Category Archives: Nursing

‘This will translate to the real world’: Nursing students learn skills through virtual reality

Nursing student being introduced to a scenario at UNE

Nursing students have had few opportunities to learn in hospital settings because of the COVID-19 pandemic. But, as this report from reports the Maine News Center demonstrates, virtual reality simulation from OMS is allowing students at the University of New England’s School of Nursing and Population Health  to learn skills that prepare them for the real world.

During class on UNE’s Portland campus, nursing students use virtual reality scenarios from OMS to assess patients as they would in real life. 

Having opportunities to build confidence and competence in this way is vital, as research shows that only 23% of nurses graduate feeling prepared for practice and 50% of entry-level nurses are involved in practice errors.

The inability to practice has only been made worse over the pandemic. As Dawne-Marie Dunbar, the director of the UNE Simulation Center notes:

“With the challenges of COVID-19, oftentimes are units are closed to our students, so being able to experience in the virtual reality has been a huge benefit”

— Dawne-Marie Dunbar, Director of the UNE Simulation Center

Nursing student being introduced to a scenario at UNE
Nursing student being introduced to a scenario at UNE
Dawne-Marie Dunbar, Director of the UNE Simulation Center

Some scenarios takes place in a hospital maternity ward. Students must first determine the symptoms of a pregnant patient, who was just sent over from her doctor’s office. Students check reflexes, vital signs of both mom and baby. 

As VR immerses completely immerses students in the virtual world, it convinces  the brain into believing the experience is real. Kathleen Humphries, who is a senior in the program, said the scenarios make her feel like she is actually in the room with the patient and allows more practice in emergency cases: 

“It allows us to screen for more critical cases where we need to do interventions and call providers”

— Kathleen Humphries, nursing student

After the students run through a scenario, they get immediate feedback on their mistakes without the stress of “practicing” skills on a real patient.

Developing this confidence is crucial to develop independent, capable nurses of the future. A 2020 report highlighted poor clinical decision-making as a factor in 65% of entry-level nurse errors and also found that just one-third of graduate nurses are confident in their practice. 

The good news is that VR simulation scenarios such as those used by UNE can significantly improve knowledge retention and self-confidence in learners. Unlike with traditional training, scenarios can also can be repeated as often as needed to improve skills.

“A lot of times we can go back in and redo the scenario and it’s a good opportunity to really learn”

— Katy Hancock, nursing student

Following the ongoing success of the VR program in nursing, the team at UNE are now looking to expand VR to cover PAs and other healthcare professionals. 

Interested in trying VR sim? Arrange a free demo with us today.

VR Simulation at Johns Hopkins University School of Nursing

Johns Hopkins Student Nurse
Johns Hopkins Student Nurse
Johns Hopkins Student Nurse

“It’s amazing. You feel like you’re in a whole other world!”

Melissa Boggan, Nursing Student


Johns Hopkins University (JHU) School of Nursing is one of the world’s leading nursing programs, driving advancements in education, research, and practice.

As their simulation program expanded, the team at JHU were looking to scale delivery of simulation quickly, using the leading technology and software available. They therefore implemented Oxford Medical Simulation (OMS) Virtual Reality scenarios in pre-licensure and advanced practice programs across the nursing school.

The newly implemented VR program is part of their integrated simulation training program, including manikins and live actors, and complements clinical visits with hospital patients.

JHU’s Virtual Reality lab provides fully immersive virtual placements for multiple nursing programs, including the newly launched DNP Nurse Anesthesia and DNP Pediatric Dual Primary/Acute Care Nurse Practitioner programs. The program’s implementation in 2020 helped JHU maintain training momentum during the COVID-19 pandemic.

“We rolled out the [OMS] virtual simulation platform over the summer, during COVID, and were able to train about 400 students in a short time frame,” says Kristen Brown, advanced practice simulation coordinator at the School of Nursing.

Johns Hopkins Simulation VR team

VR simulation, a growing movement in nurse training before the pandemic, took on new meaning when restrictions impacted learning. VR simulation made socially distanced simulation possible. The spread of coronavirus “put steam behind moving the project forward,” says Nancy Sullivan, clinical simulation director at the school. 

