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Running head: VIRTUAL SIMULATION IN NURSING EDUCATION

Virtual Simulation in Nursing Education: A Literature Review

David Staten

Azusa Pacific University

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VIRTUAL SIMULATION IN NURSING EDUCATION

Virtual Simulation in Nursing Education: A Literature Review

Students utilize modern technological approaches to enhance their learning capabilities

(Wright, Tinnon, Rebecca, & Newton, 2018). Clinical virtual simulation is a technological

intervention that supplements traditional nursing education (Liaw et al., 2015). The purpose of

this paper is to conduct a literature review on the effect of virtual simulation in improving

nursing education and discuss research methodologies, sampling, key findings, and limitations.

Background

Wright et al. (2018) defines three different types of virtual simulation as virtual reality,

gaming simulator, and web-based simulators that digitally replicate patient scenarios within

hospital settings. Second year nursing students were recruited by their nursing universities for

virtual simulation studies. Modern technology has shifted the educational paradigm from

students being passive listeners during lectures to having instant access to real time information,

multitasking capabilities, visual graphics preference, and instant gratitude (Padilha, Machado,

Riberio, Ramos, & Costa, 2019). Nursing students engage in a traditional education method of

didactic lecture and clinical rotation. However, nursing students have limited experiences at

clinical rotations due to decreased clinical opportunities (Gu, Zhu, Chen, 2017).

According to Gu, Zhu, and Chen (2017), virtual simulation can be a cost-effective

method in providing repeated practice opportunities that are safe, accessible, and standardized.

The National Council for State Boards of Nursing promotes the use of virtual simulation to be

effective as learning within traditional clinical settings (Wright et al., 2018). The following

PICOT question will be addressed: For second year undergraduate and graduate nursing

students, what is the effect of nursing education with virtual simulation compared to not using
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virtual simulation in improving clinical reasoning and learning satisfaction within two to four

months?

Literature Review

Methodology

Four of the eight selected studies conducted randomized control trials which are known

to have the least selection bias and best for demonstrating causality (Polit & Beck, 2017; Padilha

et al., 2019, Gu et al., 2017; Bayram & Caliskan, 2019; Liaw et al., 2015). Two studies

performed quasi-experimental trials that lack randomizing participants but provide substantial

baseline data (Polit & Beck, 2017; Wright et al., 2018; Samosorn, Gilbert, Bauman, Khine, &

McGonigle, 2020). Koivisto, Multisilta, Niemi, Katajitso, and Eriksson (2016) conducted a

cross-sectional descriptive study. Chia (2013) performed a self-reported questionnaire at

university in Singapore. Dang and Dearholt (2017) rank research designs into three evidence

levels: randomized control trials as level I, quasi-experimental as level II, and cross-sectional

descriptive study and the self-reported questionnaire as level III. Randomized control trials are

ranked as the strongest evidence level, quasi-experimental as the second strongest, and the cross-

sectional study and questionnaire as the third strongest (Polit & Beck, 2017).

Virtual Reality Simulators. All four articles similarly defined virtual reality as digital

replications of hospital settings that individuals can interact with dynamic life-like patient

scenarios to display their clinical knowledge and skill (Padilha et al., 2019; Gu et al., 2017;

Wright et al., 2018; Samosorn et al., 2019;). The four articles discuss that all virtual reality

simulators were platformed for computers (Padilha et al., 2019; Gu et al., 2017; Wright et al.,

2018; Samosorn et al., 2020). Virtual reality simulators are mainstreamed such as vSIM or

alternative virtual reality simulators created by university computer-expert staff (Padhila et al.,
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2019; Gu et al., 2017; Wright et al., 2018). There are no direct comparisons between mainstream

virtual reality simulators and alternative virtual reality simulators. Wright et al. (2018) states that

vSIM is supported by three reputable organizations such as Laerdal Medical, National League

for Nursing, and Wolters Kluwer Health.

Gaming Simulators. Gaming simulators was similarly defined as virtual simulators that

allowed individuals to learn, explore, and compete against time, others, and themselves (Chia

2013; Koivisto et al., 2016; Bayram & Caliskan, 2019). Bayram and Caliskan (2019) explain that

gaming simulators are platformed for computer or cellphone application. Chia (2013) and

Kovisito et al. (2016) utilized computer gaming simulators while Bayram and Caliskan (2019)

utilized a cellphone gaming simulator. There are no direct comparisons between computer

gaming simulators and cellphone gaming simulators. Cellphone gaming simulators allow

individuals to play at any place and time, however; Bayram and Caliskan (2019) reported a slight

improvement with their cellphone gaming simulator.

