Simulation has long been a staple of nursing education dating back to the mid-1800s when nurse trainees used anatomical models to practice bandaging limbs. Today, high-fidelity simulation is the mainstay of nursing education. The American Association of Colleges of Nursing even called for nursing programs to embrace simulated training programs as part of its Vision for Academic Nursing, declaring: “Nurse educators must be nimble enough to embrace new technology and explore fresh approaches to teaching.”

 While computer-based virtual simulation has long been considered the gold standard of many nursing education curriculums, some academic programs are now seizing on the “next big thing” and adopting virtual reality simulations. However, not all modalities are created equal.

 To explore the application of virtual reality and its potential drawbacks, I have invited Sentinel U® Thought Leadership Advisory Council member David Bodily, MS, RN, to share his insight on this subject.

Healthcare education can be facilitated through multiple simulation modalities.  Any modality can be more or less effective depending on how it is matched to a given situation and to student learning outcomes.  Until a shared taxonomy is well-established, our discussions of the effectiveness and limitations of any given modality must be preceded by as complete a description of the modality as possible.

The term “virtual” is used in many contexts.   By some definitions, all healthcare simulation is a “virtual” experience.  For purposes of this post, we refer to what is commonly referred to as “Virtual Reality” or “VR.” The defining characteristics of this modality are:

  • an entirely computer-generated visual field
  • presentation of that visual field through a head-mounted display, versus on a traditional computer display
  • three-dimensional, 360-degree field of view, synchronized with head movements
  • there is no view “through” the computer-generated image of actual physical surroundings, such as in what is typically referred to as “Augmented Reality” or “AR”

Cybersickness Limits VR Applications

Use of VR can be hindered by subject response. A sizeable number of people are susceptible to a unique form of VR-related motion sickness, commonly called cybersickness. They report feeling nauseous, disoriented or experiencing vertigo. One study by a University of Minnesota kinesiologist found that 40 to 70 percent of virtual reality gaming system users felt sick after only 15 minutes, and in some applications, 100 percent of users became ill.

Cybersickness can be related to the visual presentation.  One key study for the journal Virtual Reality found that the level of cybersickness experienced is related to the type of virtual reality environment, with fully immersive VR causing the most severe cases.

Cybersickness symptoms are the result of three physiological factors:

  1. Lag time – The way virtual reality works is the equipment, specifically a head-mounted display, senses when the user turns their head. As their perception changes, so does the image being sent to the eyes. The time that lapses between when they move their head and when the picture actually shifts is one of the root causes of cybersickness.
  2. Frame rate – Closely related to lag time, frame rate is the frequency at which consecutive images are displayed. Thirty frames per second is standard for most television shows, while feature films are viewed at 24 frames per second. With virtual reality, the frame rate is often not adequate for the imagery between what your eyes see in the apparatus and what your brain processes.
  3. Alignment – Inter-pupillary distance misalignment occurs when the headset or goggles are not perfectly aligned so the images being displayed in your eyes are offset. When things are a little offset, a feeling of motion sickness can develop.

When to Use VR

This factor is something those creating nursing simulations need to take into consideration. Content creators and software developers must keep the constraints of the equipment in mind, being cognizant of how moving within that virtual space might affect a user. There are certain scenarios that will warrant the use of fully immersive VR simulation and others where a lower-impact modality, such as screen-based virtual simulation or even physical manikins, would be preferred.

The desired learning outcome also impacts which type of simulation would be preferable. For instance, if the outcome is to recognize when to initiate CPR on a patient, then virtual simulation – either VR or screen-based simulation – is a viable option. The simulation scenario can take the nurse through the assessment and the steps leading up to actually performing CPR, stopping before any movements could cause cybersickness. However, if the outcome is to determine if the nurse can properly perform CPR, then that scenario is better suited to a hands-on, toe-to-toe simulation using a manikin.

Offering Alternatives

We all hope to use technology to the advantage of our learners, and VR is clearly at the cutting edge. Pragmatism pushes back at the use of VR as a first choice.  Like many modalities, VR has virtues, but it also has its drawbacks. Simulator sickness, or cybersickness, is a very real limitation.

No learning outcome should be coupled to a simulation that can only be presented through virtual reality. We need to make sure there is always an alternative, fallback solution for those students prone to cybersickness. We must prioritize learning outcomes over technology and fully utilize more practical alternatives like screen-based simulation.  Any computer-generated environment that can be presented through VR can be presented through a screen-based platform.  Although an argument can be made that VR gear is more immersive, proper focus on learning outcomes and scenario design can certainly outweigh this unproven advantage.

Nursing education relies heavily on simulation. Technology supporting toe-to-toe and computer-based environments to deliver the paradigm has evolved over years, and we better understand how to capitalize on advancements. While each modality has merits, we should not rush past practical and proven modalities for the latest alluring tech. Until VR technology evolves and improves to the point where cybersickness is no longer a concern, I don’t believe simulation scenarios that rely on VR should command a bulk of our effort.  We should instead prioritize investigation of the contribution of VR to immersion and the contribution of that immersion to learning.

David Bodily, MS, RN, is the program director for ReNEW and RN-BSN program at the University of Wyoming’s Fay W. Whitney School of Nursing. David also provides simulation consultation and reviews manuscripts for Clinical Simulation in Learning.