Implementating VR in Practice

“Since March and the beginning of restrictions for in-person clinical experiences, traditional clinical and simulation for MSN (Entry Into Nursing) students were conducted virtually to enhance and sometimes replace clinical hours. Virtual or remote simulation also replaced non-direct clinical hours for advanced practice DNP students.” 

Maximizing experiential learning opportunities, JHU learners begin with the scenarios on-screen. Students who score 80% and above can visit the school’s brand-new Virtual Reality Lab, where COVID-19 safety protocols enable them to use the VR headsets for a fully immersive experience.

Whether on-screen or via VR headset, each OMS scenario places the learners in a virtual setting with a nursing assistant, who helps users assess and manage their virtual patients. With adaptive conversation, dynamic physiology, and powered by artificial intelligence, OMS virtual patients enable patient avatars to alter their behavior based on the learner’s interventions. “Depending on when you do something, the physiological response of the patient changes,” Brown explains. “When I put the oxygen on, or how much oxygen I give, changes the scenario. It adjusts to the learner.”

Johns Hopkins Virtual Simulation Lab

“I first used the on-screen version last semester,” recalls Kristin White, a pre-licensure student who graduates from the Entry into Nursing Practice program in May. “It was an asthma patient. We practiced at home and had to score 80% on different tasks. Then we got to do it with the headset on campus, which was great, almost like real life.”

Another nursing student, Melissa Boggan, says, “It’s amazing. You feel like you’re in a whole other world.”

Following Virtual Reality sessions, students gather, at a safe distance, with their instructors to participate in a group debrief session. Together with their instructors, students discuss the case, review their performance, ask questions, learn as a team, and become better prepared for clinical practice. 

Students then repeat scenarios to help improve their performance and reduce the emotional stressors that can derail procedures. “And they don’t run the risk of hurting anyone,” Brown says. “They learn critical thinking skills while being exposed to high-risk situations not seen very often. It’s great preparation.”

Benefits of VR in Nursing Education

Virtual Simulation has numerous benefits for nursing students:

  • Increasing experiential learning opportunities 
  • Improving performance and reducing emotional stressors through repetition
  • Better preparing new nurses to enter the workforce
  • Ultimately protecting patients and improving patient care
Johns Hopkins Simulation Lab

VR simulation, as a tool in the sim toolbox, has extensive benefits for the nursing profession. “It has implications on enrollment and increased delivery of online programs, allowing nurses to remain in the workforce while advancing education,” Brown says. “More education rooted in experiential learning will produce a better-prepared workforce improving patient care.”

Brown and Sullivan are also researching how VR compares with other simulation methods and clinical practice. Early results are positive, with user  ratings being “very high in terms of usability and the scenario debriefing.” 

Vitally, when students compare OMS VR scenarios to traditional simulation and clinical experience, they either rated OMS “‘’similar’ or ‘higher'” illustrating the quality of the VR experience relative to traditional approaches. 

The JHU simulation team is now expanding OMS use in their virtual simulation program, continuing to provide world-leading simulation opportunities to their students. 

Read more from JHU

  1. Amidst Covid-19, Virtual Reality Makes “Social Distancing” Simulation Possible
  2. School Of Nursing Introduces A New, Cost-effective Form Of Training: Virtual Reality
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Virtual Simulation for Clinical Hours

Virtual simulation for clinical hours
Virtual simulation for clinical hours

Healthcare institutions are no strangers to disruptionOver the past 10 years, they have faced an ever-evolving landscape from introducing new technologies such as electronic medical records, insurance regulatory reforms, the birth of new competitors, and now a global pandemic. To build greater resilience, institutions must become instinctive. 

The most recent challenge facing universities and hospitals is effectively training and maintaining the next wave of healthcare providers, in the face of ever-decreasing opportunities to train students and clinicians through clinical placements. The answer just might be dynamic, high-fidelity, virtual simulation.

The question of how to supplement clinical hours with simulation has been an ongoing debate for some time. With the loss of physical simulation and clinical placements during the pandemic, educators realized simulation was no longer a “nice to have” learning modality but a “need to have” to supplement lost clinical hours and placements. 