Web-based Simulators. Liaw et al. (2015) has defined web-based simulators as a

multimedia technology that includes text, video, and audio to create clinical environments that

individuals can perform real-life nursing tasks. Web-based simulators can be utilized by various

platforms that have internet connection capability (Liaw et al., 2015). There are no other selected

articles that use web-based simulators to compare against. Liaw et al. (2015) states that web-

based simulators are effective as mannequin-based simulations. Web-based simulators have

more benefits than mannequin-based simulations such as schedule flexibility, train larger nursing

cohorts, easily repeatable than mannequin-base simulations, and require less financial and

physical resources (Liaw et al., 2015).

Sampling
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All sampling sites were performed at technical nursing schools, college, and university

campuses. Polit and Beck (2017) emphasize the importance of selecting sample sites that include

adequate sample numbers and diversity to ensuring research goals. Polit and Beck (2017) explain

that site selection is important for maintaining research goals and ethical requirements. Two

studies were performed at two universities that result in better generalizability (Polit & Beck,

2017; Wright et al., 2018; Koivisto et al., 2016).

All eight of the studies had a sample population of nursing students that varied among

grade levels, beginning from first year undergraduate students to second year graduate students.

Koivisto et al. (2016) and Liaw et al. (2015) reported the age of the majority was in their early

twenties. Differences in the sample population are difficult to compare, although; majority of the

sample populations were undergraduate nursing students.

The population sample size ranges from 21 to 166 nursing students. Polit & Beck (2017)

discusses that larger sample sizes improve validity. Majority of the studies calculated and

complied with sample size requirements and sample significance. Bayram and Caliskin (2019)

included an inclusion and exclusion criteria. According to Polit & Beck (2017), eligibility

criteria improves internal validity while decreasing external validity.

Research Findings

Six of the eight studies calculated their results to be statistically significant (P < 0.05).

Three studies utilized variants of analysis of variances (ANOVA) in finding statistical

significance between the independent variable and multiple dependent variables (Polit & Beck,

2017; Padilha et al., 2019; Kovisto et al., 2016; Liaw et al., 2015).Two of the studies scored a

higher range of Cronbach’s alpha that ranged from 0.97 to 1.33, indicating that the measuring

instruments had higher internal consistency (Polit & Beck, 2017; Padilha et al., 2019; Liaw et al.,
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2015). Liaw et al. (2015) scored an interrater reliability (ICC) of 0.98 that indicates a high

agreement between judges using the same instruments as explained by Polit and Beck (2017).

All virtual reality studies discussed positive results with the use of virtual reality

simulators. Padilha et al. (2019) found positive results of virtual reality simulation for increasing

knowledge retention and learning satisfaction. Gu et al. (2017) discussed that the experimental

group utilizing virtual reality scored higher for a knowledge test compared to the control group.

Wright et al. (2018) reported three positive results of virtual reality simulation from their survey

question, 90 percent of students agreed that virtual simulation challenged their knowledge and

that it was a helpful tool, and 74 percent of students agreed that virtual simulation was easy to

use. Samosorn et al. (2020) describe nursing students post-test scores were significantly higher

with virtual reality simulators with a 100% increase of average scores and an effect size of 2.33.

Studies for gaming and web-based simulators highlighted positive results. Bayram and

Caliskan (2019) discuss that the gaming experimental group scored higher than the control group

in skills performances, inner cannula skill, and peristomal care. Koivisto et al. (2016) explained

strong correlations for gaming simulator in identifying problems and setting goals, in addition to

the application of nursing knowledge and problem identification. The authors reported that

students felt safe in making mistakes with the gaming simulator (Koivisto et al., 2016). Chia

(2013) listed findings of the self-reported questionnaire for over 90 percent in learning

satisfaction, clinical confidence, and knowledge retention with a gaming simulator. Liaw et al.

(2015) reported higher post test scores for the clinical performance compared the pretest score

and for the experimental group over the control group by students using a web-based simulator.

Study Limitations, Critical Appraisal, and Future Implication

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Several major limitations exist with all eight studies. Five out of the eight studies were

conducted at one university site, which results in a decrease of generalizability (Polit & Beck,

2017). Three of the studies calculated a higher number and percentage of female nursing students

compared to male nursing students (Padilha et al., 2019; Samosorn et al., 2020; Liaw et al.,

2015). As stated by Polit & Beck (2017), sample populations that are highly or strictly

homogeneous limit generalizability. One study listed that over half of sample population was

between the ages of 21-25 and that a major age demographic will decrease generalizability (Polit

& Beck, 2017; Koivisto et al., 2016; Liaw et al., 2015).

