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Virtual Clinical Simulation: The State of the Science
Clinical Simulation in Nursing (2013) 9, e279-e286
www.elsevier.com/locate/ecsn
Review Article
Virtual Clinical Simulation: The State of the Science Cynthia Foronda, PhD, RN*, Lyndon Godsall, EdD, JoAnn Trybulski, PhD, ANP-BC, DPNAP University of Miami School of Nursing & Health Studies Coral Gables, FL 33124-3850, USA KEYWORDS 3D gaming; clinical; education; nursing; online; simulation; virtual; web-based
Abstract Background: The Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health provides direction for educators to use simulation and Web-based learning. Virtual clinical simulation (VCS) is an innovative approach offering Web-based simulations. The aim of this article is to provide an integrative review of the literature and explore the state of the science of VCS in nursing. Method: The Cumulative Index to Nursing and Allied Health Literature database and Medline were explored, and 86 articles were selected as relevant and reviewed. Results: Only 3 studies were located that formally examined the use of VCS in nursing. Conclusion: VCS is an emerging educational venue that warrants further investigation. Cite this article: Foronda, C., Godsall, L., & Trybulski, J.A. (2013, August). Virtual clinical simulation: the state of the science. Clinical Simulation in Nursing, 9(8), e279-e286. http://dx.doi.org/10.1016/ j.ecns.2012.05.005. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
According to a national survey regarding online education in the United States, more than 5.6 million students took an online course during the fall 2009 term, ‘‘an increase of nearly one million students over the number reported the previous year’’ (Allen & Seaman, 2010, p. 2). Online education is increasing at a rapid pace. The Institute of Medicine (2010) report titled The Future of Nursing: Leading Change, Advancing Health acknowledges this trend and provides direction for educators to use ‘‘simulation and web-based learning’’ to ‘‘break down traditional barriers to learning together’’ (p. 203). The flexibility and accessibility of Web-based education is creating a paradigm shift toward online pedagogy. Traditional online methods attempt to stimulate student engagement and critical * Corresponding author: [email protected] (C. Foronda).
thinking with the use of wikis, discussion boards, debates, blogs, group projects, presentations, and videoconferencing. However, these methods offer limited applicability to the clinical setting. Virtual clinical simulation (VCS) is a promising virtual teaching method, or cybergogy (Killion, Reilly, & Gallagher-Lepak, 2011), to bridge the gap of theory to practice in nursing. Also known as three-dimensional (3D) virtual worlds, serious gaming, or massively multiplayer virtual worlds, VCS involves students using avatars to navigate within an environment (Hansen, 2008; Figure 1). Multiple platforms or virtual worlds are available. The extent of student engagement and the dynamics of the virtual environment vary depending on the platform. Some 3D environments allow for display of PowerPoint presentations with an interactive audio conference. More-sophisticated virtual
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environments are programmed, similar to high-fidelity human patient simulation (HPS), with algorithms to provide appropriate physical responses, by producing changes in heart rhythms and vital signs, to the interventions students select on their computer. Students calculate and administer IV fluids and medications, reposition patients, check Key Points laboratory test results, view VCS is a promising virelectrocardiogram morpholtual teaching method ogy and imaging reports, or cybergogy. and document through an The word ‘‘virtual’’ electronic health record was rarely found in (Figure 2). VCS entails the nursing literature live dialogue, allowing in conjunction with students to ask and respond 3D interactive gaming. to questions of their patients VCS researchers are and colleagues, facilitating in the earliest stages problem-based learning, of data gathering. critical thinking, teamwork, and therapeutic communication. Instructors provide direction and immediate feedback in real time through the computer. VCS provides a place to educate nurses in a safe, interactive, and dynamic way. Because of the breakthrough nature of this technology, little is known about the outcomes of VCS.
Aim The aim of this article is to provide an integrative review of the literature and explore the state of the science of VCS in nursing. Furthermore, a critique with analysis of the state of the science is presented.
Background History of Virtual Simulation According to Rolfe and Staples (1986), the use of simulation for training purposes commenced with flight simulators in World War II. Pilots were trained on systems that were 3D renderings of a virtual world seen through the aircraft’s windows. Web-based simulation efforts began in 1995, providing Internet-based to simulations running Common Gateway Interface scripts and programs (Miller,
Figure 1 care.
Three-dimensional virtual world sites used in health
Figure 2 Image from a virtual clinical simulation created by CliniSpaceÔ.
Seila, & Tao, 2000). Additionally, work began on Javabased simulation packages, systems, and environments that would run on the Web. Web-based simulation for the public emerged in 1996. Multiplayer real-time virtual worlds, known as multiuser domains or dimensions (MUDs), including the game Dungeons and DragonsÒ, were developed. Further development led to objectorientated multiuser domains, or text-based virtual reality systems used commonly as a means of socializing or game playing. The growth and development of the World Wide Web resulted in many disciplines’ evaluating education and training possibilities for computer-based simulation, adapting a gaming technique used by the general population to professional education (Page, 1999).
Uses of Virtual Simulation in Medicine Virtual simulations have prepared physicians to practice in a multitude of situations. Virtual worlds have been used to simulate hospital experiences, placing physicians in computer-generated clinical environments and demanding they make critical decisions on the spot (Youngblood, 2005). The United States military has initiated and funded much of the research regarding virtual worlds in medicine. The army has used virtual worlds to train military personnel to respond to chemical, biologic, radiologic-nuclear, and explosive (CBRNE) incidents (Dev, Youngblood, Heinrichs, & Kusumoto, 2007). The Office of Naval Research used PULSE!! to teach clinical skills and diagnostic thought processes (Hansen, 2008). The University of Michigan Medical School used the Virtual First Responder in Second LifeÒ (SL) to simulate and triage in disaster scenarios (Stephens, 2009). Palter and Grantcharov (2010) suggested using virtual reality simulations to teach physicians to perform bronchoscopy, colonoscopy, laparoscopy, and endoscopic procedures. Heinrichs, Youngblood, Harter, and Dev (2008) performed research on using a virtual world to train emergency personnel. In one study, these researchers used scenarios on computers to train emergency department (ED) teams to manage individual
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trauma cases by assigning 14 medical students to an HPS group and 16 medical students to a virtual world group. Using the emergency medicine crisis resource management rating scale, instructors rated the students’ performance during the computer-based simulation. Both groups indicated they felt ‘‘immersed’’ in the scenarios as if they were actually there. As a result, students indicated increased confidence in their ability to lead an ED team. The rating scale showed no significant differences in the gain scores between the two groups, suggesting the two simulation formats (HPS and virtual world) were comparable in learning outcomes. Heinrichs et al. (2008) pilot tested a CBRNE scenario and an Online Interactive Virtual Environment with eight paramedics and emergency medical technicians, eight ED physicians, and four nurses. The participants responded to an explosion that had occurred at a bank and completed a triage. Surveys indicated 62% of participants thought multiplayer gamedbased training was as effective as or more effective than traditional methods, and 75% said the game environment would be useful for refresher training. This research in medicine suggests virtual worlds may be valuable to teach technical skills, decisionmaking, and teamwork.