Instead of asking if virtual simulation can make up lost clinical hours, educators are asking how virtual simulation can supplement or replace those clinical hours?

Eye examination in virtual reality
Pediatric nurse care in virtual reality

Can Virtual Simulation Replace Clinical Hours?

Can virtual simulation be used to replace clinical hours at all? According to a statement released by Dr. Cynthia Foronda, president of INACSL, and Robert Armstrong, president of SSH, the answer is Yes! Evidence supports the use of virtual simulation to replace clinical hours. 

Ultimately, it comes down to the governing board’s regulatory requirements to determine the scope of virtual replacement. Lawmakers quickly responded to COVID-19, loosening restrictions and allowing flexibility to fulfill clinical hour requirements. Already faced with shortages in medical personnel, the COVID-19 pandemic paved the way to leverage simulation resources and promote healthcare learners to practicing professionals while still providing them with the best educational experience possible. 

For institutions already using high-fidelity simulation for clinical hour replacement, the next question is, does virtual simulation count as high-fidelity simulation? According to the SSH definition, the answer is a clear Yes!

SSH defines high-fidelity simulation as:

Simulation experiences that are extremely realistic and provide a high level of interactivity and realism for the learner

In short, virtual simulation meets the definition perfectly.

Watch our on-demand webinar to learn how you can replace clinical hours with virtual simulation. Webinar hosted by Molly Schleicher MSN, RN, CHSE.

How Much Virtual Simulation Equals Clinical Experience?

Our next question is how many clinical hours can virtual simulation replace. The increased intensity and efficiency of simulation makes it an ideal and efficient replacement for clinical time. Evidence supports using a 1:2 ratio for high-fidelity simulation to clinical hours. As we have established, virtual simulation is high-fidelity simulation, we can argue this same ratio applies. 

Depending on the virtual simulation source and how simulation is supported, learners could replace 1 to 4 hours of clinical time through a single virtual simulation scenario. Resources provided before and after, the simulation structure, and curriculum integration are all considerations to replace clinical hours with virtual simulation adequately.

Designing Virtual Simulation to Replace Clinical Hours

Design begins at the source, learning objectives. Educators must first determine what learning objectives they wish to meet and select an appropriate simulation scenario. 

Just as ‘no man is an island’, no simulation should stand alone. Following the INACSL Standards of Best Practice to support simulated patient experiences pre-briefing, orientation, learning objectives, reflection, and debriefing should be included in simulation design. These practices enhance the learning experience, increase the simulation’s value as a clinical replacement and increase the time defended for clinical experience. 

Pre-briefing

Pre-briefing a virtual simulation doesn’t look all that different from a physical simulation experience. Learners receive learning objectives, room orientation, equipment orientation, pre-simulation activities, simulation timeline, and the opportunity to ask questions in simulation pre-briefing. Virtual simulation lesson plans can incorporate traditional pre-briefing activities. Educators or former learners can also include a prerecorded shift report for learners to review before entering the virtual scenario. 

The most significant difference between a physical simulation pre-brief and virtual simulation pre-brief is the responsibility and time required to complete it falls more on the learner than the simulation faculty. Providing an expected timeline for this experience will help the learners guide and track their time as part of the simulation. 

Deliberate Practice

Deliberate practice improves critical thinking, clinical judgment, decision-making, and confidence. Virtual simulation provides learners with the opportunity to repeat scenarios as many times as they’d like. This reflective practice offers the personalized and individualized experience of running a scenario repeatedly without adding the time, space, or cost associated with running a physical simulation again and again. 

Virtual simulation is ideal for deliberative practice as the standardization is consistent, regardless of repetition. With the OMS platform, the scenario evolves based on the learner’s clinical decision-making. Individualized feedback post-scenario provides the learner with resources to enhance their experience with each repetition. When building a simulation program to replace clinical hours, consider requiring learners to complete the scenario at least twice. 

Reflection

A key component of any experiential learning activity is reflection. This can occur mid-scenario as part of a reflective pause (reflection-in-action), or post-scenario (reflection-on-action). Combined with deliberative practice, learners can immediately return to the same scenario, now with the knowledge and insight gained from the first pass through, preparing learners to reflect-in-action in the follow-up experience. 

