Face-to-face versus 360 VR video: a comparative study of two teaching methods in nursing education

doi:10.21203/rs.3.rs-3398530/v1

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Research Article

Face-to-face versus 360 VR video: a comparative study of two teaching methods in nursing education

https://doi.org/10.21203/rs.3.rs-3398530/v1

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published 25 Mar, 2024

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Background

The practical sessions during skills laboratory simulation or clinical simulation are cores of nursing education. For this, different modalities have been devised to facilitate psychomotor skills learning. One of the commonly used educational material or instructional method to supplement skills learning across various disciplines is video-based teaching method. The opportunities of traditional two-dimensional (2D) video might be limitless and maximized with 360 virtual reality (VR) video, which offers immersive experience. This study incorporates 360 VR video into skills laboratory training as an alternative approach to face-to-face procedure demonstration.

Methods

An open-label, parallel (1:1), comparative study design was conducted among third-year undergraduate nursing students at Hiroshima University, Japan. The nursing students were block-randomized into 360 virtual reality (VR) video and face-to-face demonstration group. After a 3-hour theoretical class of patient management on ventilator and closed-suction principles of mechanically ventilated patients in an Intensive Care Unit (ICU) focused class, the 360 VR group watched the 360 VR video of closed tracheal suction (including oral) using the Head Mounted Display (HMD) of Meta Quest 2 individually, while the face-to-face group attended the instructor’s demonstration. A week after the skills laboratory, the students’ psychomotor skills, knowledge, satisfaction, confidence were evaluated, in addition to the 360 VR video groups’ perception; Wilcoxon rank-sum test was used to compare the two groups.

Results

A total of 57 students were analyzed; 27 students in the 360 VR video group and 30 students in face-to-face group. There were no statistically significant differences between both groups in skills, knowledge, and confidence. However, the face-to-face group had higher satisfaction level than the 360 VR group; this difference was statistically significant. In the 360 VR video group, 62% agreed that VR makes learning more interesting; more than half of students (62.5%) experienced VR sickness symptoms, and “feeling of drunk” is the highest. The students appreciated the ready to use, immersiveness, and realism; however, symptoms and discomfort, difficult perspective and production limitations were improvements recommended.

Conclusion

360 virtual reality

VR sickness symptoms

closed tracheal suctioning

psychomotor skills

Clinical training is an indispensable foundation in nursing education; in principle, it is the pathway to prepare nursing students, ensure competence, and achieve patient`s safety in the healthcare system. The pathway to ensuring competent nurse is the translation of theoretical knowledge to practical knowledge(1, 2); this is enabled through skills laboratory. The practical sessions during skills laboratory simulation or clinical simulation are cores of nursing education. For this, different modalities have been devised to facilitate psychomotor skills learning. However, despite the adoption of strategies to ensure the application of theory into practice, nursing education still experiences nursing students and newly graduates with deficient practical skills(3–5).

One of the commonly used educational material or instructional method to supplement skills learning across various disciplines is video-based teaching method(6–10). Medical students source educational videos to learn clinical skills(11), and 90% of medical students reported using videos to learn procedures(12). Moreover, the use of educational technology is part of nursing education and nurses are forerunners(13). It is argued that learning through image is relatively experiencing the real situation or an experiential process(14). The use of educational videos in teaching positively affects the learning process(15, 16), and has shown to enhance performance(13, 17), significantly reduce study time compared to text-based material(17), and improve confidence in performing some procedures(18).

The opportunities of traditional two-dimensional (2D) video might be limitless and maximized with 360 virtual reality (VR) video, which offers immersive experience. 360 VR video employ real-world images captured with an omnidirectional camera or multiple cameras simultaneously to create an immersive environment(19). The term VR and 360 VR video are used interchangeably; although VR is generated by using computer graphics, 360 VR video is created from real-world images(19, 20). It is noteworthy that the defining factor of a VR system in research reviews is the VR technology rather than the level of interactivity. The undivided attention offered by 360 positively influences conceptual and spatial learning(21). The 360 with VR head-mounted display (HMD) might provide an edge over 2D videos where environmental distractions are in view.

