Desktop Virtual Reality Versus Face-to-Face Simulation for Team-Training on Stress Levels and Performance in Clinical Deterioration: a Randomised Controlled Trial

Analysis of stress responses in medical students during simulated pericardiocentesis training using virtual reality and 3D-printed mannequin

We investigated the effectiveness of Virtual Reality (VR) and three-dimensional (3D)-printed mannequins in replicating stress levels during pericardiocentesis training and compared their impact on learners' emotional and physiological responses. A secondary analysis explored how demographic, lifestyle, and academic factors influence stress responses, providing deeper insights into the variability of physiological markers among medical trainees. We conducted a randomized study involving 108 final-year medical students (mean age: 23.6 years, 87% female) to compare stress responses during pericardiocentesis training using a 3D-printed mannequin and VR model as simulation modalities, both custom-designed by the research team. We investigated the influence of demographic, lifestyle, and academic factors, including medication use and perceived stress, on heart rate variability (HRV) markers. The two simulations showed similar HRV parameters, validating their effectiveness in replicating physiological stress levels associated with clinical scenarios. Secondary analysis revealed significant associations between the low frequency/high frequency ratio and family income and a trend-level effect for anxiolytic use, suggesting an interplay of socioeconomic and pharmacological factors on stress responses. Age and sex interacted significantly with HRV metrics, with younger students demonstrating heightened sympathetic activation. Our results suggest that the incorporation of VR into medical training programs may enhance learning outcomes and accessibility.

Effectiveness of Virtual Simulations Versus Mannequins and Real Persons in Medical and Nursing Education: Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

BACKGROUND

Virtual simulation (VS) is a developing education approach with the recreation of reality using digital technology. The teaching effectiveness of VSs compared to mannequins and real persons (RPs) has never been investigated in medical and nursing education.

OBJECTIVE

This study aims to compare VSs and mannequins or RPs in improving the following clinical competencies: knowledge, procedural skills, clinical reasoning, and communication skills.

METHODS

Following Cochrane methodology, a meta-analysis was conducted on the effectiveness of VSs in pre- and postregistration medical or nursing participants. The Cochrane Library, PubMed, Embase, and Educational Resource Information Centre databases were searched to identify English-written randomized controlled trials up to August 2024. Two authors independently selected studies, extracted data, and assessed the risk of bias. All pooled estimates were based on random-effects models and assessed by trial sequential analyses. Leave-one-out, subgroup, and univariate meta-regression analyses were performed to explore sources of heterogeneity.

RESULTS

A total of 27 studies with 1480 participants were included. Overall, there were no significant differences between VSs and mannequins or RPs in improving knowledge (standard mean difference [SMD]=0.08; 95% CI -0.30 to 0.47; I2=67%; P=.002), procedural skills (SMD=-0.12; 95% CI -0.47 to 0.23; I2=75%; P<.001), clinical reasoning (SMD=0.29; 95% CI -0.26 to 0.85; I2=88%; P<.001), and communication skills (SMD=-0.02; 95% CI: -0.62 to 0.58; I2=86%; P<.001). Trial sequential analysis for clinical reasoning indicated an insufficient sample size for a definitive judgment. For procedural skills, subgroup analyses showed that VSs were less effective among nursing participants (SMD=-0.55; 95% CI -1.07 to -0.03; I2=69%; P=.04). Univariate meta-regression detected a positive effect of publication year (β=.09; P=.02) on communication skill scores.

CONCLUSIONS

Given favorable cost-utility plus high flexibility regarding time and space, VSs are viable alternatives to traditional face-to-face learning modalities. The comparative effectiveness of VSs deserves to be followed up with the emergence of new technology. In addition, further investigation of VSs with different design features will provide novel insights to drive education reform.

TRIAL REGISTRATION

PROSPERO CRD42023466622; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=466622.

Neurobiological stress markers in educational research: A systematic review of physiological insights in health science education

BACKGROUND

Traditional self-reported measures in health science education often overlook the physiological processes underlying cognitive and emotional responses.

PURPOSE

This review aims to analyze the frequency, sensitivity, and utility of physiological markers in understanding cognitive and emotional dynamics in learning environments.

METHODS

A systematic PubMed search identified 156 records, with 13 studies meeting inclusion criteria. Markers analyzed included heart rate (HR), heart rate variability (HRV), cortisol, alpha-amylase, testosterone, s-IgA, blood pressure, oxygen saturation, and respiratory rate.

MAIN FINDINGS

HR and HRV were sensitive to educational stressors. Cortisol and alpha-amylase showed mixed results, while testosterone and s-IgA showed limited utility in directly assessing stress responses. No consistent link was found between any marker and immediate learning success.

