Abstract
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Purpose
This study aimed to evaluate the effects of a virtual reality (VR) program and simulation training on nursing students’ ability to measure vital signs in children.
-
Methods
This mixed-methods study, which included a randomized controlled trial and a qualitative study, was conducted from June 12 to November 15, 2023. Forty-four nursing students from a university in South Korea were randomly assigned to either the experimental or control group. The experimental group first participated in a VR program focused on measuring vital signs in children, followed by a high-fidelity simulation training. The control group received the training in the reverse order. The participants’ knowledge, confidence in practice, and satisfaction with the practice were analyzed using the repeated-measures analysis of variance. VR learning experiences were analyzed through qualitative content analysis.
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Results
Both the experimental and control groups showed significant increases in knowledge and confidence in practice after the interventions compared to baseline. However, there were no significant differences in changes in knowledge, confidence in practice, and satisfaction with practice between the two groups. Three themes were identified from the nursing students’ experiences with VR learning: ‘realistic learning training,’ ‘overcoming learning limitations,’ and ‘perceiving drawbacks.’
-
Conclusion
The VR program was as effective as high-fidelity simulation training in improving nursing students’ ability to measure children’s vital signs. Moreover, VR program offered additional benefits in addressing limitations of simulation-based learning. These findings suggest that VR program can serve as a valuable educational tool to enhance pediatric nursing skills.
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Key words: Nursing students; Pediatric nursing; Simulation training: Virtual reality; Vital signs
INTRODUCTION
Vital signs in children are crucial indicators of overall health, and changes reflect shifts in health status. Practicums focused on measuring children’s vital signs are a vital component of the curriculum for nursing students, reflecting the high practical need in their training [
1]. Due to an extremely low birth rate, few children are hospitalized at medical institutions, which complicates the process of securing pediatric nursing practicum centers. As a result, college nursing students have limited opportunities to engage in direct nursing tasks, such as taking vital signs, during their clinical practice to ensure patient safety. Consequently, these practicums are primarily observational [
2]. There is a need to establish effective strategies to address the limitations of clinical practice in pediatric nursing.
As a result, simulation education is utilized as a method to supplement the limited clinical practice available for pediatric care in Korea. This educational approach involves designing scenarios that mimic real clinical situations, enabling students to develop their problem-solving skills through critical thinking in a risk-free setting. However, it has the drawback of only being able to accommodate a small number of students simultaneously. Furthermore, it is expensive, requiring costly simulation equipment, dedicated space for setup, and staff to manage and operate the equipment [
3,
4].
Children are more susceptible to infections than adults, necessitating high-quality, attentive nursing care. Following the coronavirus disease 2019 (COVID-19) pandemic, the use of virtual reality (VR) programs has been expanding as one of the non-face-to-face education that can minimize the spread of infection in pediatric nursing education [
4]. VR employs computer-generated artificial environments that mimic real-life scenarios, enabling learners to make decisions and execute nursing tasks within these virtual settings [
5]. Moreover, VR offers cost-saving benefits by eliminating the need for expensive simulation equipment and dedicated spaces through the development of VR programs. It also supports remote operation via networks, allowing learners to non-face-to-face practice without geographical or temporal limitations, while ensuring participant safety [
6].
While improvements in knowledge, performance, satisfaction, confidence, and communication skills are commonly reported benefits of VR programs in nursing education, these effects were not observed in some studies [
7-
9]. Recent research on VR programs for pediatric care education involving nursing students has been limited. Current studies have focused solely on post-operative care for children following appendectomy [
9], as well as the development and effectiveness of educational programs for managing infections in high-risk neonates [
10,
11] and in children with COVID-19 [
12].
In pediatric nursing practice, measuring vital signs is one of the most fundamental and essential skills for assessing a child’s condition and evaluating the effectiveness of nursing interventions [
1]. It is a core competency that nursing students must acquire; however, opportunities for pediatric clinical practice are often limited due to safety and ethical concerns, making it difficult to provide sufficient hands-on experience [
5,
6]. To compensate for these limitations, high-fidelity simulation training has been widely used as an alternative teaching method, and more recently, VR programs have gained increasing attention as innovative educational tools.
