Extended Reality Integration in Nursing at CSU Channel Islands
Extended Reality Integration in Nursing at CSU Channel Islands
Jaime Hannans, PhD, RN, CNE - Associate Professor & Colleen Nevins, DNP, RN, CNE - Assistant Professor
Project Abstract: The aim of this project: Extended Reality Integration in Nursing, is to provide immersive simulated experiences in clinical courses across the curriculum at CSU Channel Islands (CSUCI) using extended reality: mixed and virtual reality, with both individual students and within small groups of students to enhance learning in ways not currently offered while also establishing standards of nursing education practice and faculty training. The project covers Academic Year 2019 - 2020.
Keywords/Tags: nursing education; extended reality; mixed reality; virtual reality; simulation; simulated experience
Instructional Delivery: Laboratory setting
Pedagogical Approaches: Active/Inquiry-based Learning; Adaptive Teaching-Learning; Simulation best practices [Mixed & Virtual Reality]; Transformation Theory
Current Structure & Limitations
Currently the simulation lab at CSUCI has one simulation bay. This results in constraints on the time in simulation that an individual student or group of students have, as well as the frequency in use of simulation. Most nursing programs have a minimum of three or more, 4-hour simulations as part of the lab component in each clinical course. At present, CSUCI's Nursing Program is only able to provide four 1-hour simulations per clinical group per semester. A secondary limitation is difficulty in securing the desired number of clinical hours at most local area healthcare agencies due to competing nursing programs, impacting the ability to provide students with suitable alternatives to clinical hours.
Goals & Perceived Value in Project
Mindful of structural and clinical limitations, the goal of the Extended Reality (XR) Integration in Nursing project is to offer immersive simulated experiences in which the learner has an opportunity to see, hear and feel what it is like to go through a disease or situation as a patient or family/support individual. Virtual reality (VR) and mixed reality (MR) enable an immersive experience individually and within small groups; these experiences cannot currently be offered in other ways without extensive preparation, time, expense, faculty expertise, and technology.
The value with VR immersion allows for a realistic embodied experiences from the perspective of the patient in a relatively short period of simulated time (7 - 30 minutes), leading to a high degree of impact in far less time than high-fidelity simulation (30 - 60 minutes); the value of MR immersion allows for realistic simulated experiences for students to practice difficult conversations that they otherwise would not have opportunity to engage in within actual clinical settings.
Creating experiences that enhance development of empathy, effective communication, increased confidence, and ensure advocacy skill is critical to teaching patient-centered care. Integrating high impact practices through these immersive virtual and mixed reality experiences, offers increased opportunities for memorable learning using innovative approaches. The immersive teaching-learning methodology enhances learning in an advanced spectrum while fulfilling needed clinical hour requirements.
CSUCI's Nursing Program enrolls students in a cohort model, requiring three years of nursing course work. Students tend to be 80-90% female and 10-20% male, which is typical in nursing programs nationwide.
Below are charts indicating campus student body characteristics compared to enrolled nursing program student body characteristics. Of notice is that the nursing program student body is not equally representative of the campus in any category.
Advice Given to Students to Be Successful
The plan is for the student to have at least one VR experience each academic year; and, junior and senior students participate in one or more MR simulations. Nursing students will have both didactic and clinical knowledge as a basis for the XR experiences. The framework for facilitation of XR to assure student success is built on the INACSL Standards of Best Practices for Simulation where students are provided instruction and guidance based upon whether they are participating in MR or VR.
Mixed Reality Instruction (SIMPACT)
- Students are provided scenario information and resources as part of the pre-briefing instruction
- Students are given a short overview and orientation immediately to the start of simulation
- During the simulation, one student at a time rotates in the "action seat"to interact with the avatar(s); 3-4 students rotate into the "action seat" per session, depending on the session time allotment
- During simulation, students who are not in the "action seat" are considered the "brain" and are supportive of the student whose in the "action seat" during the "pause" moments, where discussion and suggestions can be made for how to progress within the scenario
- In session debriefing and discussion occurs among the student group with facilitation by faculty, allowing students to "stop time" or "pause" the simulation and get direction or support from the student group (brain) for how to continue or guidance from the faculty facilitator
Virtual Reality Instruction (Embodied Labs)
- Students are provided course content that aligns to the scenario lab with specific information and resources distributed at least 2 weeks prior to the session
- Students are given a short overview including a review of the objectives along with a 10-15 minute pre-brief discussion prior to the start of the simulation
- During the immersive simulation, students are encouraged to let faculty know if there are concerns, e.g., VR headset or emotional concerns
- After all students have completed the immersive experience, debriefing occurs in a small student group setting of 8 - 12 students
- An additional post-experience reflective activity facilitates individual response and learning
Impact of Student Learning Outcomes/Objectives on Course Redesign
As an intentional integration plan, the XR experiences are aligned to the curriculum by content, and then within each course by aligning to the Student Learning Outcomes (SLOs) that are identified for the course. In turn the SLOs and XR objectives are included as pre-briefing information for the activity.