Method A preliminary literature search was performed through the Cumulative Index to Nursing & Allied Health Literature (CINAHL). The keywords virtual, nursing, and education were combined, yielding 230 documents from 2006 to 2012. The database Medline (Ovid) yielded 58 results for the combination of virtual, simulation, and nursing from 2006 forward. Abstracts were reviewed for relevance. An ancestral approach was used to obtain further relevant articles, including classics. In total, 86 documents were read. Most articles were purely informative in nature, as opposed to formal research.
Results Virtual Applications in Nursing The term virtual has been used in multiple contexts. At times, virtual simply means offered on a computer, Webbased, or offered online. Virtual has been linked to twodimensional (2D) computerized case studies, CD-ROMs, videos, games, or study programs. More commonly, virtual has been associated with 3D virtual communities. Virtual was rarely found in the nursing literature in conjunction with complex, 3D interactive gaming in nursing. Educators in health professions have been using virtual modalities successfully to teach a variety of concepts and skills in every learning domain. Harless et al. (2007) used a voice-activated, interactive, virtual dialogue to educate patients about prostate cancer. Johnston and McAllister (2008) taught anatomy and physiology to BSN students through a virtual laboratory. Gaming was used to teach community
health nursing skills and interviewing skills (Hogan, Kapralos, Cristancho, Finney & Dubrowski, 2011; Sweigart, Hodson-Carlton, Campbell, & Lutz, 2010). The American Nurses Credentialing Center contracted with DigitellÒ to create and offer a virtual poster session hall with more than 1,400 nurses registered to visit (ANCC expands virtual poster session hall, 2011). Threedimensional environments were used most often to improve communication and social networking rather than for highfidelity simulation. Virtual environments have been used effectively to support learning in the affective domain. To increase students’ interest in working with older people, Edwards, Nash, Sacre, Courtney, and Abbey (2008) reported developing a virtual learning environment that was engaging and appealing to nursing students. Dal Pai and Lautert (2007) formed virtual discussion groups to write in a field diary for an undergraduate program in nursing and found the technique gave ‘‘new dynamism’’ to the process. Virtual environments have been used as a platform for clinical conferences (Hermanns & Kilmon, 2011) and journal clubs (Lehna, Berger, Truman, Goldman, & Topp, 2010) and to simulate faculty meetings (Candela et al., 2009). Virtual applications were described in relation to the psychomotor domain as well. Corradi, Silva, and Scalabrin (2011) used virtual objects to support the teachingelearning process of physical examination. Virtual means were used to teach hands-on skills such as driving a laparoscopic camera (Nyswaner, 2007), administering IV injections (Tsai, Fung, Tsai, Jeng, & Doong, 2008), learning port-acath injections (Tsai et al., 2008), and programming IV pumps (Luctkar-Flude, Pulling, & Larocque, 2010).
Virtual Communities The use of virtual communities in nursing education was a dominant theme in the literature. Linden Lab’s SL was the most popular platform. Additional virtual communities mentioned were Stilwell, Mirror Lake, The Neighborhood, BlackboardÒ Virtual Tour, BlackboardÒ Virtual Learning Environment, Killardton, and Centralia. The Duke University School of Nursing established a virtual learning community as an inquiry network that enabled educators in geriatric nursing to promote learning and communication among instructors (Egerton, McConnell, Corazzini, Kitzmiller, & Crook, 2010). Weiner, McNew, Trangenstein, and Gordon (2010) used SL to teach simulation management to nursing faculty. Beadle and Santy (2008) used a BlackboardÒ Virtual Learning Environment as a virtual town to teach social inclusion. Giddens, Shuster, and Roehig (2010) researched student outcomes associated with the use of The Neighborhood. Surveying 248 junior and senior nursing students, those who expected a grade lower than an A reported more perceived benefits from the virtual community (p ¼ .041). ‘‘Ethnic minority students reported more benefits overall’’ (Giddens, Shuster, et al., 2010, p. 358). In a different study, Giddens, Fogg, and Carlson-Sabelli
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(2010) surveyed 350 first-level baccalaureate students to examine learning and engagement with a virtual community. This study contradicted the previous study as white and Asian students reported greater learning utility of the virtual community than minority students did. The researchers found a positive relationship (p ¼ .001) between the frequency of virtual community use and its perceived benefits. Shuster, Giddens, and Roehrig (2011) evaluated the experiences of BSN students who used The Neighborhood in one or more of their courses. From their qualitative study with 40 students enrolled in a BSN program, two themes emerged: (a) Students indicated The Neighborhood led them to develop an emotional connection to the specific characters or families, and (b) students integrated the characters and events into learning activities. Students reported that the virtual experience helped them link concepts taught in class with patients seen in clinical. The authors concluded that virtual communities provided a viable strategy for teaching nursing concepts and their application. Ward and Killian (2011) compared the experience of students who received virtual community internships with that of students receiving traditional lecture. In pre- and posttests that used a modified version of the Community-Oriented Health Care Competency Scale, all 184 accelerated nursing program students demonstrated gains in knowledge and skills. None of the students changed their attitudes or intent to practice community-oriented nursing. The virtual internship students had outcomes equivalent to those of the students who received traditional lecture. The authors supported virtual internships with modified problem-based learning as effective teaching methods. Hermanns and Kilmon (2011) described the experience of students and faculty having a mental health clinical conference in SL. In a qualitative study, nine nursing students said they liked the SL conference format and would like future conferences offered in that format. One student mentioned being present in her pajamas, and another student described the conference as ‘‘laid back.’’ The students felt SL was not difficult to learn, but they felt limited in their choice of avatar. Faculty noted extra time was needed to ‘‘set up,’’ and faculty needed to know how to offer teleport invitations. Technical issues were noted as an obstacle, and students were annoyed by the presence of ‘‘creepy people’’ or ‘‘griefers’’ in the environment (Hermanns & Kilmon, 2011). Puterbaugh, Shannon, and Gorton (2010) investigated nurses’ attitudes and perceptions about the use of SL as a tool to deliver distance education. Seventy-seven nurses responded to a 30-question online survey that examined the level of the participants’ experience with distance education, computer skill level, and involvement with online gaming environments. Participants’ feelings toward distance education and the possible use of SL were examined. Results from the survey indicated a positive attitude from nurses at all academic levels toward distance education and a willingness to explore the academic use of a virtual environment. For instance, 81% responded that they would have an interest in attending if