Despite this growing interest, research comparing the effectiveness of VR programs and high-fidelity simulation training in teaching pediatric vital sign measurement remains limited. Therefore, this study aims to compare the effects of these two educational approaches on nursing students’ learning outcomes.
Furthermore, recognizing that quantitative research alone may not fully capture learners’ experiences and perceptions, this study adopts a mixed-methods approach by incorporating qualitative interviews exploring participants’ learning experiences with the VR program [
13]. Through this approach, the study seeks to provide comprehensive and practical insights into effective educational strategies for pediatric nursing practice.
Therefore, this study was designed to address the inherent limitations of clinical practice by applying both quantitative and qualitative research methods to examine the effectiveness of a VR program and high-fidelity simulation training as innovative educational strategies for enhancing the ability to measure pediatric vital signs, one of the most fundamental skills in assessing children’s health status. The first objective was to compare the effectiveness of a VR program with that of high-fidelity simulation training in teaching nursing students how to measure children’s vital signs. Additionally, the study compared the differences according to the order in which the VR program and high-fidelity simulation training are implemented. Furthermore, it explored the learning experiences of nursing students participating in the VR program.
METHODS
Ethical statements: This study was approved by the Institutional Review Board (IRB) of Seoul Women’s College of Nursing (IRB no., SWCN-202304-HR-002). Informed consent was obtained from all participants.
1. Study Design
This study employed a mixed-methods approach, comprising both a randomized controlled trial and a qualitative study. It aimed to evaluate the impact of a VR program and simulation training on nursing students’ ability to measure vital signs in children, and was conducted at Seoul Women’s College of Nursing in South Korea (
Figure 1). The research adhered to the Consolidated Standards of Reporting Trials (CONSORT) statement [
14] and the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines [
15]. Additionally, the study was registered with the Clinical Research Information Service (CRIS) prior to the collection of baseline data (registration number: KCT0008536).
This study was conducted with students at a nursing college in Seoul, South Korea, from June 12 to November 15, 2023. The inclusion criterion was limited to third-year students who had no experience in pediatric nursing practicum. The study included only those participants who provided informed consent; students who declined to participate or who had completed a pediatric nursing practicum were excluded.
The required number of participants for each group was determined to be 22, as calculated using G*Power ver. 3.1.9.7 (Heinrich-Heine-Universität Düsseldorf) [
16]. We employed repeated-measures analysis of variance (ANOVA) along with a within-between interaction, setting the effect size at .25, the significance level at .05, the power at 95%, the number of measurements at 3, and the correlation coefficient at .50. This effect size was chosen based on findings from a previous study [
17].
Given the potential for a 10% dropout rate, 50 nursing students (25 per group) were recruited by convenience sampling and then the 50 recruited students were randomly assigned to either the experimental group or the control group, with 25 students in each group, using a random number generator program based on their application numbers. During the study, a total of six participants dropped out due to health issues (such as COVID-19 infection) and private scheduling conflicts, resulting in a final sample size of 44 participants (22 participants in each of the experimental and control groups) in the quantitative data collection. Of the 44 participants, 10 participants (five per group) volunteered for the interview in the qualitative data collection (
Figure 2).
1) Knowledge about the measurement of vital signs in children
Knowledge about the measurement of vital signs in children was measured using a scale developed by researchers based on a VR program for the measurement of vital signs in children [
1]. The scale consisted of seven items related to handwashing, checking body temperature, monitoring the apical pulse, and assessing the respiratory rate. Each item received a binary score, where 1 indicates a correct answer and 0 denotes an incorrect answer or a response of “I don’t know.” A higher score reflects a better understanding of how to measure vital signs in children. The content validity index (CVI) was measured at 0.90, as assessed by two pediatric nursing professors and three clinical nurses, each with over 5 years of experience in pediatric fields. Cronbach’s alpha for this study was 0.63.
