A qualitative study explores the benefits and limitations.

NURSING PROGRAMS SHOULD PREPARE students for real-life clinical experiences, but several factors influence the amount of orientation time a novice nurse receives, including cost, time constraints, familiarity with electronic health records, and the ability to provide patient-centered care and perform hands-on skills. Woon and colleagues note that today’s nursing students, who belong to the technologically adept Generation Z, benefit from advances like virtual reality (VR) simulations.

According to Liu and colleagues, VR simulations, which use headsets that allow the user to view a scenario in three-dimensions, help students develop critical thinking, bedside, and teamwork skills. However, as VR technology continues to evolve, educators must carefully assess its benefits and drawbacks before integrating it into nursing programs.

VR simulation: Advantages and challenges

Research by Park and Yoon shows that nursing students who use VR simulations exhibit increased confidence in performing procedures and greater satisfaction with their learning experiences. VR-based education allows students to practice invasive and privacy-sensitive skills in a simulated environment, which would be difficult to replicate repeatedly with actual patients. According to Wu and colleagues, reflective practices within these simulations help students analyze their actions and understand how the experiences translate to the clinical setting.

Wu and colleagues also note that VR simulation has proven especially valuable in the event of limited traditional clinical placements, such as during the COVID-19 pandemic. The technology offers an immersive platform for training in emergency responses and various scenarios that students might not experience otherwise. Studies (including by Chang and Lai, Saab and colleagues, and Wu and colleagues) suggest that short, low-immersion VR sessions—ideally lasting 30 minutes—prove the most effective for learning, as they prevent cognitive fatigue and improve material retention. In contrast, as Saab and colleagues note, intense VR gaming scenarios can induce motion sickness; however, this is less of an issue with educational VR applications.

The cost-effectiveness of VR offers another advantage. According to Shorey and Ng, virtual simulation costs approximately $1.08 per session compared to $3.62 for manikin-based simulation. Although initial setup costs for VR can be high, its long-term cost utility makes it a viable option compared to traditional simulation methods.

According to Woon and colleagues and Wu and colleagues, VR simulations offer valuable learning opportunities in short sessions that supplement clinical training, addressing both practical and theoretical aspects of nursing education. Despite concerns about cost and motion sickness, the benefits of VR simulation in nursing education are significant, providing a controlled and immersive environment for skill development and competency building.

This project

Motivated by the growing interest in improving student learning outcomes and innovative education strategies, this research was conducted at the university during the senior year of a BSN program, building on prior coursework in research and evidence-based practice and supported by faculty mentorship to ensure rigor and validity.

The Institutional Review Board approved the study, which used a qualitative design to understand the impact of VR simulation on nursing students in the skills lab setting.

VR simulation

In the pediatric blood transfusion immersive VR headset simulation, participants follow a programmed scenario protocol to deliver safe care, monitor a patient during a blood transfusion, communicate using the SBAR (Situation Background Assessment Recommendations) format, and support the patient and their family. Via peer-to-peer facilitation, learners work in small groups with rotating roles: one provides care to the VR patient, another triggers pre-programed dialogue and assumes provider or family roles, and a third observes and takes notes for debriefing.

Up to three learners can work in the same simulation, sharing tasks and focusing on teamwork and problem-solving. Woon and colleagues describe a hands-on approach like this as enhancing practical skills and reinforcing effective communication and collaboration.

Participants

Thirty-eight prelicensure, BSN students from one U.S. midwestern university participated in the study. We used convenience and snowball sampling in which students encouraged peers to participate in the focus groups after completing the VR simulation experience. The students sat for one theoretical lecture about blood administration concepts and took part in a 4-hour skill lab practice the day of the pediatric blood administration VR simulation.

We promoted the study by asking course faculty to post study information and participant date options in the learning management system. At the start of the skills lab course, researchers delivered an in-person presentation about the study, answered student questions, and distributed consent forms and contact details. On the dates of the three focus groups, we answered additional questions and ensured the completion of consent forms before beginning. Focus groups served as an optional station during and after assigned skills lab days. (See Participant demographics.)