The potential benefits of 360 VR video on learning outcomes(22), and suitability for action-oriented activities requiring visual details, which is infeasible in a traditional 2D Video(23) has been demonstrated in research. This immersive and involvement opportunity in 360 VR video has raised a debate on its use in retention of information and enhancement of learning over traditional 2D video. Harrington et. al(24) reported 65% of students preferred 360 Video over 2D; the 360 VR video group demonstrated significant higher engagement and no difference in information retention. Contrarily, Rupp et al(25) found the overwhelming feeling of presence contributed to less information recall. It is well established that 360 VR video improves student learning performance(26–28). A systematic review of 360 VR video technology by Baysan et al(20) including majority of non-interactive 360 video systems concluded that the use is convenient and effective for nursing education. For this, robust research is essential as disparities exist between studies.

In Japan, research interest in VR and using VR in nursing education is increasing. However, to the best of our knowledge, the adoption of VR in nursing education is not widespread in any country. In nursing skills laboratory, procedures are demonstrated to students by nursing instructors of the intended procedure; a web video is provided to complement for future reference. The instructors deliver the procedure to the total number of students at once; this crowding could hamper the ease of understanding and better visualization. It has been reported in research that a video-based group perceived the teaching method to facilitate ease and better understanding than live demonstration(29, 30). Closed tracheal suction is one of the important nursing procedures in Intensive Care Unit (ICU) and involves an action-oriented activities requiring visual details. If this demonstration is captured in immersive 360 VR, it could offer an individualized experience, be reused by students without the need for web video as supplement and reduce faculty dependence in future demonstration of the procedure. Moreover, video-based teaching is a self-directed learning approach and could reduce the number of instructors needed to conduct hands-on practice in nursing skills laboratory; teachers’ dependence of students is one of the negatives of live demonstration(31). Therefore, this study incorporates 360 VR video into skills laboratory training as an alternative approach to face-to-face procedure demonstration. The purpose of this study was to examine the effects of 360 VR video and face-to-face teaching method in learning closed tracheal suction (including oral suction). We hypothesized that (1) nursing students who learned the procedure with 360 VR video would have higher skill performance scores than students who received the face-to-face demonstration, (2) the 360 VR video group would have better theoretical knowledge than the face-to-face group, (3) the nursing students who watched the 360 VR video would self-report higher satisfaction and confidence level than the students who received face-to-face demonstration, and (4) the 360 VR video would have considerably good perception of the use of the technology.

Study design and Participants

An open-label, parallel (1:1), comparative study design was conducted among undergraduate nursing students at Hiroshima University, Japan. Participants were third-year nursing students enrolled in the Practicum in Adult Nursing in 2023.

In the third year, students study each nursing science area after completing basic nursing subjects; they study theory and skills in parallel, and after completion, they go on to clinical practice.

Data collection procedure

Since this study was implemented in the regular class, the data for this analysis was obtained after the class completion as an opt-in basis. Prior to commencement of the specified class explained below, students were informed of the purpose of this experiment, procedure, voluntarily of participation, no disadvantages of withdrawal and/or no participation, and the secondary use of the data. Then, students submitted the written consent form for providing their data submitted in the class to the researcher who is not involved in the course.

After a 3-hour theoretical class of patient management on ventilator and closed-suction principles of mechanically ventilated patients in an ICU focused class, a seven-question knowledge pretest was conducted for all the available nursing students enrolled in the course; a total of 62 students completed the pretest for randomization.

Randomization and allocation

To assure equal distribution in terms of academic achievement or intelligence, the pretest score was used as a factor to block randomize the students into the 360 VR video training group (360 VR group: an intervention group) and the face-to-face traditional training group (face-to-face group: a control group). A block size of 2 resulted in 31 blocks, and students assigned from each block into the face-to-face and 360 VR groups. Figure. 1 shows the study procedure during the course.

Development of the 360 VR Video

A video of a certified nurse in critical care performing closed-suction procedure in a high-fidelity mannequin-based simulation was recorded with Insta360 (ONE X2). The procedure of suctioning was conducted in a step-by-step manner following a checklist developed by the research team. The video involved a voice over of the instructor explaining the procedure, and the nurse performing the procedure. This was edited using Adobe Premiere Pro ver (23.2.0); the final product of the video was 18 minutes divided into three phases for better understanding of the procedure: Preparation and assessment phase; instrument identification and oral suction phase; tracheal suction and patient report phase (Figure. 2).