2) Confidence in practice
Confidence in practice for the measurement of vital signs in children was measured using a scale developed by researchers based on a VR program for the measurement of vital signs in children [
1]. The scale was composed of eight items about preparing materials, explaining the purpose and procedure, checking body temperature, monitoring the apical pulse, assessing the respiratory rate, and recording the findings. Each item was rated on a 10-point Likert scale, where 1 indicated “not at all” and 10 signified “strongly agree.” A higher score reflected greater confidence in performing vital signs measurements in children. The CVI, assessed by two pediatric nursing professors and three clinical nurses with over 5 years of experience in pediatric fields, was 0.90. Cronbach’s alpha for this study was 0.89.
3) Satisfaction with practice
Satisfaction with practice regarding the measurement of vital signs in children was measured using a scale developed by the researchers considering antecedent studies [
10,
18]. The scale consisted of eight items; each rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (strongly agree). A higher score reflects greater satisfaction with the practice of measuring vital signs in children. The CVI, assessed by two pediatric nursing professors and three clinical nurses with over 5 years of experience in pediatric fields, was 0.90. Cronbach’s alpha for this study was 0.95.
One day prior to the intervention, all participants who had completed the pre-test survey were provided with a handout detailing the vital sign measurement procedure. This was to allow them to voluntarily study the material both before and during the practicum.
1) Virtual reality program on the measurement of vital signs in children
The VR program on the measurement of vital signs in children (henceforth, “VR program”) was a self-practicum that utilized the contents developed by Park et al. [
1]. Learners accessed the program individually through the university website or the designated domain (vr.xxjc.ac.kr) using web browsers such as Chrome and Edge on either a personal computer or a mobile phone. The program included content that enabled learners to review patient information and learning objectives, and to virtually practice the procedures for measuring body temperature, pulse rate, and respiration rate. During the session, learners could access reference data, tackle related questions (multiple choice, input type, and recording type), and view their performance levels and scores for these tasks. Each session lasted between 10 and 15 minutes. Learners were allotted approximately 50 minutes to engage freely with the VR-based practicum for measuring vital signs in children.
2) High-fidelity simulation on the measurement of vital signs in children
High-fidelity simulation for measuring vital signs in children was conducted using the Tetherless SimBaby simulator (SimBaby, Laerdal Medical, Norway, 2020) at the university’s nursing simulation center. This simulation program replicated the same vital sign values (body temperature, pulse rate, and respiration rate) as those found in the VR-based child vital sign content. In a manner similar to the self-practicum at the university, participants were organized into three groups, with each group consisting of eight to nine members. Each group was allotted 50 minutes to complete the self-practicum.
5. Procedure and Data Collection
1) Quantitative data collection
Quantitative data were collected through a series of online assessments and intervention sessions. All participants completed an online pre-test 1 day prior to the start of the intervention. After the pre-test, participants were provided with a handout on the procedure for measuring vital signs in children, which they were instructed to review independently. In the first intervention, the experimental group participated in the VR program, while the control group engaged in high-fidelity simulation training. Immediately after completing the first intervention, both groups took the first online post-test. The interval between the first and second interventions was set at 1 week, based on findings from previous studies that considered the spillover effect of the pre-test and potential diffusion effects between groups [
19]. In the second intervention, the experimental group received the high-fidelity simulation training, whereas the control group participated in the VR program. Both groups completed the second online post-test immediately after finishing the second intervention. Because the self-administered online survey required participants to answer all questions before submission, there were no missing data in the final analysis.
2) Qualitative data collection
Qualitative data were collected from volunteers in each group until data saturation was reached, resulting in a total of 10 participants (five per group). In this study, the inclusion of 10 interview participants was deemed sufficient to achieve data saturation, based on previous research indicating that qualitative data saturation is typically reached with nine to 12 participants [
20]. Participants were interviewed regarding their experience with the VR program following the second post-test. These interviews focused on their overall impressions of the VR program, including what they learned, what they enjoyed, what they felt was missing, and what could be improved.
