Full Citation:

Kimzey, M., & Mastel-Smith, B. (2022). Impact of dementia simulation on nursing students:
When empathy breeds awareness. Teaching and Learning in Nursing, 17(2), 169–173.
https://doi.org/10.1016/j.teln.2021.11.010

Type of Study:

Level 1 Systematic Review

Meta-Analysis

Notes:

Methodology:

Focused Question/Hypothesis:

The aim of the study as described in the discussion section is to “explore the impact of virtual
dementia tours on nursing students' attitudes toward and empathy for people with dementia,
dementia knowledge, self- confidence to care for people with dementia and impact on future
nursing care.”

Population:

Inclusion Criteria: a convenience sample was conducted where

participants included nursing students enrolled in a behavioral health course.
Students are in their 3rd year of their BSN and are now required to complete the
course as part of their introduction to behavioral health and emphasis of nursing
strategies for health promotion. 56 students participated with 4 separate focus
groups of 14 students.

Exclusion Criteria:

Exclusion criteria includes anyone not involved with the universities nursing
program. The study was limited in the sense that it was only offered to one
 program of students and only students. I would have liked to see the inclusion of
other health care programs and professionals

Intervention(s):

1. Did the reviewers try to identify all relevant studies?

Reviewers took data around empathy levels of health care professionals and inserted the
information into the scope of improving empathy for dementia patients across the nursing
profession. As a meta analysis personal reflection was provided for researchers to assess
the overall success of the intervention and determine where improvements could and
should be made.

2. Did the reviewers assess the quality of the included studies?

The quality of the studies were not assessed throughout the intervention as relevant studies
consisted of background knowledge of dementia and providing a strong background for viewers
to understand the effects of the disorder along with how implementing improved empathy could
improve overall care. The included studies were relevant for viewers to understand the current
gaps being addressed in healthcare.

3. If the results of the studies have been combined, was it reasonable to do so?

Results were identified and used to assess what implications could be made through the findings
of virtual stimulation of dementia and what the expected and desired outcomes would be. It is
reasonable to combine the results of this trial/ analysis along with those of prior research to help
improve the stimulation which in turn improves healthcare.

Outcomes of Interest:

Subjective: Nursing students

● Perceived compassion
● Perceived patience
● Perceived awareness of the present moment
● Perceived dignity
● Perceived self confidence
● Perceived empathy levels
 Objective

Subjective

Statistical Tests used for meta-analysis list:

● Post test questions were provided to participants via questions to determine levels of
empathy, new learning, impacts as a participant, what could be changed for future tests
● After post test: audio taped focus group interviews to discuss limitations and potential
improvements through participants eyes. Discussions of what the outcomes will do for
the students in practice and the relevance of the study.

Is/are the chosen test(s) appropriate for the analysis? (Y) N

Why? Other options?

The chosen tests being self questionnaires and focus discussions are appropriate as it allows
researchers to assess each participant and their experiences regarding empathy levels and
knowledge around the dementia population and care for the dementia population. Other options
could include pre and post test questions that are correct or incorrect answers instead of opinion
and experience based questions. If the participants had their BSN it would be possible to evaluate
their treatment of dementia patients before and after going through a virtual dementia simulation.

Results & Conclusions

Findings:

Statistically significant: 4 focus groups of 14 students participated in

virtual simulations for dementia with improvements in themes of attitudes about
people with dementia, empathy for people with dementia, dementia knowledge,
and impact on future nursing care. Improvement findings are relevant for both
statistical significance and clinical significance.

Clinically significant: Post-test questions were offered to students

regarding their experience including how students' levels of empathy and
appreciation for current healthcare professionals working with dementia patients
has changed or not changed. Along with questions regarding the influence of
 virtual dementia simulations and what could be improved for overall better
implications on practice.

Author’s Conclusions:

Authors conclusions focus on education for students through dementia training that are
meaningful and innovative. The virtual dementia tour had positive impacts on the attitudes of
students along with empathy levels for people with dementia and dementia knowledge. Due to
interviews and focus discussions a course is now available for nursing students to better their
knowledge, improve their empathy, and provide better practice for this population.

Discussion:

What are the strengths of the study?

Strengths of the study include the simulation causing students to reach out further in attempts to
understand dementia and its impacts daily life in a more indepth way. The study was the impetus
to dementia care course development.

What are the limitations of the study?

Limitations to the study include participants only being selected from one nursing class where all
the participants were enrolled in the same course. The PI’s involvement in the focus group also
could have hindered student responses in the focus group discussions. Although limited to only 1
nursing program the study does indeed focus around a group of students that are beneficial to
dementia care and improvement.