All eight of the studies were conducted by nurses to improve nursing education. Seven of

the eight studies conducted were within five years except for one study that was conducted

within 2013 (Chia, 2013). Three studies performed a pretest-posttest design that increases

internal validity but causes external validity to decrease (Polit & Beck, 2017; Padilha et al.,

2019; Samosorn et al., 2020; Liaw et al., 2015). Gu et al. (2017) and Wright et al. (2018)

performed their studies with a posttest design, according to Polit and Beck (2017), a major

disadvantage with this design is that causation cannot be established due to the lack of pretesting.

However, the two research designs provide baseline data for further research designs such as the

Solomon Four Group Design, which provides full control over experimental variables that result

in more accurate results and findings for virtual simulation (Shuttleworth, 2020).

Majority of the studies recommended long-term research on the effects of virtual

simulation on nursing students’ education. Padilha et al. (2019) suggested that virtual simulation

be researched in other educational fields. Few studies advised further research on their virtual

simulation type with other educational methods or tools. Future nursing research should directly

compare the effectiveness of the different types of virtual simulation.

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Conclusion

Overall, this paper reviewed the effects of virtual simulation on nursing education. The

studies varied in research methodologies, sampling, key findings, and limitations. However, all

three types of virtual simulation had a positive impact on nursing education. Future research on

virtual simulation should be researched with other educational fields, tools, and directly compare

the effectiveness of each virtual simulation type. All eight studies provide framework for future

research, clinical implications, and evidence-based practice with the PICOT intervention.

Clinical Implications

This paper will discuss clinical implications to the following PICOT question: For second

year undergraduate and graduate nursing students, what is the effect of nursing education with

virtual simulation compared to not using virtual simulation in improving clinical reasoning and

learning satisfaction within two to four months? Research studies from the literature review will

be applied for the implementation of changes within nursing education of clinical knowledge and

retention. Dearholt and Dang (2017) rank randomized control trails as level I, quasi-experimental

as level II, and cross-sectional/survey as level III while Polit & Beck (2017) rank randomized

control trials as level II, quasi-experimental as level III, and cross-sectional/survey as level VI.

Majority of the research studies were randomized control trials and quasi-experimental which

provide substantial data and information (Polit & Beck, 2017). The purpose of this paper is to

implement and discuss a virtual simulation intervention for nursing education, evidence and

barriers to implementation, ethical/cultural/spiritual considerations, and gaps within the

literature.

Key Findings
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Padilha et al. (2019) and Samosorn et al. (2020) reported positive findings of higher post

test scores, knowledge retention, learning satisfaction with customized (alternative) virtual

reality. Gu et al. (2017) and Wright et al. (2018) discussed a mainstream virtual reality simulator,

vSim, had a positive impact on knowledge, was easy to use, and found to be a helpful tool.

Virtual gaming simulations improved clinical skills, identifying problems, setting goals, and

applying nursing knowledge (Bayram & Caliskan, 2019; Koivisto et al., 2019). Chia (2013)

highlighted her findings of the self-reported questionnaires for virtual gaming simulation to

improve learning satisfaction, clinical confidence, and knowledge retention. Liaw et al. (2015)

explained a higher clinical performance score for nursing students utilizing a web-based

simulator.

Implementation Plan

Virtual reality simulation. The virtual reality simulation that will be modeled after the

mainstream brand known as vSim. Authors such as Gu et al. (2017) and Wright et al. (2018)

utilized vSim for their studies with positive success and Wright et al. (2018) mentions that vSim

is founded and maintained by three organizations: Laerdal Medical, National League for

Nursing, and Wolters Kluwer. According to Wolter Kluwer (2015), the expertise of the three

organizations include the integration of solutions with student nursing curriculum (Wolter

Kluwer), expertise in medical simulation (Laerdal Medical), and best in-class solutions for

nursing curriculum (National League for Nursing). The three-way partnership ensures that vSim

content prepares nursing students for their clinical opportunities and continue to expand and

adapt their simulators for all areas of nursing (Wolter Kluwer, 2015).

Nursing students and nursing educators should be involved with key stakeholders such as

the Nursing Department Chair, Deans of Nursing, and Nursing Financial Officers to
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incorporating vSim into the nursing curriculum. Gu et al. (2017) emphasized the significance of

vSim for nursing students needing to remediate for missed clinicals and Padilha et al. (2019)

highlights that virtual reality simulators help prepare nursing students for future clinical skills

and reasoning. Professor Tade, a clinical instructor at Azusa Pacific University provided

information that National University has an online virtual reality simulator through the

Assessment Technologies Institute (ATI) to help their nursing students have better clinical

confidence and reasoning. Virtual reality simulators such as vSim can be highly beneficial when

nursing students are not able to attend a clinical rotation due to external influences such as the

quarantining process of the Coronavirus (COVID-19). Wolter Kluwer (2015) states that vSim

allow students to make clinical decisions without the need for instructors needing to be present

and allow instructors to completely keep track of their students’ progress and performances.