presentations ‘‘were offered in real-time within a virtual world or gaming environment’’ (p. 296), and 65% felt distance education was an adequate means to present nursing education. Negative comments surfaced as well; ‘‘Human, face-to-face interaction must remain the key component in nursing training, because teamwork is so important to the profession’’ (p. 298). Another student stated, ‘‘I believe nursing is too important to learn online’’ (p. 298). When asked if they would consider attending distance education classes in a virtual world, 100% of those who were novices in computer proficiency said they would attend (p. 302). Faculty responses indicated conflicting views. ‘‘I am very involved in teaching in SL. I know it works and with advancements in technology, it will only get better’’ (p. 304). One faculty participant responded, ‘‘I really hope that education does not go this way. It seems counter to what nursing is all about’’ (p. 306). Lewis (2009) performed a quantitative, descriptive study investigating the effects of partial VCS using the 2D computer-based gaming software Virtual Clinical Excursions 3.0Ò by Elsevier. Lewis examined (a) the differences in postinstruction exam achievement scores on the Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical Exam among higher education students taught with and without virtual simulation instruction, (b) the differences in preepost exam achievement scores in students taught with and without virtual clinical instruction, and (c) the differences in pre- and post-instruction perceived competence among students who received VCS instruction (VCSI). Ninety-eight higher education medicalesurgical nursing students were given VCSI or traditional instruction. Students in the VCSI group scored significantly higher than those taught with traditional instruction (p ¼ .000). For the second question, 46 students were evaluated for significant differences between students in the VCSI group and traditional instruction control group after instruction (p ¼ .000). For the third question, VCSI students (n ¼ 17) indicated they felt they had achieved high competence in medicalesurgical content. Other reported themes were safety, enjoyment, convenience, and motivation. Heinrich (2011) also studied the effects of a 2D intervention in which 56 BSN students participated as a group in classroom case study simulations using Laerdal’s MicroSimÒ. Students were pre- and posttested regarding knowledge of topics incorporated in the simulations, including pulmonary emboli and diabetic ketoacidosis. A student perception survey was also given. Students’ mean difference between pretest and posttest was significant (p < .001), demonstrating increased knowledge. ‘‘All 56 students agreed learning occurred and MicroSimÒ increased their knowledge’’ (p. e7). Grady (2011) investigated whether standard videoconferencing technology could be used to provide an effective virtual clinical experience for nursing students and how students perceived the Virtual Clinical PracticumÒ (VCP). The VCP was part of a federally funded project focusing on innovations in telehealth. A videoconferencing unit was rolled into the patient’s room, where a military nurse
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preceptor wore a headset to communicate with students. The associate degree nursing students watched and verbally interacted from the college’s technology lab. Grady (2011) administered the VCP Attitude Survey, a 20-item Likerttype scale containing two subscales of work effectiveness and user satisfaction. The instrument had a content validity index of .90 and reliability ranging between .86 and .90. Students indicated a more positive attitude toward the VCP after experiencing it (p < .001). Open-ended surveys with qualitative comments revealed positive student reactions. The lack of hands-on experience was noted as the largest drawback. Technical support on both sides of the connection was necessary. This well-designed study demonstrated a highly innovative and creative way to administer a clinical practicum virtually.
Research with VCS Only three studies were located that described the use of 3D VCS in nursing (Aebersold, Tschannen, Stephens, Anderson, & Lei, 2011; Broom, Lynch, & Preece, 2009; McCallum, Ness, & Price, 2011). Broom, Lynch, and Preece (2009) explored student perceptions in a 2nd-year child health course that used a virtual ward simulation of a child with a fever of unknown origin in conjunction with blogging. Students accessed a virtual pediatric ward, read nursing notes, and reflected on their learning experiences with other students through a blog. In focus groups, students indicated that the advantages of simulation were developing knowledge and helping with clinical practice. When asked about the disadvantages, students indicated, ‘‘they are not the real thing’’ (p. 35) and ‘‘technical restrictions’’ (p. 36). From surveys, 49% strongly agreed and 38% agreed to the following statement: ‘‘Computer simulation provides a suitable experience for learning this skill.’’ All agreed or strongly disagreed that ‘‘the blog was a good way of collaborating with the learning process’’ and that the simulation helped ‘‘apply knowledge to practice’’ (p. 35). Noted difficulties arose with differing firewalls and computer configurations. This study contributes by demonstrating a unique application of VCS; however, key information such as sample size and instrumentation was lacking. Aebersold et al. (2011) evaluated the student experience of an SL simulation with 15 senior-level nursing students who participated in the 10- to 15-minute virtual simulation. The following three scenarios were developed: (a) safety issues with medication, (b) difficult interprofessional communications, and (c) priority setting. Students completed a six-question, Likert-type survey, with a comments section, about their experience. No reliability or validity data were reported on the instrument. On the scale, with 1 ¼ strongly disagree and 5 ¼ strongly agree, ‘‘SL helped prepare me for clinical’’ was rated 2.5, with a range of 1 to 4. ‘‘SL was realistic’’ had a mean score of 2.8 and a range of 1 to 4. ‘‘SL is an effective learning experience’’ had a mean score of 2.8. ‘‘SL improved decision-making skills’’ scored a mean of 2.7, with
a range of 1 to 4. ‘‘SL reinforced learning objectives’’ had a mean score of 3 with a range of 2 to 4. Overall, the experience was rated a 3.1. Some comments revealed benefits. One student said, ‘‘The experience was better than or as good as SimManÒ’’ (p. e5), and another stated, ‘‘It is a real good practice system and since it resembled real life scenarios, it gave almost the same experience one would have received in ordinary simulations’’ (p. e5). Students wished they could have set up their own avatars. The text chat function was slow and difficult for poor typists. The authors recommend using voice over internet rather than texting. One strength of the study was that it incorporated mixed methods. However, the study would have yielded more data if instructor-derived assessment data were incorporated in addition to the students’ self-reporting. McCallum, Ness, and Price (2011) explored nursing students’ decision-making skills through the use of a 3D virtual environment such as SL. This exploratory, qualitative study employed semistructured interviews after students participated in a 1-hour simulation of caring for six patients. The student nurses (n ¼ 5) were enrolled in a 3-year diploma of higher education/bachelor of nursing or bachelor of arts in nursing studies adult nursing course. The students’ decision-making during the scenario was evaluated. The majority of decisions (n ¼ 21) were made in response to a situation or a patient request and were ‘‘reactive’’ rather than proactive (n ¼ 9). ‘‘Only one student carried out vital signs (VS) assessment on a newly admitted patient’’ (p. 699). The interviews produced two themes, performing decision making and improving learning. The simulation helped students realize they could perform decision making as they felt themselves prioritizing, making decisions, and delegating (p. 703). ‘‘The absence of visual cues such as pre-operative checklists, VS observation charts and nil by mouth signs may offer a rationale for why students were more reactive or did not make certain important decisions’’ (p. 703). Students typed in their communications in SL. Instructor evaluation of the communications revealed poor performance. The typing and focusing on the screen may have impeded fluid communication. Furthermore, students noted difficulty with the ‘‘hands-on skills needed to run an avatar in SL’’ (p. 703). The authors concluded that SL should be further explored as a teaching strategy for decision making. The objective approach of quantifying accurate responses and using instructors’ evaluations as part of the data was a strength. Limitations include the small sample size and the evaluation of typed communications when students may have struggled with typing.
