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Innovation in Nursing
Nursing is a rapidly evolving profession that requires highly specialized and trained individuals. Nurses uphold a wide variety of roles including caregiver, advocator, researcher, and innovator. Due to the increased demands on the healthcare system, nurses are faced with challenges that require them to advocate for change and to become innovators through their roles as researchers. To improve the quality of care to patients and reduce health care costs, innovation is required to meet these demands.

Innovation, defined by International Council of Nurses (2009), is “the process of developing new approaches, technologies, and ways of working. It can apply to tools and technologies and processes, or to the way an organization or an individual behaves, works, or acts” (p.3). In order for the successful adoption and implementation of innovative practices, several factors must be considered. The innovative technology or process must be considered to have a relative advantage, thereby improving the status quo; must be compatible, fits the organizational culture and vision; must be simple to implement and use; trialability, having the ability to be tested and trialled; observability, having a clear advantage and outcome; reinvention, ability to be adjusted to new contexts or environments.

Although nurses may not be directly involved in developing the recent technology advancements in healthcare, nurses are the ones utilizing these developments, and therefore, play an indirect role in the success of these innovations. Through education, nurses are exposed to a wide variety of technologies to improve their knowledge, skills, and abilities.

Nursing Education
The goal of nursing education is to provide learning opportunities to students that resemble real-life clinical scenarios to allow them to develop the knowledge and skills required for independent practice. Although, the literature review conducted by Jenson and Forsyth presented the challenges that limit optimal learning opportunities for nursing students: increasing patient acuity, high student-to-faculty ratio, patient safety concerns from faculty, and student anxiety, all of which minimize the opportunity for nursing students to learn. Due to high patient acuity and the lack of increase in staff, nurses have an increased workload, which includes teaching nursing students. In addition, a shortage of nursing faculty has caused an undesirable student to faculty ratio, therefore, additional teaching strategies must be implemented by faculty and nurse educators. The research and use of virtual reality in nursing education remains scarce, although virtual reality simulation has become an increasingly utilized educational tool.

Simulation in Nursing Education
Practical experience is essential to learning and maintaining nurses knowledge and skills. Due to higher-acuity patients, reduced hospital stays, and technological advancements, nurse educators are faced with the challenge of preparing nursing students for the clinical environment that demands the competency of a wide range of skills in complex situations.

The teaching of knowledge and skills can be imparted by a variety of simulation modalities, including low to high fidelity simulation and virtual reality simulation. Simulation is defined as an educational approach that attempts to mimic potential or real-world characteristics or situations. Simulation has become increasingly utilized as a pedagogical tool in the nursing profession since the 1990s as it allows for individuals to develop their clinical skills in a safe and controlled environment, while reducing the risk to patients.

Types of VR: Degree of Immersion
Virtual reality simulation, a computer-generated technology, creates a “three-dimensional environment in real time,” creating a sense of presence in a simulated environment (p.313). Virtual reality systems can be classified according to the degree of immersion: highly immersive to minimally immersive. A minimally or non-immersive virtual environment is displayed on a desktop screen, using a movement device, such as a mouse or joystick, to navigate and control the system. For example, a video game is considered a minimally-immersive virtual system. A medium immersive virtual reality system, CAVE, a customized projection-based virtual reality, utilizes a projector to display images on a wall where users move to create new images. A highly-immersive virtual system involves multiple screens with the user wearing a head-mounted display, creating a total immersion experience in the virtual environment. In addition to the systems, additional equipment can be added to further promote user participation. For example, specialized gloves for tactile sensations and to provide feedback, or tracking devices which transmit positioning information to the system allowing the system to adjust the view and location.

Virtual Reality Simulation Studies
Several studies have developed virtual reality simulations to evaluate the effectiveness of virtual reality in nursing education  A recent study investigated the acceptability and usability of virtual reality simulation in training nurses with instrumentation set-up in a perioperative environment. The study aimed to see if there was a difference in learning among expert scrub nurses and non-experts. Through the use of self-reported evaluations and the validated assessment tool, NASA Task Load Index, the results showed no significant difference in acceptability of the simulator among expert scrub nurses and non-experts. The authors concluded age, gender, or expertise had no impact on the use of the virtual simulator, therefore indicating the simulator can be used to teach skills to a wide variety of nurses, thereby demonstrating that the simulator can be used for different levels of training.