To collect qualitative data, each participant was initially given an open-ended questionnaire to complete. Following this, they participated in an in-depth, face-to-face interview that lasted approximately 60 minutes. Interviews were conducted in a private, quiet setting. To ensure participant comfort, conversations began with general questions before moving to more in-depth topics. The interview questions were developed based on relevant literature, previous research findings, and the researcher’s experience. To explore participants’ VR program experiences in depth, a semi-structured interview guide was used. Researchers began with the main question, “Please tell us about your VR program experiences,” and followed up with probing questions to encourage more detailed responses, such as “What was helpful for your learning?” and “Do you have any other comments about the VR program?” The interview was voice-recorded, and pertinent details were noted in a notebook. When necessary, additional data were gathered through individual interviews, and the information compiled by researchers was subsequently re-verified.
6. Data Analysis
The quantitative data were analyzed using IBM SPSS ver. 25.0 (IBM Corp.). The chi-square test and independent t-test were conducted to evaluate the homogeneity of the experimental and control groups prior to the intervention. Repeated-measures ANOVA was used to examine differences in outcome variables based on the intervention.
The qualitative data were analyzed using the inductive content analysis approach across three stages: preparation, organizing, and reporting [
21]. During the preparation stage, the interview data were transcribed and read multiple times to understand the overall content and select an analytical unit. In the organizing stage, meaningful statements were extracted and categorized according to the analytical units. Finally, during the reporting stage, the categories were presented.
The researchers, drawing on their extensive experience providing simulation coursework, maintained methodological rigor. Throughout the study, they diligently reviewed qualitative research literature to ensure a comprehensive and in-depth exploration and description of participant experiences. The study employed established qualitative methods to ensure trustworthiness [
22]. Credibility was achieved through open-ended questions and member checking (participant review of transcripts and findings). In addition, participants’ statements were directly cited in the results. Transferability was maximized using purposeful sampling until data saturation. We maintained dependability by strictly following the content analysis approach [
21] and conducting regular team discussions. The interview data were repeatedly reviewed to extract meaning units, which were subsequently categorized. To enhance the credibility and trustworthiness of the analysis, the research team discussed and reviewed the validity of both the data interpretation and the categorization process. Throughout the process, the researchers’ objectivity ensured confirmability by preventing personal biases in data handling.
RESULTS
1. Homogeneity Testing of Participants’ General Characteristics
The mean ages of the experimental group and control group were 23.45±2.89 years and 23.18±2.46 years, respectively. In terms of knowledge about measuring vital signs in children, the experimental group scored 4.04±1.39, while the control group scored 3.68±1.72. Regarding confidence in practicing the measurement of vital signs in children, the experimental group scored 3.31±0.47, and the control group scored 3.09±0.52 (
Table 1).
Upon conducting homogeneity tests between the groups, we observed no significant differences in age, previous semester’s school grade, satisfaction with the major, knowledge of vital signs in children, or confidence in practice (
Table 1).
Table 2 summarizes the effects of the VR program on the measurement of vital signs in children. The analysis of knowledge regarding the measurement of vital signs in children revealed no significant differences between the groups (F=2.85,
p=.099). However, there were significant differences over time (F=46.59,
p<.001). The interaction effect between the groups and time was not significant (F=2.54,
p=.099). The experimental group, which had an initial score of 4.04±1.39 on the pre-test, showed a significant increase to 5.72±0.76 on post-test 1 (t=6.14,
p<.001). Similarly, the control group demonstrated an improvement, with scores rising from 3.68±1.72 on the pre-test to 4.77±1.06 on post-test 1 (t=2.94,
p=.008), and further increasing to 5.59±1.00 on post-test 2 (t=3.25,
p=.024).
In terms of confidence in measuring vital signs in children, significant differences were observed between the groups (F=13.95, p=.001), as well as based on time (F=106.49, p<.001). However, no significant interaction effect between the groups and time was noted (F=2.27, p=.112). The experimental group, which had an initial score of 3.31±0.47 on the pre-test, showed a significant increase to 4.59±0.50 on post-test 1 (t=10.84, p<.001), and further to 4.77±0.42 on post-test 2 (t=6.80, p<.001). Similarly, the control group demonstrated an improvement from 3.09±0.52 on the pre-test to 3.95±0.57 on post-test 1 (t=4.82, p<.001), and further to 4.45±0.59 on post-test 2 (t=3.92, p=.001).