How do the results of this study apply to our practice?

These results, although focused around nursing students, apply similarly to Occupational
Therapy as both fields work with dementia patients and can benefit and improve their treatment
plans with improved empathy. After going through the simulation participants claimed to have
begun understanding why dementia patients act and do some of the things that they do as part of
understanding life in a completely different way day to day. Analyzing these results will be
critical to improved therapy and treatment across the healthcare field including Occupation
Therapy as the clients centered model becomes more of the focus and more commitment and
understanding of the patients themselves.

Action Plan (how do I plan to use these results)?

These results will be used in our EBP project as it focuses on the same generalized question that
we are focused around. Although the main focus in this study is around nursing students the
same principles apply as focus is around empathy levels of change in students after going
through dementia simulations. The results were as expected as empathy levels across the board
rose for the patients that the nursing students were working with. Many students explained that
their view on dementia and other cognitive impairments have changed drastically as the
simulation allowed them to see life with a completely different lens. By taking this information
we as healthcare providers will be able to suggest this simulation for anyone working with
dementia patients as well as implement it as a training program to ensure better treatment of
patients.

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Critical Appraisal Form for Systematic Reviews & Meta-Analyses

Full Citation:

\Hirt, J., & Beer, T. (2020). Use and impact of virtual reality simulation in Dementia Care
Education: A scoping review. Nurse Education Today, 84, 104207.
https://doi.org/10.1016/j.nedt.2019.104207

Type of Study:

Level 1 Systematic Review

Meta-Analysis

Notes:

Methodology:

The researchers wanted to address the use and impact of virtual reality simulation in dementia
care education. In hopes to guide further research in this field, the researchers conducted a
scoping review. They chose the model of Arksey and O'Malley (2005), extended by Levac et al.
(2010) as a methodological framework. The model of Arksey and O'Malley framework includes
6 stages, the sixth being optional. For the researchers, this implied a stepwise procedure: (1)
formulating the research question, (2) identifying relevant studies, (3) selecting studies, (4)
charting the data, and (5) collating, summarizing and reporting the results. Within this
framework, the reviewers followed the PRISMA-ScR reporting recommendations.

Focused Question/Hypothesis:

The aim of this study was to map the use and impact of virtual reality simulation in dementia
care education.

Population:

The researchers sought out to gather literature from six databases that included MEDLINE,
CINAHL, PsycINFO, Web of Science Core Collection, ERIC, and Inspec. Along with those six
databases, the researchers incorporated an additional hand search as well as backward and
forward citation tracking of included studies.

Inclusion Criteria:

The inclusion criteria involved literature studies with all types of qualitative or quantitative
design published since 2007 in English, French or German were included if a virtual reality
intervention was examined in a dementia care education setting (e.g. nursing school, caregiver
training). The literature search was conducted in six databases (MEDLINE, CINAHL,
PsycINFO, Web of Science Core Collection, ERIC, and Inspec), including an additional hand
search as well as backward and forward citation tracking of included studies. The search strategy
comprised four components (simulation, education, nursing, dementia) with multiple synonyms.

Exclusion Criteria:

After excluding duplicates and screening of 1467 references by title and abstract, 47 full texts
were assessed for eligibility. The reasons for exclusion of 41 full texts were not fulfilling the
criteria of an empirical study (n = 24), the intended intervention (n = 9), and the field of dementia
(n = 8).

● Excluded by title and abstract screening: n=1420

● Excluded by full text screening: n=41
● No empirical study: n=24
● Analog intervention: n=8
● Not dementia specific: n=8
● Web-based intervention: 1

Intervention(s):

Nursing Students

● VR simulation how it feels to live with dementia

 ● Entering a virtual world, creating an avatar virtually interacting with other avatars

Informal caregivers

● 360 VR simulation movie to invoke the experience of having dementia

● VR support group in a virtual environment to interact via real-time chat

1. Did the reviewers try to identify all relevant studies?

The reviewers ensured an overview of all available completed and ongoing studies by extracting
study characteristics (country, aim, participants, and intervention), methods (design,
measurements, evaluation time), and main results. Within the methods section, the researchers
formulated their research question, identified the studies relevant to their topic, figured out what
would be the literature eligibility criteria, gathered information on sources and searches, and
selected the studies.

2. Did the reviewers assess the quality of the included studies?

Yes, the reviewers assessed the quality of the included studies. The reviewers eligibility criteria
included already completed as well as ongoing studies with all types of qualitative or quantitative
design published since 2007 in English, French or German. These studies were of interest if a
virtual reality intervention was examined in a dementia care education setting (nursing
school,university, caregiver training).