Discussion Critique of the State of the Science This review of the literature presents the state of the science of VCS in nursing and reveals that research regarding VCS
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reflects the earliest stages of data gathering. The current body of knowledge in VCS is scant. The few studies related to VCS (Aebersold et al., 2011; Broom et al., 2009; McCallum et al., 2011) lacked rigor as a consequence of small sample sizes, lack of reliable and valid instruments, and weak methods, yet these few studies have made a genuine contribution. Nurse educators may build on this research, sharing student feedback, outcomes, and lessons learned related to scenario development, implementation, and technological challenges. Educational researchers may benefit from collaborative efforts across disciplines (Schaefer et al., 2011), using existing published tools to build reliability and validity data (Kardong-Edgren, Adamson, & Fitzgerald, 2010) and garnering ideas for research designs from the behavioral and medical sciences.
resources, compounded with student demand for accessibility, VCS is a safe venue to explore. Educators are facing a new generation of student, the millennials, and 3D gaming technology builds on their existing learning frameworks and prepares them to embrace technology, a central component of nursing practice (Dutile, Wright, & Beauchesne, 2011). With cost being a likely hindrance, nurse faculty must promote awareness of these new opportunities in education and contemplate creative ways to maximize resources. In addition to investing in expensive, high-fidelity simulators, equipment, and facilities, nurse administrators may consider allocating funds to virtual simulation and its research.
Limitations
VCS presents an engaging modality with the possibility for helping nursing students to develop cognitive skills critical to the profession. As courses are rapidly migrating to online platforms, the VCS framework expands and transforms the level and type of education possible. Just as HPS has grown rapidly, VCS has similar potential. There is evidence that HPS works in nursing and the real world (Decker, Grady, Jeffries, & Kardong-Edgren, 2011). As the pedagogical phenomenon of VCS progresses, educators must validate its application and place in nursing education (Schiavenato, 2009).
This review was limited in several ways. CINAHL and Medline were the only databases searched as they are oriented to research in nursing. The ancestral approach incorporated subjectivity in regard to obtaining additional relevant studies. The strategy was intentionally chosen to focus on the state of the science in nursing rather than outside disciplines. The keywords gaming, 3D, and multiplayer were not used. Inclusion of these terms may have elicited additional relevant articles. By the end of the literature review, the recurrence of certain works led us to conclude that our search was thorough.
Conclusion
Acknowledgments Implications and Recommendations At this time, the body of research is slim, and thus, one cannot make a strong endorsement for or against VCS. However, this limitation offers exciting opportunity. VCS incorporates concepts of experiential learning, problembased learning, constructivism, self-directed learning, and andragogy. Thus, VCS may be an exceptional educational tool. Rather than a substitution, VCS might supplement or enhance clinical practicum. There is evidence to suggest that nursing students and faculty approve of VCS as well as evidence to suggest that nurses want to maintain a face-to-face andragogy. In 2002, Sandelowski demonstrated her vision of the future challenges with respect to role of the nurse in virtual worlds with her statement, ‘‘For a practice discipline, such as nursing, which has sought to define its boundaries paradoxically as between boundaries, the posthuman conflation of bodies and information poses the greatest challenge yet to its secure place, presence, and identity in health care’’ (p. 68). Future research will illuminate the efficacy and confines of VCS. As advancing technology is growing newfound pedagogies, educators must apply and test these innovations. Nursing is entering a new era. With faculty shortages, increased demand for clinical placements, and decreased
This project was supported by funds from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), and Department of Health and Human Services (DHHS) under grant number D11HP19238, Nurse Education Practice and Retention, award amount of $721,912. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any official endorsement be inferred by, the DN, BHPr, HRSA, DHHS, or the U.S. government. This project had no commercial financial support.
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Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Johnston, A., & McAllister, M. (2008). Back to the future with hands-on science: Students’ perceptions of learning anatomy and physiology. Journal of Nursing Education, 47(9), 417-421. http://dx.doi.org/10. 3928/01484834-20080901-04. Kardong-Edgren, S., Adamson, K. A., & Fitzgerald, C. (2010, January). A review of currently published evaluation instruments for human patient simulation. Clinical Simulation in Nursing, 6, e25-e35. http: //dx.doi.org/10.1016/j.ecns.2009.08.004. Killion, C., Reilly, J., & Gallagher-Lepak, S. (2011). Becoming an ‘‘onliner’’: Students’ perceptions of moving from traditional to virtual learning. Online Journal of Nursing Informatics, 15(1), 10p, Retrieved June 5, 2012, from http://ojni.org/issues/?p¼139. Lehna, C., Berger, J., Truman, A., Goldman, M., & Topp, R. (2010). Virtual journal club connects evidence to practice: An analysis of participant responses. Journal of Nursing Administration, 40(12), 522-528. http://dx.doi.org/10.1097/NNA.0b013e3181fc19c0. Lewis, R. A. (2009). The effect of virtual clinical gaming simulations on student learning outcomes in medical-surgical nursing education courses. Doctoral dissertation, Marshall University. Theses and Dissertations. Paper 139. http://mds.marshall.edu/etd/139. Luctkar-Flude, M., Pulling, C., & Larocque, M. (2010). Ending infusion confusion: Does a virtual intravenous pump educational module enhance transfer of skills to practice? Clinical Simulation in Nursing, 6(3), e118-e119. http://dx.doi.org/10.1016/j.ecns.2010.03.047. McCallum, J., Ness, V., & Price, T. (2011). Exploring nursing students’ decision-making skills whilst in a Second Life clinical simulation laboratory. Nurse Education Today, 31(7), 699-704. http://dx.doi.org/10. 1016/j.nedt.2010.03.010. Miller, J. A., Seila, A. F., & Tao, J. (2000). Finding a substrate for federated components on the Web. In Proceedings of the 32nd conference on Winter simulation (WSC ’00) (pp. 1849-1854). San Diego, CA: Society for Computer Simulation International. Retrieved June 21, 2012 from http://www.informs-sim.org/wsc00papers/253.PDF. Nyswaner, A. (2007). ‘‘Driver’s ed’’ for the OR nurse. RN, 70(3), 45-48, 50. Page, E. H. (1999). Beyond speedup: PADS, the HLA and Web-based simulation. In Proceedings of the thirteenth workshop on Parallel and distributed simulation (PADS ’99) (pp. 2-9). Washington, DC: IEEE Computer Society. ISBN:0-7695-0155-9. Palter, V. N., & Grantcharov, T. P. (2010). Virtual reality in surgical skills training. The Surgical Clinics of North America, 90, 605-617. http: //dx.doi.org/10.1016/j.suc.2010.02.005. Puterbaugh, M. D., Shannon, M., & Gorton, H. (2010). A survey of nurses’ attitudes toward distance education and the educational use of 3-D virtual environments. Journal of Electronic Resources in Medical Libraries, 7(4), 292-307. http://dx.doi.org/10.1080/15424065.2010.527243. Rolfe, J. M., & Staples, K. J. (1986). Flight simulation. Cambridge, UK: Cambridge University Press. Sandelowski, M. (2002). Visible humans, vanishing bodies, and virtual nursing: Complications of life, presence, place, and identity. Advances in Nursing Science, 24(3), 58-70. Schaefer, J. J., III, Vanderbilt, A. A., Cason, C. L., Bauman, E. B., Glavin, R. J., Lee, F. W., et al. (2011). Literature review: Instructional design and pedagogy science in healthcare simulation. Society for Simulation in Healthcare, 6(7), S30-S41. http://dx.doi.org/10.1097/SIH.0b013e31822237b4. Schiavenato, M. (2009). Reevaluating simulation in nursing education: Beyond the human patient simulator. Journal of Nursing Education, 48(7), 388-394. http://dx.doi.org/10.3928/01484834-20090615-06. Shuster, G., Giddens, J. F., & Roehrig, N. (2011). Emotional connection and integration: Dominant themes among undergraduate nursing students using a virtual community. Journal of Nursing Education, 50(4), 222-225. http://dx.doi.org/10.3928/01484834-20110131-02. Stephens, M. R. (2009). Exploring virtual worlds as a platform for education: The virtual first responder. PowerPoint presentation retrieved June 5, 2012, from http://www.slideshare.net/marqueA2/final-sl-for-edvfr-03june2009.