In terms of satisfaction with the practice of measuring vital signs in children, there were no significant differences between the groups (F=0.02, p=.319) or based on time (F=1.59, p=.215). Additionally, no significant interaction effects between the groups and time were observed (F=0.00, p=1.000).
3. Learning Experiences with the VR Program for the Measurement of Vital Signs in Children
After analyzing significant statements from the data collected from participants, the experience of participating in VR programs for practicums on measuring children’s vital signs was categorized into three main themes: “realistic learning training,” “overcoming learning limitations,” and “perceiving drawbacks.” Additionally, eight subcategories were created (
Table 3).
1) Category 1: realistic learning training
(1) Subcategory 1: similarity to the real clinical field
Participants experienced a sense of realism because the VR program closely mimicked an actual hospital setting, helping them become acquainted with the environment. Despite interacting through a computer or laptop screen, participants reported that activities such as preparing materials, checking on patients, and communicating with guardians closely resembled real clinical practice. Furthermore, they were able to perform tasks like measuring children's respiration rates by observing abdominal movements, identifying the sound of the apical pulse while listening to pulse sounds, and documenting their conversations with guardians. This process effectively taught them how to measure vital signs in children, mirroring a real-life setting.
(2) Subcategory 2: feeling novel
Participants were impressed by VR and found participating in the VR program interesting. They expressed amazement at the lifelike details, such as the patient blinking and the movement of the patient’s abdomen on the screen. Additionally, they were surprised to hear the patient’s mother speak in a weary voice, reminiscent of an actual clinical guardian. Participants also found it interesting to practice measuring children's vital signs through VR.
(3) Subcategory 3: feeling confident in future practice
Participants reported that practicing vital sign measurements through the VR program felt akin to an actual practicum, and they believed it would improve their skills in clinical practice. They expressed confidence in their future clinical performance, attributing this to their ability to accurately measure children's pulse and respiration rates, provide clear explanations to guardians, and refine their communication skills by reviewing recorded explanations within the VR environment. Additionally, they noted that the VR program offered them preliminary exposure to hospital terminology, supplies, and atmosphere, which they felt would help them adapt more effectively to clinical settings.
2) Category 2: overcoming learning limitations
(1) Subcategory 1: learning accurate methods
Participants stated that the VR program enabled them to learn how to accurately measure vital signs. Specifically, they gained precise knowledge of children’s characteristics and the necessary precautions for measuring vital signs. This was achieved by administering a quiz midway through the program, which helped identify and correct any inaccuracies in their understanding by reviewing the answers. Additionally, participants noted that, in contrast to simulation training, the VR program followed predetermined procedures. This structure allowed them to meticulously practice each stage according to standard procedures, which they found beneficial.
I could accurately know how to measure children’s vital signs through a quiz. (Participant #34)
I found VR helpful because it allowed me to follow each stage and practice the correct procedures. (Participant #17)
(2) Subcategory 2: having no time or place limitations
Participants noted that the VR program was not constrained by time or place. In other words, the VR program could be accessed at any time and from any place, if portable electronic devices were available, such as tablet computers or mobile phones. Participants also mentioned that simulation training, which involves multiple people participating as a team, is time-consuming as they must wait for their turn. In contrast to the VR program, which can be conducted anytime and anywhere without spatial or temporal restrictions, simulation training must be conducted in a designated practicum room, necessitating travel to a specific location.
Simulation training was time-consuming because multiple people had to participate in it. Additionally, there was a constraint of place. However, VR is not constrained by time or place, and I could access it anytime I wanted without having to wait. (Participant #7)
(3) Subcategory 3: ability to repeat practice
Participants appreciated the VR program for its interactivity and the opportunity to engage in multiple practice sessions. They described it as customized learning, highlighting the ability to practice repeatedly at their own pace and according to their individual skill levels. The repeatability of the program was seen as a significant benefit, allowing them to continually practice and refine their understanding of the procedure to address their weaknesses.