3. If the results of the studies have been combined, was it reasonable to do so?

Yes, if the results of the studies would have been combined it would be reasonable to do so. In
order to continue further research on this topic, studies will need to be combined in order to gain
more information and data.

Outcomes of Interest:

Subjective: Nursing Students

● Perceived confidence
● Perceived competence
● Perceived compassion
● Educational effectiveness

Subjective: Informal caregivers

● Empathy
● Perceived pressure from care
● Perceived competence
● Quality of the relationship
Statistical Tests used for meta-analysis list:
● Pre-interventional baseline data was collected one week before intervention
● Time of pre-interventional measurement was not indicated in two other studies
● Post-interventional evaluation time varied between immediately, one week and three
weeks after the virtual reality intervention.

Is/are the chosen test(s) appropriate for the analysis? Y N

Why? Other options?

Yes, the statistical tests chosen for the analysis were appropriate for this specific study. The
analysis shows that the evidence collected was evaluated and presented in the research as
important. There were various indicators that virtual reality can be an effective intervention to
train nursing students and caregivers of people with dementia.

Findings:

The findings concluded that virtual reality seems to be hardly used for therapeutic and training
reasons in the dementia care setting. The findings of this review indicate that there are scientific
efforts to evaluate the use and impact of virtual reality in dementia care education. Nevertheless,
virtual reality in this educational setting seems to be an innovation and not yet evaluated in an
appropriate way. This is indicated by non-rigorous study designs to evaluate effectiveness.

Statistically significant:

For the caregivers, the impact of the virtual reality simulation interventions resulted in
statistically significant improvements of empathy, an increase in perceived competence, and
reduction in perceived stress. The descriptive analysis showed an improvement for all other
outcomes: empathy, perceived pressure from care, quality of the relationship. loneliness,
depressive mood, and caregiver burden.

Clinically significant:

For the 6 studies selected, there were different information gathering modalities between them
all. Pre-test, post-test, support groups, individual comments, and specific measurements and
outcomes were collected. All in which address the common theme of confidence, competence,
compassion, effectiveness, empathy, and quality of the relationship.

Author’s Conclusions:

The reviewers stated that several conclusions can be drawn from the current state of research
regarding the impact of virtual reality simulation in dementia care education. They concluded
that the means of this scoping review exposed a research gap. The reviewers went on to say that
“A systematic approach to analyze available studies by its effects and effectiveness, for example
a systematic review, is not indicated since the available studies are hardly comparable. In
contrast, further empirical research is indicated”. The reviewers came to the conclusion that
virtual reality applications focusing on dementia care scenarios should be developed and further
evaluated.

Discussion:

What are the strengths of the study?

A methodological strength of this scoping review consisted of a comprehensive literature search

including additional components like a hand search as well as backward and forward citation
tracking. By completing the backward and forward citation tracking, it helped to yield two
further references that otherwise wouldn't have been included. Another strength of this study was
that the review process resulted in the inclusion of six studies published between 2012 and 2017.
Two studies are ongoing, three studies had a one group pre-post-test design, and one study had a
post-test only design that was applied. The samples within the studies consisted of nursing
students as well as caregivers of people with dementia and varied in size between seven and 126.
Along with that, eight different outcomes were measured, e.g. empathy, competence, and stress.
The interventions within the gathered studies resulted in improvements of caregivers' and
students' empathy and competences among other outcomes when working with dementia
patients. Since studies are rare and do not address effectiveness, the findings of this review can
substantially contribute to guide further research on this topic.

What are the limitations of the study?

One limitation of this study was that the literature selection was conducted only by one person.
Having only one person in the selection process increases the risk of overlooking potential
relevant studies in the process of screening titles, abstracts, and full texts for inclusion. Little is
known about the use and impact of virtual reality in dementia-related education, making the
search pool very small. With that being said, another limitation of this study was that within the
six selected literature studies, not one included a controlled design and group comparison.
Without having control group data, it is very difficult to compare.

How do the results of this study apply to our practice?

Although this study primarily focused on nursing students and caregivers, occupational therapists
are well within the scope of working with people who have dementia. The results of this study
apply to occupational therapy practice because the profession as a whole is always trying to
innovate and find new ways to further improve therapeutic techniques. A quality study regarding
the use of virtual reality, dementia simulation, and education can help open doors to new and
more advanced ways to educate and train occupational therapists. The results of this study state
that there were improvements in the nursing students and caregivers' empathy, communication,
competence, and stress. When occupational therapists work with dementia patients, empathy,
communication, and understanding are vital to the therapeutic process (management of
symptoms, cognitive decline, relationships, and quality of life).
Action Plan (how do I plan to use these results)?
I plan to use the results from this study to further my learning and comprehension of the
positives and negatives of a dementia simulation. Sifting through and finding the most credible
articles to justify why a dementia simulation can help nursing students, caregivers, and
occupational therapists in regards to their quality of care, is essential for my EBP project. More
research and evidence can assist in the encouragement and development of this type of learning
throughout the entire healthcare profession.