Data collection and analysis

To evaluate the effectiveness of the pediatric blood administration reaction immersive VR simulation, we conducted three focus groups, each with 11 to 13 participants, immediately after the simulation. Each session lasted from 15 to 20 minutes, constrained by the students’ need to rotate through bedside and table skill labs alongside the VR simulation.

We developed a question framework, based on our literature review (including Liu, Park, and Saab) and expert input from Certified Healthcare Simulation Educators, aimed at eliciting detailed feedback. To capture comprehensive insights and students’ experiences with VR simulation, we audio recorded the sessions and transcribed them verbatim for analysis. This approach sought to balance the need for in-depth feedback with the practical constraints of the students’ training schedule.

Two investigators conducted independent thematic analysis. The entire research team then reviewed the analysis to identify student themes and sub-themes. The analysis of focus group discussions revealed two main themes regarding the use of VR simulations in nursing education: Benefits and challenges. Various sub-themes, each reflecting different aspects of the VR experience, support the two broader themes. (See Themes explained.)

Theme #1: Benefits

Subthemes that support the benefits of VR simulation include critical thinking, realistic patient interaction, safe learning environment, and application of skills.

Critical thinking. VR simulations immerse students in realistic scenarios that foster deep engagement and critical thinking. Unlike traditional lectures, VR allows students to actively participate and make decisions in a controlled environment, which helps to identify knowledge gaps. By participating in simulations, students receive exposure to situations that require prioritization, interprofessional collaboration, and emergency management.

Saab and colleagues and Woon and colleagues describe the contrast between the active learning environment of VR simulation and passive learning methods such as lectures. Saab and colleagues note that observers in VR simulations can analyze peers’ actions and reflect on alternative approaches, enhancing their understanding of the decision-making process. This observational role supports critical thinking and strategic planning.

Realistic patient interaction. VR simulations offer more authentic patient interactions compared to using manikins. According to Chang and Lai and Liu and colleagues, this interaction helps students develop therapeutic communication skills and understand the nuances of patient engagement. The ability to engage with simulated patients in VR helps bridge the gap between theoretical knowledge and real-world practice. This interaction supports the development of empathy and cultural sensitivity.

Safe learning environment. VR simulations provide a risk-free environment where students can practice emergency procedures, such as resuscitations and allergic reactions, without the fear of causing real harm. As described by Wiese and colleagues, this safety allows for repeated practice and reflection. In addition, the structured debriefing sessions after VR simulations offer students the opportunity to reflect on their experiences, discuss their actions with peers, and explore different strategies. According to Jefferies and colleagues, this reflection is integral to the learning process.

Application of skills. VR simulations present complex, realistic scenarios that require students to apply their knowledge and problem-solving skills. This contrasts with traditional skill labs, which may not fully capture the intricacies of real-world situations. As noted by Jefferies and colleagues and Woon and colleagues, by immersing students in intricate scenarios, VR helps them integrate theoretical knowledge with practical skills, preparing them for diverse clinical situations.

Theme #2: Challenges

Limitations of fine motor skill development. Although VR simulations offer visual and auditory feedback, they lack the tactile sensations essential for mastering fine motor skills. Hands-on practice is crucial for developing skills such as I.V. access, catheter insertion, and blood administration. The ability to physically manipulate equipment and practice procedures with actual materials aids skill acquisition. VR can’t fully replicate these physical interactions, which limits its effectiveness in developing manual skills.

Technical issues. Despite advances in VR technology, technical issues such as account setup difficulties and headset malfunctions can detract from the learning experience. These issues frequently require additional support from educators, which can disrupt the simulation process. They also can consume valuable learning time, impacting the overall effectiveness of the simulation and potentially frustrating students.

Space and answer limitations. Limited physical space can restrict movement and realism during VR simulations. Students may feel constrained by the virtual boundaries, which impacts their ability to interact fully with the simulation. In addition, the predetermined answers and restricted interaction options can limit the range of possible scenarios and decision-making processes, affecting the authenticity of the experience.

Limited perspectives. In scenarios with multiple participants, the restriction to a single perspective for observers can limit their understanding of the simulation. Observers may miss critical details and opportunities to engage with the scenario effectively. In addition, viewing only one participant’s perspective can hinder collaborative learning and reduce the overall effectiveness of the simulation for those not directly involved.