3) Category 3: perceiving drawbacks
(1) Subcategory 1: an unfamiliar system
Participants were sometimes confused due to their unfamiliarity with the VR system. Initially, they struggled to locate the quiz and occasionally clicked on the wrong answer. Additionally, they had difficulty hearing pulse sounds clearly because they had not prepared earphones. Furthermore, their lack of familiarity with the recording process prevented them from successfully recording their explanations for the guardian within the allotted time under the given circumstances.
(2) Subcategory 2: wanting to practice directly
Participants expressed disappointment with the VR program because it did not enable them to perform nursing care directly. They acknowledged that while the VR program assisted in visualizing situations and learning procedures sequentially, it fell short by not allowing hands-on practice with actual objects, unlike simulation training. They emphasized the necessity of direct practice to effectively familiarize themselves with nursing skills.
DISCUSSION
The changes in knowledge, confidence in practice, and satisfaction with practice in experimental group, who first participated in the VR program and then in high-fidelity simulation training, were similar to those observed in the control group, who experienced the programs in the reverse order. Both the experimental group and the control group demonstrated improvements in knowledge and confidence in practice after both interventions compared to their baseline levels. However, satisfaction with practice did not differ between the two groups from the first to the second intervention. A meta-analysis on the effectiveness of VR in nursing education suggested that while VR education effectively enhances the knowledge of nursing students, it does not significantly differ from other educational methods, such as simulation training, in boosting confidence and satisfaction [
8]. This finding is consistent with the results of this study.
To address the challenges in clinical practicum education, which often prevent nursing students from providing direct patient care, simulation training has been introduced and utilized. It has been reported that high-fidelity simulation effectively enhances nursing students’ knowledge [
23]. However, the educational effectiveness of simulation training can be influenced by the characteristics or competencies of the clinical practice faculty who conduct the training [
24,
25]. In contrast, VR programs offer consistent education, as all users are exposed to the same content, thereby avoiding the unintended effects of the personal characteristics of clinical practice faculty. Furthermore, a previous study that explored the demand for VR practicum education found that nursing students expected to receive standardized practicum education through VR [
25]. Participants in this study noted that they were able to follow each stage and learn the accurate content because the VR program was conducted according to predetermined content and procedures. Therefore, VR can be utilized to implement standardized practical training in nursing education settings.
Furthermore, simulation training is constrained by time and place as it requires multiple participants to gather at a specific place at a specific time. In contrast, the web-based VR program can be accessed from any location at any time using an electronic device, offering the flexibility to overcome these physical constraints. This allows learners to practice as often as they desire [
1]. In this study, while participants had to wait their turn to engage in direct simulation training and travel to the practicum room, they could use the VR program whenever they chose, free from the restrictions of time and place. Participants identified the greatest benefit of the VR program as its repeatability. They viewed the VR program as a tailored learning tool that enabled them to practice repeatedly, depending on their level of skill. Previous research has also highlighted that a web-based VR program is a cost-effective approach that allows numerous learners to undertake individual training sessions [
26]. Thus, the web-based VR program will allow nursing students to repeatedly practice essential nursing skills, proving to be both cost-effective and efficient.
In this study, participants experienced a heightened sense of realism as the VR program closely mimicked an actual hospital environment. They also honed their communication skills by interacting with a virtual patient and subsequently explaining their actions to a guardian. Given that nursing students often feel overwhelmed when communicating with patients or guardians in clinical settings [
27], the VR program was specifically designed to facilitate the explanation of vital signs measurement procedures in children to their guardians. It allowed students to record their explanations, and then review these recordings, thus providing ample opportunity for communication practice. Participants were particularly impressed with the realistic depiction of a hospital ward, complete with sounds of pulses and breathing, as well as the inclusion of a recording device and a quiz. VR programs that incorporate interactive features have been shown to be more effective in knowledge retention [
28]. Through repeated practice, participants gained confidence in handling clinical practicums. They expressed that engaging with the VR program prior to actual clinical practicums would be beneficial, as it provides a preliminary experience of a hospital setting. The VR program could be implemented before clinical practicum to assist nursing students in preparing for and adjusting to the clinical environment.