360 VR group

After the theoretical class, the 360 VR group watched (see Figure. 2a) the 360 VR video using the HMD of Meta Quest 2 individually; after then, the students answered the VR safety questionnaire developed by the researcher. For hands-on practice, the students engaged in self-directed practice with group feedback in 5 subgroups for 90 minutes; each subgroup containing 6 students except one with 7 students.

Face-to-Face group

The face-to-face group attended the face-to-face demonstration of the same nurse that carried out the procedure in the video using the researcher developed checklist. After then, the students engaged in hands-on practice in 5 subgroups for 90 minutes; each subgroup containing 6 students except one having 7 students; clinical instructors (experienced registered nurses) were present in each subgroup during the practice.

For both groups, the critical care nurse captured in the video was available between the intervention and control groups to address the students’ concerns and questions. After the hands-on practice, the control group was provided the usual supplemental procedural video for closed suctioning attached to their study material, and the intervention group could either rewatch the 360 VR video with VideoLAN Client (VLC) player or request for use of the HMD at their convenience.

A week after the skill demonstration and hand-on practice, a total of 9 instructors (nursing faculties and registered nurses) assessed and evaluated the students’ closed suction skills (including oral suction) using the procedure checklist. To ensure consistent evaluation, a session was held to communicate the grading criteria. The students were requested to perform the procedure in an Objective Structured Clinical Exam (OSCE) and evaluated by clinical instructors. At the end of the skills evaluation, both groups answered the google forms on knowledge, satisfaction, and confidence. In addition, the 360 VR group answered the VR perception questionnaire. According to the study procedure, it was planned to explore the perception of the face-to-face group on VR by watching the 360 VR video after skills evaluation, but none of the students watched the 360 VR video.

Evaluation outcomes and Instrument

Evaluation was conducted under the framework of psychomotor skill, knowledge, confidence, and satisfaction of the closed tracheal suction technique. For the 360 VR group, video perception and VR sickness symptoms were also explored.

Closed tracheal suction checklist (including oral suction)

A Closed tracheal suction (including oral suction) checklist was developed from available literature review of evidence-based practice (32–38) to evaluate the skills of the nursing students. To ensure the validity of the checklist, the developed checklist was submitted to certified critical care nurses of Hiroshima University Hospital, and a version of procedure checklist available at the unit was received by the researchers as a guide. The checklist was further modified resulting in 38-steps procedure (items) checklist. To assign grades to the steps, each step was dichotomized to critical and non-critical. For a critical step, a score of 4, 2, 0 was assigned to satisfactory, unsatisfactory, and not performed, respectively; a score of 2, 1, 0 was assigned to a non-critical item as aforementioned for the level of performance. The criterion for the three level of performance was outlined for each item for consistent rating. To establish the content validity, using Lynn’s (1986) technique (39), the checklist was submitted to four certified critical care nurses; the relevance, accuracy of terminology, and grading of the steps were evaluated. The checklist was reviewed and modified based on the experts’ opinion, and the final checklist score ranges from 0 to 64. The item-level content validity index (I-CVI) was computed for each item; the scale-level content validity index of universal agreement (S-CVI/UA) was 0.97.

Knowledge test scores for suction in ventilated patients

The researchers developed practical knowledge questions on tracheal suctioning. A total of 24 questions were outlined, and after the researchers’ group discussion, it was reduced to 17 questions. This was pretested with two certified critical care nurses for an expert-driven pretest to assess the face and construct validity of the questionnaire. The nurses answered the questionnaire, and suggested modifications or discard of some questions were addressed accordingly. After then, two questions were added, and 19 questions were pretested with two different certified critical care nurses. In order to achieve a 20-questions questionnaire, one question was included to the final expert-driven pretest. From the 20 questions developed, 7 questions, which were identified to address the basics and overview of tracheal suctioning, were used for pretest. For the post test, the total of 20 questions was administered; the correct answer is given 1 point, and the incorrect answer is given 0 points.

