urinary catheter insertion two weeks after completing practice sessions when
comparing subjects that practiced with the VR game to those that practiced on a
task trainer?
Approximately two weeks after the initial practice session, each study participant returned to the simulation center for a follow-up demonstration of urinary catheter insertion. All demonstrations were digitally recorded and scored by a blinded reviewer using the criterion-based checklist utilized by the School of Nursing for skills validation. All twenty study participants were scored and given either a pass or fail based on the checklist. A second blinded reviewer scored five randomly chosen demonstrations in an attempt to assess for rater agreement. Using SPSS 22 (IBM Corp., 2013), Cohen’s kappa
was measured at .545 showing moderate agreement between raters (Laerd Statistics, 2015). Pass rates between groups was identical at 60%.
Summary of Findings
A purposive sample of 20 undergraduate nursing students in the fifth and sixth semester of an eight semester baccalaureate program participated in this mixed method study. The primary purpose of the study was to determine the usability of a game-based virtual reality system for practicing procedural skills, specifically urinary catheter insertion. All twenty students signed informed consent and all students completed all parts of the study. Analysis of the demographic data confirmed similarity of groups except for semester representation with the DP control group having a higher percentage of sixth semester students. Self-reported experience with catheter practice on a manikin and insertion on human patients demonstrated that students had similar experience regardless of semester placement.
Study participants rated overall usability of the system in the Good to Excellent range. Subjects agreed that practicing with this VR game was enjoyable and engaging. Most participants did not find the system uncomfortable, however the movement within the game was an issue for two of the students who reportedly liked the game but
complained of either headache or dizziness after use. The group did not agree on preference to practice with the VR game versus traditional practice on a manikin, but 70% agreed that they would be more likely to practice catheter insertion using this game. The VR game subjects practiced significantly more minutes and completed significantly more procedures than the DP control group. Observations and analysis of themes that emerged during practice supported the survey data. In addition to enjoyment,
engagement, comfort, preference, and likelihood to practice with the VR game, other themes included motivation, competition, feedback (the need for more in the game), and developing confidence. The VR game group practiced the procedure significantly more than the control group; interestingly, the follow-up demonstration pass rate for both groups was 60%.
CHAPTER FIVE: DISCUSSION AND IMPLICATIONS
Learning to perform procedural skills safely is a primary responsibility of undergraduate nursing students. In order to become competent and confident in their skills, student nurses need to practice. Promoting procedural skill development while ensuring patient safety is an ongoing concern and primary responsibility of nurse educators.
Simulation-based education in nursing has become an accepted and rather commonly used teaching methodology to help prepare student nurses for practice in a complex health care environment. Simulation provides a realistic patient care
environment where student nurses can practice on manikins and task trainers prior to practicing with patients. Simulation can take many forms, but one of the goals of all forms of simulation is to give students the opportunity to actively participate in their own learning experience. For this study, game-based learning was considered one form of simulation-based education that shares several of the same features of SBE including clear learning goals, immediate feedback so learners can monitor their progress,
increasing difficulty, and the opportunity for repetitive practice (Issenberg et al., 2005). In addition, game-based learning includes challenge, motivation, scaffolding—and infinite patience (Federation of American Scientists, 2006).
The development team hypothesized that combining game-based learning elements with the latest virtual reality technology could provide educators a new and
innovative way to help students deliberately and repetitively practice procedural skills. The purpose of this study was to explore the usability of, and user reaction to, a game- based virtual reality system designed to practice one such procedural skill. This VR game uses Oculus Rift headgear and wearable haptic technology to immerse and engage the student in the experience of catheter insertion—the student is in a patient’s room, practicing the procedural skill virtually. This study was an initial analysis of the first iteration of this unique game-based VR system.
This chapter provides a summary and discussion of the findings related to the study research questions. The chapter also includes discussion of the strengths and limitations of the study. Finally, this chapter discusses implications for nursing education and research with recommendations for further study.
Summary and Discussion of the Findings
Four research questions formed the basis of this study exploring the use of a virtual reality game as a method to help undergraduate nursing students practice
procedural skills, using urinary catheter insertion as exemplar. Each question and related study results will be addressed separately.
This study combined descriptive statistics and qualitative data to form an overall interpretation of the usefulness of the game-based VR system as a learning tool. A triangulation design convergence model was used to compare, contrast, and corroborate results from a System Usability Survey (Brooke, 1996) with added adjective rating (Bangor et al., 2009) and a user reaction survey completed immediately after use of the VR game with direct observation of subjects’ reactions while practicing catheter insertion within the VR game.
Question 1: How do subjects rate the usability of a game-based virtual reality
system for practicing urinary catheter insertion?
Participants’ ratings on the SUS were highest in the categories considering ease of use, desire to use the system frequently, well-integrated functions, and confidence using the system. Along with rating the system easy to use, participants also reported feeling the need for support from a tech person to use the simulation, with one participant adding “only for set-up.” Rather than including a tutorial (as many video game players are accustomed to), for the first iteration of the game participants were set-up in the system and walked through the first run-through of the game by one of the members of the development team. Participants did, in this case, need help with tech support, something to be considered going forward. It is possible to set-up a profile for each participant ahead of time so that when they go in to practice, the system would recognize them and there would be no need for a tech support person to help with calibrating and syncing the system as occurred in this trial run. Low ratings in this category influenced the overall SUS score. Despite consistently low scores in that category, participant ratings of the VR game averaged 72.5, ranging from 42.5 to 92.5. This rating places the system in the Acceptable range or, using the adjective rating scale, in the Good to Excellent range.