The authors share the multiphase rollout for the use of VR in nursing curriculum and discuss the challenges and interventions emerging between a screen-based and VR headset modalities for developing nursing practice competencies including clinical reasoning (nursing process) and clinical judgement (decisions based on process).

Abstract: Nightingale College’s continuous focus on innovative, evidence-based design keeps the organization iterating on the curriculum with new higher education approaches and curriculum resources. One initiative includes the College’s multiyear virtual reality (VR) project focus to deliver a hands-on, simulated nurse training environment to enhance clinical reasoning and practical skill building. Learners use VR headsets to apply their skills and knowledge in the safety of a virtual environment that mimics real-life nursing situations. They are immersed in typical nursing scenarios, including diagnosing patients, instigating treatments, and interacting with the interdisciplinary team of virtual avatars. They may repeat experiences as often as they like, with the system offering multiple adapted outcomes based on their responses to fully interactive, simulated patients and their family members. They receive personalized feedback, performance metrics, and a synchronous faculty facilitated debrief. Initial pilot data indicated excellent student feedback and improved outcomes in critical thinking and clinical reasoning, and data from the full program rollout of this resource continues to trend upward. As most of the College learners use the VR headsets to complete their simulation assignments, some learners require the use of the screen-based version of the simulations to allow for academic accommodations and American Disabilities Act (ADA) compliance. The authors share the multiphase rollout approach for the use of VR in nursing curriculum and discuss the challenges and interventions implemented between the initial pilot, full program rollout and the use of dual simulation modalities (Olsen & Kolde, 2022, 2023) . The authors share updated data around learners’ improvement in clinical reasoning skills using VR as compared to the use of screen-based versions. Additionally, we discuss future augmentation of this initiative, including designing policies around VR/screen-based usage, specific curriculum changes needed to ensure learning equity and partnering in the creation of customized VR solutions based on identified curriculum gaps. Background: As lockdowns and isolation measures were implemented during the COVID-19 pandemic 2020, it became evident that the traditional approach to providing direct patient care experiences faced challenges. There was a pressing need to reassess how to develop curriculum experiences that were consistent, replicable, and aligned with the desired educational outcomes. Given the restricted access to traditional in-person facilities, it became crucial to fast-track the implementation of high-quality virtual simulation spaces to ensure learners could continue their educational journey and engage in meaningful interactions with clients. A multi-phase approach was initiated to innovate the curriculum to include Virtual Reality (VR) and actively validate its impact on learner outcomes. The first phase involved integrating 2D computer-based simulation clients into a single curriculum course to provide support and maintain or enhance learning during the transition. The second phase expanded the integration to include using the 3D environment. This expansion ensured that the distribution, technical support, and faculty engagement were appropriately scaffolded to continue promoting academic success. The third phase curriculum integrated virtual reality simulations into all clinical courses across the undergraduate nursing curriculum. Plans for the final/ fourth phase of VR implementation include integration into non-clinical classes and soft skills training. Curriculum: The Nursing Program uses a concept-based curriculum. Conceptual learning is an educational method that centers on big-picture ideas and learning how to organize and categorize information. Unlike more traditional learning models, which concentrate on the ability to recall specific facts, conceptual learning focuses on understanding broader principles or ideas (concepts) that can later be applied to various specific examples. The concept-based structure of the curricula facilitates the learner's journey through increasingly complex concepts, behaviors, and skills, providing opportunities for the learner to progress along the novice-to-expert continuum. Based on situated learning and cognition principles, all courses integrate concepts and information from all major areas of nursing practice within a contextual format of immediate and continuous application of prior knowledge and experiences. Within each concept-based curriculum plan, there is a defined list of concepts emphasized throughout the corresponding academic program. Developers consistently refer to critical concepts to select exemplars and sequencing of didactic instruction and experiential learning activities to support an integrated curriculum. The curricula are structured to ensure fundamental knowledge acquisition with a solid medical-surgical foundation occurring early in the pre-licensure programs. Specialty concepts are concentrated in the higher-level and master's degree