What we learned

Our findings highlight both the advantages and limitations of immersive VR simulations in nursing education. The benefits—such as enhanced critical thinking, realistic patient interactions, and a safe learning environment—illustrate its potential to complement traditional teaching methods. VR simulations provide a platform for immersive learning and application of skills, bridging gaps left by theoretical lectures and skill labs.

However, challenges need to be addressed. The absence of tactile experiences in VR simulations, for example, can hinder the development of fine motor skills crucial for nursing practice. Technical difficulties and spatial limitations further impact the effectiveness and realism of the simulations, while the restriction to a single perspective prevents full collaborative learning and comprehensive understanding.

To maximize the benefits of VR simulations, nurse educators must integrate them effectively with hands-on practice and address the identified challenges. By refining VR technology and ensuring adequate space and technical support, educators can enhance the overall learning experience and better prepare students for real-world clinical situations.

Limitations

Limitations of this study include the exclusive involvement of BSN students from a single academic setting, preventing its applicability to a broader range of participants with different experience levels and from various types of institutions.

In addition, the use of convenience sampling may introduce selection bias, limiting representation of the participants from the broader population of nursing students. The sample size also lacked diversity in demographic factors such as race, ethnicity, gender, and socioeconomic background. These factors require consideration when implementing VR simulation within more diverse student populations. They also should be considered when interpreting study findings and planning for future research to address education gaps.

Recommendations for future research include multiple academic institutions within more diverse geographic locations. Including students from various healthcare disciplines would provide a more comprehensive understanding of the impact of simulation-based learning across the healthcare education spectrum. A longitudinal study following students throughout their education within various educational settings could provide insight into the long-term impact of VR simulation-based learning on clinical competence and patient outcomes.

Complementary approaches

As technology advances, VR is becoming more common, offering substantial benefits for healthcare education. It allows nursing students to engage in realistic simulations, enhancing their critical thinking skills and experiences without putting patients at risk. However, VR’s limitations—such as insufficient fine motor skill development and technical issues—highlight the continued importance of lab time focused on physical skills. The literature and student feedback confirm that VR and hands-on labs complement each other, with labs supporting skill acquisition and VR aiding practical application and critical thinking.

Alyssa Zweifel is an assistant professor and Healthcare Simulation Center director at South Dakota State University in Brookings. Nancy Khuu is an RN at Sanford Health in Sioux Falls, South Dakota.

References

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Liu K, Zhang W, Li W, Wang T, Zheng Y. Effectiveness of virtual reality in nursing education: A systematic review and meta-analysis. BMC Med Educ. 2023;23(1):710. doi:10.1186/s12909-023-04662-x

Park S, Yoon HG. Effect of virtual-reality simulation of indwelling catheterization on nursing students’ skills, confidence, and satisfaction. Clin Simul Nurs. 2023;80:46-54. doi:10.1016/j.ecns.2023.05.001

Saab MM, Hegarty J, Murphy D, Landers M. Incorporating virtual reality in nurse education: A qualitative study of nursing students’ perspective. Nurse Educ Today. 2021;105:105045. doi:10.1016/j.nedt.2021.105045

Shorey S, Ng ED. The use of virtual reality simulation among nursing students and registered nurses: A systematic review. Nurse Educ Today. 2021;98:104662. doi:10.1016/j.nedt.2020.104662

Wiese LK, Love T, Goodman R. Responding to a simulated disaster in the virtual or live classroom: Is there a difference in BSN student learning? Nurse Educ Pract. 2021;55:103170. doi:10.1016/j.nepr.2021.103170

Woon APN, Mok WQ, Chieng YJS, et al. Effectiveness of virtual reality training in improving knowledge among nursing students: A systematic review, meta-analysis and meta-regression. Nurse Educ Today. 2021;98:104655. doi:10.1016/j.nedt.2020.104655

Wu ML, Chao LF, Xiao X. A pediatric seizure management virtual reality simulator for nursing students: A quasi-experimental design. Nurse Educ Today. 2022;119:105550. doi:10.1016/j.nedt.2022.105550

Key words: nursing students, virtual reality simulation, skills lab