For innovative practices to be sustained, Augstin notes how leaders and management must embrace and support innovation. In a particular study, nursing faculty were evaluated on their readiness to adopt and implement a virtual reality simulation in their university. The virtual reality simulation involved a computer program and haptic arm, promoting realism for the users. The results concluded that nursing faculty supported the use of virtual reality simulation as a valuable learning strategy for nursing students.

Using a minimally-immersive virtual reality system, Dubovi and colleagues conducted a study using the Pharmacology InterLeaved Learning Virtual Reality (PILL-VR) environment. This study noted how nurses felt a disconnect between what is taught in university and what is expected of them in the actual clinical environment, therefore, the authors’ study aimed to evaluate the impact this learning tool had on nursing students’ practical skills of medication administration. The study concluded that the use of a non-immersive virtual reality system contributed to a “greater, persistent and consolidated understanding of the practical skills” compared to learning through traditional methods of lectures (p.24).

Advantages of Virtual Reality Simulation in Nursing Education
Virtual reality simulation in nursing education allows for “unlimited practice of procedures, provides rapid student and faculty feedback, and is beneficial in reducing patient errors and meeting healthcare expectations” (p.312). Through unlimited practice of simulations, virtual reality sessions can contribute to lower levels of student anxiety and increased confidence. In addition, the students have the ability to learn at their own pace, maintaining control over their learning needs and requirements. With immediate feedback from the virtual reality system, students can ensure “proper and consistent technique” (p.314). For faculty, it reduces workload and time and allows for faculty to monitor student progress at any given time.

Overall, the main advantages of virtual reality simulation include: sense of realism, promotes critical thinking and decision making, allows for errors without affecting patients, unlimited practice, and provides immediate feedback to improve judgement and skills. As seen in the study conducted by Dubovi and colleagues, a virtual reality environment can “bridge the gap between formal and practical learning of professionals,” a requirement of independent nurses (p. 26).

Jenson and Forsyth note how virtual reality simulation can improve the learning experiences of nursing students. Firstly, they note that students will be competent in performing skills, allowing the students to focus on “caring for higher-acuity patients”, thereby improving the quality of interaction between the nursing student and preceptor (p.317). Secondly, as patient safety is a major concern of faculty, students will have more experience through practice, “better {preparing} them for clinical practice” (p.317). Furthermore, through repeated practice, student anxiety levels decrease, thereby creating safe clinical practices for students.

Limitations of Virtual Reality
Although the benefits of using virtual reality as a teaching strategy in nursing education are evident, it is not without its limitations. The most cited limitations associated with virtual reality as a teaching strategy include cost and time commitment. In relation to cost, the cost of designing or purchasing the software and cost associated with troubleshooting, maintenance, and updates can create barriers. In addition to cost, the time commitment required to train educators on the system and the time expected of educators to create patient scenarios that are realistic, evidence-based and relevant could prevent the implementation of a virtual reality system. If the sessions are unrealistic, it can provide an invaluable learning experience for the students. In addition, if students require training on the systems, it can detract from valuable learning time. Motion sickness and physical discomfort from headsets were also cited as limitations of using a virtual reality system.

Future of Virtual Reality in Nursing Education
As Dubovi and colleagues note, a virtual reality system with higher immersion is usually associated with a greater degree of a sense of presence. Despite the study of Dubovi et al. (2017) using a low-immersive virtual reality system, the study has shown to facilitate “a strong sense of being engaged in the experience, a sense of presence” (p.25). This study demonstrates how low-immersion virtual reality systems are also effective in “providing high-presence experience to users” and therefore can be used as an effective teaching tool, providing more learning opportunities to students (p.25).