Virtual reality (VR) in simulation offers an exciting opportunity for learners to experience, explore and immerse themselves in challenging clinical and patient-centered scenarios, evoking hard-to-predict emotional responses. Nestel et. al (2018) points out that through clinical simulation, stressful and challenging scenarios can be recreated while providing a safe environment for learners to retain information and develop skills, while providing potential opportunities to explore both conscious and unconscious behaviors. Through the medium of virtual reality, the unique emotional response of each individual learner can be managed and discussed in a safe and contextualized risk-free environment, which would be difficult to provide in a clinical setting.
In recent years, the use of healthcare simulation has been recognized as an effective tool for learning and teaching across a wide range of medical disciplines. Simulation can occur in many forms, including the use of role-playing, case study scenarios and the use of high-end mannequins that allow for practice of clinical skills such as Sim-Man. More recently, this also includes the use of robots (Johanson et al. 2019), with many institutions benefiting from their inclusion in teaching and training methodologies. Different types of simulation are often classified or referred to as low- or high-fidelity simulations (Kilmon et al. 2010, Elliman et al. 2016, Tiffany & Hoglund 2016). The degree of fidelity relates to how much of the relevant stimuli are made available, as well as how much change occurs with each action the participant decides upon. Thus the fidelity of a scenario is limited by its weakest component-producing stimuli (Riley, 2008).
According to Freina & Ott (2015), virtual reality is defined as a “ … computer-generated simulation of a three-dimensional image or environment that can be interacted with in a seemingly real or physical way by a person using special electronic equipment, such as a helmet with a screen inside or gloves fitted with sensors” (page 1). VR is not a new term nor a nascent concept; its history dates back to the early 19th century, when the first evidence of 360-degree panoramic mural art appeared (Freina & Ott, 2015).
Approximately 100 years later, Morton Heiling applied his cinematography experience to pioneer one of the earliest known examples of immersive virtual reality, the Sensorama 1, which was developed over several years beginning in 1957, and then patented in 1962. Sensorama 1 was a mechanical device for one to four people, which provided a multimodal or multisensory experience of riding a motorbike. The experience included the use of a full-color 3D film, smell, stereo sound, a vibrating seat to represent the feeling of motion and the movement of air to provide the sensation of wind, all of which helped to create the illusion of reality (Hassan, 2019, Rheingold, 1991)
Non-immersive VR is created by using a 3D environment that can be directly manipulated and interacted with, but is generated through conventional computer graphics using a monitor, a keyboard and mouse (Robertson, G. G., Card, S. K., & Mackinlay, J. 1993). Examples of effective non-immersive VR simulations that have been used within nurse and healthcare education are the web-based platform “Second Life”; and virtual clinics, wards and hospitals which have been designed and tailored to the unique needs of the individuals, such as “Nightingale Isle” (Tiffany & Hoglund 2016, Elliman et al. 2016).
VR experiences in which participants are fully immersed in the virtual environment are supplied by head-mounted displays (HMD) or projection-based displays (PBD). One of the most popular PBD systems is referred to as "the CAVE" (computer automatic virtual environment). This projection-based display uses the floor, walls and ceiling to display images, which when joined, form a 3D-immersive room (Cruz-Neira, Sandin, & DeFanti, 1993). The individual, who can wear optional 3D glasses, can move around freely in this projected world and experience an immersive visual and interactive experience.
CAVE technology has become popular in cultural heritage, with museums, researchers and educators using this system to effectively communicate the cultural content of an exhibit (Carrozzino & Bergamasco, 2010). While this form of VR has potential, and in some ways offers greater fidelity than HMD, the relative costs associated with setting up these environments, coupled with the need for a dedicated space, serve as limitations to its accessibility and practical usage in education and training. HMD technology currently offers more cost-efficient and easier access to simulations and experiences, and due to technological advances, HMD systems are becoming increasingly portable.
For the purpose of this article, the term “immersive virtual reality” (IVR) will be used to differentiate it from other possible formats of Virtual Reality (VR). LaValle (2017) defined IVR as “inducing targeted behavior in an organism by using artificial sensory stimulation, while the organism has little or no awareness of the interference” (page 1). From the perspective of its use within nursing education, this means that specific behavioral or emotional responses could be induced using artificial sensory stimulation, without the individual being aware of this. For this immersion to occur, the individual must feel that the simulated environment is perceptually convincing. In essence, it must look authentic for the individual to feel as if they are there. Sherman & Craig (2018a & 2018b) suggest that IVR has the potential to allow individuals to behave and react as closely as possible to reality.