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Sweigart, L., Hodson-Carlton, K., Campbell, B. R., & Lutz, D. R. (2010). Second Life environment: A venue for interview skill development. CIN: Computers, Informatics, Nursing, 28(5), 258-263. http: //dx.doi.org/10.1097/01.NCN.0000388349.67292.3c. Tsai, S. L., Chai, S. K., Hsieh, L. F., Lin, S., Taur, F. M., Sung, W. H., & Doong, J. L. (2008). The use of virtual reality computer simulation in learning port-a-cath injection. Advances in Health Sciences Education, 13(1), 71-87. http://dx.doi.org/10.1007/s10459-006-9025-3. Tsai, W., Fung, C., Tsai, S., Jeng, M., & Doong, J. (2008). The assessment of stability and reliability of a virtual reality-based intravenous injection simulator. CIN: Computers, Informatics. Nursing, 26(4), 221-226.
Ward, L. S., & Killian, P. (2011). Virtual community internships in the classroom. Nurse Educator, 36(1), 40-44. http://dx.doi.org/10.1097/ NNE.0b013e3182001e6c. Weiner, E., McNew, R., Tragenstein, P., & Gordon, J. (2010). Using the virtual reality world of Second Life to teach nursing faculty simulation management. Studies in Health Technology and Informatics, 160, 615-619. http://dx.doi.org/10.3233/978-1-60750-588-4615. Youngblood, P. (2005). A virtual learning environment for team training in trauma management. Academic Emergency Medicine, 12(8), 792-793. http://dx.doi.org/10.1197/j.aem.2005.05.013.
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Review Article
Virtual Clinical Simulation: The State of the Science Cynthia Foronda, PhD, RN*, Lyndon Godsall, EdD, JoAnn Trybulski, PhD, ANP-BC, DPNAP University of Miami School of Nursing & Health Studies Coral Gables, FL 33124-3850, USA KEYWORDS 3D gaming; clinical; education; nursing; online; simulation; virtual; web-based
Abstract Background: The Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health provides direction for educators to use simulation and Web-based learning. Virtual clinical simulation (VCS) is an innovative approach offering Web-based simulations. The aim of this article is to provide an integrative review of the literature and explore the state of the science of VCS in nursing. Method: The Cumulative Index to Nursing and Allied Health Literature database and Medline were explored, and 86 articles were selected as relevant and reviewed. Results: Only 3 studies were located that formally examined the use of VCS in nursing. Conclusion: VCS is an emerging educational venue that warrants further investigation. Cite this article: Foronda, C., Godsall, L., & Trybulski, J.A. (2013, August). Virtual clinical simulation: the state of the science. Clinical Simulation in Nursing, 9(8), e279-e286. http://dx.doi.org/10.1016/ j.ecns.2012.05.005. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
According to a national survey regarding online education in the United States, more than 5.6 million students took an online course during the fall 2009 term, ‘‘an increase of nearly one million students over the number reported the previous year’’ (Allen & Seaman, 2010, p. 2). Online education is increasing at a rapid pace. The Institute of Medicine (2010) report titled The Future of Nursing: Leading Change, Advancing Health acknowledges this trend and provides direction for educators to use ‘‘simulation and web-based learning’’ to ‘‘break down traditional barriers to learning together’’ (p. 203). The flexibility and accessibility of Web-based education is creating a paradigm shift toward online pedagogy. Traditional online methods attempt to stimulate student engagement and critical * Corresponding author: [email protected] (C. Foronda).
thinking with the use of wikis, discussion boards, debates, blogs, group projects, presentations, and videoconferencing. However, these methods offer limited applicability to the clinical setting. Virtual clinical simulation (VCS) is a promising virtual teaching method, or cybergogy (Killion, Reilly, & Gallagher-Lepak, 2011), to bridge the gap of theory to practice in nursing. Also known as three-dimensional (3D) virtual worlds, serious gaming, or massively multiplayer virtual worlds, VCS involves students using avatars to navigate within an environment (Hansen, 2008; Figure 1). Multiple platforms or virtual worlds are available. The extent of student engagement and the dynamics of the virtual environment vary depending on the platform. Some 3D environments allow for display of PowerPoint presentations with an interactive audio conference. More-sophisticated virtual
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environments are programmed, similar to high-fidelity human patient simulation (HPS), with algorithms to provide appropriate physical responses, by producing changes in heart rhythms and vital signs, to the interventions students select on their computer. Students calculate and administer IV fluids and medications, reposition patients, check Key Points laboratory test results, view VCS is a promising virelectrocardiogram morpholtual teaching method ogy and imaging reports, or cybergogy. and document through an The word ‘‘virtual’’ electronic health record was rarely found in (Figure 2). VCS entails the nursing literature live dialogue, allowing in conjunction with students to ask and respond 3D interactive gaming. to questions of their patients VCS researchers are and colleagues, facilitating in the earliest stages problem-based learning, of data gathering. critical thinking, teamwork, and therapeutic communication. Instructors provide direction and immediate feedback in real time through the computer. VCS provides a place to educate nurses in a safe, interactive, and dynamic way. Because of the breakthrough nature of this technology, little is known about the outcomes of VCS.
Aim The aim of this article is to provide an integrative review of the literature and explore the state of the science of VCS in nursing. Furthermore, a critique with analysis of the state of the science is presented.
