Using virtual reality to train student nurses in medicine management

Introduction

Medication errors in children’s care represent a persistent challenge to safe nursing practice. Double-checking is believed to reduce errors (Marufu et al 2022; Westbrook et al, 2021; Koyama et al, 2020) and many UK hospital policies mandate this for most children’s medicine (Marufu et al, 2022).

For student nurses, this often means they are either removed from the checking administration process or are a ‘third checker’ with a limited sense of responsibility in the process. This lack of clinical practice experience could risk patient safety. In their systematic review, Marufu et al (2022) identified that interventions such as medication safety education that incorporates simulation could reduce medication errors. The aim of our project was to develop an engaging simulated experience in medicine management teaching.

In a study exploring paediatric nurses’ adherence to double checking, Alsulami et al (2014) highlighted a variation in practice. The complexity of the stages of checking and the importance of independent drug dose calculation in children’s medicine management were identified as key skills for nurses to develop. Another key area of development need was error recognition.

It is known that more than one factor contributes to medication errors (Marufu et al, 2022). The ‘Swiss cheese model’ illustrates how errors can occur when several safety checks fail, with each ‘hole’ representing a potential error (Wiegmann et al, 2022). When safety mechanisms fail, the holes line up, increasing the risk of a medication error and affecting patient safety (Wiegmann et al, 2022).

Simulation has become an increasingly important teaching and learning strategy, and allows healthcare students to make decisions and reflect on their practice (Tang et al, 2020; Flott and Linden, 2016). Virtual reality (VR) can give students a memorable and immersive experience that would, otherwise, not be possible. Meta analysis of VR education has shown it can improve nursing students’ knowledge and is equal to other education methods in measures of student confidence and performance time (Chen et al, 2020). The use of VR has also been shown to improve clinical reasoning skills (Sim et al, 2022).

VR technology is becoming increasingly affordable and, for this project, we had access to equipment that would allow us to 3D film simulations of real-life clinical scenarios for students’ learning. By creating our own content, we could specifically tailor it to clinical procedures in children’s nursing practice, which is not readily available in commercially created content.

Project development

In 2021, the Covid-19 pandemic required a rapid shift to digital teaching and learning, and many academic schools in Cardiff University adopted simulation methods, such as VR, in curriculum delivery. Since then, Nursing and Midwifery Council (NMC) (2023) standards for pre-registration nursing programmes have increased the number of allowed simulated practice hours from 300 to 600. This has, in turn, encouraged an exploration of innovative ways to deliver skills and simulation-based sessions.

Immersive technology such as VR in the nursing curriculum is valuable for student learning and may positively affect patient care (Brown et al, 2023). The unique advantage of VR-based learning is that it provides immersion into situations that are impossible or difficult to replicate in traditional teaching methods (Chen et al, 2020). Other notable benefits of VR in education are that it can supply cost-effective solutions (Tang et al, 2020) and enhance collaborative learning (Jochecová et al, 2022).

It is well known that critical understanding of learning theories and how students learn is crucial to developing effective pedagogical approaches (Hamilton et al, 2021). Evidence suggests that these theories can give educators a pedagogical framework with which they can design effective VR-based learning experiences (Marougkas et al, 2023). Taking this into account, and to improve students’ learning experience, a project team comprising three nursing lecturers and a simulation technician was appointed to develop storyboards and design medicine management scenarios.

The overarching aims were to:

• Provide students with immersive learning environments that simulate real-world experiences;
• Facilitate learning through problem solving.

This approach is not new to the nursing curriculum and emphasises the use of real-world problems to teach students new skills and knowledge (Marougkas et al, 2023). VR can enhance this approach by providing an immersive, interactive environment that allows students to apply critical thinking and decision-making skills to solve real-world problems (Sedlák et al, 2022).

Use of 360-degree immersive video technology was chosen for this project, to give students a level of realism and authenticity. The technology also allows students to be brought into an immersive space, where they can follow a patient journey or engage with the day-to-day activities of a ward, and pause at relevant points to check their knowledge and understanding before moving to the next activity. As children were involved in the filming, a risk assessment was done and the relevant proforma completed before filming to comply with the university’s health and safety regulations. Formal consent was gained from parents.

