VR Nursing

Research

In our initial research, we sought to understand what the NCLEX exam entails and who our user is, including their needs, goals, and challenges.

What is the NCLEX?

The NCLEX, which stands for the National Council Licensure Examination, is a computer adaptive test that is required for nursing graduates to successfully pass to be licensed as a Registered Nurse in the US and Canada.

The National Council State Boards of Nursing (who administers the NCLEX) announced that they are planning to include a variety of new question types in 2023 that better measure clinical judgement. At the start of this project, there is no existing solution to prepare for these next generation questions.

User Challenges

The current simulations to help prepare nursing students for real-world medical scenarios are not adequate. They are unable to cover scenarios as complex as hypovolemic shock.

Nursing students face challenges including:

Group class anxiety

Limited simulation days

Fear of failure

Lack of real-life experience

RN Turnover

Taking a look at RN turnover helps us see the impact of a positive nursing education. This data shows how crucial it is that educational institutes deliver a holistic learning experience to help prepare the nurses of tomorrow.

In 2021, the average cost of resident nurse turnover costs $40,000.
For the average hospital, RN turnover costs over $5 million per year.
Turnover rate increased 8.4% in 2021.

National Average

The challenge we were faced with is to understand how we can improve upon the current simulations in place in order to provide a more immersive education, and, more specifically, to prepare students for the new NCLEX format.

Virtual Reality

According to a study on virtual reality and memory by the University of Maryland, students have recall improved by 8.4% when working in immersive environments as opposed to traditional computer screens.

Why VR?

Builds students' skills and confidence without any potential harm

Can be a catalyst in teaching patient empathy

Helps beat phobia of interacting with real patients and prepare for stress of clinical settings

Improve on skills such as critical thinking, patient communication, and knowledge acquisition

Unparalleled realism and immersion; feeling of presence in environment

Lower long-term cost despite initial investment

Competitive Analysis

We scoped out the competition to evaluate how other schools are incorporating VR or XR into learning methods for medical professions. Additionally, we employed the feedback received on these existing programs to better understand the needs and challenges of our user group.

Existing VR-based Nursing Simulations

Currently, one student in a class gets to complete traditional simulations acting as the primary nurse. They do not have the ability to repeat the simulation multiple times.

VR does not replace traditional skills training or high-fidelity simulation; students will continue to participate in hands-on experiences. What VR simulation does is increase the number of experiences for each learner. Students will always be able to complete simulations as the primary nurse and can repeat the simulation multiple times.

The schools shown above as well as some others have begun to dabble in the VR/XR space in innovative ways. For example, Vanderbilt University introduced VR simulations of campfires, galaxies, and snowy landscapes to help relax both students and patients.

User Survey

Before beginning our own development, we decided to first gather an understanding of how effective the current simulation labs are and how much exposure the students have had to VR-based learning. This was important to address questions of desirability and feasibility of our solution.

We asked a mixture of quantitative and qualitative questions to probe students on previous VR experience, previous experience with simulation labs, what sections they find difficult on practice NCLEX exams, and current learning strategies.

Key Insights

54 total responses

55% wanted to learn through VR simulation again

Students found traditional sim labs to be long and hard to attend with already hectic schedules

Content does not keep up with students' increasing skillsets

Students often feel like they "aren't learning anything new"

These insights we gained from the user survey helped validate our work by confirming the student's dissatisfaction with the current nursing simulations and excitement to try virtual reality.

Contextual Inquiry

In order to assess how students are able to navigate through VR experiences, we performed a contextual inquiry at the nursing school. We worked with 6 nursing students, only one of which had previously experienced virtual reality.

We set up these students in a VR nursing simulator called UbiSim and asked them to perform some basic clinical tasks. During this process, we asked questions and observed responses and also conducted an exit interview with each student to gain additional feedback.

Key Insights

"Enjoyed the simulation. Very realistic and immersive. A valuable tool."

"Loved it - I'd rather do this than a sim with mannequins, this is way more real!"

"I could see it being helpful for NGN-style questions or case studies."

"Makes the next-gen questions come to life more."

"Takes book learning to a whole new level!"

"Helps in imagining the scenarios in real life."

Filming

Gathering together all the insights from our research, we discussed how we want to execute the nursing simulation in VR. Our decision was to film a 360° video of an acute medical scenario overlaid with NCLEX next-gen format questions at key points.

The decided situation was a 72-year-old patient experiencing hypovolemic shock, evidenced by rectal bleeding. The script was written and reviewed by medical professionals in the Jefferson School of Nursing.
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The first step was, of course, filming. We hired actors to play the patient, nurse, and doctor and filmed the scenario using an Insta360 Titan we borrowed from the school.

I operated this monster camera - for maximum quality, there are 8 different lenses, each of which has its own SD card. We had to shoot 7 different scenes and we went through quite a lot of takes.

After filming, it was up to me to load the 360° videos off the camera and use Insta360's proprietary software to stitch them into the proper format.

High-Fidelity Mockups

Now that we had the videos filmed and formatted, we were ready to start on the interface design. We had to create a screen for the Electronic Medical Record and for the question at the end of each scenario. These questions mimic those of the NCLEX next-gen redesign to familiarize students with the format.

We first designed the screens in Figma to figure out the layout and style we wanted to use.

Initial EMR screen

Full EMR screen

Drag & Drop question

Select All that Apply question

Select Multiple question

Incorrect Answers

Development

Unity

I had previously used Unity for development in VR, but it turns out development for Meta headsets is a whole different beast than for the HTC Vive. The more I immersed myself in Unity, the closer I came to realizing that Unity may not be the right tool for the job. For a short project, I was spending too much time installing the proper dependencies and building a framework.

Unity is well suited to building complex projects with physics and colliders and complicated interactions. What we wanted to create is a proof-of-concept: a minimalist simulation to show it can be done.

Unity User Interface

CenarioVR

I discussed this concern with one of my advisors at Jefferson, who introduced me to the tool CenarioVR. CenarioVR is an online VR authoring program which allows one to create VR experiences without requiring any coding or complex dependencies.

Although CenarioVR's interface may look to be a lot going on, it is unfathomably simpler than Unity, and in that sense perfectly suited to our task. It took me a couple hours to become acquainted with the software.

In just a few weeks' time I was ultimately able to upload all of the 360° videos and create screens for questions which users are actually able to interact with and answer, all without writing a single line of code. This tool was wonderful to create the proof of concept simulation that we needed.

Final Result

Putting it all together, here is a video of what a student viewing the nursing simulation will see in VR. Throughout the experience, students are able to look around in all directions, open up the EMR, and answer questions at the end of each scene.

This was our finalized scenario. In terms of next steps, we would conduct usability testing to assess the satisfaction rate of students, develop the simulation in a more robust editor, and potentially film more scenarios to add to the library.

Elon Skolnik

VR Nursing Simulation

Project Overview

Role

Topics

Timeline

Methods

Tools

Research

What is the NCLEX?

User Challenges

RN Turnover

How might we help nursing students to prepare for the new exam format through trial-based learning while giving them exposure to clinical procedures?

Virtual Reality

Why VR?

Competitive Analysis

Existing VR-based Nursing Simulations

User Survey

Key Insights

Contextual Inquiry

Key Insights

Filming

Time to begin development!

High-Fidelity Mockups

Development

Unity

CenarioVR

Final Result