The plan to implement virtual reality simulator begins with a day dedicated to learning

the basic functions of Medical-Surgical vSim. Second-year nursing students will utilize Medical-

Surgical vSim for one hour, once a week, and for a length of four months. Clinical knowledge

retention will be one of the two primary outcomes measured with a pretest and posttest that

consist of ten questions that have true-false and multiple-choice questions. The pretest will be

administered the week after nursing students learn the basic functions of vSim and the posttest

will be given at the end of the fourth month. Learning satisfaction will be the other primary

outcome that will be measured with a 5-point Lickert scale composed of five questions that

determine the level of learning satisfaction of the second-year nursing students.

Barriers to Implementation

Finances, system requirements, and technical computer knowledge are barriers to

implementing vSim. According to Wolters Kluwer (2020), the price for Medical-Surgical vSim
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is $99.95 which can be fairly expensive for students or nursing schools to afford. Tech-X

Corporation (2019) discusses that vSim can operate on older Windows platform such as

Windows 7 and Windows 8 but runs optimally with 3D Graphics with Windows 10. Other

system requirements involve having the latest graphic drivers, 1.2 Gigabytes free space, and

having a minimum monitor resolution of 1280x80 as part of the user interface becomes cut off

the screen (Tech-X Corporation, 2019). Nursing students will need basic technical computer

skills to install and operate vSim or require other individuals to help them with the installation

process.

Ethical, Cultural, and Spiritual Considerations

Virtual simulation is beneficial for nursing education but requires ethical considerations.

According to Baumann, Sharoff, and Penalo (2018), virtual simulations promotes beneficence on

a global scale. Beauchamp and Childress (2013) discuss that the principle of beneficence

encompasses the respecting of others’ dignities at an individual, societal, national, and global

level. Virtual simulation can be programmed to include patient scenarios that require medical

care and bioethics consideration (Baumann et al., 2018). Baumann et al. (2018) explain that

virtual simulation programs incorporate nursing students to identify and respect physical,

cultural, spiritual, and financial differences.

Matthew, Brewer, Crist, and Poedel (2017) describe the integration of cultural

competency and virtual simulation. Their study involved selective recruiting within the medical

community to create criteria for cultural competency (Matthew et al., 2017). Medical

professionals such as nursing educators and nursing students had to assess a virtual patient and

make culturally competent decisions for five clinical scenarios (Matthew et al., 2017). Matthew

et al (2017) reported that virtual simulation can promote culture competencies for nursing
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students. The authors concluded that the promotion of cultural competency not only apply for

nursing students but the nursing workface as well (Matthew et al., 2017).

Virtual reality simulation provides spiritual care for individuals at end of life care

(Osborne, 2017). Osborne (2017) stated that the National Health Service in the United Kingdom

lacks necessary resources to providing comfortable care. One British hospice, Loros, has funded

charities for virtual reality equipment to be used by those at end of life. Osborne (2017)

illustrates that virtual reality simulations help individuals to revisit memorable experiences,

places, or explore new areas that were limited to their severe illness or disease. The author’s final

statement is that virtual reality simulators allow end of life individuals to enjoy experiences that

were not possible due to their condition (Osborne, 2017).

Gaps within the Literature and future research

Nursing within modern society has increasingly depended upon technology to help

prepare nursing students for their future roles in the clinical and hospital settings. Researchers

have no direct comparison of the most useful virtual simulation type for nursing students. Direct

comparison between all different virtual simulation is needed for future research. The

significance of finding the most useful virtual simulation type can impact the nursing student’s

opportunities to learn, for example on or off campus, and how effective nursing students are at

retaining knowledge and learning satisfaction. Authors such as Padilha et al. (2019) and Liaw et

al. (2015) state that future research need to investigate virtual simulation over a longer period of

time.

Conclusion

Overall, the research studies from the literature review provide positive findings for the

clinical implementation of virtual simulation. A mainstreamed virtual reality simulator, vSim,

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will be highly beneficial for the clinical aspect of nursing education. Virtual simulation is a

unique solution for nursing faculty and students in dealing with limited clinical opportunities.

Past, current, and future research can continually improve evidence-based practice for nursing

students and help future nurses to be clinically confident and competent.

