Authors
Stephanie Justice, DNP, RN, CHSE1
1Center for Healthcare Innovation and Leadership, The Ohio State University College of Nursing, Columbus, Ohio
Conflict of Interest Statement
The author has no conflicts to disclose.
Corresponding Author
Stephanie Justice, Center for Healthcare Innovation and Leadership, The Ohio State University College of Nursing, Columbus, Ohio
(email: justice.85@osu.edu)
Introduction
Advance practice registered nurse (APRN) students have many challenges to navigate in their role transition. One critical difference between a registered nurse (RN) and APRN education is the National Organization of Nurse Practitioner Faculties’ (NONPF’s) core competency of diagnostic reasoning (Smith et al., 2022). Clinical reasoning uses knowledge and experience to think critically through a clinical situation. In comparison, diagnostic reasoning requires developing a leading hypothesis, formulating a list of differential diagnoses, then implementing a plan of care (Nurse Practitioner Role Competences (2022), 2022; Smith et al., 2022).
Virtual reality (VR) software has been incorporated to develop clinical reasoning skills in undergraduate and postgraduate nursing students. VR has shown to enhance knowledge application and clinical performance with a significant improvement in the development of clinical reasoning skills, especially since the COVID-19 pandemic. However, there is little information in the literature about the use of VR in the transition between using clinical reasoning as an RN and using diagnostic reasoning as an APRN, leading to the exploration of using VR in an Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) program.
Incorporating various teaching strategies provides options for APRN students to focus on what enhances their learning while allowing educators to maximize the students’ potential to meet competencies. The visual, auditory, reading/writing, and kinesthetic (VARK) learning style approach engages multiple senses, creating a diverse learning style and experience (Prithishkumar & Michael, 2014). A blended learning format was created using the VARK learning style by adding VR to the existing didactic and hands-on procedural skills.
Methods
The incorporation of the VR software into the graduate nursing program was piloted within the AGACNP curriculum. Twelve students could simultaneously complete their individual VR patient case scenarios in the same room. The students act as the primary provider who can converse with and evaluate the patient, interpret clinical findings including laboratory and diagnostic results, and interact with a nurse. The software does not identify abnormal findings such as infiltrates on a chest radiograph. This gives the student an opportunity to practice identifying abnormal findings and using diagnostic reasoning to care for each patient. The VR patient case scenario is timed to last a maximum of 15 minutes. If students do not delegate tasks to the nurse, they run out of time, thus learning the importance of task delegation and time management in an emergent situation as a provider. The students were able to repeat the case until they achieved satisfactory results.
Following the completion of the scenario, there was an opportunity for self-debriefing by providing the student guided debriefing questions and individual performance data. The diagnosis, case summary, clinical findings, and expected learner actions are displayed, followed by critical aspects of care that went well and areas for improvement. Each action is time-stamped and contains a rationale, allowing the student to review and reflect on their performance before repeating the scenario. The software allows the faculty to review data and track improvement over time for an individual student or the entire class. Multiple VR acute care provider scenarios can be selected by the faculty that are preloaded for the students to participate. The students are provided a link and can sign up when convenient for them to be on campus to complete their VR experience in the VR lab. An unexpected benefit is the time and resource allocation because faculty do not need to be present to facilitate these sessions.
The curriculum was developed to prepare learners to demonstrate the advanced decision-making needed in acute clinical situations while providing diverse skills acquisition with the VARK learning-style approach (Prithishkumar & Michael, 2014). Using this design, the AGACNP student can practice diagnostic reasoning to formulate actual and differential diagnoses while making independent treatment decisions. The student can delegate tasks to bedside nurses. Visual and auditory learning was stimulated by including a didactic and hands-on procedure practice, whereas kinesthetic learning was encouraged by participating in the chosen VR patient case scenario.
The topic of spontaneous pneumothorax was chosen, and the didactic portion was delivered with an in-person lecture covering the acute management of pulmonary conditions. In preparation for the hands-on skills practice of chest thoracostomy, students were given access to procedural videos. Procedure indications and step-by-step techniques were covered during the pre-briefing session. Students were paired in groups of 2 or 3 to perform the thoracostomy procedure independently. Procedural technique, potential complications, and appropriate aftercare management were discussed during a post-debrief session.
The VR scenario followed promoting kinesthetic learning through movement and direct application of their acquired skills. The students were unaware of the scenario before the exercise to simulate a real-life clinical situation. In this scenario, a 77-year-old male patient who presented with the chief complaint of shortness of breath. The students could practice prompt recognition and proper intervention of a pneumothorax to prevent clinical deterioration. To meet the NONPF core competency of diagnostic reasoning, the student must draw upon previous knowledge, including history taking and physical assessment, to conclude the actual diagnosis of a pneumothorax while investigating and ruling out other differential diagnoses (Nurse Practitioner Role Competences (2022), 2022). In addition, students had to formulate a plan of care, prioritize, and delegate tasks to perform tube thoracostomy promptly.
Results
After piloting the VR software, faculty created a Likert scale survey of 6 questions to understand what students thought about the VR scenario and whether it enhanced their understanding of the acute management of the primary diagnosis. Nearly all responses were overwhelmingly positive, with most students responding in the “strongly agree” category when asked whether the VR scenario solidified their knowledge of how to manage a spontaneous pneumothorax and increased enthusiasm in participating in future VR patient case scenarios. The students were asked about any physical side effects of symptoms such as headaches, dizziness, nausea, or vomiting. Primarily, mild headaches were reported, followed closely by dizziness (Oh & Son, 2022). None of the learners commented on these symptoms in the open-ended responses, although a student verbally shared that she was prone to motion sickness but experienced no symptoms. In conversation in the VR lab, one student expressed that he only had clear vision in one eye, had difficulty with video games, and was hesitant, yet was amazed that he could witness the full scope of the VR scenario. Of the 26 students, only one noted a negative response, mainly centered around the learner’s inability to become familiar with the VR system in the allotted time. The plan to mitigate this is to provide a video tutorial covering the function of the VR system prior to the student’s participation.
Discussion
One of the challenges in transitioning from an RN to an APRN is the ability to interpret diagnostic data, develop a hypothesis, and formulate a list of differential diagnoses (Smith et al., 2022). VR may help cultivate diagnostic reasoning in APRN education, providing scenarios for students to act as the provider and delegate tasks. The faculty concluded that the positives of VR were the ability of the students to self-schedule, limited faculty facilitation during scenario performance, and an additional tool to evaluate independent clinical performance. The students’ enthusiasm for other opportunities to participate in VR enhanced our goal to incorporate VR throughout our AGACNP program.