. Outcomes are accomplished by repeated performance of desired cognitive and/or psychomotor skills, along with rigorous assessments that give the learner specific feedback and facilitate improved skills performance.

The three categories of simulation used in nursing education (Seropian, Brown, Gavilanes, & Driggers, 2004) are based on the use of task and skill trainer models characterized by various degrees of complexity, sophistication, and realism, described as fidelity (Yaeger et al., 2004). Low-fidelity trainers, such as a plastic arm used to practice intravenous catheter insertion, facilitate the practice of a single skill or a limited number of skills. High-fidelity models, such as the computerized human patient simulator, are programmed to produce a variety of responses to nursing interventions, including changes in vital signs, ECG tracings, breath sounds, and verbal responses. Full-scale simulations may use a combination of computerized patient simulators and include various members of a health care team as participants in a recreated clinical environment.

Computer-based simulations include virtual worlds, such as Second Life, where users manipulate onscreen representations of themselves in a highly realistic environment. At this time, the use of immersive virtual reality in nursing is an area that has been largely unexplored.

What Is Immersive Virtual Reality? Gaddis (1997) defines virtual reality as a computer-generated simulation of a three-dimensional environment the user is able to view and manipulate or interact with. The immersive virtual reality environment prevents the user from perceiving any elements of the real world. Thus, the user is completely immersed in the virtual environment created by the system. Key features of the virtual reality environment include: a) three-dimensional imaging, b) the ability to actively interact with the virtual environment, and c) visual and auditory feedback (Mantovani, Castelnuovo, Gaggioli, & Riva, 2003). These features combine to give the user a feeling of being part of the simulated experience and experiencing it firsthand.

Flight simulators, long used in aviation as a means of safely training pilots to manage in-flight emergencies, are an example of how virtual reality is useful in an educational context. More recently, immersive virtual reality has been used to make abstract concepts perceptible, for example, demonstrating dynamic forces for physics students (Dede, Salzman, & Loftin, 1996). Immersive virtual reality technology can also allow extreme close-up examination of objects (e.g., molecules) and provide experiences that would be impossible in real life (e.g., traveling inside the human body).

To create a completely immersive virtual reality environment, the system must generate imagery that occupies the user's entire field of vision. Brooks (1999) and Van Dam, Forsberg, Laidlaw, LaViola, and Simpson (2000) describe two different methods of accomplishing this: head-mounted displays and caves. With head-mounted displays, an immersive environment is obtained by generating the environment on small screens near the user's eyes. With caves, immersion is created by surrounding the user with three or more large projection screens.

With regard to training users with computer simulations, previous research studies (Patrick et al., 2000) have shown that large projection displays are as effective an environment for learning as head-mounted displays, while being far less expensive. Other research (Tan, Gergle, Scupelli, & Pausch, 2003) has demonstrated improved performance when users are trained using large projection displays as opposed to standard desktop computing environments. Given the effectiveness of large projection displays in training environments, Ni et al. (2006) provide a survey describing various approaches and tools that are available for implementing such a system.

Immersive Virtual Reality in Health Care Education The use of fully immersive virtual reality for health care education is in an early stage of development. In medical education, one may find a large variety of surgical procedure trainers, such as robotic surgery and colonoscopy and arthroscopy simulators (Sun et al., 2007). Many of these are made available by manufacturers of the equipment used for these procedures.

BioSimMER is a fully immersive, distributed, virtual reality platform used to train medical emergency-response personnel (Stansfield, Shawver, Sobel, Prasad, & Tapia, 2000). Freeman et al. (200 I) describe a virtual reality patient simulation system for teaching emergency response skills to Navy medical providers. Both of these programs were developed for casualty stabilization scenarios rather than for hospital settings.

Researchers are beginning to combine virtual reality with other simulation methods to provide maximum realism in training for complex situations that are difficult to replicate. Lee et al. (2007) created an immersive virtual environment where disaster response teams can practice learning to care for casualties in a realistic environment that includes visual, sound, and smoke effects seen in mass casualty or battlefield situations. As the technology for this method of instruction develops and options become more affordable, virtual reality applications could become a practical learning strategy, either used alone or in creative combinations with other simulation strategies.

In nursing, high-fidelity simulations may be especially useful to prepare students for situations that may be dangerous, such as bomb threats, treating battlefield casualties, or dealing with violent patients. They could also help overcome logistical problems, simulating situations that occur infrequently in actual clinical practice, or that involve the use of equipment that is prohibitively expensive to use in practice situations. For example, virtual reality may be used to help inexperienced nurses become proficient in their ability to function as members of hospital medical emergency response teams, without endangering patients or consuming expensive medications and supplies.

Because situations can be standardized and performance easily monitored and recorded (Mantovani et al., 2003), virtual reality has potential as a means of evaluating student performance. When speed and accuracy of response are critical, as in emergency situations, virtual reality can provide objective documentation of improvement as well as an opportunity to practice required skills.

