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Virtual reality (VR) is the use of computer technology to create an interactive three-dimensional (3D) world, which gives users a sense of spatial presence. In nursing education, VR has been used to help optimize teaching and learning processes.
The purpose of this study was to evaluate the effectiveness of VR in nursing education in the areas of knowledge, skills, satisfaction, confidence, and performance time.
We conducted a meta-analysis of the effectiveness of VR in nursing education based on the Cochrane methodology. An electronic literature search using the Cochrane Library, Web of Science, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature), up to December 2019 was conducted to identify studies that reported the effectiveness of VR on knowledge, skills, satisfaction, confidence, and performance time. The study selection and data extraction were carried out by two independent reviewers. The methodological quality of the selected studies was determined using the Cochrane criteria for risk-of-bias assessment.
A total of 12 studies, including 821 participants, were selected for the final analysis. We found that VR was more effective than the control conditions in improving knowledge (standard mean difference [SMD]=0.58, 95% CI 0.41-0.75,
The results of this study suggest that VR can effectively improve knowledge in nursing education, but it was not more effective than other education methods in areas of skills, satisfaction, confidence, and performance time. Further rigorous studies with a larger sample size are warranted to confirm these results.
With the rapid development of information technology and shortages of nurse workforce, a transformation of nursing education is needed to prepare nursing students for evolving and complex health care environments [
The ultimate goal of nursing education is to promote the application of theoretical knowledge in clinical practice [
Simulation has been shown to be a valuable teaching-learning strategy to support the changing world of nursing education and to help optimize the teaching process [
With the development of simulation technology, the virtual world was discovered—initially used in military and medical science and later, in medical education [
As VR technology advances and becomes increasingly affordable, nursing education is being transformed [
Although the use of VR has many advantages, some researchers have reported that VR is not more effective than other traditional methods on some outcomes such as knowledge and performance scores [
This meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines [
An electronic literature search was carried out in the Cochrane Library, Web of Science, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from their inception to December 2019. The search strategies used in PubMed, Embase, and the Cochrane Library are listed in the
This study included randomized controlled trials (RCTs) or trials employing quasi-experimental randomized design, including those in the form of dissertations and conference papers, based on the PICO (Population–Intervention –Comparison–Outcome) method. In this study, the PICO elements were as follows:
Population: pre-/post-registration nursing students or nursing staff
Intervention: all kinds of VR education methods
Comparison: traditional education methods (including presentations, classes, written instructions, etc) and non-VR simulation methods (including high/low fidelity simulation, mannequin-based simulation, etc)
Outcomes: knowledge, skills, satisfaction, confidence, and performance time
Two reviewers (FQC and YFL) independently extracted information based on preset standards, including authors, publication date, nation, sample size, participants type, research project, intervention regimens, and outcomes.
Two reviewers (FQC and YFL) assessed the studies’ quality independently by referring to the Cochrane Handbook for Systematic Reviews of Interventions [
The meta-analysis was conducted using RevMan 5.3 [
A total of 2716 potential studies were identified from 5 databases (n=2712) and relevant references (n=4). After removing 1072 duplicates, the remaining articles were reviewed and those that did not meet the inclusion criteria were excluded. A total of 1644 articles were screened by title and abstract, of which 1581 articles were excluded. A total of 63 full-text articles were downloaded and assessed, from which 51 were excluded. Finally, 12 studies, including 821 participants, were selected for this study. A flow chart of the study selection process is presented in
Flowchart of the study selection process. RCT: randomized controlled trial.
Studies included trials conducted in 7 countries: United States [
Characteristics of the 12 included studies.
Author (year), country | Type of participant | Research project | Number of participants | Outcomes | ||
|
|
|
Total (number of groups) | Experimental group (VRa) | Control group (condition) |
|
Bryant et al (2015) [ |
Nurse practitioner students | Advanced health assessment | 60 (2) | 22 | 38 (traditional education) | Satisfaction, confidence |
Butt et al (2018) [ |
Junior level nursing students | Urinary catheterization | 20 (2) | 10 | 10 (traditional education) | Performance time |
Cobbett and Snelgrove-Clarke (2016) [ |
Third-year nursing students | Maternal -newborn nursing | 56 (2) | 27 | 28 (non-VR simulation) | Self-confidence |
Haerling (2018) [ |
Fifth- and sixth-quarter associate degree in nursing students | Nursing care of patients with chronic obstructive pulmonary disease | 28 (2) | 13 | 15 (non-VR simulation) | Knowledge assessment, |
Ismailoglu and Zaybak (2018) [ |
Second-year |
Intravenous catheter insertion | 65 (2) | 33 | 32 (non-VR simulation) | Knowledge assessment, |
Jung et al |
First-year nursing students |
Intravenous injection | 114 (3) | 38 | 38 (non-VR simulation) and 38 (VR plus non-VR simulation) | Procedure score, |
Leflore et al (2012) [ |
Senior nursing students |
Care of pneumonia and cystic fibrosis exacerbation | 93 (2) | 46 | 47 (traditional education) | Knowledge assessment |
Liaw et al (2014) [ |
Senior nursing |
Assessing and managing deterioration | 61 (2) | 31 | 30 (non-VR simulation) | Performance scores |
Padilha et al (2019) [ |
Second-year |
Respiratory process in relation to ineffective airway clearance and hypoxia | 42 (2) | 21 | 21 (non-VR simulation) | Knowledge assessment, |
Smith et al (2018) [ |
Senior nursing students | Decontamination training | 172 (3) | 59 (immersive VR) |
55 (traditional education) | Knowledge assessment |
Tsai et al |
Novice nurses | Port-A cath injection | 82 (2) | 42 | 40 (traditional education) | Knowledge assessment |
Gu et al |
Second-year students | Course of fundamental of nursing | 28 (2) | 14 | 14 (traditional education) | Knowledge assessment |
aVR: virtual reality.