Alignment of SLOs With LIT Redesign
Each XR activity is mapped out and aligned to the session objectives, course/student learning outcomes, and the program learning outcomes
Refer to XR Alignment to Program & Course LO
Assessments Used to Measure Students' Achievement of Student Learning Outcomes
- The mixed reality experiences are evaluated by the instructor during the simulated experience and facilitated to lend to discussion among the student group to meet SLOs
- The virtual reality experiences include a debriefing session allowing for discussion that can evaluate SLOs, in addition to a reflection activity following the experiences to further assess learning outcomes
- Consideration could be made for more concrete methods of evaluating if the SLOs are being met, such as a rubric or post experience student reflection with MR
Accessibility, Affordability & Diversity Accessibility
Within the nursing program, there are physical requirements to be able to function in the professional nursing role. However, some types of disabilities have been considered, and accommodations have been facilitated for the following incidences:
- Physical limitation: Students who have temporary physical impairments (for example a walking boot/brace) could participate in the experience in a seated position without any barrier to learning.
- Claustrophobia: More than one student has reported concern about the VR headset and a sense of claustrophobia. Since the scenarios are 5-8 minutes, students have been able to complete the activity with the option of removingthe headset during the session, or in between parts of any given scenario experience.
- Hearing impairment: VR and MR has been facilitated with a student who had hearing loss and hearing aides without any challenges.
- Emotional impact: Students are pre-briefed related to the content of the scenarios. Students are advised they may become emotional, and throughout the experience they are monitored to determine if they are comfortable continuing with the experience. Students may refrain from participating if content is felt too sensitive, i.e., end-of-life.
We intend in continuing to work closely with our accessibility resource staff while further implementing activities.
The AL$ effort at the CSU Channel Islands campus (openCI) has worked with various faculty within the nursing program. Some courses have lended to no cost materials (HLTH/NRS 348, NRS 352, NRS 342), while other affordable efforts have been made by program adoption of bundled e-books reducing textbook costs as well as continuing to evaluate opportunities for affordable approaches that allow greater affordability for students.
There are costs associated with equipment and license fees to the Embodied Labs scenarios to run the VR scenarios; the equipment is currently being lent from another department and the Embodied Labs is an annual license with unlimited access. There are ongoing costs annually for contract hours to facilitate MR sessions with SIMpact. The securement of Nursing Program equipment and annual licensing costs is an ongoing discussion for sustainability, with focused efforts to find funding to purchase equipment for the Nursing Program and to cover licensing costs absorbed through program operational funds and/or student lab fees.
The VR and MR scenarios present various cultural, gender, and ethnic considerations embedded in the simulation. Review of literature addressing learner preference, learning style, and student characteristics about specific needs in XR related to learning has not occurred. However, feedback in preliminary data from students in the pilot phase is promising for meeting all student's needs in the program thus far. Continued efforts to consider cultural, ethnic, gender, student learning style preferences, socioeconomic status, first generation students, etc. are important factors to consider.