Background History of Virtual Simulation According to Rolfe and Staples (1986), the use of simulation for training purposes commenced with flight simulators in World War II. Pilots were trained on systems that were 3D renderings of a virtual world seen through the aircraft’s windows. Web-based simulation efforts began in 1995, providing Internet-based to simulations running Common Gateway Interface scripts and programs (Miller,
Figure 1 care.
Three-dimensional virtual world sites used in health
Figure 2 Image from a virtual clinical simulation created by CliniSpaceÔ.
Seila, & Tao, 2000). Additionally, work began on Javabased simulation packages, systems, and environments that would run on the Web. Web-based simulation for the public emerged in 1996. Multiplayer real-time virtual worlds, known as multiuser domains or dimensions (MUDs), including the game Dungeons and DragonsÒ, were developed. Further development led to objectorientated multiuser domains, or text-based virtual reality systems used commonly as a means of socializing or game playing. The growth and development of the World Wide Web resulted in many disciplines’ evaluating education and training possibilities for computer-based simulation, adapting a gaming technique used by the general population to professional education (Page, 1999).
Uses of Virtual Simulation in Medicine Virtual simulations have prepared physicians to practice in a multitude of situations. Virtual worlds have been used to simulate hospital experiences, placing physicians in computer-generated clinical environments and demanding they make critical decisions on the spot (Youngblood, 2005). The United States military has initiated and funded much of the research regarding virtual worlds in medicine. The army has used virtual worlds to train military personnel to respond to chemical, biologic, radiologic-nuclear, and explosive (CBRNE) incidents (Dev, Youngblood, Heinrichs, & Kusumoto, 2007). The Office of Naval Research used PULSE!! to teach clinical skills and diagnostic thought processes (Hansen, 2008). The University of Michigan Medical School used the Virtual First Responder in Second LifeÒ (SL) to simulate and triage in disaster scenarios (Stephens, 2009). Palter and Grantcharov (2010) suggested using virtual reality simulations to teach physicians to perform bronchoscopy, colonoscopy, laparoscopy, and endoscopic procedures. Heinrichs, Youngblood, Harter, and Dev (2008) performed research on using a virtual world to train emergency personnel. In one study, these researchers used scenarios on computers to train emergency department (ED) teams to manage individual
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trauma cases by assigning 14 medical students to an HPS group and 16 medical students to a virtual world group. Using the emergency medicine crisis resource management rating scale, instructors rated the students’ performance during the computer-based simulation. Both groups indicated they felt ‘‘immersed’’ in the scenarios as if they were actually there. As a result, students indicated increased confidence in their ability to lead an ED team. The rating scale showed no significant differences in the gain scores between the two groups, suggesting the two simulation formats (HPS and virtual world) were comparable in learning outcomes. Heinrichs et al. (2008) pilot tested a CBRNE scenario and an Online Interactive Virtual Environment with eight paramedics and emergency medical technicians, eight ED physicians, and four nurses. The participants responded to an explosion that had occurred at a bank and completed a triage. Surveys indicated 62% of participants thought multiplayer gamedbased training was as effective as or more effective than traditional methods, and 75% said the game environment would be useful for refresher training. This research in medicine suggests virtual worlds may be valuable to teach technical skills, decisionmaking, and teamwork.
Method A preliminary literature search was performed through the Cumulative Index to Nursing & Allied Health Literature (CINAHL). The keywords virtual, nursing, and education were combined, yielding 230 documents from 2006 to 2012. The database Medline (Ovid) yielded 58 results for the combination of virtual, simulation, and nursing from 2006 forward. Abstracts were reviewed for relevance. An ancestral approach was used to obtain further relevant articles, including classics. In total, 86 documents were read. Most articles were purely informative in nature, as opposed to formal research.
Results Virtual Applications in Nursing The term virtual has been used in multiple contexts. At times, virtual simply means offered on a computer, Webbased, or offered online. Virtual has been linked to twodimensional (2D) computerized case studies, CD-ROMs, videos, games, or study programs. More commonly, virtual has been associated with 3D virtual communities. Virtual was rarely found in the nursing literature in conjunction with complex, 3D interactive gaming in nursing. Educators in health professions have been using virtual modalities successfully to teach a variety of concepts and skills in every learning domain. Harless et al. (2007) used a voice-activated, interactive, virtual dialogue to educate patients about prostate cancer. Johnston and McAllister (2008) taught anatomy and physiology to BSN students through a virtual laboratory. Gaming was used to teach community
health nursing skills and interviewing skills (Hogan, Kapralos, Cristancho, Finney & Dubrowski, 2011; Sweigart, Hodson-Carlton, Campbell, & Lutz, 2010). The American Nurses Credentialing Center contracted with DigitellÒ to create and offer a virtual poster session hall with more than 1,400 nurses registered to visit (ANCC expands virtual poster session hall, 2011). Threedimensional environments were used most often to improve communication and social networking rather than for highfidelity simulation. Virtual environments have been used effectively to support learning in the affective domain. To increase students’ interest in working with older people, Edwards, Nash, Sacre, Courtney, and Abbey (2008) reported developing a virtual learning environment that was engaging and appealing to nursing students. Dal Pai and Lautert (2007) formed virtual discussion groups to write in a field diary for an undergraduate program in nursing and found the technique gave ‘‘new dynamism’’ to the process. Virtual environments have been used as a platform for clinical conferences (Hermanns & Kilmon, 2011) and journal clubs (Lehna, Berger, Truman, Goldman, & Topp, 2010) and to simulate faculty meetings (Candela et al., 2009). Virtual applications were described in relation to the psychomotor domain as well. Corradi, Silva, and Scalabrin (2011) used virtual objects to support the teachingelearning process of physical examination. Virtual means were used to teach hands-on skills such as driving a laparoscopic camera (Nyswaner, 2007), administering IV injections (Tsai, Fung, Tsai, Jeng, & Doong, 2008), learning port-acath injections (Tsai et al., 2008), and programming IV pumps (Luctkar-Flude, Pulling, & Larocque, 2010).