Degree of satisfaction and confidence in learning

To assess the students’ satisfaction and confidence, the Japanese version (40) of the Students Satisfaction and Self-Confidence in Learning by the National League for Nursing (NLN) was adopted to assess the students’ satisfaction and confidence. It consists of 13 questions in two different questionnaire; five questions for satisfaction and eight questions for self-confidence. The questionnaire is on a 5-point Likert scale form 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, and 5 = strongly agree; the higher the score, the higher the satisfaction and confidence. The satisfaction score ranges from 5 points to 25 points and confidence from 8 points to 40 points. As reported by NLN, the Cronbach alpha for the satisfaction and self-confidence are 0.94 and 0.87, respectively. In this study, the Cronbach alpha for satisfaction and self-confidence is 0.93 and 0.92, respectively.

Perception of VR use

The perception of students was assessed with an adapted tool from Peart et al(41) study. The tool was developed based on the Technology Acceptance Model (TAM) and includes 6 items on a 7-point Likert scale (strongly disagree, disagree, somewhat disagree, cannot decide, somewhat agree, agree, and strongly agree) and 2 open ended questions. However, to fit in our study, only one of the open-ended questions was retained (is there a way that the use of X could be improved). The tool was forward and back translated by the researchers, and an additional two questions (1. How was the comfort and ease of understanding of VR; 2. If you notice anything else or have any impressions, please write it down) were added to the open-ended questions. In Peart et al(41), the Cronbach alpha was > 0.7. As the tool was translated and adapted, the Cronbach alpha in this study is 0.61

The safety questionnaire was developed to explore the side effects of using the VR. The VR sickness symptoms explored in the questionnaire were based on the Meta Quest 2 health and safety manual and other VR studies(20, 26, 42, 43). It consisted of two questions (1) did you have any symptoms (2) please, pick all that applies. Ten symptoms were provided as option with an “other” option to allow for free answer.

Ethical consideration

The study was conducted according to the Declaration of Helsinki and the Ethical Guidelines on Clinical Studies of the Ministry of Health, Labor and Welfare of Japan. This study was reviewed and approved by the Hiroshima University Epidemiological Ethics Review Committee (E2023-0054). One of the researchers who is not part of the adult health nursing course explained the study purpose and data collection procedure, and consent was received from students agreeing to secondary use of the data. It was explained that not consenting to the provision of data obtained in class would not affect the class grade in any way, and there would be no disadvantage on the part of the students; a written informed consent was obtained from all the students. Therefore, to ensure the class instructors would not be able to know which students had consented, consent procedure and data extraction were done by the research coordinator.

Data analysis

Data analysis was performed with JMP, Pro 17 (SAS Institute Inc., Cary, NC, 1989–2023). Due to the non-normal distribution, descriptive data was presented in median, quartile, frequency, and percentage. Wilcoxon rank-sum test was used to compare the two groups in skill, knowledge, satisfaction, and confidence. The perception was presented as frequency, and percentages based on the level of agreement on the Likert scale; the open-ended questions were analyzed following the conceptual content analysis method to describe the attitudinal and behavioral responses of the students toward the 360 VR video. The VR side effects was presented as frequency and percentage. The level of statistical significance was considered at 0.05.

Out of the 62 students randomized for the study, data of 57 students were used for analysis (Fig. 3). They were all females and aged between 20 and 22 years.

Table 1 shows the median score of both groups based on the knowledge pretest for randomization. Both groups were equally randomized, and there is no significant difference between the two groups.

Table 1: Pretest score for students allocated into face-to-face and 360 VR Video groups
								(N = 57)
Teaching Method	n	Median	25% Quartile	75% Quartile	Max	Min	Z	P-value
Face-to-Face	30	5	4	6	7	3	0.158	0.874
360 VR video	27	5	5	6	7	3	0.158	0.874
Max = maximum score (7)		Min = minimum score (0)
There is no significant difference between the two groups based on the pretest used for block ranndomization
Scores based on knowledge pretest

Psychomotor skills of the students on closed endotracheal suctioning

The median scores for face-to-face and 360 VR groups were 56.5 and 56.0, respectively; there is no significant difference between the two teaching methods (Z= -0.385, P = 0.700) (Table 2 & Fig. 4).