Development of an Immersive Virtual Reality Program Work in progress by the authors provides an example of a virtual reality application chat targets speed and accuracy of nurse response in emergency situations. In order to compile a database, the research team collaborated with local hospitals to acquire visual images of drugs and equipment used during carcliopulmonary resuscitation. Using those images, a highly realistic, life-size, prototype virtual crash cart was developed and is operational on a couch-sensitive monitor. (Screen captures of the prototype are displayed in the three Figures below.)




After exploring several options, including the use of finger sensors and GPS technology, the touch screen monitor was deemed to be the most practical way to display the cart and measure user responses with the degree of accuracy needed co detect drug measurement errors. The large touch screen also enables the use of detailed representations of objects. For example, medication boxes can be rotated and moved closer so that expiration dates and directions for use can be read. Touch screen responses can be programmed in a highly realistic manner. Clinical experts helped the programmer separate images into components that would need to be manipulated and to identify what would normally be done with assembled objects. These actions were then programmed to allow for intuitive responses by users. A background scene showing a hospital room can be displayed onscreen with the cart or on the walls of a virtual learning laboratory.

The team is currently exploring the use of more compact and user-friendly platforms that could make the program more widely available and easier to use. These include augmented reality in which the computerized image would be displayed against a real simulation laboratory background and adaptation of the cart for use in Second Life, an Internet-based virtual world. As the cart is tested and refined, the research team will develop the background elements, case studies, and a virtual patient in preparation for future studies that will incorporate those elements.

When all elements of the program have been developed and tested, the virtual environment and crash cart can be combined with a resuscitation or computerized manikin to enable a full virtual reality experience for a single nurse or team of nurses. Unlike the sluggish virtual reality environments of the past, this research project will eventually develop distributed algorithms for the virtual reality simulation and execute them on parallel processors to achieve high-performance, near-realistic interactions.

Through experimental testing with a population of nursing students and novice nurses from area hospitals and local medical centers, the environment will be refined and new, dynamic scenarios created. Expert knowledge of the dynamic interactions between an emergency response team and the patient's medical condition, encapsulated through the vital life sign parameters, will be acquired, analyzed through artificial intelligence techniques, and then modeled in the immersive environment.

Summary and Conclusions Immersive virtual reality clinical simulations are an emerging learning strategy for nurses. The rapid development of sophisticated hardware, software, and programming skills basic to the production of realistic immersive simulations makes possible a level of realism that could only be imagined a few years ago. As this technology becomes more widely available and affordable, the use of immersive simulations could become commonplace in nursing education.

Although highly realistic immersive simulations could be useful in the education of beginning nursing students, they may have greater potential as a method to help nurses learn advanced skills, such as those needed in chaotic or unusual situations. Scheduling of technology-based learning may be easier than scheduling of experiences that require multiple teachers and actor patients, enabling this type of experience to be offered more frequently and for smaller groups of learners than is currently the case. Scheduling flexibility and the accommodation of small groups of students could be assets to educators of practicing nurses in institutions where patient care cannot be disrupted.

There is a need for interdisciplinary collaboration in the development of products for immersive virtual reality simulations. Specialists with programming skills and technology system design skills will need to work with educators and nurses with a strong base of clinical expertise. Development of immersive clinical scenarios is time and labor intensive. Detailed images must be acquired and animated to permit user manipulation and zooming in to see details of the image. Highly realistic patient scenarios must be created, with anticipated correct and incorrect responses by the user. Feedback for anticipated responses must be planned and programmed. Necessary reference materials that would be available in an actual situation must be incorporated. These elements must be programmed in such a way that the computer can process them rapidly enough to permit realistic response times. Therefore, the availability of external funding for such projects is critical to their success.

Before the use of immersive virtual reality can become widespread, there will be a need to standardize the technology used for programming. Few organizations will have the technical capability to replicate highly individualized virtual reality simulations with unique and complex combinations of hardware and software. However, applications developed for platforms in widespread use could become a feasible alternative to other methods of instruction.

As the use of simulations in nursing education grows and becomes increasingly sophisticated, it is time to begin taking the next bold step into immersive virtual reality. What used to be science fiction may soon intersect with nursing science.

Carol A. Kilmon, PhD, RN, is an associate professor at the College of Nursing and Health Sciences, University of Texas at Tyler. Leonard Brown, PhD, is an associate professor and Sumit Ghosh, PhD, is a professor, Department of Computer Science, University of Texas at Tyler. Artur Mikitiuk, PhD, was an assistant professor, Department of Computer Science, University of Texas at Tyler at the time this article was written. He is currently an assistant professor, Professor Kotarbiaski Olsztyn Academy of Computer Science and Management, Olsztyn, Poland. Contact Dr. Kilmon at Development of the virtual crash cart described in this article was supported by a faculty research grant from the University of Texas at Tyler.


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Author:Kilmon, Carol A.; Brown, Leonard; Ghosh, Sumit; Mikitiuk, Artur
Publication:Nursing Education Perspectives
Date:Sep 1, 2010
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