Virtual Communities The use of virtual communities in nursing education was a dominant theme in the literature. Linden Lab’s SL was the most popular platform. Additional virtual communities mentioned were Stilwell, Mirror Lake, The Neighborhood, BlackboardÒ Virtual Tour, BlackboardÒ Virtual Learning Environment, Killardton, and Centralia. The Duke University School of Nursing established a virtual learning community as an inquiry network that enabled educators in geriatric nursing to promote learning and communication among instructors (Egerton, McConnell, Corazzini, Kitzmiller, & Crook, 2010). Weiner, McNew, Trangenstein, and Gordon (2010) used SL to teach simulation management to nursing faculty. Beadle and Santy (2008) used a BlackboardÒ Virtual Learning Environment as a virtual town to teach social inclusion. Giddens, Shuster, and Roehig (2010) researched student outcomes associated with the use of The Neighborhood. Surveying 248 junior and senior nursing students, those who expected a grade lower than an A reported more perceived benefits from the virtual community (p ¼ .041). ‘‘Ethnic minority students reported more benefits overall’’ (Giddens, Shuster, et al., 2010, p. 358). In a different study, Giddens, Fogg, and Carlson-Sabelli
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(2010) surveyed 350 first-level baccalaureate students to examine learning and engagement with a virtual community. This study contradicted the previous study as white and Asian students reported greater learning utility of the virtual community than minority students did. The researchers found a positive relationship (p ¼ .001) between the frequency of virtual community use and its perceived benefits. Shuster, Giddens, and Roehrig (2011) evaluated the experiences of BSN students who used The Neighborhood in one or more of their courses. From their qualitative study with 40 students enrolled in a BSN program, two themes emerged: (a) Students indicated The Neighborhood led them to develop an emotional connection to the specific characters or families, and (b) students integrated the characters and events into learning activities. Students reported that the virtual experience helped them link concepts taught in class with patients seen in clinical. The authors concluded that virtual communities provided a viable strategy for teaching nursing concepts and their application. Ward and Killian (2011) compared the experience of students who received virtual community internships with that of students receiving traditional lecture. In pre- and posttests that used a modified version of the Community-Oriented Health Care Competency Scale, all 184 accelerated nursing program students demonstrated gains in knowledge and skills. None of the students changed their attitudes or intent to practice community-oriented nursing. The virtual internship students had outcomes equivalent to those of the students who received traditional lecture. The authors supported virtual internships with modified problem-based learning as effective teaching methods. Hermanns and Kilmon (2011) described the experience of students and faculty having a mental health clinical conference in SL. In a qualitative study, nine nursing students said they liked the SL conference format and would like future conferences offered in that format. One student mentioned being present in her pajamas, and another student described the conference as ‘‘laid back.’’ The students felt SL was not difficult to learn, but they felt limited in their choice of avatar. Faculty noted extra time was needed to ‘‘set up,’’ and faculty needed to know how to offer teleport invitations. Technical issues were noted as an obstacle, and students were annoyed by the presence of ‘‘creepy people’’ or ‘‘griefers’’ in the environment (Hermanns & Kilmon, 2011). Puterbaugh, Shannon, and Gorton (2010) investigated nurses’ attitudes and perceptions about the use of SL as a tool to deliver distance education. Seventy-seven nurses responded to a 30-question online survey that examined the level of the participants’ experience with distance education, computer skill level, and involvement with online gaming environments. Participants’ feelings toward distance education and the possible use of SL were examined. Results from the survey indicated a positive attitude from nurses at all academic levels toward distance education and a willingness to explore the academic use of a virtual environment. For instance, 81% responded that they would have an interest in attending if
presentations ‘‘were offered in real-time within a virtual world or gaming environment’’ (p. 296), and 65% felt distance education was an adequate means to present nursing education. Negative comments surfaced as well; ‘‘Human, face-to-face interaction must remain the key component in nursing training, because teamwork is so important to the profession’’ (p. 298). Another student stated, ‘‘I believe nursing is too important to learn online’’ (p. 298). When asked if they would consider attending distance education classes in a virtual world, 100% of those who were novices in computer proficiency said they would attend (p. 302). Faculty responses indicated conflicting views. ‘‘I am very involved in teaching in SL. I know it works and with advancements in technology, it will only get better’’ (p. 304). One faculty participant responded, ‘‘I really hope that education does not go this way. It seems counter to what nursing is all about’’ (p. 306). Lewis (2009) performed a quantitative, descriptive study investigating the effects of partial VCS using the 2D computer-based gaming software Virtual Clinical Excursions 3.0Ò by Elsevier. Lewis examined (a) the differences in postinstruction exam achievement scores on the Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical Exam among higher education students taught with and without virtual simulation instruction, (b) the differences in preepost exam achievement scores in students taught with and without virtual clinical instruction, and (c) the differences in pre- and post-instruction perceived competence among students who received VCS instruction (VCSI). Ninety-eight higher education medicalesurgical nursing students were given VCSI or traditional instruction. Students in the VCSI group scored significantly higher than those taught with traditional instruction (p ¼ .000). For the second question, 46 students were evaluated for significant differences between students in the VCSI group and traditional instruction control group after instruction (p ¼ .000). For the third question, VCSI students (n ¼ 17) indicated they felt they had achieved high competence in medicalesurgical content. Other reported themes were safety, enjoyment, convenience, and motivation. Heinrich (2011) also studied the effects of a 2D intervention in which 56 BSN students participated as a group in classroom case study simulations using Laerdal’s MicroSimÒ. Students were pre- and posttested regarding knowledge of topics incorporated in the simulations, including pulmonary emboli and diabetic ketoacidosis. A student perception survey was also given. Students’ mean difference between pretest and posttest was significant (p < .001), demonstrating increased knowledge. ‘‘All 56 students agreed learning occurred and MicroSimÒ increased their knowledge’’ (p. e7). Grady (2011) investigated whether standard videoconferencing technology could be used to provide an effective virtual clinical experience for nursing students and how students perceived the Virtual Clinical PracticumÒ (VCP). The VCP was part of a federally funded project focusing on innovations in telehealth. A videoconferencing unit was rolled into the patient’s room, where a military nurse
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preceptor wore a headset to communicate with students. The associate degree nursing students watched and verbally interacted from the college’s technology lab. Grady (2011) administered the VCP Attitude Survey, a 20-item Likerttype scale containing two subscales of work effectiveness and user satisfaction. The instrument had a content validity index of .90 and reliability ranging between .86 and .90. Students indicated a more positive attitude toward the VCP after experiencing it (p < .001). Open-ended surveys with qualitative comments revealed positive student reactions. The lack of hands-on experience was noted as the largest drawback. Technical support on both sides of the connection was necessary. This well-designed study demonstrated a highly innovative and creative way to administer a clinical practicum virtually.