The scoping review by Fealy et al. (2019) explored the use of IVR in tertiary nursing education programs, concluding that there was a lack of research within nursing education. This review supported the findings of an earlier study by Cant and Cooper (2017) that the general extent and application of VR within undergraduate nursing and midwifery was largely unknown. Although there is insufficient data to substantiate that simulation directly improves patient outcomes, studies have shown that learners and educators alike appear to recognize simulation's significance in providing excellent opportunities to exercise their clinical judgment in a safe environment (Fey et al., 2014). A study using virtual reality in medical education to teach empathy (Dyer et al., 2018) allowed a diverse range of medical and healthcare students to experience being a patient with age-related health and disability conditions, reporting significant improvement in the students’ understanding of the patient’s viewpoint.
Although there is an overall paucity of IVR research within nursing education, the available literature on the use of VR and IVR from other disciplines of healthcare and education has been highly suggestive of the potential benefits offered by this technology for training and education purposes. One of the key objectives for exploring the use of IVR outside of the area of skill development was to consider whether it was a suitable tool for creating, exploring, assessing and managing emotional responses in students whom are immersed in challenging situations. It was therefore important, when examining recent publications, to explore how they had approached and considered the emotional aspect of the simulation, and to what extent IVR had influenced this perspective.
One of the main themes when exploring the emotional aspect of the simulation centered on empathy. According to Davis (1983), empathy consists of the ability to view the world from another person’s perspective, coupled with emotional reactions to that perspective, usually typified as feelings of concern for others. Preston and de Waal (2002) suggest that the perceptual and behavioral processes that are associated with empathy enable group living and form the foundation for beneficial social interactions. Having a greater level of empathy usually results in more socially competent behaviors and better social adjustment, and is associated with more helping behaviors (Blanke et al. 2016, Eisenberg and Miller 1987, Pavey et al. 2012).
Work undertaken by Shin (2018), explored the disparity between levels of empathy experienced by those observing video footage of a young girl in a refugee camp viewed through IVR head-mounted displays, and those who viewed the same material in a more traditional 2D, flat-screen format. The research confirmed that those viewing the material in IVR experienced greater levels of empathy and engagement than those who viewed the materials in traditional 2D format. Students involved in research by Kolomaznik, Sullivana and Vyvyan (2017) were provided with a team-working task. One group was given the task to complete in a IVR environment provided through HMD, and the other group was instructed to conduct the activity in a traditional classroom environment. The study concluded that those participating in the IVR environment experienced increased emotional engagement and immersion with the task, and expressed an improved attitude toward teamwork. This increased engagement was also observed by the staff conducting the scenarios.
Buchman & Henderson’s study (2018) explored the use of VR through 360-degree video and an embodiment VR simulation, where students adopted the role of a patient experiencing periods of dizziness, including a daydream sequence. In evaluations following this experience, students reported greater empathy and a deeper level of understanding of the conditions, day-to-day experiences and challenges that patients with these symptoms encounter. The students particularly commented on how the embodiment experience gave them new insights into how they might react to an individual with this condition, and how they would use this information to inform and tailor the care they provided. Buchman & Henderson (2018 and 2019) reported that the students in their studies developed greater empathy as a result of increased presence and immersion, as the participants were able to experience embodiment and realism firsthand.
In simulation, and VR/IVR in particular, the word "embodiment" is used to describe the perceptual experience of an individual, through taking on the identity of a different person (Ahn et al. 2013). In VR/IVR, embodiment can mean literal representation through an avatar within the simulated environment, or a more generalized feeling of characterization and appreciation of the simulated world. Within their work, Ahn et al. (2016) broadened the perspective of embodiment by creating IVR scenarios where individuals were able to explore environments from the perspective of an animal. The results demonstrated that this experience allowed individuals to gain a closer connection with the environment, and promoted a greater understanding between the individual and nature.