However, participants in this study often felt confused because they were not familiar with VR. Therefore, it is essential to provide thorough explanations and guidance before starting the program to help learners become accustomed to the VR system. Additionally, while participants acknowledged that VR aids in visual understanding and sequential learning of procedures, they were disappointed by its inability to allow hands-on practice with actual objects, unlike simulation training. They emphasized the necessity of practicing nursing skills directly to gain proficiency. In this study, participants accessed the VR program either through a web browser or by visiting the university’s homepage on their mobile phone or tablet computer. However, it is challenging to improve motor skills with web-based VR programs, as they do not require physical movement to perform nursing skills. Furthermore, a meta-analysis on the effectiveness of VR in nursing education indicated that VR education did not enhance the skills of nursing students more effectively than simulation training [
8]. This shortfall is attributed to the gap between virtual scenarios and actual practice. Learner satisfaction with VR education also inevitably varies based on the technical quality of the VR system. When developing a VR program, user proficiency must be considered. It should be designed to be user-friendly so that even individuals with low technical skill can easily use it and focus on the educational content.
To improve the nursing skills of nursing students, the development and integration of augmented reality technologies, such as holograms, motion sensors, and haptic devices, should be pursued [
29]. However, augmented reality involves high costs, requires specialized equipment, and necessitates dedicated space for setup and operation. Unlike web-based VR programs, which are less restricted by time and location, augmented reality has physical constraints and does not easily support simultaneous multiple users. Consequently, web-based VR programs, which are more accessible and can be used repeatedly, are a preferable option for improving the performance of nursing students.
This study has some limitations. It utilized convenience sampling from nursing students at a single university, so caution should be exercised when interpreting and generalizing the findings. The study involved the application of a VR program for measuring children’s vital signs to nursing students. Looking ahead, there is a need to develop and implement a variety of pediatric care topics to enhance the pediatric care competencies of nursing students. Given that nursing education can benefit from both web-based VR programs and augmented reality programs, future research should explore the use of both technologies to maximize their features and benefits.
Nevertheless, this study’s unique significance lies in the following findings. This study revealed that when a web-based VR program and high-fidelity simulation training were implemented sequentially, there was a significant increase in practice confidence. This improvement was consistent even when the order of the training methods was reversed. Consequently, this study demonstrates the potential for web-based VR programs to be effectively integrated with high-fidelity simulation training or augmented reality.
Based on these findings, in clinical practice, efforts should be made to ensure practical clinical training is carried out in collaboration with nursing education institutions to foster competent pediatric nurses. From a research perspective, empirical evidence must be established by developing diverse pediatric nursing education methods and verifying their reliability and validity. For education, the effectiveness of training should be enhanced by utilizing various methods like VR, AR, and simulation, which allow students to safely and repeatedly practice core nursing skills. Furthermore, from a nursing education policy standpoint, it is necessary to standardize both nursing skills and educational methods.
CONCLUSION
This study was conducted to evaluate the impact of a VR program on nursing students' ability to measure vital signs in children, using a mixed-methods approach. It was found that the VR program was as effective as high-fidelity simulation training in enhancing students’ knowledge and confidence in practice when measuring children’s vital signs. By addressing learning limitations and offering realistic training, the VR program enhanced the clinical competence of nursing students. These findings suggest that the VR program may serve as a valuable tool for improving pediatric nursing education.
ARTICLE INFORMATION
Figure 1.Research design. Con., control group; Exp., experimental group; VR program, virtual reality program on the measurement of vital sing in children; Simulation training, high-fidelity simulation of the measurement of vital sing in children.
