Virtual Reality (VR) provides an innovative and immersive experience that has shown effectiveness with increasing learning, cognitive, and psychomotor performance (Choi et.al., 2021). The evolution of VR use in a variety of fields has proven successful and for this group of nursing professional development (NPD) practitioners, when the challenge to design teaching methods and instructional modalities to learner needs came, our team at the Texas Children's Hospital in Houston leveraged VR to improve nursing skills and patient outcomes.

Central line-associated bloodstream infections (CLABSIs) lead to increased hospital stays, care costs, morbidity, and mortality (Gupta et.al, 2021). Evidence-based practices (EBP) to decrease CLABSI rates demand continuous training and skill validations that can be labor intensive and costly. Aligning with the organization’s nursing strategic plan to leverage technology, we conducted a needs assessment, formed an interprofessional work group, looked at the evidence, and implemented VR for CLABSI prevention education and competency.

Identifying the Need for VR

Our journey began with a thorough assessment of CLABSI rates, nursing practices, and current training methods. The data analysis revealed central line care practice variations, as well as increased supply usage for training. This posed safety issues which required immediate remediation and a call for education. The need for human, time, and material/financial resources was a challenge already identified. Simultaneously, learner preferences and the role of advanced technology in NPD practice called for innovative teaching strategies. The VR three-dimensional computer-generated environment allows the user to feel immersed in their surroundings, which can be developed to mirror practice environments. This option served as the driving force to implement an innovative educational plan to streamline nursing practices and decrease the use of sterile supplies for staff training.

Next, we led an extensive collaborative effort to reduce CLABSI rates. Various subject matter experts across the organization were included to form a VR design group. The interprofessional group offered unique perspectives and insights ranging from quality and infection control to vascular access and nursing clinical practice. The goal was to design a VR lesson for CLABSI nursing education and competency. EBP, checklists, and care bundles reflective of the literature were utilized to target central line care processes of sterile cap change and dressing change. The group worked together to incorporate the clinical learning points into the VR environment.

To aid the VR design team in creating a replica practice environment, we created a database of photos and videos of current supplies, patient rooms, and central line processes that mimicked an average space in our practice setting. In the simulated patient care room, learners are expected to demonstrate the donning of sterile gloves and perform a sterile cap change ​and a sterile dressing change​ on a patient with a central line. The lesson plan and learning objectives were solidified. Technical support played a significant role in ensuring the VR connectivity demands could interface with the hospital’s network and would not pose a threat to data breech or loss. 

Using VR to Enhance Learning

Following the creation of the VR environment and content, end-user testing began. We supervised six user acceptance testing sessions to ensure the technology operated seamlessly and the lesson’s content was accurate and reflected current bedside EBP.​

VR has unique features that enhance the learning experience. With our program, learners can complete a brief tutorial on how to navigate through VR before advancing to the nursing skill lessons. The tutorial provides learners with an opportunity to become familiar with the 360-degree VR environment, how to operate the controllers by using the joystick and teleport features to move around in the environment, as well as how to pick up and hold items. ​There is also a feature within the learning environment that addresses the potential for motion sickness. While in the VR lesson, the learner can adjust the speed at which they move around in the environment. This sets the learners up for success.

The three lessons our team created are very interactive and allow the learner to communicate with patients and nursing staff.​ When the lesson begins, the learner receives a shift change report in which they discuss elements of the CLABSI prevention bundle. This interaction was deliberately included to reinforce the key bundle elements that need to be assessed and discussed for all patients with central lines.​ The nurse and patient conversation covers key concepts related to patient safety, communication, and patient education. For instance, the nurse must validate two patient identifiers in which the patient responds. The nurse also has to explain the procedure and rationale to the patient and address patient concerns.

Additionally, there are two lesson modes—training and assessment—to select from depending on the competency level of the learner​. In the training mode, a virtual instructor provides verbal step-by-step instructions to support novice to advanced beginners. Other features include closed captions with written prompts and a demonstration video for the learner to watch prior to performing complex, multi-step actions. Benefits of the training mode include information retention and the ability to complete the lesson repeatedly to aid in building confidence in clinical skills through repetition.

The assessment mode, however, does not have a virtual instructor. The expectation is that the learner knows how to perform the steps in sequential order and therefore does not need guidance. The target audience for this mode is competent and proficient learners, and it shows a progression percentage as the learner navigates the lesson until completion. If the learner performs a skill out of sequence, an error buzzer sounds and instructs the learner to try again. After three errors, the lesson ends and the learner is instructed to review the steps again, practice in the training mode, then return to the assessment mode at another time.​ This mode also allows for analytics that educators can use to identify trends or education needs.

Piloting the VR Lessons

We are currently piloting the VR lessons aimed to improve CLABSI care practice in a pediatric clinical setting. Selection of the pilot area was strategic based on numerous factors, such as staff knowledge gaps versus knowledge level, skill set needed for the patient population, leadership support, and technical skills of NPD practitioners.

Additional comprehensive resources to support the VR project were created for sustainability. This included train-the-trainer sessions with unit level NPD practitioners and customized user manuals for each VR headset. The implementation of VR into clinical education is currently ongoing and has been a notable enhancement to current CLABSI prevention training initiatives within our organization. We are currently conducting train the trainer sessions with NPD practitioners at one of our organization’s community campuses where approximately 100 inpatient nurses will start utilizing the VR lessons as a training modality.

References:  

Bracq, M.-S., Michinov, E., Arnaldi, B., Caillaud, B., Gibaud, B., Gouranton, V., & Jannin, P. (2019). Learning procedural skills with a virtual reality simulator: An acceptability study. Nurse Education Today, 79, 153–160. https://doi.org/10.1016/j.nedt.2019.05.026  

Chen, P.J., & Liou, W. K. (2022). Exploring the Impact of the Use of Immersive Virtual Reality Interactive Experiences on Student Learning of Obstetrical Nursing. International Journal of Nursing Education, 14(3), 121-126. https://doi.org/10.37506/ijone.v14i3.18364 

Choi, J., Thompson, C. E., Choi, J., Waddill, C. B., & Choi, S. (2021). Effectiveness of immersive virtual reality in nursing education. Nurse Educator, 47(3). https://doi.org/10.1097/nne.0000000000001117  

Gupta, P., Thomas, M., Patel, A., George, R., Mathews, L., Alex, S., John, S., Simbulan, C., Garcia, M. L., Al-Balushi, S., & El Hassan, M. (2021). Bundle approach used to achieve Zero central line-associated bloodstream infections in an adult coronary intensive care unit. BMJ Open Quality, 10(1). https://doi.org/10.1136/bmjoq-2020-001200  

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