About the Instructors
Left to Right: Dr. Colleen Nevins & Dr. Jaime Hannans
Colleen Nevins is an Assistant Professor in Nursing at California State University Channel Islands. She primarily teaches didactic and clinical medical-surgical nursing courses. Previously, Colleen served as the Simulation Lab Instructor at CSU Channel Islands, overseeing the skills lab and simulations from January 2009 through August 2014 for both the generic and RN to BSN tracks. Colleen has also taught in vocational and other baccalaureate nursing programs. Her practice experience includes ER, home care, ICU, neurology, GYN post – surgery, and 16 years of management. Colleen obtained her BSN from the University of Wisconsin, Eau Claire; a Masters in Nursing from UCLA; and a Doctorate of Nursing Practice from Western University of Health Sciences. Scholarly pursuits include self-care practices and simulated learning of baccalaureate nursing students. Awards include the Cal State 2019 Tech Gold Award for Innovation in Teaching, Learning &/or Accessibility; Online Learning Consortium 2019 Effective Practice Award; ATI Nursing Education 2018 Nurse’s Touch Award; and CSU Channel Islands’ 2017 Legacy Award for Outstanding Student Organization Faculty Advisor.
Jaime Hannans is an Associate Professor in Nursing at California State University Channel Islands. She obtained her BSN and MSN from CSU Chico, and Ph.D. from University of Nevada, Las Vegas. With over 18 years critical care and float pool clinical experience, Dr. Hannans teaches medical-surgical, gerontology, and critical care content in online, blended, or on-ground courses. She has been awarded CSU Faculty Innovation and Leadership Award and the AACN Excellence and Innovation in Teaching Award, related to her work exploring and sharing innovative teaching and learning practices, including projects related to digital badges, open educational resources, open courses, digital storytelling, extended reality (augmented, virtual and mixed), and best practices in online and blended teaching-learning. Her commitment to student success, particularly for low-income first-generation students, is highlighted by her role as the CSU Affordable Learning Solutions (AL$) Campus Co-Coordinator. Her research interests are most recently focused on immersive virtual reality experiences, reflective learning, simulation, and the use of technology and open educational resources in higher education.
Colleen Nevins, RN, DNP, CNE
Jaime Hannans, RN, PhD, CNE
CSUCI XR Program
Video of SIMpact (previously named Teach Live): Education and Nursing Students
XR Integration & Course Redesign
The design plan for integration and implementation of XR involved not one individual course but multiple courses across the curriculum with a focus on innovative and diverse methods to improve students’ understanding of patient perspectives, and practice communication skills to optimally provide safe, holistic patient-centered care. In addition, building empathy in the curriculum was an objective that was felt would broaden the horizons for how CSUCI could continue to improve teaching - learning, impact knowledge, skills, and attitudes in higher education, specifically in this case with impact for future patients.
Curricular and pedagogical considerations that were considered to support the design during the planning and implementation included: 1) faculty time to fully integrate the VR and MR experiences; 2) faculty development needs to expand the ability to facilitate VR and MR in all clinical sections; 3) considerations for redesign of past scheduling practices for clinical course hours; and 4) student needs in terms of gaps in the current curriculum. The following design elements emerged:
- Restructuring simulation experiences offered during all medical-surgical courses by replacing one high fidelity session with VR or MR or adding a XR activity
- Restructuring leadership clinical course to include a MR session
- Developing syllabus, clinical lab and/or LMS statements for faculty as communication to students for introduction to VR and MR activity
- Designing scheduling templates for VR and MR sessions
- Developing facilitation in-session guidelines for each VR and MR session
Clinical Course Set Up & XR Technology
Clinical class hours are mandated by the Board of Registered Nurses (BRN) based on units of the course and weeks in a semester, with most of our clinical courses as 3 unit courses translating to 144 hours per semester. In California, the BRN allows up to 25% simulation in lieu of direct clinical care. CSUCI's use of simulation in clinical course ranges from 5 - 15%. The clinical class sizes (ratio of faculty to students) is constructed per Nursing Program policy, and based on level and needs of learners. In turn, XR session sizes are designed around sections within a clinical course with XR session time allocated in consideration of pre-briefing, facilitation and debriefing. The clinical class sizes and XR session sizes and hours are:
- Clinical class sizes range from 8 - 15 students
- VR sessions designed for 8 - 10 students over 2.5 - 3 hours
- MR sessions designed for 10 or more students over 2 - 3 hours
- LIT Integration Plan for Clinical Courses AY 2019 - 2020
The technology used for the XR in the design plan includes:
- VR: Licensing secured from Embodied Labs which has pre-developed virtual scenarios focused on patient healthcare issues and experiences. Embodied Labs' scenarios are constructed using the framework of prepare, embody and reflect with learner goals of knowledge and training, insight and transformation, communication and team building. Each lab scenario has a guideline that includes a substantial number of reflective questions applicable to pre-briefing and debriefing. Alienware laptop and occulus rift wired headset with hand tracking sensors are used to facilitate the virtual experience.