Three scenarios based on current clinical practice and relevant to the care of children were written and scripted by the project development team, before being filmed in a simulation suite using a chest-mounted 360-degree video camera. This gave the viewpoint of the nurses in practice, adding to the viewer’s feeling of immersion. The camera was worn by the lecturer acting the part of the nurse, who practised the reduced walking speed needed to manage camera wobble.

The 360-degree video camera uses dual lenses to capture a full view of a scene. Images from each lens were then ‘stitched together’ and edited by the simulation technician to generate a coherent 360-degree environment. Appropriate still images and supplemental information (for example, images of a prescription chart) were also incorporated into the 360-degree environment to highlight areas of interest and aid navigation within the environment. After the editing process, these scenarios were uploaded to the VR headsets to create the experience of being inside the simulated clinical environment.

The first VR scenario (Box 1) was of a 12-year-old child, whose antibiotic was accidentally administered to another patient. The aim was to show students how multiple factors can contribute to a drug error. Students saw how distraction, failure to follow procedure, peer pressure and emergency situations can all lead to an error situation. In the debrief, students explored what had gone wrong at each stage, as well as the factors that might have contributed to unsafe decision making. They also discussed how to manage the situation when a drug error occurred.

In the second scenario (Box 2), students were presented with three different responses to a child who was refusing to take their medicine when experiencing an acute asthma attack. In the debrief, the students reflected on the implications of the situations and what would constitute best practice.

The third scenario projected a routine drug administration round and the prescribing of an antibiotic to an eight-year-old who had been admitted with an upper respiratory tract infection. This scenario enabled students to spot multiple prescription errors on the prescription chart and discuss the wider implications for practice.

The expectation was that students participating in the VR scenarios would gain confidence in making the right decisions and escalating care accordingly – all learned in a safe environment.

Challenges

Lack of earlier proof of concept for the use of 360-degree video in the School of Healthcare Sciences meant no funding was available for equipment. The camera equipment available to the technician was of consumer grade and not ideally suited for moving shots owing to insufficient picture stabilisation features. Although the actor took every care to avoid excess movement when wearing the camera, some ‘wobble’ was evident in the final product. Use of tripod-mounted stationary cameras was considered to try to eliminate the effect of camera movement. However, the value of a first-person view, afforded by a chest-mounted camera that could present the scenario through the nurse’s eyes, was seen as one of the technology’s strengths.

No video editing software capable of processing 360 footage was available, so a time-limited demonstration version of Apple’s Final Cut Pro was used. This limited the resolution quality of the final export, leading to a lower-quality final product.

Although the lower resolution and camera movement may have affected the viewer’s experience, and some of our students reported feeling nauseous or “seasick”, Chao et al (2021) reported similar effects for other immersive VR education activities.

Implementation

The VR scenarios were first successfully used for a second-year children and young people (CYP) undergraduate nursing cohort as part of their year two skills and simulation-based sessions. A group of five to six students was timetabled to attend each session, with a facilitator in the room to support their learning.

Students were briefed and introduced to the VR headsets. The simulation technician was present to deal with any technical issues and answer any queries. Students were recommended to pause the scenario and remove the headset if they experienced motion sickness or any other side-effects. The video included a 30-second scenario brief, followed by 15-20 minutes of 360-degree VR scenarios. Students could, if they wished, pause the scenario at certain points and take notes for the post-session reflection and debrief.

Afterwards, and as part of a facilitated group discussion, students were asked to reflect on specific questions relating to the scenario they had completed, such as:

• How would you manage this situation?
• How would you explain why it is important to take medicine in this way?
• They also had the opportunity to:
• Discuss what went well in each scenario;
• Critically reflect on their learning;
• Identify any knowledge gaps;
• Share their overall experience.
• They were also each asked to complete a feedback questionnaire.

The debrief was facilitated by lecturers discussing medicine management in the three scenarios. Each was explored, with incidences and errors linked to relevant theory, guidance and frameworks.

Evaluation and feedback

Thirty-four CYP student nurses completed the evaluation form for the first VR medication management session. This consisted of six questions using Likert scale ratings (strongly agree to strongly disagree) to measure students’ responses to the session. Combined ‘agree’ and ‘strongly agree’ responses showed that:

• 97% of students said the session had improved their understanding and knowledge of medicines management;
• 85% said the VR headset enabled them to view scenarios from the perspective of the nurse administering the medication;
• 82% considered the use of VR headsets as beneficial to the session;
• 94% thought the scenarios used were relevant to practice.