Table 2

Psychomotor skill scores of closed tracheal suction (including oral suction)
								N = 57
Teaching Method	N	Median	25% Quartile	75% Quartile	Max	Min	Z	P-value
Face-to-Face	30	56.5	49.75	59	64	38	-0.385	0.7
360 VR video	27	56.0	49	59	64	22	-0.385	0.7
Max = maximum score (64)			Min = minimum score (0)
There is no significant difference between the two groups
Difference was evaluated using Wilcoxon 2- sample (Rank Sum)

Knowledge of the nursing students

Among the 57 students, 55 students answered the knowledge test (Face-to-Face = 29; 360 VR = 26). The median scores for face-to-face and 360 VR groups were 16 and 15, respectively. No statistically significant difference was observed between the groups (Z = 0.059, P = 0.952). Table 3 presents the median scores of the respective teaching methods.

Table 3: Knowledge scores of closed tracheal suction (including oral suction)
								N = 55
Teaching Method	N	Median	25% Quartile	75% Quartile	Max	Min	Z	P-value
Face-to-Face	29	16	14	16.5	19	9	-0.059	0.952
360 VR video	26	15	13	17	19	10	-0.059	0.952
Max = maximum score (20)		Min = minimum score (0)
There is no significant difference between the two groups
Difference was evaluated using Wilcoxon 2- sample (Rank Sum)

The levels of satisfaction and confidence

Table 4 and Fig. 4 presents the comparison between the level of satisfaction and confidence of the face-to-face and 360 VR groups. While there was statistically significant difference in the level of satisfaction between the two groups, the difference in the confidence level was not significant. On the item level satisfaction, all the statements are statistically significant except, “the teaching material used in this simulation were motivating and helped me to learn” (P = 0.063).

Table 4

a: Satisfaction and Confidence scores of students using the face-to-face and 360 VR Video teaching method
					N = 54
Variables	Teaching Method	N	Median	Z	P-value
Satisfaction	Face-to-Face	28	20	-3.252	0.0011
Satisfaction	360 VR video	26	16.5	-3.252	0.0011
Confidence	Face-to-Face	28	32	-1.097	0.2728
Confidence	360 VR video	26	30	-1.097	0.2728
Satisfaction: maximum score (25)			minimum score (5)
Confidence: maximum score (40)			minimum score (8)
Difference was evaluated using Wilcoxon 2- sample (Rank Sum)
Scores based on a five-point Likert scale

Table 4b: Satisfaction scores of students using the face-to-face and 360 VR Video teaching methods
					N = 54
Satisfaction	Teaching Method	N	Median	Z	P-value
The teaching method was helpful and effective.	Face-to-Face	28	4	-2.877	0.004
The teaching method was helpful and effective.	360 VR video	26	3	-2.877	0.004
The simulation provided me with a variety of learning materials and activities to promote my learning	Face-to-Face	28	4	-2.899	0.004
	360 VR video	26	4	-2.899	0.004
I enjoyed how my instructor taught the simulation.	Face-to-Face	28	4	-3.194	0.001
I enjoyed how my instructor taught the simulation.	360 VR video	26	3.5	-3.194	0.001
The teaching materials were motivating and helped me to learn.	Face-to-Face	28	4	-1.863	0.063
	360 VR video	26	4	-1.863	0.063
The way my instructor(s) taught the simulation was suitable to the way I learn.	Face-to-Face	28	4	-3.674	< 0.001
	360 VR video	26	3	-3.674	< 0.001
Satisfaction: maximum score (25), minimum score (5)
Difference was evaluated using Wilcoxon 2- sample (Rank Sum)
Scores based on a five-point Likert scale; higher score indicating better satisfaction

