Transitioning to Online Facilitation of Immersive VR Simulations

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Education in nursing has evolved from traditional classroom and clinical rotations to integration of simulated experiences.  Simulated experiences that mirror clinical situations, are a pedagogical approach for enhancing knowledge, skills and self-confidence, thus positively impacting the learning process (Araújo et al., 2018).  There is a growing interest to integrate virtual reality (VR) in nursing education.  VR includes donning of goggles and headset to view a scenario in three dimensions, to advance knowledge and skill sets through an immersive experience, which in nursing is beneficial to understanding disease processes and patient experiences (Foronda et al., 2017; Kavanagh et al., 2017; Shin et al., 2019). Additionally, immersive VR has been effective in increasing knowledge, confidence and empathy in health care professional education (Elzie & Shaia, 2021; Dyer et al., 2018).

Virtual simulation methodology is still in an exploration phase, yet our observation of integrating immersive VR aligns to a small amount of literature where there is significant impact with learners gaining self-confidence and empathy in a short time span. While immersive VR is often designed as an individual experience with single use of goggles and headset, the pandemic has resulted in the need for rethinking or reimagining of how simulated practices should be adjusted in delivery online. Known is that best practices for simulation by using a framework that includes pre-briefing (preparation prior to simulation), facilitation (the unfolding of the simulated experience), and debriefing (reflection on action), has been proven to enhance the teaching-learning experience (INACSL Standards Committee, 2016; Sittner, 2015).

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Transition to Online Teaching March 2020 and Beyond

When the pandemic transitioned higher education online, nursing programs needed to pivot traditional experiential learning opportunities and hands on practice toward a blend of online and in person learning. In person clinical or lab learning required strict adherence to COVID guidelines, limiting clinical opportunities and adjusting lab time.

California State University Channel Islands (CI) baccalaureate nursing program had previously started down the path of integrating immersive VR (using Embodied Labs) into the curriculum. Individual student VR experiences for multiple course sections in a lab setting became prohibitive with mandates for 6 feet of socially distancing, masking guidelines, and sanitizing equipment between learners. Therefore, rethinking immersive VR in a remote learning space led to delivery online and a group distributed mode, where students view the virtual experience during live synchronous sessions in small groups. To assure best practices in teaching and learning for simulated practices, the INACSL framework was adhered while pivoting to the new delivery model. In coordination with Embodied Labs, facilitation guides for the experience were adapted into templates for faculty facilitating the online delivery in small groups.

Prior to a VR session, students are provided information on the type of scenario and how to prepare. In the online group distributed mode, small groups of 8 to 15 students connect with a faculty facilitator and tech support over web conferencing, such as Zoom. Pre-briefing is conducted to inform students of the session plan, timing, and basic ground rules for engagement during the simulation and the use of pause points for guided discussion. The tech or faculty support person launches the VR simulation as the virtual user, embodying the “patient” scenario while wearing the headset with goggles and screen-sharing.

The faculty facilitator guides student discussions at predetermined pause points during the VR scenario. Open questions are asked by the faculty facilitator to prompt students to discuss what they feel, notice, and explore aspects of the scenario that tie to learning concepts during the pause points. The strategically placed pause points allow students to explore their perceptions as the “patient” embodied in the session, as well as a unique opportunity for in-session debriefing. The simulation session ends with closing discussion or debriefing. In most courses, an individual reflection of 4 to 6 questions is assigned following the VR experience to further enhance individual learning.

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CSUCI Virtual Reality In Nursing Education, 2020

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Ongoing exploration of possibilities of immersive VR for learning, and computerized VR is needed, and specifically is important for online teaching and learning. In healthcare professional programs, VR is a feasible strategy to impact student learning outcomes and can be effectively delivered online or in-person.

While student reaction has been highly positive in both the individual face to face and online group delivery modes, teaching-learning may be more enhanced in the group distributed mode where the use of pause points within small groups allows for discussion to clarify content, apply concepts and express feelings at specific times versus waiting until the completion of simulation scenarios. We feel that based on the desired learner outcomes, type of scenario content and concepts within the VR simulation, there is great opportunity to begin to differentiate when to use individual face to face versus a group distributed mode to enhance the learner experience.

Recommendations are for faculty and healthcare professional programs to explore opportunities for integrating VR learning modalities along with the traditional experiential learning experiences to deepen knowledge and empathy of patient experiences. Following best practices in simulation serve well to guide the design, delivery, and facilitation of available VR products to maintain quality learning experiences.


Araújo, P., Duarte, T., & Magro, M. (2018). Effect of simulation for meaningful learning. Ufpe Online Nursing Journal, 12(12), 3416-3425. doi:

Dyer, E., Swartzlander, B. J., & Gugliucci, M. R. (2018). Using virtual reality in medical education to teach empathy. Journal of the Medical Library Association, 106(4): 498-500.

Elzie, C.A., & Shaia, J. (2021). A Pilot study of the impact of virtually embodying a patient with a terminal illness. Medical Science Educator.

Foronda, C. L., Alfes, C. M., Dev, P., Kleinheksel, A. J., Nelson, D. A., O’Donnell, J. M., & Samosky, J. T. (2017). Virtual nursing: Emerging technologies in nursing education. Nursing Educator, 42(1), 14-17.

INACSL Standards Committee (2016, December). INACSL Standards of Best Practice: Simulation©: Simulation. Clinical Simulation in Nursing, Volume 12, S5-S50.

Kavanagh, S., Luxton-Reilly, A., Wuensche, B., & Plimmer, B. (2017). A systematic review of virtual reality in education. Themes in Science and Technology Education, 10(2), 85-119.

Shin, H., Rim, D., Kim, H., Park, S., & Shon, S. (2019, December). Educational characteristics of virtual simulation in nursing: An integrative review. Clinical Simulation in Nursing, 37(C), 18-28.

Sittner, B. J. (2015). INACSL Standards of Best Practice for Simulation: Past, Present, and Future. Nursing Education Perspectives (National League for Nursing), 36(5), 294–298.


Hannans, J., & Nevins, C. (2021). Transitioning to online facilitation of immersive vr simulations. In A. deNoyelles, A. Albrecht, S. Bauer, & S. Wyatt (Eds.), Teaching Online Pedagogical Repository. Orlando, FL: University of Central Florida Center for Distributed Learning.

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