- MR: Contract secured with SIMpact (CSU Northridge) to facilitate the mixed reality simulations with a virtual avatar and live actor facilitated through web-conferencing using Zoom. Students are not told how the avatar response and technology works in allowing for a simulated experience that models live experiences in which students could not otherwise directly manage. There are three scenarios currently available for nursing students. Each scenario has unfolding events depending upon the learner responses and directions taken by the avatar during the simulation to retain life-like situations for students to respond to, practicing effective communication skills during difficult healthcare related conversations. During the simulation the "pause" feature allows for in session guidance and debriefing. Each scenario also has a learner guide and language for faculty to provide students resources for preparation (content based), pre-briefing instruction, and reflective questions for further debriefing.
Professional Development Activities During the XR Course Redesign
- June 2019: Open discussion and exploration of XR teaching approaches with other CSU campus nursing faculty (Margaret Brady, Chancellor's Office & CSULB; Cal State LA; San Francisco State) hosted at CSUCI
- August 2019: CSU Tech Conference in San Diego, CA.
- August 2019: Faculty orientation and training on XR facilitation and debriefing in preparation for curriculum integration in the CSUCI Nursing Program
- September 2019: Jaime Hannans attended and presented VR and MR approaches at the National League of Nursing Education Conference in National Harbor, DC
- October 2019: Presentation with selected nursing students at the CSUCI Annual President's Fundraiser Dinner, allowing community members to explore VR
- October 2019: Jaime Hannans presented for Sigma Theta Tau Chapter in Humboldt County for Nurses Night Out on XR and textbook affordability
- Actively recognized as ATI Champions since 2017 for web-based products used in the nursing program inclusive of computer-based virtual experiences
Additional Resources for the Redesign
- Prior to LIT Grant and ongoing is a collaboration with the Teaching & Learning Institute team at CSUCI for tech support, scheduling of MR space, and facilitation of the portable equipment for events
- Coordination with the Nursing Program administration has been ongoing prior to and during the grant to address potential for further integration, faculty support, lab space, and sustainability
- Coordination with Nursing Program Analyst to manage grant budget and allocate funds as proposed
- Communication and coordination with SIMpact at CSUN to provide MR and Embodied Labs to facilitate VR experiences
- Institutional Research Board consulted for research data collection; review of IRB application criteria determined that survey data collection would fall under "exempt"
LIT Redesign Impact on Teaching and Learning
The course redesign strategies has affected instruction through providing structure and faculty support. Pedagogical strategies aligned to best practices in simulation were integrated to facilitate pre and debriefing approaches to strengthen the delivery of the experiences. New perspectives on delivery have been explored due to the transition during Spring 2020 to online/virtual instruction. This has lead to the exploration of new opportunities to deliver the VR and MR experiences using Zoom.
Student responses were extremely positive in multiple courses where VR or MR assignments occurred. Additionally, there was positive feedback when piloting the online delivery approach. The integration has been successful overall with continued plans toward sustainability, even given the unexpected changes during this academic year.
Evidence of learning was demonstrated through survey responses, reflective writing, and in session live responses. Overall there was no significant change to student success based upon grades. Clinical courses utilize pass/fail grading.
|Course||Term||# Enrolled||# Failed|
|NRS 223||Fall 2018||40||2|
|NRS 223||Fall 2019||49||2|
|NRS 421||Fall 2019||47||3|
|NRS 421||Spr 2020||49||0|
|NRS 461||Spr 2019||22||0|
|NRS 461||Fall 2019||49||0|
Of all courses above, NRS 223 is the most representative of the change from one AY to the next. Due to the pandemic, Spring 2020 courses were impacted by transition to online delivery, with a number of students choosing to withdrawal until Fall 2020. Additionally students compared in NRS 461 were from two different campus cohorts, thus the class sizes were significantly different. There were not any unexpected results from the integration of VR and MR in clinical lab courses with students, however, the slow completion time or inability to complete faculty training and address engagement was not expected.