The work on engagement and embodiment, and their effects on empathy, are pertinent to this area of research as they offer up possibilities into how effective VR might be in terms of assessing emotional responses to challenging situations. Evidence increasingly suggests that VR, and in particular IVR, can provide opportunities to effectively create meaningful emotional responses in participants. The technology allows for the creation of events and situations that can better equip student nurses for practice without the potential for causing patient harm. While traditional forms of simulation may be argued to offer similar opportunities, in addition to the benefits of feeling stronger connections with subjects from total immersion simulation, VR/IVR also provides consistency between multiple users, as all participants experience the same simulation. They all see, hear and experience the same conditions; and therefore all have the same embodiment experience (Buchman & Henderson, 2018, Shin 2019, Dang et al., 2018).
The opportunity to develop empathy through engagement and presence in a VR/IVR simulation offers interest and relevance across all healthcare disciplines. Indeed, studies by Ogle et al. (2013) demonstrated that medical students with higher levels of empathy show greater clinical competence. Moyers et. al (2016) concluded that clients have better outcomes when treated by therapists with greater empathy. Parsons and Mitchell (2002) explored the potential of creating virtual environments to support those with autism-spectrum disorders. The review concluded that this ability to immerse individuals within these environments offers opportunities for individuals to practice behaviors within role-playing situations, and provides a safe environment to practice rule learning and repetition of tasks. They acknowledge that this flexible approach allowed for encouragement of problem-solving skills, and a greater understanding and increased awareness of the participants' thoughts and feelings by the practitioners.
Regarding the reaction of participants to challenging situations, a significant question is whether negative emotional responses and actions to real-world situations can be reduced through IVR simulation training. While there has not been any work of this kind within healthcare, there has been work undertaken in the military that explores this area. Pallavicini et al. (2016) concluded that IVR could provide possibilities to assess individuals’ resilience to stress, as well as identifying the impact that stress may have on psychological reactions including empathy. They argue that the response to stressors makes it possible to train practitioners and to identify those that have resilient behaviors. The ability to create and recreate stressful scenarios using IVR has also been used successfully in disaster and emergency training. (Feng et al. 2018) While these works focused on areas outside of healthcare, the possibility of exploring and applying these tools to healthcare education offers a significant opportunity.
The review of the literature has confirmed a gap in research and an area of potential future study. Expanding upon this, a thematic analysis of the literature has provided evidence of some of the factors that underpin a successful IVR simulation that need to be considered in future research and research design. The work conducted by the military and social sciences in exploring the use of environments to develop coping skills to known stressful environments, and for teaching social skills to those with autistic tendencies, demonstrates that IVR offers areas of further exploration. As Freina & Ott (2017) and Jensen (2018) confirm in their literature reviews, IVR and VR have the potential to be effective tools for learning, and their use for these purposes will continue to grow.
The limitations of this study were that the review was focused on a specific area of IVR usage, and from within a specific field of healthcare; this limited the data that could be included to review. While this highlighted the need for further research focused on nursing education, it also meant that some existing work on the usage of IVR to assess emotional responses could not be included. For example, the work of Albert Rizzo offers some interesting data, particularly his work on a Virtual Iraq and the treatment of post-traumatic stress disorders (Gerardi et al. 2008, Rizzo et al. 2012). However, references to these works have been included where specifically appropriate to this discussion.
This article was primarily concerned with the use of VR and IVR environments that could be created and used to elicit emotional responses in students. These experiences have the potential to offer unique insight into individual patient circumstances and perspectives, allowing healthcare professionals to develop a deeper understanding of a range of health conditions and disabilities. The potential for immersion and embodiment within these experiences could promote stronger relationships between patients and healthcare professionals, and ultimately lead to a more person-centric approach to care.
It is time that undergraduate and postgraduate nursing courses recognize the importance of preparing students for professional practice while being able to maintain patient safety, and that VR and IVR offer opportunities to develop empathetic nursing practitioners of the future (Jenson & Forsyth 2012). This review was undertaken prior to the COVID-19 pandemic, and the authors note that there has been an increase in research and interest in using a variety of VR technology methods throughout healthcare, and in particular, nursing education.
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Today's article was guest authored by Leisa Anderton, RN, RNT, BSc, QTLS, PgDip, MSc Healthcare Education, Senior Lecturer in Nursing at Sheffield Hallam University.
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