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Critical Appraisal Form for Systematic Reviews & Meta-Analyses

Full Citation:

Julian Hirt, Thomas Beer, Use and impact of virtual reality simulation in dementia care
education: A scoping review, Nurse Education Today, Volume 84, 2020, 104207, ISSN
0260-6917, https://doi.org/10.1016/j.nedt.2019.104207.

Type of Study:

Level 1 Systematic Review

Meta-Analysis

Notes:

Methodology:

The researchers conducted a systematic search for the literature in Cumulative Index to Nursing
and Allied Health Literature in accordance with PRISMA guidelines. They used MEDLINE and
ProQuest to find relevant peer-reviewed studies published between 2010 and 2021. The
researchers approach consisted of using the Boolean operator search approach, the keyword
"dementia care" was combined with "AND/OR" and other search terms. In addition, a
descendent and an ascendent search were conducted to find other relevant studies.

Focused Question/Hypothesis:
The aim of this systematic review was to synthesize evidence on the effect of clinical
experiential learning approaches on pre-licensure nursing students' competence in dementia care
and to identify associated challenges. The researchers wanted to examine evidence in the
published literature on the effect of clinical experiential learning experiences (face-to-face,
simulation, virtual and hybrid) on pre-licensure nursing students' competence in dementia care.
In order to do so, the researchers produced this systematic review of published literature to
answer the following research questions:
1. What effect do clinical experiential learning approaches have on pre-licensure nursing
students' competence in dementia care?
2. What are the challenges experienced by pre-licensure nursing students in learning
dementia care competencies during clinical experiential rotations?

Population:

Inclusion Criteria:

The inclusion criteria for the selection of studies were:

● Inclusion of pre-licensure nursing students in the sample

● Focus on dementia care experiential learning
● Published in the English language peer-reviewed journals between 2010 and 2021

Exclusion Criteria:

The exclusion criteria for the selection of studies were:

● Not primary research (e.g., secondary analyses, commentaries and editorials)

● Psychometric research studies
● Studies that did not include an experiential learning experience related to dementia care

Intervention(s):

1. Did the reviewers try to identify all relevant studies?

Yes, three researchers conducted the database search for all relevant and published studies from
January-April 2021 using the Boolean search approach. Within the boolean search approach, the
keyword dementia care was combined with the following search terms: Knowledge, skills,
attitudes, older adults, student nurses, face-to-face, clinical, virtual, simulation and experiential
learning. With the search terms selected, the researchers followed the following electronic
databases: The Cumulative Index to Nursing and Allied Health Literature (CINAHL; n = 10),
MEDLINE (n = 11) and ProQuest (n = 603).

2. Did the reviewers assess the quality of the included studies?

Yes, two of the three researchers assessed the quality of the found studies and then selected the
eligible studies. From there, the search strategy yielded 624 potentially eligible studies and 611
out of the 624 were excluded due to duplication and/or irrelevancy. The researchers retrieved the
full texts of the remaining 13 studies found. Out of the 13 studies, 3 were excluded because they
focused on the experiential learning of dementia care among professional healthcare students
such as medical, social work, or counseling students rather than pre-licensure nursing students.

After that, 3 more articles were excluded because they did not include clinical experiential
learning. From there, the researchers excluded 1 more article because it did not provide enough
methodological details. The researchers received the full text from the remaining 6 articles and
then implemented the decedent search. The descendant search approach went through and found
the relevant articles that were listed as references within the 6 full text articles. After that, a total
of 17 articles that met the inclusion criteria for the PRISMA-P flowchart were picked.

3. If the results of the studies have been combined, was it reasonable to do so?

Yes, if the results of the studies would have been combined it would be reasonable to do so. In
order to continue further research on this topic, studies will need to be combined in order to gain
more information and data.