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Nursing Science Quarterly, 31(4), 374-378. https://doi.org/10.1177%

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Bayram, S. B., & Caliskan, N. (2019). Effect of a game-based virtual reality phone application

on tracheostomy care education for nursing students: A randomized controlled trial.

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Beauchamp, T.L. & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.). N.Y.:

Oxford Press.

Chia, P. (2013). Using a virtual game to enhance simulation-based learning in nursing education.

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/ehost/pdfviewer/pdfviewer?vid=5&sid=4c0b94ef-4440-44c4-9dc6-

3a68c01cf079%40sessionmgr4008

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Guidelines, 3rd Ed. Indianapolis, IN: Sigma Theta Tau International Honor Society of

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playing: A cross-sectional descriptive study of nursing students’ experiences of learning

clinical reasoning. Nurse Education Today, 45, 22–28. https://doi.org/10.1016

/j.nedt.2016.06.009
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Liaw, S. Y., Wong, L. F., Chan, S. W. Ho, J. T., Mordiffi, S. Z., Ang, S. B., Goh, P. S., & Ang,

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Grading Rubric for Clinical Project: Clinical Implications Paper:
Category Exemplary
90 – 100%
Transition Section Problem clearly identified.
Thesis statement and focus of
Maximum the paper clear to reader.
10 points Significance to nursing
discussed.
PICOT question included
Body – Plan for Appropriate findings from your
change literature review identified and
discussed.
Maximum Uses inference and reason to
30 points draw logical conclusions about
implications and
consequences.
Identifies a strategy and
potential problems.
Provides support for change or
innovation.
Transitions link sections and
paragraphs well.
Content vocabulary
appropriate, used well.
Evaluation outcome clearly
discussed and supported
Clear plan developed to
implement change in
practice.
Grading of Evidence, Barriers/Facilitators to change
Barriers/Facilitators identified and addressed,
to change, considered possible ethical
spiritual/cultural and implications, demonstrates
ethical insight and depth in
considerations discussion. Cultural and
20 points Spiritual Considerations
included.
Summary statement of grading
of evidence with citation.
Conclusion Clear, thorough summary.
Maximum Relevance to nursing clearly
15 points stated.
Recommendations clear and
supported.
No new content introduced
Assignment Addresses all required
Max. 5 points elements of assignment &
expands them.
Grammar & Spelling No grammar or spelling errors.
Max. 10 points
APA Format for Citations include all elements
Citations of APA formatting, according
examples in APA 7.01.
Max. 5 points
*Formatting Follows all APA formatting
guidelines; uses Word
Max.5 points functions appropriately,
introduction and conclusion
included
Meets Requirements
80 – 90%
Problem identified.
Thesis statement clear to
reader
Significance to nursing
identified.
PICOT question included
Literature review incorporated
adequately.
Draws logical conclusions.
Identifies a strategy and
potential problems.
Proposed change is
understandable and has
support in literature.
Evaluation outcomes
included.
Minor problems with
transition and order of
paragraphs or sections.
Content vocabulary generally
accurate.
Plan developed to
implement change in
practice, but not clear.
Minimal discussion of
possible barriers/facilitators,
minimal insight and/or depth.
Ethical, spiritual or cultural
considerations not all
included.
Summary statement of
grading of evidence with
citation.
Problem and findings
summarized.
Relevance to nursing
appropriate.
Recommendations
supported.
Addresses all required
elements of assignment.
1-2 minor errors per page.
No more than two minor
errors in APA style formatting
in all citations. Follows
examples in APA 7.01.
Follows all formatting
guidelines; minor problems
with Word functions.
Needs Improvement Points
<79%
Problem unclear.
Thesis statement unclear
or missing.
Significance to nursing
not addressed.
PICOT question not
included
Literature review not
incorporated adequately.
Findings unclear.
Strategies unclear or not
logical.
No support for proposed
changes.
No evaluation outcome or
evaluation outcome not
clearly supported.
Many or significant
problems with transition
and order of paragraphs
or sections.
Significant errors in
content vocabulary.
Plan unclear for change
in practice
No discussion of possible
barriers/facilitators, no
ethical considerations, no
spiritual/cultural
considerations, no
insight/depth
demonstrated.
No summary statement of
grading of evidence with
citation.
Summary inadequate.
Relevance to nursing
unclear or missing.
Recommendations
unclear or unconnected.
New content introduced
Fails to address all
required elements of
assignment
3 or more errors per
page.
More than two minor
errors or one significant
error in formatting in all
citations. Does not follow
examples in APA 7.01.
Formatting errors; page
length incorrect; poor use
of Word functions.