Within the OMS platform, learners are prompted to self-reflect immediately following each scenario. They receive personalized, objective feedback based on their clinical decision-making. Finally, there is a place provided for learners to complete and document a proper self-debrief or self-reflection. While the research on self-debrief, post-virtual-simulation is ongoing, so far the news is “it works!”

Debrief

Simulation debriefing is one of the most crucial simulation-based education components and the cornerstone of the learning experience. Each simulation must have a debriefing or feedback method. It should be consistent and is an absolute necessity when using virtual simulation to replace clinical hours. 

With virtual simulation, debriefing techniques – such as PEARLS debriefing tool are built into the platform. These can support and facilitate synchronous or asynchronous debriefing. The effectiveness of the debriefing experience in physical simulation depends on the facilitator’s expertise, time, and tools. 

While debriefing immediately after the experience is ideal, it may not always be possible. The pandemic restrictions made us reconsider how we debrief virtually, at a distance, and occasionally asynchronously.

Depending on scheduling, a group debrief immediately following the simulation experience may be possible.  This could be in-person or virtually via a video conferencing platform. A chatroom-style classroom on a learning management system also allows synchronous or asynchronous group debriefing.

When unable to coordinate group debriefs, learners can complete a self-reflection and conduct a self-debrief using the feedback, guided questions, and supplemental post-simulation activities. If a later group debrief is scheduled, learners can then review and bring their input to this group discussion. 

Although there is some debate on how long debrief sessions should last, research and best practice suggest debriefing approximately twice the scenario’s length. For example, a 20-minute simulation scenario should incorporate about 40-minutes of debriefing.

Post Simulation Activities

Post-simulation activities are another opportunity to extend a learner’s experience and physical practice. 

Learners can practice documenting their virtual experience assessment. On-screen virtual simulation, in particular, lends itself to this nicely to this experience. Learners can take notes as they go and catch missed items in their subsequent runs of the scenario. Practice notes or EHR notes provide learners the opportunity to practice completing documentation. Institutions without an EHR platform can build distance-friendly solutions through Excel or Google Forms, creating a simulated EHR experience that can be tracked and reviewed by faculty.

Another post-simulation activity option is a shift-to-shift report based on the scenario. Learners can record a shift-to-shift report and post the recording to the LMS for peer review and instructor feedback. 

Additional design resources:

Book a demo and connect one-to-one with an Educational Specialist to learn more about replacing clinical hours with simulation.

Virtual Simulation Example

In an OMS Distance nursing simulation scenario participants engage with George, a 28-year-old male presenting with chills and feeling generally unwell. His medical history includes Testicular Cancer and Type 1 Diabetes. Lab results reveal low WBC and high lactic acid levels correlating with vital signs suggestive of sepsis. George needs antibiotics but has a severe penicillin allergy.

Note: This same structure can also be used for the medical scenarios or interprofessional education scenarios, depending on the implementation.

Goals:

  • Allow learners the opportunity to practice critical thinking and efficient patient care.
  • Provide a post-scenario structure that allows for self-reflection, personalized feedback, and scenario debrief.
  • Create a virtual experience that meets expectations to qualify for clinical hour replacement.

Timeline (mileage may vary per learner):

ComponentDetails/ExamplesTime
Pre-briefingPresent learning objectives

Provide relevant reading 

Assign tutorial scenario

20 minutes
Deliberate PracticeComplete virtual simulation

Example: George, SNR101US

20 minutes
ReflectionReview scenario feedback

Complete reflective practice (Reflection must be three or more sentences and shared with your clinical lead)

10 minutes
Deliberate PracticeRepeat virtual simulation

Example: George, SNR101US

20 minutes
ReflectionReview scenario feedback

Complete reflective practice (Compare and contrast your current attempt to your previous)

10 minutes
Debrief/

Post Simulation Activities

Group debrief

Simulation documentation

Individual debriefing worksheet

40 minutes
Total time:2 hours

In our example, a single virtual reality simulation scenario provided 2 hours of meaningful simulated clinical experience. We are utilizing the 1:2 replacement ratio that equates to 4 hours of clinical time.