Figure 2.CONSORT (Consolidated Standards of Reporting Trials) flow diagram of participants’ enrollment. Con., control group; Exp., experimental group; Simulation training, high-fidelity simulation of the measurement of vital sing in children; VR program, virtual reality program on the measurement of vital sing in children.
Table 1.Homogeneity testing of participants’ general characteristics (N=44)
|
Variable |
Exp. (n=22) |
Con. (n=22) |
t/χ2
|
p
|
|
Age (yr) |
23.45±2.89 |
23.18±2.46 |
0.34 |
.738 |
|
School grade |
|
|
1.28 |
.733 |
|
≥A0
|
6 (27.3) |
5 (22.7) |
|
|
|
B+
|
5 (22.7) |
8 (36.4) |
|
|
|
B0
|
6 (27.3) |
6 (27.3) |
|
|
|
≤C+
|
5 (22.7) |
3 (13.6) |
|
|
|
Satisfaction with major |
4.00±0.69 |
3.72±0.55 |
1.45 |
.155 |
|
Knowledge of vital signs (points) |
4.04±1.39 |
3.68±1.72 |
0.77 |
.447 |
|
Confidence in practice (points) |
3.31±0.47 |
3.09±0.52 |
1.50 |
.141 |
Table 2.Effects of a virtual reality program for the measurement of vital signs in children (N=44)
|
Variable |
Pre-test |
post-test1 |
post-test2 |
Differencea)
|
Differenceb)
|
Group |
Time |
Group*Time |
|
t (p) |
t (p) |
F (p) |
F (p) |
F (p) |
|
Knowledge |
|
|
|
|
|
2.85 (.099) |
46.59 (<.001) |
2.54 (.099) |
|
Exp. (n=22) |
4.04±1.39 |
5.72±0.76 |
5.59±0.90 |
6.14 (<.001) |
.83 (.418) |
|
|
|
|
Con. (n=22) |
3.68±1.72 |
4.77±1.06 |
5.59±1.00 |
2.94 (.008) |
3.25 (.024) |
|
|
|
|
Confidence in practice |
|
|
|
|
|
13.95 (.001) |
106.49 (<.001) |
2.27 (.112) |
|
Exp. (n=22) |
3.31±0.47 |
4.59±0.50 |
4.77±0.42 |
10.84 (<.001) |
6.80 (<.001) |
|
|
|
|
Con. (n=22) |
3.09±0.52 |
3.95±.057 |
4.45±0.59 |
4.82 (<.001) |
3.92 (.001) |
|
|
|
|
Satisfaction with practice |
|
|
|
|
|
0.02 (.319) |
1.59 (.215) |
0.00 (>.999) |
|
Exp. (n=22) |
- |
4.72±0.45 |
4.81±0.39 |
|
|
|
|
|
|
Con. (n=22) |
- |
4.59±0.59 |
4.68±0.56 |
|
|
|
|
|
Table 3.Learning experiences with a virtual reality program for the measurement of vital signs in children
|
Category |
Subcategory |
Qualitative data |
|
Realistic learning training |
Similarity to the real clinical field |
It felt so real because the VR looked exactly like a hospital setting. (Participant #7) |
|
Feeling novel |
I was impressed by the VR program. It was very high-quality. (Participant #28) |
|
Feeling confident in future practice |
I liked how the pulse and breathing sounds were very clear. I believe I can measure them accurately in clinical practice too. (Participant #17) |
|
Overcoming learning limitations |
Learning accurate methods |
I could accurately know how to measure children’s vital signs through a quiz. (Participant #34) |
|
Having no time or place limitations |
VR is not constrained by time or place, and I could access it anytime I wanted without having to wait. (Participant #7) |
|
Ability to repeat practice |
I learn more slowly than others and have to repeat a procedure many times to learn it. I liked VR because it allows me to repeat the practice. (Participant #7) |
|
Perceiving drawbacks |
An unfamiliar system |
I did not know where the quiz was at first and clicked on the wrong answer many times. (Participant #25) |
|
Wanting to practice directly |
It would have been better if I could practice directly on an object rather than just clicking everything. (Participant #7) |
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