Outcomes of Interest:

Subjective:

● Knowledge
● Dementia knowledge
● Skills
● Attitudes
● Empathy
● Self-Efficiency
● The Awareness Questionnaire
● University of West England Interprofessional Questionnaire (UWEIPQ)

Statistical Tests used for meta-analysis list:

● Alzheimer’s Disease Knowledge Scale (ADKS)

● Assessment Tool version 2 (DKAT v2)
● Dementia Supporter Caravan (DKT-SC)
● Adult Gerontology Primary Care Nurse Practitioner Scale (Modified)
● Counseling Competencies Scale (Modified
● Comprehensive State Empathy Scale (CSES)
● Confidence in Dementia Scale (CDS)
● Dementia Attitudes Scale (DAS)
● General Self-Efficacy Instrument (Modified)
● Interpersonal Reactivity Index (IRI)
● Jefferson Scale of Empathy-Health Professional Students (Chinese Version)
 ● Self-Efficacy Scale (SES)

Is/are the chosen test(s) appropriate for the analysis? Y N

Why? Other options?

Yes, the chosen tests are appropriate for the aim of this study. The analysis shows that the
evidence collected was evaluated and presented in the research as important. There were various
indicators proven that there are positive and convincing impacts on nursing students' knowledge,
skills and attitudes when provided with experiential dementia care learning.

Results & Conclusions

Findings:

Statistically significant:

The results of this study conclude that dementia education has the ability to improve the attitudes
of those providing care to people living with dementia. However, the researchers noticed how the
evidence indicates a lack of basic knowledge in person-centered dementia care among nurses.
The lack of basic knowledge in person-centered dementia care among nurses and nursing
students is a significant factor contributing to poor health and wellness outcomes of patients with
dementia.

Clinically significant:

The researchers concluded that it would be clinically significant for nursing educators to
consider involving people living with dementia and their caregivers in the teachings about
dementia. The researchers pointed out that this is a gap in the research and if the caregivers were
included, it would ultimately improve the nursing students’ person-centered dementia care skills.

Author’s Conclusions:

The researchers stated that several conclusions can be drawn from the current state of research
regarding the impact of experiential dementia care learning on knowledge, skills and attitudes of
nursing students. They concluded that the evidence in this literature review could inform new
curriculum development, teaching methods, experiential learning experiences and clinical
placements of pre-licensure nursing students with regards to dementia care.

Discussion:

What are the strengths of the study?

The researchers concluded that the strengths of this review include the following:
 ● The studies selected had a wide range of published research conducted in geographically
different locations.
● All of the studies selected evaluated the impact of clinical experiential learning
approaches on pre-licensure student nurses’ dementia care competence.
● Many of the reviewed studies were predominantly conducted on the impact of
face-to-face and significantly smaller numbers of studies on virtual and simulated
dementia care clinical experiential learning.
○ Evidence from this review suggests that face-to-face experiential learning is the
most effective pedagogy to increase pre-licensure nursing students’ dementia care
competence.
● Simulated and virtual experiential learning experiences have a positive impact on
students’ dementia care competence.

What are the limitations of the study?

The researchers concluded that the limitations of this review include the following:

● None of the reviewed studies compared the impact of the different approaches against
each other.
● The use of the inclusion criteria may have excluded studies published in non-English
language, those not published between 2010 and 2021 and published in gray literature.
● The focus of the studies were older adults with dementia and there were no studies that
addressed early onset dementia among young adults.
● The use of convenience and purposive sampling methods may have introduced potential
sampling biases and limit the generalizability of the findings.
● The lack of longitudinal studies prevents a valid prediction of the long-term impact of the
various clinical experiential methods.
● Assumption of causality among variables cannot be made from the reviewed quantitative
studies’ findings because all of the designs were cross-sectional.
● Few of the reviewed quantitative studies reported the instruments’ psychometric data
such as the reliability score.
● Some of the studies used self-report and non-validated measures or questionnaires to
assess change on outcomes.

How do the results of this study apply to our practice?

Although this study primarily focused on nursing students and caregivers, occupational therapists
are well within the scope of working with people who have dementia. The results of this study
apply to occupational therapy practice because the profession as a whole is always trying to
innovate and find new ways to further improve therapeutic techniques. A quality study regarding
the impact of experiential dementia care learning on knowledge, skills and attitudes of nursing
students can help the occupational therapy profession in regards to learning new and more
advanced ways to care for their patients. Along with that, the evidence from this study suggests
that the incorporation of the family and caregivers of the patient with dementia would help to
improve the nursing students’ person-centered dementia care skills, which is useful information
for the educators preparing occupational therapy students to work with a wide variety of patients.
Action Plan (how do I plan to use these results)?
I plan to use these results to further my research and understanding within the topic of dementia
simulation and education. The results from this study confirm that experimental dementia care
learning can positively affect a nursing student's ability to empathize, understand, and work
alongside a patient with dementia. This is important information, as it can help future healthcare
educators and healthcare professionals in looking at a new way to further their knowledge, skills,
and attitudes when working with the dementia population.