Creating Interprofessional Virtual Reality Healthcare Simulations

Healthcare simulation is commonplace in multiple disciplines and is often recognized as an essential component of curricula. Simulations are used to recreate real-life scenarios in a psychologically safe, do-no-harm environment to allow students the opportunity to learn, acquire skills, and develop critical thinking to practice safely in a complex healthcare setting. Specific to nursing is the accepted definition (through the American Association of Colleges of Nursing, AACN) of simulation as “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions” [1]. In addition, simulation also offers alternatives to the decreasing number of clinical sites, qualified faculty, and the increasing patient population complexity [2].

Virtual Reality Simulation Overview

An evolving simulation modality to heighten practice readiness for face-to-face (FTF) campus-based programs and online distance programs is virtual reality (VR).  This simulation modality provides contactless learning, is not bound by place or time, and may be a more affordable alternative with less use of resources [3]. As is known, simulation can be costly in relation to equipment, space, and maintenance [4]. Albeit Bumbach et al. note that VR simulations are approximately 40% less costly and require 22% less time than high-fidelity experiential simulations [5].

The immersive experience through “VR provides an interactive three-dimensional (3D) learning platform enabling students to visualize and interact within a seemingly real world” [6]. VR simulation has two variations: desktop virtual simulation and immersive VR simulation [7, 8].  Immersive simulation provides “a sense of immersion in the environment through 360-degree visuals by aid of a head-mounted-display (HMD),” and auditory stimulation through the use of earphones [8]. With centricity of presence, students are able to work through the immersive VR simulation, avoiding distractions, enabling focus on critical thinking and clinical decision-making skills while immersed in the scenario. For those who are unable to tolerate immersion, the desktop option is available. VR in “nursing education has demonstrated positive educational outcomes, including increased knowledge, confidence, engagement, immersion, clinical reasoning skills, and scenario applicability” [5].

Purpose for Interprofessional VR Simulation Development

After learning about the possibilities of immersive VR as a simulation option for experiential learning, nursing faculty embarked on the creation of three interdisciplinary scenarios. The intended purpose was to:

• Provide an avenue for interprofessional faculty, VR experts, local stakeholders, and students to learn together and work collaboratively in the creation and evaluation of innovative, equitable simulations.
• Develop three sustainable interprofessional VR simulations for experiential learning for undergraduate nursing and social work students in acute care settings and a community setting.
• Integrate the VR scenarios across the undergraduate curricula of nursing and social work for equitable use (online and FTF students alike) for all aligned students to gain knowledge and experience in their select discipline and with interprofessional collaboration through VR simulation.

The interprofessional collaboration element was key throughout all developed simulations. According to Kleib et al., “research shows that when simulation incorporates interprofessional activities, outcomes of learning are further enhanced, allowing students from different disciplines to interact and gain knowledge of each other's roles, philosophies, and abilities” [9]. Through this collective learning experience and shared decision-making, team collaboration, cohesiveness, and performance can be enriched [9]. Combining the two disciplines offered students a better understanding of the interaction and collaboration needed to provide patients with more positive outcomes. As such, students from each discipline could essentially “walk in each other’s shoes” and view an interdisciplinary perspective as well.

Cultural Humility Lens

To further enhance the learning experience, the interprofessional VR simulations were aligned through a cultural humility lens to also respect diversity, inclusion, and equity (DEI). “In a multicultural world where power imbalances exist, cultural humility is a process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after willingly interacting with diverse individuals. The results of achieving cultural humility are mutual empowerment, respect, partnerships, optimal care, and lifelong learning” [10]. According to Buchanan and O’Connor, “cultural humility can serve as a framework for DEI in simulation” [11].  Specifically, simulation can provide an opportunity “for enhancing skills relevant to DEI, such as integrating awareness of inequity into care or maintaining a culturally humble stance” [11].

Essential Components for Developing VR Simulations

First and foremost, the collaboration with an experienced healthcare simulation VR developer was instrumental in helping faculty become familiar with VR capabilities and in the creation of scenarios. The VR developer was equipped with the tools for filming and editing the simulations and advised on VR goggle selection. Basic HMD googles were selected for cost efficiency and ease of use. The HMDs enabled the students to use their own smartphones and earbuds (headphones) to view the scenarios.