courses and threaded throughout the programs. VRS: Virtual reality simulation (VRS) has emerged as an established educational method in nursing, helping learners tackle the challenges of transitioning to professional practice. With nursing schools facing increased competition for clinical placements and a heightened emphasis on patient safety, there is a growing need for alternative pathways that allow students to refine their essential clinical judgment skills. This necessity is underscored by the introduction of the NextGen (NGN) version of the National Council Licensure Examination (NCLEX-RN) in April 2023, which prioritizes clinical judgment in its question items (Dickison, 2019). VRS presents a crucial opportunity to enhance exam readiness. Virtual reality simulation (VRS) and traditional simulation each offer distinct advantages but also share overlapping benefits. Due to their hands-on nature, physical task trainers and mannequins excel in teaching procedures like IV insertion and in-situ training. In contrast, VRS excels in providing flexible, repeatable, and standardized scenarios. Despite these differences, both methods can effectively address many learning objectives interchangeably. Brown (2021) compared VRS to traditional simulation in nursing emergency scenarios, finding VRS rated "good to excellent" for usability and providing a learning experience similar to face-to-face simulation. Current research in healthcare education strongly supports the effectiveness of VRS compared to traditional screen-based learning. VRS is valued for its immersive qualities that enhance learning experiences and its ability to transfer knowledge and skills to real-world patient care scenarios effectively. Gutierrez's (2007) study in healthcare education demonstrated that VRS significantly surpasses screen-based learning in improving learning outcomes. Results To ensure learners continued succeeding at normative levels, the College continued to assess learners utilizing the same nationally normed Health Education Systems Incorporated (HESI) exam, noting that the scores range between 0-1500, with 850-900 being the recommended performance range. The fully online simulated experiences were rolled out in successive phases to ensure that individual populations could demonstrate success with the intervention at each level. Phase I Rollout The results of these interventions phase 1 demonstrate that the introduction of high-fidelity simulation in this course increases learner performance, and at each new transition in modality to increasing levels of technological sophistication, learners have seen steady and incremental gains in outcome performance. Phase II Rollout Overall, in the 3.5 years of tracking data, the initial low has risen to a 171 increase from the first to last measure currently averaging since the introduction of the simulation resources in the low-mid 900s, above the nationally normed predictor scores for NCLEX-RN first-time pass rate at 900 for high probability score of passing on a first attempt. Phase III Rollout Those performing in the 3D Goggle environment demonstrated a 5.59% higher average score on simulation assignments than those working in the 2D environment; however, there is a positive correlation between scores and minutes spent in simulation in both the 3D and 2D groups. While both groups can score within similar levels within a margin of error, the 3D goggles groups appear to score marginally higher in fewer attempts and less time in the simulation. Challenges The exact reasons for the slight statistical performance success delta between the 2D and 3D environments remain a subject of investigation to ensure that those receiving accommodations for ADA or other health concerns are not intentionally or unintentionally disadvantaged by receiving accommodations. Investigation of additional interventions for those with provided accommodations to ameliorate potential disparate performance gaps between groupings remains to ensure design equity. Next Steps Further assessment into the transition of knowledge from simulated reality to physical practice in a clinical space remains a rich vein for research. References Brown, K. M., Swoboda, S. M., Gilbert, G. E., Horvath, C., & Sullivan, N. (2021). Integrating virtual simulation into nursing education: A roadmap. Clinical Simulation in Nursing, pp. 000, 1–9. https://doi.org/10.1016/j.ecns.2021.08.002 Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. doi:10.3928/01484834-20190122-03 Gutiérrez, F., Pierce, J., Vergara, V. M., Coulter, R., Saland, L., Caudell, T. P., Goldsmith, T. E., & Alverson, D. C. (2007). The effect of degree of immersion upon learning performance in virtual reality simulations for medical education. Stud Health Technol Inform, 125, 155-160. PMID: 17377256. Olsen, J., Kolde, J., Pottle, J., Schleicher, M. (2022). Challenging the Status Quo in Nursing Education: Digital Transformation with Virtual Reality. Proceedings of the Interservice/Industry Training, Simulation, and Education Conference (I/ITSEC) 2022, 11 pages. Olsen, J., Kolde, J., Pottle, J. (2023). Disrupting the Status Quo in Nursing Education: Digital Transformation with Virtual Reality. Proceedings of the Interservice/Industry Training, Simulation, and Education Conference (I/ITSEC) 2023, 13 pages.

Dr. Jeffrey Olsen

President at Nightingale College

Dr. Juliet Kolde

President at Nightingdale Innovations