Research with VCS Only three studies were located that described the use of 3D VCS in nursing (Aebersold, Tschannen, Stephens, Anderson, & Lei, 2011; Broom, Lynch, & Preece, 2009; McCallum, Ness, & Price, 2011). Broom, Lynch, and Preece (2009) explored student perceptions in a 2nd-year child health course that used a virtual ward simulation of a child with a fever of unknown origin in conjunction with blogging. Students accessed a virtual pediatric ward, read nursing notes, and reflected on their learning experiences with other students through a blog. In focus groups, students indicated that the advantages of simulation were developing knowledge and helping with clinical practice. When asked about the disadvantages, students indicated, ‘‘they are not the real thing’’ (p. 35) and ‘‘technical restrictions’’ (p. 36). From surveys, 49% strongly agreed and 38% agreed to the following statement: ‘‘Computer simulation provides a suitable experience for learning this skill.’’ All agreed or strongly disagreed that ‘‘the blog was a good way of collaborating with the learning process’’ and that the simulation helped ‘‘apply knowledge to practice’’ (p. 35). Noted difficulties arose with differing firewalls and computer configurations. This study contributes by demonstrating a unique application of VCS; however, key information such as sample size and instrumentation was lacking. Aebersold et al. (2011) evaluated the student experience of an SL simulation with 15 senior-level nursing students who participated in the 10- to 15-minute virtual simulation. The following three scenarios were developed: (a) safety issues with medication, (b) difficult interprofessional communications, and (c) priority setting. Students completed a six-question, Likert-type survey, with a comments section, about their experience. No reliability or validity data were reported on the instrument. On the scale, with 1 ¼ strongly disagree and 5 ¼ strongly agree, ‘‘SL helped prepare me for clinical’’ was rated 2.5, with a range of 1 to 4. ‘‘SL was realistic’’ had a mean score of 2.8 and a range of 1 to 4. ‘‘SL is an effective learning experience’’ had a mean score of 2.8. ‘‘SL improved decision-making skills’’ scored a mean of 2.7, with
a range of 1 to 4. ‘‘SL reinforced learning objectives’’ had a mean score of 3 with a range of 2 to 4. Overall, the experience was rated a 3.1. Some comments revealed benefits. One student said, ‘‘The experience was better than or as good as SimManÒ’’ (p. e5), and another stated, ‘‘It is a real good practice system and since it resembled real life scenarios, it gave almost the same experience one would have received in ordinary simulations’’ (p. e5). Students wished they could have set up their own avatars. The text chat function was slow and difficult for poor typists. The authors recommend using voice over internet rather than texting. One strength of the study was that it incorporated mixed methods. However, the study would have yielded more data if instructor-derived assessment data were incorporated in addition to the students’ self-reporting. McCallum, Ness, and Price (2011) explored nursing students’ decision-making skills through the use of a 3D virtual environment such as SL. This exploratory, qualitative study employed semistructured interviews after students participated in a 1-hour simulation of caring for six patients. The student nurses (n ¼ 5) were enrolled in a 3-year diploma of higher education/bachelor of nursing or bachelor of arts in nursing studies adult nursing course. The students’ decision-making during the scenario was evaluated. The majority of decisions (n ¼ 21) were made in response to a situation or a patient request and were ‘‘reactive’’ rather than proactive (n ¼ 9). ‘‘Only one student carried out vital signs (VS) assessment on a newly admitted patient’’ (p. 699). The interviews produced two themes, performing decision making and improving learning. The simulation helped students realize they could perform decision making as they felt themselves prioritizing, making decisions, and delegating (p. 703). ‘‘The absence of visual cues such as pre-operative checklists, VS observation charts and nil by mouth signs may offer a rationale for why students were more reactive or did not make certain important decisions’’ (p. 703). Students typed in their communications in SL. Instructor evaluation of the communications revealed poor performance. The typing and focusing on the screen may have impeded fluid communication. Furthermore, students noted difficulty with the ‘‘hands-on skills needed to run an avatar in SL’’ (p. 703). The authors concluded that SL should be further explored as a teaching strategy for decision making. The objective approach of quantifying accurate responses and using instructors’ evaluations as part of the data was a strength. Limitations include the small sample size and the evaluation of typed communications when students may have struggled with typing.
Discussion Critique of the State of the Science This review of the literature presents the state of the science of VCS in nursing and reveals that research regarding VCS
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reflects the earliest stages of data gathering. The current body of knowledge in VCS is scant. The few studies related to VCS (Aebersold et al., 2011; Broom et al., 2009; McCallum et al., 2011) lacked rigor as a consequence of small sample sizes, lack of reliable and valid instruments, and weak methods, yet these few studies have made a genuine contribution. Nurse educators may build on this research, sharing student feedback, outcomes, and lessons learned related to scenario development, implementation, and technological challenges. Educational researchers may benefit from collaborative efforts across disciplines (Schaefer et al., 2011), using existing published tools to build reliability and validity data (Kardong-Edgren, Adamson, & Fitzgerald, 2010) and garnering ideas for research designs from the behavioral and medical sciences.
resources, compounded with student demand for accessibility, VCS is a safe venue to explore. Educators are facing a new generation of student, the millennials, and 3D gaming technology builds on their existing learning frameworks and prepares them to embrace technology, a central component of nursing practice (Dutile, Wright, & Beauchesne, 2011). With cost being a likely hindrance, nurse faculty must promote awareness of these new opportunities in education and contemplate creative ways to maximize resources. In addition to investing in expensive, high-fidelity simulators, equipment, and facilities, nurse administrators may consider allocating funds to virtual simulation and its research.
Limitations
VCS presents an engaging modality with the possibility for helping nursing students to develop cognitive skills critical to the profession. As courses are rapidly migrating to online platforms, the VCS framework expands and transforms the level and type of education possible. Just as HPS has grown rapidly, VCS has similar potential. There is evidence that HPS works in nursing and the real world (Decker, Grady, Jeffries, & Kardong-Edgren, 2011). As the pedagogical phenomenon of VCS progresses, educators must validate its application and place in nursing education (Schiavenato, 2009).
This review was limited in several ways. CINAHL and Medline were the only databases searched as they are oriented to research in nursing. The ancestral approach incorporated subjectivity in regard to obtaining additional relevant studies. The strategy was intentionally chosen to focus on the state of the science in nursing rather than outside disciplines. The keywords gaming, 3D, and multiplayer were not used. Inclusion of these terms may have elicited additional relevant articles. By the end of the literature review, the recurrence of certain works led us to conclude that our search was thorough.
Conclusion
Acknowledgments Implications and Recommendations At this time, the body of research is slim, and thus, one cannot make a strong endorsement for or against VCS. However, this limitation offers exciting opportunity. VCS incorporates concepts of experiential learning, problembased learning, constructivism, self-directed learning, and andragogy. Thus, VCS may be an exceptional educational tool. Rather than a substitution, VCS might supplement or enhance clinical practicum. There is evidence to suggest that nursing students and faculty approve of VCS as well as evidence to suggest that nurses want to maintain a face-to-face andragogy. In 2002, Sandelowski demonstrated her vision of the future challenges with respect to role of the nurse in virtual worlds with her statement, ‘‘For a practice discipline, such as nursing, which has sought to define its boundaries paradoxically as between boundaries, the posthuman conflation of bodies and information poses the greatest challenge yet to its secure place, presence, and identity in health care’’ (p. 68). Future research will illuminate the efficacy and confines of VCS. As advancing technology is growing newfound pedagogies, educators must apply and test these innovations. Nursing is entering a new era. With faculty shortages, increased demand for clinical placements, and decreased
This project was supported by funds from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), and Department of Health and Human Services (DHHS) under grant number D11HP19238, Nurse Education Practice and Retention, award amount of $721,912. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any official endorsement be inferred by, the DN, BHPr, HRSA, DHHS, or the U.S. government. This project had no commercial financial support.
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