To become familiar with the VR product capabilities and design, all project personnel (faculty and students) viewed an example VR nursing simulation provided by the developer. As intended, this viewing prompted questions and discussion with the VR developer as faculty readied for simulation scenario creation. Once the concerns had been addressed, the faculty decided on three simulation scenario topics to reflect current trends and issues (sex trafficking, substance abuse, and domestic violence with gun violence). These also aligned with three differing areas of practice and settings: mental health (emergency department), community health (group home), and acute care (medical-surgical hospital unit).

Student actors were recruited from the theater department of the university to aid in the realism needs for the VR simulations. Likewise, actual nurses and social workers were recruited for filming and to add authenticity. Settings for filming were chosen and included a simulation center and a group home environment.

Scenario Development

Scenario development was guided by the International Nursing Association of Clinical Simulation and Learning (INACSL) “Healthcare Simulation Standards of Best Practice Simulation Design” and “Healthcare Simulation Standards of Best Practice Guided Simulation-Enhanced Interprofessional Education” [12, 13]. With this guidance, nursing faculty with expertise in each of these areas developed the nursing focus for each scenario while social work faculty and graduate students shaped the social work perspective. Overall learning objectives were developed to include those specific to social work, nursing, and combined/interprofessional (see Table 1).

Table 1. Learning objectives for VR simulations.

Lead faculty on this project worked with all faculty and graduate students to finalize the scenarios to meet the specifications of the VR developer. Initial requirements included providing learning objectives/outcomes, patient background stories, additional persons/characters included in the scenarios, the environment to be used for filming, and identification of necessary props. Further development of the scenarios laid out nursing actions with correct and incorrect decisions/pathways, as well as social work actions and decisions with correct and incorrect pathways.

Faculty were then tasked with developing storyboards for each of the three outlined scenarios (see Figure 1). Zoom sessions to review storyboards with the VR developer followed as corrections were suggested, questions were answered, and development continued. As each storyboard scene evolved, it was aligned with dialogue for the actors and actions depicted. In addition, decision choices were reviewed and depicted with the correct response and detractor/incorrect responses (see Figure 1). The latter were also created with a rationale explaining why a decision was incorrect.

Figure 1. Example storyboards from a domestic violence scenario that represent decision points.

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Storyboards to Filming

Cant et al. note a concern regarding the transferability of knowledge in patient care from VR avatar interactions to actual human interactions [14]. Thus, these VR simulations utilized simulated participants (human actors and actual professionals) instead of avatars (computer-generated figures) to heighten the reality index. In addition, contextual elements such as the use of a real hospital room, moulage, medical equipment, actual nurses and social workers (see Figure 2) helped student learners abandon any disbeliefs in order to be fully immersed and present throughout their learning experience/simulation [15]. Authenticity of all elements was key.

Figure 2. Elements to enhance realism include an authentic hospital room and tools, moulage to depict a wound, an electronic vital signs monitor, the actor (patient), and an actual registered nurse.

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As noted, the storyboards were built from a nursing perspective and a social work perspective to illustrate the care that each discipline brings to the patient situation. In addition, each storyboard also included “bookend” scenarios of a scene showing an interaction between the two interdisciplinary professionals from the nursing perspective and then from the social work perspective. As the storyboards neared completion, the lead faculty and VR developer met and agreed that each scenario should be kept to a length of approximately 10 minutes. This time limitation would provide for a positive immersion experience and decrease the chance of students becoming dizzy when using the HMD googles.

Once the storyboards were reviewed, edited, and completed, lead faculty recruited students from the theater department of the university to play the roles of patients and companions. The actors were given background information for their scenario and their roles. Additional dialogue was discussed with the actors directly related to the patient’s background.  The actors were given freedom to add any additional flair to their character and/or ad lib as deemed appropriate for the scenario while maintaining accuracy. All actors chose their outfits for their scenario and their facial appearance. For example, the actor portraying the underage sex-trafficked victim dressed in provocative clothing, added a tattoo marking, wore ample facial makeup, and had a stuffed animal in her possession (see Figure 3). Likewise, the group home/substance abuse actor chose to mispronounce the medication prescribed for addiction (Naltrexone) as Nalrex to illustrate his character’s basic familiarity with the drug. The nursing and social work students and professionals were given the opportunity to review the scenarios with the actors prior to filming.