Table 4c: Confidence scores of students using the face-to-face and 360 VR Video teaching methods
					N = 54
Confidence	Teaching Method	N	Median	Z	P-value
I am confident that I am mastering the simulation activity my instructors presented to me.	Face-to-Face	28	4	-1.811	0.07
	360 VR video	26	2	-1.811	0.07
I am confident that this simulation covered critical content	Face-to-Face	28	4	0.359	0.719
	360 VR video	26	4	0.359	0.719
I am confident in my skills development and obtaining the required knowledge to perform necessary tasks in a clinical setting	Face-to-Face	28	4	-0.702	0.483
	360 VR video	26	4	-0.702	0.483
My instructors used helpful resources to teach the simulation.	Face-to-Face	28	4	-0.918	0.359
	360 VR video	26	4	-0.918	0.359
It is my responsibility to learn what I need to know from this simulation activity.	Face-to-Face	28	4	0	1.000
	360 VR video	26	4	0	1.000
I know how to get help on the concepts covered in the simulation.	Face-to-Face	28	4	-0.710	0.476
	360 VR video	26	4	-0.710	0.476
I know how to use simulation activities to learn critical aspects of these skills.	Face-to-Face	28	4	0.0198	0.984
	360 VR video	26	4	0.0198	0.984
It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time..	Face-to-Face	28	4	0.647	0.518
	360 VR video	26	4	0.647	0.518
Satisfaction: maximum score (40), minimum score (8)
Difference was evaluated using Wilcoxon 2- sample (Rank Sum)
Scores based on a five-point Likert scale; higher score indicating better confidence

Figure 5a: Satisfaction scores of students using the face-to-face and 360 VR Video teaching

method

The perception of the 360 VR use

Table 5

shows the perception of the 360 VR group regarding the VR use. It was intended to introduce the 360 VR to the face-to-face group and explore their perception, but no student in the face-to-face group volunteered to watch 360 VR video after the class. Therefore, the endpoint of comparing how both groups perceived the 360 VR video use was not achieved. Out of the 27 students in the VR video group, a total of 26 students answered the questionnaire. Among them, 81% of the students disagreed that VR is a bad idea; 62% agreed that VR makes learning more interesting; however, 35% of the student cannot decide if they would like to use VR video in future clinical skills, and 42% disagreed.
Table 5:Perception of students using the 360 VR Video
							N (%)
Question	Strongly disagree	Disagree	Somewhat disagree	Cannot decide	Somewhat agree	Agree	Strongly agree
I find VR useful for learning	0 (0)	5 (19.2)	4 (15.4)	6 (23.1)	7 (26.9)	4 (15.4)	0 (0)
VR helped me develop confidence in performing the skill	0 (0)	5 (19.2)	7 (26.9)	7 (26.9)	5 (19.2)	2 (7.7)	0 (0)
I find VR easy to use	0 (0)	10 (38.5)	8 (30.8)	5 (19.2)	3 (11.5)	0 (0)	0 (0)
Using VR is a bad idea	7 (26.9)	9 (34.6)	5 (19.2)	3 (11.5)	1 (3.9)	1 (3.9)	0 (0)
VR makes learning more interesting	1 (3.9)	2 (7.7)	2 (7.7)	5 (19.2)	7 (26.9)	8 (30.8)	1 (3.9)
I would like to use VR in future clinical skills training	2 (7.7)	2 (7.7)	7 (26.9)	9 (34.6)	5 (19.2)	1 (3.9)	0 (0)
N (%): Number of participant and percentage; N = 26

VR sickness symptoms

Table 6 presents the VR sickness symptoms reported by the students using 360 VR video. More than half of students (62.5%) experienced VR sickness symptoms, and “feeling of drunk” is the highest.

Table 6

VR sickness symptoms reported by the students using 360 VR Video
	N = 24
VR sickness symptoms	N(%)
VR sickness symptoms	15 (62.5)
	N = 24
Specific symptoms	N(%)
Feeling of drunk	12 (50.0)
Vomitting	0 (0)
Nausea	1 (4.2)
Diziness	0 (0)
Wobble	1 (4.2)
Fall due to wobble	0 (0)
Sweating	0 (0)
Eye fatigue	8 (33.3)
Fatigue	1 (4.2)
Epilepsy	0 (0)
Headache	3 (12.5)
Neck pain	1 (4.2)
Face pain	1 (4.2)
N (%): Number of participant and percentage; N = 24

Qualitative analysis of the open-ended questions

The open-ended questions were analyzed, and yielded 5 categories. The students appreciated the ready to use, immersiveness, and realism; however, symptoms and discomfort, difficult perspective and production limitations were improvements recommended. Moreover, the impression of the students concerning the 360 VR video was preference for face-to-face teaching because it offers the opportunity to engage with the instructor and ask practical questions. Another aspect is some students believed regular videos are easier to watch. One of the students noted “Difficult, because I have to use equipment (headset) to review videos”. Table 7 presents the analysis of the open-ended questions.