In addition to tracking clinical course grades, compared to prior terms, faculty surveys and student surveys were conducted for those engaged with MR or VR experiences.
- Student Feedback on MR
- 17 student responses (20% response rate)
- All respondents stated it was a positive experience
- 100% of students felt the experience modeled real life situations for professional nurse roles
"The interactive quality is excellent and great practice. Experience/practice in nursing is so valuable and it is the one major thing new nurses lack, I think. This helps a lot."
"We get to be involved in a scenario that we may encounter in the future so this helps us to know what to expect and how we could approach the situation. Also, this is a safe setting to make mistakes and to learn from them."
- Faculty Feedback on MR
- 3 faculty responses (100% response rate for those faculty who attended MR sessions scheduled; 2 additional faculty planned to attend but unable)
- All 3 reported the MR experience was impactful to student learning
- Student Response on VR Experience
- Fall 2019: Alfred Lab (n=21) and Beatriz Lab (n=9)
- Spring 2020: Dima Lab (n=42)
- Spring 2020: Group Distributed mode online with the Eden Lab (n=6) and Clay Lab (n=37), providing a different survey for feedback
- Student Feedback on VR (continued)
- 92.9% indicated sufficient information was provided in pre-briefing to prepare for the VR experience
- 95.8% indicated the experience increased their knowledge about the content
- 97.2% indicated the experience increased their confidence to care for a patient with the same disease process presented in the scenario
- 100% indicated the VR experience increased their empathy and understanding the perspective of the individual diagnosed with the disease presented in the scenario
"I personally enjoy virtual reality a lot. I think it is an excellent learning tool. I like how the simulation projects different aspects to learn about the disease, meaning, it touches on the behavioral component, as well as the cognitive since pathophysiology of the disease is explained throughout the simulation. It creates emotions and also it allows us to use our motor functions by performing small tasks such as picking up a pencil or a glass and feeling frustrated of not being able to do so. It makes the learner feel on the patient's shoes and it totally makes a difference when caring for a patient with such disease. I currently work taking care of patients with dementia and I believe it would be great for all caregivers taking care for patients suffering from dementia to experience embodied labs and be able to empathize as well as comprehend such patients in order to provide the best care possible."
- Faculty Feedback on VR
- 10 faculty responded, with involvement in leading the pre-briefing (7), in session facilitation for students (8), and debriefing (9)
- Positive responses about the impact to students
- Concerns about scheduling and timing for students and faculty, as well as ongoing needs for faculty preparation with facilitatiom
Additional Considerations related to Findings
- The VR and MR experiences were counted toward clinical time, alleviating some of the scheduled hours for on-site facility experience for the clinical courses by 2 - 6 hours per clinical course, depending upon the mapping of the experiences to curricular content. This was especially valuable when transitioning online during Spring 2020 where the online group distributed mode was available.
- Providing content in simulated VR or MR experiences allows for confirmation that students will be exposed consistently to specific patient care content topics. In the clinical setting, there is variance to what students will experience. XR integration can provide consistency for delivery of the same intentional content to all students.
- Student surveys were posted in course announcements in Fall 2019, but with lower response rates; surveys were included as part of the VR or MR experience as an "assignment" for Spring 2020 to obtain greater feedback.
- Throughout the integration plan, there was significant progress in the development of faculty support and resources to effectively deliver the XR experiences.
Student Perceptions of VR (Embodied Labs)
Challenges Students Encountered
Two clear challenges emerged for students during XR integration:
- Scheduling: Creating schedules across student cohorts with multiple faculty created challenges to facilitate the sessions, train faculty, and remain aware of student schedules. Timing considerations for facilitation in smaller groups has to be planned. MR experiences rely on scheduling within the SIMpact scheduling availability.
- Online transition mid-Spring semester COVID19: This created new challenges (MR cancellation), as well as new opportunities to explore online delivery (VR group distributed mode).
Lessons Learned & Redesign Tips
Considerations in redesigning curriculum that integrates XR starts with preparing through sustaining within curriculum, should include the following:
|Alignment to Course(s)||√||√||√|
|Barriers & Limitations||√||√||√|
|Equipment &/or Licensing Fees||√||√||√|
|Faculty Training & Support||√||√||√|
|Impact on Learner||√||√||√|
|Roles & Expectations||√||√||√|
Course Redesign Obstacles
Course redesign challenges that occurred during the integration related to faculty buy-in, scheduling, low survey response rates, and transition to online instruction mid-semester in Spring 2020.