The full results are shown in Table 1.

In addition, students were asked four questions that enabled free-text responses:

• What aspects of the session did you find useful?
• What did you like about using VR headsets?
• What did you dislike about using VR headsets?
• What have you gained from this session that will improve your practice?

Their responses are summarised below.

What students liked or found useful

The students liked having different scenarios that addressed various aspects of medicine management in children’s nursing. They said the scenarios were authentic, relevant, relatable to practice and reminded them of how easily things can go wrong in practice. One student said it had developed their understanding of:

“…how things can lead to medication errors and what to do if this situation happens”.

Students said using VR made it feel like real life, allowing them to look around, assess the whole area and view the scenario from the nurse’s perspective. One said:

“The VR helped to make you feel you were in the scenario and made everything clear from that perspective.”

It gave them an immersive experience, which they enjoyed and found more useful than merely talking through the scenarios:

“[It] really helped to immerse myself in the scenario and understand from the nurse perspective.”

Some technical benefits of VR were also highlighted, such as the ability to work through the scenarios individually at the student’s own pace, and pause and rewind:

“Having the ability to pause and rewind was good to check errors and double check.”

Students found the interactive discussion that took place afterwards useful for reflecting on the scenarios and gaining a better understanding of medicines management. It helped them name errors they may have missed, find opportunities during a scenario to avoid these, and learn how to deal with them. One student said:

“The discussion at the end helped me understand the scenarios and gain a better understanding [of medicines management].”

There was excitement and enjoyment at the opportunity to learn in an up-to-date and innovative way. Students said that, as well as being relevant to practice, the scenarios gave them a safe, controlled environment in which to experience aspects of clinical practice that are not available to them while on placement.

What students disliked

Students’ main complaint about using the VR headsets was the feeling of motion sickness, with some image blur:

“Sometimes felt queasy – better resolution needed.”

Improved knowledge and understanding

After the session, students said they felt they had increased their knowledge and understanding of medicine management. They also felt it had given them a better understanding of how easily medicine management errors could occur and how multiple issues in a busy environment could increase the risk of errors. They reported a greater appreciation of the importance of fully concentrating when performing medicine checks to avoid errors and minimise risk.

Students also highlighted the importance of following the correct procedure, clear communication with colleagues and not assuming written information was correct. They felt that using VR scenarios to recognise poor practice, combined with a discussion of what was good, evidence-based care, made them better equipped for clinical practice. One student highlighted the benefits as:

“Discussing the correct practices to carry out as a qualified nurse, understanding how to limit the risk of error”.

Lessons learned

Inclusivity had to be considered. This included a simple video of the scenarios running on a laptop for those who could not tolerate the VR mask, such as those affected by motion sickness. Breaks from the headsets were important to reduce any discomfort and having the footage available on a laptop meant everyone could take part in the session and contribute to the debrief. It was also noted that students who wear headwear (for example, turbans) in daily life needed extensions on the VR straps.

Inadequate filming equipment and video production software reduced the final image quality, which detracted away from the immersiveness of the experience. However, funding has since been granted to the technician’s team to purchase up-to-date 360-degree cameras, audio equipment and production software.

The team plans to refilm the scenarios with the updated equipment. This, along with experience gained from the project, will allow us to deliver a more polished product to improve the student experience. It will also be an opportunity to film the scenarios in Welsh as well as English. We need to work in alignment with Cardiff University’s (2021) Yr Alwad/Embrace It Welsh language strategy and supply resources to students wishing to complete part of the bachelor of nursing programmes in Welsh.

Conclusion

Safe medicines management can benefit from innovative teaching practice. The use of VR-based teaching is fast growing in nursing education, and judicious use of VR can enhance theoretical knowledge and help learners recognise and narrow the theory–practice gap. Our experience shows that VR can help prepare student nurses to identify stages in medication errors and respond to clinical decision making with practised confidence. Students particularly value the immersive experience provided by VR and being able to view scenarios from the nurse’s perspective. Investing in more up-to-date equipment has the potential to improve the student experience.