Table 7

Qualitative analysis of student comments of 360 VR video teaching method (N = 26)
Categories	Positives/Improvements
Immersiveness and Realism	(Positive) - The immersiveness and close to reality of the demonstration was appreciated by the students. A total of 11 students believed it was very realistic and this could be leveraged as an alternative to face-to-face demonstration. The students represented this with positive reviews like “up close and personal” “sense of realism” “immersive experience is high”. Direct Quotes: “It was nice to have a sense of realism.” “The head set was heavy. But it was very realistic. It was more up close and personal than actually seeing a faculty member's demonstration.” “In person, it was difficult to see the procedure of the teacher at the front of the classroom in a large group, but in VR it was easier to see the procedure up close.”
Ready to Use and Pacing	(Positive) - The teaching method offers the opportunity to reuse the video to review procedures at convenience. Four students considered the reusability as an effective strategy to teach procedures. This appeared in the texts as “review exercises” and “watch over and over”. Direct Quotes: “It was very realistic. I liked the fact that I could go back and look at the parts I didn't understand over and over again.” “I think if you think about when to use VR, it can be used effectively. (e.g. reviewing exercises in VR at home)” “I wasn't sure if it needed to be in VR. But I do think being able to watch it over and over again is effective for learning.”
Production Limitation	(Improvement) - The technical issue and limitations associated with the production like inability to look down, audiovisual problem, and uncomfortable positioning were some of the concerns of the students. Students (N = 13) represented this as but not limited to “hard to hear distant sounds”, “angle above patient”, and “difficult to look down”. Direct Quotes: “Because the angle was from above the patient, I had to look all the way down to the left to see the nurse's procedure, which was a little uncomfortable. Also, the saturation monitor was behind the patient, so I had to turn around to see it.” “I thought it would be better if the angle could be changed to a position that is easier to see. It would be better if the video could be viewed from the perspective of the person actually performing the procedure, so that the understanding could be deepened.” “It would be easier to understand if the camera position could be set at the same height as when it is implemented. It would be easier to review if you could make the rewind interval a little shorter, say 5 seconds.”
Symptoms and Discomfort	(Improvement) - The VR sickness symptoms and discomfort experienced during the demonstration was reported by the students. Students (N = 15) recounted this as but not limited to “easily intoxicated”, “a bit sick”, “head is heavy”, and “eye strain and headaches”. Direct Quotes: “I feel that I was a little easily intoxicated. It was easy to feel a bit sick.” “It was immersive and realistic, and I could feel what was going on firsthand, but the distortion of the screen and the eye strain and headaches associated with it made it difficult for me to use it on a daily basis” “The camera's viewpoint was directly above the patient, so it was easy to see the procedure, but it was difficult to turn around between the doctor and the monitor. The head set was heavy, so there was a burden on the face, and I felt sick”
Uneasy and Difficult perspective	(Improvement) - The ease of navigation through the activity-oriented demonstration was a source of concern to the students. Students (N = 9) expressed this as phrases like “little uncomfortable”, “difficult perspective”, “had to turn around”, “hassle to put it on”, and “image too large”. Direct Quotes: “I need to turn my head around and I'm tired, so I think it would be good to improve that” “I had to move my head to see some parts of the procedure, so it was more difficult to understand than a live lecture” “It was a hassle to have to put it on and watch the video every time there was a question” “It was hard to tell where things were”