- While there was initial implied support from clinical faculty as a whole, faculty buy-in was inconsistent during integration with several teams highly participatory in facilitation of XR and several individuals within teams not engaged, particularly with MR. A solution may be to conduct regular meetings with faculty. Offering training that includes a run-through appeared highly effective in several faculty teams.
- Scheduling of XR outside of regularly scheduled clinical or lab time generated issues relating to commitment from both clinical faculty and students; a solution is to consistently align XR integration within scheduled clinical or lab time.
- Pre and post-survey response rates from students improved to >95% capture with centralization of survey notifications coordinated by the researchers and in turn has provided rich data. Faculty response to MR feedback via survey format was very low with only 3 clinical faculty responding to 1 of 3 MR experiences across cohorts; data suggests low engagement, including those who responded as primarily only observing the MR simulations. In contrast, nearly 60% of clinical faculty responded to VR feedback surveys, where most identified with participating in facilitation.
- The transition to online/virtual instruction in Spring 2020 created the greatest barrier for MR which was ceased and a rethinking of VR delivery virtually. Embodied Labs was able to assist in identifying a group distributed mode for VR, which appeared as immersive in the scenarios delivered in group mode versus individual mode for the planned session on end-of-life. Additional intentional planning will be necessary with continuing MR and VR in a online/virtual mode.
Strategies Used to Increase Engagement
Pedagogical strategies used to engage students in XR experiences included:
- Active Learning/Inquiry-Based Constructivism Theory:
- Digital simulation is a basic platform for both VR and MR, allowing for immersive individualized exploration through a case scenario designed with simulated behavior of patients, families, and healthcare providers;
- Just-in-time learning through organized content based on a framework of preparation (foundational knowledge), embodiment (scenario) and reflection (debriefing); and,
- High impact cultural and sensitive considerations embedded in XR scenarios and discussed during pre- and post-experience.
- Adaptive Teaching - Learning:
- Intentional integration of VR and MR by aligning experience with course content and level of learner;
- XR integrated as an assignment in courses, which Included the feedback survey and reflection as part of the simulated experience; and,
- Alternative approach for VR simulation conducted in a group distributed mode via remote/online strategy during Spring 2020, with in-session pause points for reflection and debriefing that may serve well for future online/virtual courses, such as Fall 2020.
The plans for sustaining XR integration beyond the funding period include:
- Securing permanent program funding by working collaboratively with the Nursing Program Chair for MR and VR; this includes money for VR equipment and XR licensing fees obtained through one-time campus grants (Materials, Services, Facilities & Technology; Research, Scholarship or Creative Activity). while establishing a budget that covers ongoing licensing fees and supplies.
- Continuing efforts of faculty buy-in with XR course integration through development of training, facilitation templates, and mentoring.
- The awarding of the CSU Innovation MiniGrant for AY 2020 - 2021 will support the assessment of online virtual simulation and development of best approach for virtual nursing instruction across CSU campuses, including addressing faculty support and training.
Participation in the CSU Course Design Professional Learning Community through the LIT Grant has been a valuable process, allowing us both opportunity and support to create a foundation to sustain integration of XR into the nursing curriculum. Student response to XR experiences has exceeded our expectations and highly suggests a need for further research beyond our data collected during the grant. Opportunities to explore VR and MR options in an online modality would not have been considered without the circumstances of COVID-19 leading to mandated online/virtual instruction. Online delivery has expanded the potential for VR facilitation in a variety of approaches that appear promising to student learning.
The development of the ePortfolio website during the course design has provided a platform for constructing a structural guide and means to document a historical background in the planning and execution of XR integration at CSUCI. The ability to connect with other disciplines in the CSU Course Design Professional Community cohort has been informative in learning about their explorations and the various approaches across campuses and disciplines. Plans are to disseminate the work and findings from XR integration in nursing curriculum through publication, conferences, and other grant activity. We have been asked to present at the ATI National Educator Summit in 2021, and our goal is to continue work on XR integration, building on the pedagogy of simulated teaching and learning.