Figure 3. Cast for the sex trafficking video between takes, during filming, and as observed by faculty on a monitor during filming.

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Actual filming took place in two different locations over two days. The first location was the simulation center with actual hospital rooms and required medical props. The second location was a home in the area that resembled a group home setting. Student nurses, social work students, student actors, professional nurses, and lead faculty participated in the filming, assisting the VR developer as needed.

Copies of the storyboards were used for guidance as the scenes were set. More often than not, the scenes took several takes to create the desired outcome. The VR developer was essential in providing instruction and feedback while using caution to create the VR as faculty had intended. As the scenes were being filmed, faculty could view them on a screen in an adjacent room (see Figure 4). The VR developer also kept watch on the camera, which was being worn (on one’s head) by the individual (nurse or social worker) whose perspective was being recorded (see Figure 4). 

Figure 4. Receiving direction from the VR developer on the group home, substance abuse scenario. The social worker and nurse are shown wearing the head camera to film from the perspective of their discipline.

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Filming required careful scheduling and attention to detail. Even though storyboards had been created, gaps were identified and dealt with as filming ensued. Gaps included the addition of content that more accurately aligned with the situation in one slide. This was managed by using additional slides on the storyboard for every new change in a scene. In this manner, fluidity from scene to scene was enhanced. There was also a learning curve working with the technology and the 360-degree camera view. Prior to filming, the background had to be cleared of extraneous details (and people) due to the 360-degree view of the camera.

VR Scenario in the Classroom

Once the first VR scenario (group home, substance abuse) had been completed, nursing students involved in the production presented the VR simulation to both nursing and social work undergraduate students. Each class was given HMD googles, instructed on use, and fitted the device to their own heads and smartphones. The nursing students explained the rationale behind the scenario selection, the collaboration with social work students, and the educational benefits of using this teaching and learning simulation tool.

The overall comments were positive from both nursing and social work students as to the use of HMD googles and the VR learning strategy presented. Students were able to view both the social work and nursing roles and participate in the immersive learning activity within the scenario. Students from both disciplines offered additional feedback related to ease of use, stopping and starting the pathways, and understanding the role of another discipline and their interrelated roles in like areas of healthcare. Based on student feedback, a succinct brochure on the use of the VR goggles and the mechanics of viewing the VR simulations has been created.

Conclusion

Despite some trial and error, faculty embraced collaborative learning through the creation of sustainable, interprofessional VR simulations reflective of current healthcare issues. These offer authentic experiential learning for undergraduate nursing and social work students in acute care and a community setting. The simulations are now integrated into the undergraduate curricula of nursing and social work for junior and senior-level students to gain knowledge and experience in their selected disciplines and through an interprofessional viewpoint. The goal of this project has been to give students an opportunity to experience collaborative patient-centered care through the lens of interdisciplinary care. Going forward, an assessment of quality, learning, and student readiness for interprofessional collaboration will be addressed. Data collection has begun and will be ongoing for a few semesters.

References

Acknowledgment

This project was made possible through an Ashby Interprofessional Research and Intercultural Education Grant.

About the Authors

Kathleen Huun holds a B.S. in nursing, a B.S. in design, an M.S. in textiles, an M.S. in nursing education, and a Ph.D. in human sciences. She has an extensive background in critical care nursing and distance education. Her research/publications/presentations focus on virtual simulation (through e-simulation, video simulation, telepresence simulation, virtual reality simulation, modular skills trainers), observational learning, LMS template development, and faculty availability/presence in online courses. Dr. Huun seeks to enhance future nurses’ ability to navigate through multifaceted, technology-based health care systems.

Linda McQuiston holds an ADN in nursing, a B.S. in nursing, an M.S. in nursing education, and a Ph.D. in nursing. Her clinical experience spans multiple areas in acute care settings—including mother/baby, pediatrics, and medical/surgical—for 32 years, and nursing education, both didactic and clinical, for the past 18 years. Her research/publications/presentations focus on student success, use of diverse teaching strategies, simulation, just culture, and pet therapy.  Dr. McQuiston seeks to mentor future faculty and students as they transition into their new roles.

© Copyright is held by the owner/author(s). Publication rights licensed to ACM. 1535-394X/2025/10-3708806 $15.00 https://doi.org/10.1145/3771272.3708806