Based on the Cochrane criteria, a risk-of-bias assessment is presented in
Risk of bias analysis of each included study.
Overall risk of bias analysis of included studies.
A total of 7 studies reported knowledge scores as the outcome [
Forest plot of virtual reality on knowledge.
A total of 5 trials used skills as the outcome measure [
Forest plot of virtual reality on skills.
A total of 4 articles reported participants’ satisfaction scores [
Forest plot of virtual reality on satisfaction.
A total of 4 studies reported confidence results [
Forest plot of virtual reality on confidence.
Performance time was employed as an outcome measure in 3 trials [
Forest plot of virtual reality on performance time.
This meta-analysis assessed the effectiveness of VR simulation methods in nursing education. We found that VR education methods can improve the knowledge of nursing students. However, there was no difference between VR and other education methods on the outcomes of skills, satisfaction, confidence, and performance time.
A total of 12 trials with 821 participants were included in the meta-analysis. All studies used VR education as the interventions in experimental groups, and education methods in control groups including traditional education, high/low fidelity manikin, mannequin-based simulation, and plastic model. Among the 12 studies, 4 trials reported random sequence generation. Only 1 study described the allocation concealment; 2 studies reported the blindness of outcome assessment. In addition, blinded interventions of students and educators were not possible because of the particularity of the VR education method. In general, the overall risk of bias of the included studies was judged to be unclear due to lack of information.
For the outcome of knowledge, VR education showed more effectiveness on nursing education than traditional education or other simulation education methods. A qualitative study on VR use in nursing education also concluded that, through the concrete experience of the virtual patient simulation and the reflection tool, students could understand what they were taught and how to utilize the new knowledge [
Our results found no significant difference between VR education and other education methods for the outcome of skills, which seems to be in line with a previous systematic review [
There was no significant difference on participants’ satisfaction between VR education and education methods in control groups. High heterogeneity was found. Through sensitive analysis, we found that 1 of the 4 included studies showed that VR was more satisfactory [
The results in confidence indicated no difference between experimental and control conditions. VR could not enhance the confidence of participants more effectively than control conditions, which was consistent with a previous study from Korea [
We also conducted a meta-analysis of performance time. The results suggested that VR was not more effective on reducing performance time than other educational methods. We found large heterogeneity among studies, even when a sensitivity analysis was conducted by using the leave-one-out method. The observed heterogeneity may be due to the different research designs of the selected studies, such as operation projects, VR devices, and education methods in control groups. One study on the effectiveness of VR endoscopy simulation training analyzed performance time with sufficient data and found no difference between VR and control groups; however, the quality of the evidence was very low [
Our study has the following strengths. First, our study is the first meta-analysis assessing the impact of VR on nursing education. Second, to assess the effectiveness of VR education, we evaluated 5 outcome measurements—knowledge, skills, satisfaction, confidence, and performance time—which can probably provide reference for nursing education.
There are also some limitations in our study. First, we only included articles published in English, which may affect the results of meta-analysis. Second, some of the included studies failed to provide the details of sequence generation, allocation concealment, and blinding methods. Third, we included 12 studies that have different interventions in control groups, which may cause significant heterogeneity among the studies.
This meta-analysis provides a comprehensive evaluation of the use of VR on nursing education. We found that VR education methods can improve nursing students’ knowledge. However, for the outcomes of skills, satisfaction, confidence, and performance time, there seems to be no difference between VR and other education methods. In general, the use of VR should be considered to enhance knowledge and as a complement of other simulation strategies to improve the quality and safety of clinical practice. However, the heterogeneity and risk of bias among the included studies should be taken into consideration. Rigorously designed large-scale studies are required to further confirm the results in this review.
Search strategies of PubMed, Embase and the Cochrane Library.
Supplementary information of intervention in experimental and control groups.
cumulative index to nursing and allied health literature
Population–Intervention–Comparison–Outcome
Preferred Reporting Items for Systematic Review and Meta-Analyses
randomized controlled trials
virtual reality
ZLS was supported by Key project of Jiangsu Province Education Science 13th Five-Year Plan 2016 projects (B-a/2016/01/18), Nanjing University of Chinese Medicine 2018 Flipped Classroom Course & Open Online Course - Health Assessment, and Opening project of innovative practical teaching team of Qing Lan Project in Jiangsu Province (NZYHLXPPQL2019-25).
FQC and YFL searched the medical database and collected and extracted the data. FQC, YFL, and JFG discussed and analyzed data together and wrote papers. ZLS, DWW, CL, and BC provided suggestions for writing preparation and process. The final version of the article was reviewed by all authors.
None declared.