CONCLUSION

Physiological markers in learning environments can offer valuable insights into emotional and cognitive dynamics but should not be misconstrued as direct indicators of learning outcomes.

The effectiveness of a structured validated questionnaire to assess student perception with virtual pharmacy simulation in pharmacy practice experiential education

BACKGROUND AND OBJECTIVE

MyDispense is one of the virtual simulations that has already been established as a suitable alternative for live experiential education in the pharmacy curriculum. However, there are no structured validated questionnaires available to assess the students' perception while integrating MyDispense with pharmacy practice experiential education. Therefore, the present study aimed to validate a structured questionnaire and use the questionnaire to assess the student perception of various pharmacy practice experiential education.

METHODS

Content and construct validity procedure was used to validate the questionnaire. Two hundred students consented to participate in validating the questionnaire. The validated questionnaire assessed the students' perception of integrating MyDispense with Introductory Pharmacy Practice Experience 2 (IPPE2) and Advanced Pharmacy Practice Experience (APPE) courses. The questionnaire was structured with four domains which were: exercise, instructor, technical, and communication. Each domain carried five items; therefore, the whole questionnaire had 20 items that succeeded in content validity. In the survey, 121 fourth-year and 117 fifth-year Pharm.D. students volunteered to convey their perception of integrating MyDispense with IPPE 2 and APPE, respectively. The survey was conducted before and after the MyDispense exam in both the courses.

RESULTS

The Cronbach's α and McDonald's ω coefficients were > 0.8 in all four domains, indicating that the items related to the four domains have good internal consistency. In Exploratory Factor Analysis (EFA), two items were found to cross-load in the exercise domain and removed. Therefore, the EFA proposes 18 items for the confirmatory factor analysis (CFA). In CFA, five fit indices were found to be satisfactory, and this indicates construct was good enough to assess the student perception. In IPPE 2, the pre-test response, the students had significantly higher satisfaction (p < 0.05) with all five items related to the technical domain. In APPE, the students had a significantly (p < 0.05) higher perception of all the items related to the exercise and technical domain in the pre-test compared to the post-test. Therefore, the student's pre-test feedback allowed the instructor to identify and make the necessary corrections in the exercises to improve the quality exercises.

CONCLUSION

This study provides a validated 18-item questionnaire to assess the student perception of integrating MyDispense in experiential education. The integration of MyDispense in experiential education needs to be done carefully by assessing student perception.

Digital Educational Tools for Undergraduate Nursing Education: A Review of Serious Games, Gamified Applications and Non-Gamified Virtual Reality Simulations/Tools for Nursing Students

Educational technology has advanced tremendously in recent years, with several major developments becoming available in healthcare professionals’ education, including nursing. Furthermore, the COVID-19 pandemic resulted in obligatory physical distancing, which forced an accelerated digital transformation of teaching tools. This review aimed to summarize all the available digital tools for nursing undergraduate education developed from 2019 to 2023. A robust search algorithm was implemented in the Scopus database, resulting in 1592 publications. Overall, 266 relevant studies were identified enrolling more than 22,500 undergraduate nursing students. Upon excluding multiple publications on the same digital tool, studies were categorized into three broad groups: serious games (28.0%), gamified applications (34.5%), and VR simulations and other non-gamified digital interventions (37.5%). Digital tools’ learning activity type (categories = 8), geographical distribution (countries = 34), educational subjects (themes = 12), and inclusion within a curriculum course (n = 108), were also explored. Findings indicate that digital educational tools are an emerging field identified as a potential pedagogical strategy aiming to transform nursing education. This review highlights the latest advances in the field, providing useful insights that could inspire countries and universities which have not yet incorporated digital educational tools in their nursing curriculum, to invest in their implementation.

The effectiveness of virtual reality technology in student nurse education: A systematic review and meta-analysis

AIM

The purpose of this study was to analyze the effectiveness of virtual reality technology in nursing education.

BACKGROUND

Virtual reality technology is regarded as one of the advanced and significant instructional tools in contemporary education. However, its effectiveness in nursing education remains a subject of debate, and there is currently limited comprehensive research discussing the impact of varying degrees of virtual technology on the educational effectiveness of nursing students.

DESIGN

Systematic review and meta-analysis.

METHODS

The present systematic review and meta-analysis were applied according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. The PubMed, Embase, CINAHL, ProQuest, Cochrane Library, Web of Science, and Scopus were searched for relevant articles in the English language. The methodologies of the studies evaluated were assessed using Cochrane Risk of Bias2 (ROB 2) tool and Joanna Briggs Institute (JBI) assessment tool. We took the learning satisfaction, knowledge, and skill performance of nursing students as the primary outcomes, and nursing students' self-efficacy, learning motivation, cognitive load, clinical reasoning, and communication ability were assessment as secondary outcomes. The meta-analysis was performed using R 4.3.2 software according to PRISMA guidelines. Heterogeneity was assessed by I2 and P statistics. Standardized mean difference (SMD) and 95 % confidence intervals (CIs) were used as effective indicators.