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Virtual Nursing Simulation for Clinical Placements in the UK

Nursing Virtual Simulation Oxford Medical Simulation
Nursing Virtual Simulation Oxford Medical Simulation
Nursing Virtual Simulation Oxford Medical Simulation

The NHS has a nursing crisis

Across the UK there is a shortage of more than 100,000 staff, with a massive 36,655 vacancies for nursing staff in the NHS in 2020.

According to the Kings Fund, this shortage represents “a greater threat to health services than the funding challenges” with the RCN adding:

“We don’t have enough nurses to keep all our patients safe” Dame Donnar Kinnair

In response to shortage, two related events have occurred.

Firstly, the government releases a £15m fund for simulation. Secondly, simulation has been accepted as a replacement for clinical hours.

This piece covers both of these developments.

£15m Fund for Simulation 

In March 2021 the government announced that £15m would be awarded to English universities to invest in new simulated training facilities and technologies for nursing and other health students.

“Examples given by the government for what the funding could be spent on included virtual reality technology, manikins, role play activities, and smartphones, tablets or computers”, according to the Nursing Times.

Simulation for Clinical Placement Hours

In January 2021, revised NMC Recovery Standards were introduced. These state that “the amount of practice learning time spent in simulated practice learning experience can be up to a maximum of 300 hours across a programme’s duration.”

These standards were designed to help manage the backlog of nursing students who require placement activity. With an increasing need for new nurses in the face of clinical placement capacity issues, it it likely the standards will be in place for several years, if not indefinitely.

“We know that simulation can be an effective alternative way of learning and can be a more flexible practical learning tool to support students in progressing their studies” Mike Adams, RCN Director

As such, there is now a clear mandate to use simulation in place of clinical hour replacement, so the next question is, ‘can I use virtual simulation for clinical placements?’

Can I Use Virtual Simulation for Clinical Hour Replacement?

The answer to this question comes from a number of sources, and is resoundingly: ‘Yes!’

To emphasise this virtual reality was noted in the release comments…

“Examples given by the government for what the funding could be spent on included virtual reality technology” Nursing Times

…and this has been backed up from various sources.

From the NMC: “Simulation is defined as an artificial representation of a real world practice scenario that supports student development and assessment through experiential learning with the opportunity for repetition, feedback, evaluation and reflection.” This definition firmly encompasses VR simulation.

This is acknowledged in the HEE Simulation Strategy 2020: “Evolving technologies, such as virtual reality, allow learning to be self-guided and personalised, deliverable on a larger scale and hence more efficient in terms of time and cost”

From HEE East of England: “The various types of simulated experiences include: 1. Simulated patients; 2. Manikins; 3. Virtual reality simulators. 4. Wet labs; 5. Bench-top skills trainers

As such, VR is considered a valid tool for delivering simulation, and the NMC clearly give universities the freedom to use as they see fit: “Approved education institutions (AEIs) can chose how best to apply this recovery standard…”

Clinical hours replacement with VR simulation
Clinical hours replacement with VR simulation
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How Much Time in Virtual Simulation Equals Clinical Experience?

Now that we’ve established virtual reality simulation can be used to replace clinical hours, the question comes to how many clinical hours can be replaced with virtual simulation. 

The answer to this depends on the source of virtual simulation, the resources provided before and after and the structure in which the scenarios are implemented into the curriculum.

Nurse Educator Molly Schleicher notes that, using one OMS Nursing scenario:

“The 2 hour virtual simulation experience (based on a 20 minute scenario run twice with structured prebriefing before and debriefing after) would equal 4 hours of clinical time.”

This involves the scenario, virtual debriefing and use of deliberate practice and is based on the INACSL Standards of Best Practice. A full breakdown of how to structure learning to meet these requirements can be found here: Using Virtual Simulation to Replace Clinical Hours

Summary

Therefore, despite the huge pressures put on nursing schools recently, it has spurred positive action: the government is encouraging significant investment in simulation; virtual simulation is considered a valid approach; and there’s an acknowledgement nationally that VR “allows learning to be self-guided and personalised, deliverable on a larger scale and hence more efficient in terms of time and cost”

If you are interested in how best to implement VR simulation – please get in touch with one of our educational specialists, we’re happy to help!

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