RESULTS

Twenty-six studies were reviewed, which involved 1815 nursing students. The results showed that virtual reality teaching, especially immersive virtual reality, was effective in improving nursing students' learning satisfaction (SMD: 0.82, 95%CI: 0.53-1.11, P < 0.001), knowledge (SMD: 0.56, 95%CI: 0.34-0.77, P < 0.001), skill performance (SMD: 1.13, 95 % CI: 0.68-1.57, P < 0.001), and self-efficacy (SMD: 0.64, 95%CI: 0.21,1.07, P < 0.001) compared to traditional teaching methods. However, the effects of virtual reality technology on nursing students' motivation, cognitive load, clinical reasoning, and communication ability were not significant and require further research.

CONCLUSIONS

The results of this study show that virtual reality technology has a positive impact on nursing students. Nonetheless, it is crucial not to underestimate the effectiveness of traditional education methods, and future research could analyze the impact of different populations on nursing education while improving virtual reality technology, to more comprehensively explore how to improve the quality of nursing education. Moreover, it is imperative to emphasize the integration of virtual education interventions with real-world experiences promptly. This integration is essential for bridging the gap between the virtual learning environment and real-life scenarios effectively.

REGISTRATION NUMBER

CRD42023420497 (https://www.crd.york.ac.uk/PROSPERO/#recordDetails).

Application of mobile-based web app to enhance simple suturing skills of nurse practitioners

BACKGROUND

Suturing is a crucial clinical skill for nurse practitioners (NPs), but the effectiveness of traditional training methods (e.g., physical suture kits combined with video content) is low.

OBJECTIVE

This study compared the effectiveness and usability of a mobile-based web app (MoWa) developed for NPs to learn simple suturing skills with those of traditional instructional video-based training.

METHODS

The MoWa system utilizes mobile devices to simulate hands-on suturing and provides learning guidance and feedback to support self-learning with a physical suturing kit. Fifty-four suturing novices (NPs) were recruited as participants, divided into an experimental group (EG: 28 participants) and a control group (CG: 26 participants), and instructed to self-learn for 3 weeks. Learning effectiveness and system usability were evaluated through a pretest and posttest.

RESULTS

The EG exhibited significant improvements in learning outcomes, self-confidence, self-efficacy, and learning anxiety and expressed satisfaction with the MoWa system. Furthermore, the EG also considerably enhanced learning outcomes, self-efficacy, and learning anxiety compared to the CG, with no significant difference in self-confidence.

CONCLUSION

The MoWa system combined with deliberate practice is an effective strategy for supporting suturing skills training.

Design and Evaluation of Using Head-Mounted Virtual Reality for Learning Clinical Procedures: Mixed Methods Study

BACKGROUND

The capacity of health care professionals to perform clinical procedures safely and competently is crucial as it will directly impact patients' outcomes. Given the ability of head-mounted virtual reality to simulate the authentic clinical environment, this platform should be suitable for nurses to refine their clinical skills for knowledge and skills acquisition. However, research on head-mounted virtual reality in learning clinical procedures is limited.

OBJECTIVE

The objectives of this study were (1) to describe the design of a head-mounted virtual reality system and evaluate it for education on clinical procedures for nursing students and (2) to explore the experience of nursing students using head-mounted virtual reality for learning clinical procedures and the usability of the system.

METHODS

This usability study used a mixed method approach. The stages included developing 3D models of the necessary instruments and materials used in intravenous therapy and subcutaneous injection procedures performed by nurses, followed by developing the procedures using the Unreal Engine (Epic Games). Questionnaires on the perception of continuance intention and the System Usability Scale were used along with open-ended questions.

RESULTS

Twenty-nine nursing students took part in this questionnaire study after experiencing the immersive virtual reality (IVR) intervention. Participants reported largely favorable game perception and learning experience. Mean perception scores ranged from 3.21 to 4.38 of a maximum score of 5, while the mean system usability score was 53.53 of 100. The majority found that the IVR experience was engaging, and they were immersed in the game. The challenges encountered included unfamiliarity with the new learning format; technological constraints, such as using hand controllers; and physical discomfort.

CONCLUSIONS

The conception of IVR for learning clinical procedures through deliberate practice to enhance nurses' knowledge and skills is promising. However, refinement of the prototypes is required to improve user experience and learning. Future research can explore other ways to use IVR for better education and health care purposes.

Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study

Although most scald burn injuries involve children under six, because of the challenges of using head mounted displays with young children there is very little research exploring the use of VR in children under six. The current clinical pilot study measured the analgesic effectiveness of our new desktop VR system (with no VR helmet) in children under six during burn wound care (a within-subjects design with randomized treatment order). Between December 2021-April 2022, nine children with burn injuries (10 months to 5 years age, mean = 18 months) participated. The mean burn size was 10% Total Body Surface Area, range 2-22%. Using nurse's ratings, VR significantly reduced children's pain during burn wound care by 40% on the observational Faces, Legs, Activity, Crying, and Consolability (FLACC) pain scale. Specifically, non-parametric within-subject sign tests compared nurse's ratings of the young patients' pain during burn wound care using usual pain medications with no VR = 6.67, (SD = 2.45) vs. adjunctive Animal Rescue World VR (VR = 4.00, SD = 2.24, p < 0.01). The observational Procedure-Behavior Checklist (PBCL) nurse's scale measured a 34% reduction in anxiety with VR as compared to pharmacologic treatment alone (p < 0.005). Similarly, when using single graphic rating scales the patients' parents reported a significant 36% decrease in their child's pain during VR (p < 0.05), a 38% (p < 0.005) decrease in their child's anxiety during VR, and a significant increase in patients' joy during VR. It can be concluded that during burn wound care with no distraction (traditional pain medications), children under 6 years old experienced severe pain during a 10 min burn wound cleaning session. During burn wound care combining desktop virtual reality and traditional pain medications, the same pediatric patients experienced only mild pain during burn wound cleaning/debridement. VR significantly reduced the children's pain and anxiety during burn wound care.

Virtual Reality Animal Rescue World: Pediatric virtual reality analgesia during just noticeable pressure pain in children aged 2-10 years old (crossover design)

BACKGROUND AND AIMS

Excessive pain during medical procedures is a worldwide medical problem. Most scald burns occur in children under 6, who are often undermedicated. Adjunctive Virtual Reality (VR) distraction has been shown to reduce pain in children aged 6-17, but little is known about VR analgesia in young children. This study tests whether desktop VR (VR Animal Rescue World) can reduce the just noticeable pressure pain of children aged 2-10.

METHODS

A within-subject repeated measures design was used. With treatment order randomized, each healthy volunteer pediatric participant underwent brief cutaneous pressure stimuli under three conditions: (1) no distraction, (2) a verbal color naming task (no VR), and (3) a large TV-based desktop VR distraction. A hand-held Wagner pressure pain stimulation device was used to generate just noticeable pain sensations. Participants indicated when a steadily increasing non-painful pressure stimulus first turned into a painful pressure sensation (just noticeable pain).

RESULTS

A total of 40 healthy children participated (43% aged 2-5 years; and 57% aged 6-10 years). Compared to the no distraction condition, the 40 children showed significant VR analgesia (i.e., a significant reduction in pain sensitivity during the VR Animal Rescue World condition), t(39) = 9.83, p < 0.001, SD = 6.24. VR was also significantly more effective at reducing pain sensitivity vs. an auditory color naming task, t(39) = 5.42, p < 0.001, SD = 5.94. The subset of children aged 2-5 showed significant reductions in pain during VR. Children under 6 showed greater sensitivity to pain during no distraction than children aged 6-10.

CONCLUSION

During no distraction, children under 6 years old were significantly more sensitive to pain than children aged 6-10. Virtual reality (VR) significantly reduced the "just noticeable" pressure pain sensitivity of children in both age groups.

Cross-Sectional Study on the Comparative Assessment of Mandibular Anesthesia (Inferior Alveolar Nerve Blockage) Manual Skills Shaping among Dentists on Plastic and Biomaterial Models

Background: Providing regional anesthesia skills shaping remains relevant nowadays. A number of studies show that dentists have difficulties with these working independently. The study aim is the comparative analysis of the results of mandibular anesthesia (IANB) manual-skills shaping among dentists on plastic models and cadavers. Methods: In total, 999 participants were training in the skills of mandibular anesthesia from 2017 to 2021. The participants were divided in a random way into two groups: 700 participants were trained on plastic models, and 299 were trained on the cadaver material. After a lecture on the clinical and anatomical guidelines for IANB, a demonstration of the technique was provided, with subsequent testing of the injection technique. Satisfaction with the aspects of the training was assessed using the Likert scale. Results: the analysis of average values showed that participants from the group in which the manual skills were practiced on cadavers were more satisfied with the main aspects of the training, according to the sum of the main criteria of the modified scale. Conclusions: The important advantages of cadaver educational technology are that the sensations of tissue resistance are identical to natural ones, the individuality of each object, and the possibility of the visual study of the anesthesia technique, by dissection of the needle course and the location of the anesthetic depot.