Table 7

a Nursing students’ impression of 360 VR video teaching method (N = 26)
Impressions
	The students were asked of their impression of the new technology, and the overriding concern was for the use of regular video and face-to-face teaching. This was evident is some of the students’ statements. Direct Quotes: “It was difficult to watch and study VR over and over again, so it was easier to review if I could watch regular videos together. It was good that there was a sense of realism.” “I thought that we cannot ask the instructor to ask what we did not understand straight away.” “I thought a demonstration would be better, because I could ask any questions I had at the time on the spot.” “I appreciate the ability to replay videos when I want to review, but on a computer monitor, regular videos are easier to watch.” “Compared to watching videos on a PC, the sense of presence is superior, but considering the hassle of wearing the device, eye strain and headaches after watching, daily use or use for more than 20 ~ 30 minutes is not feasible.”

This study assesses the effectiveness of 360 VR video in teaching nursing procedure over the traditional face-to-face teaching method. Our hypotheses were that the 360 VR video group would demonstrate better skill, knowledge, confidence, and satisfaction level than the face-to-face group; these hypotheses were not supported as there was no statistically significant difference between the groups in skill, knowledge, and confidence. Moreover, the face-to-face group had higher satisfaction level then the 360 VR video group.

The research on 360 VR video is a relatively new area in medical education, and teaching method for comparison are not usually the same, which makes the evidence disparate. A complementary study by Arents et al(42) compared a group of students learning medical obstetrics and cesarean section in face-to-face combined with 360 VR video to the face-to-face group only; there was no statistical difference found between the groups in knowledge retention. To the best of our knowledge, the other available studies on 360 VR video used 2D video as a comparison group. Chao et al(26) compared nursing students learning nasogastric tube feeding with 360 VR video and regular demonstration video on the outcomes of skills, knowledge, satisfaction, and confidence. There was no statistically significant difference between the two groups in skill, knowledge, and confidence; however, the VR group demonstrated higher satisfaction than the traditional video group. This satisfaction result is also in line with Lee, Kim and Park(44) as there was statistically significant difference in satisfaction between the groups of 360 VR video and 2D video.

It was expected that the immersiveness, higher engagement and enthusiasm associated with the use of 360 VR video could afford the students a higher possibility of effective learning(45–48). The non-significant study outcomes might be that the action-oriented activities involved cognitively demanding details that requires extra attention; highly complex learning environments increase the cognitive load(49). The students reported concerns on having to move and turn in the virtual space to follow up on the procedure; it is the first time to use such novel technology to learn procedure, and it might be distracting. Moro et al(48) maintained that there is a risk of distraction with the use of VR technology; the participants reported spending more time on exploring the technology rather than learning the contents. Chao et al(26) also maintained similar conclusion. Likewise, the VR sickness and discomfort could have hampered the learning experience. The result of the VR symptoms revealed that, about 63 percent (15 out of 24 students) of the students reported VR related symptoms in this study. Moro et al(48) reported that the adverse effects of dizziness, blurred vision, and headaches were felt by 40%, 35%, and 25% of the students, respectively; this could have an impact on learning quality. The participants in Van De Broeck(50) concludes that although the immersiveness with head mount displays offer the best user experience, they are associated with cognitive burden, motion sickness and physical discomfort. Somrak et al(51) reported negative association between VR sickness discomfort levels and user experience.

Although the other study outcomes were comparable, the satisfaction level of the face-to-face group was significantly higher than the 360 VR video group in this study. The possible reasons might be that, to begin with, this study explores the satisfaction of a video-based group, which has been believed by students to lack the opportunity to ask questions and interact with the instructor(52). Likewise, the teaching method was adopted as an alternate approach rather than blending face-to-face with video for the intervention group. Alqahtani et al(29) concluded that students were reluctant to replace live demonstration with procedural video; only 40% of the students preferred the procedural video compared to the face-to-face demonstration. Our students might have appreciated the interaction opportunity in the face-to-face teaching; the use of VR is a new method of teaching and students are already familiar and accustomed to the face-to-face teaching method. The studies demonstrating significant difference in satisfaction compared two different video-based method (VR versus regular demonstration video). It is difficult to extrapolate other studies result on satisfaction to our study based on the difference in approach. Additionally, the discomfort experienced through the VR sickness symptoms might have affected their satisfaction level. Moreover, the qualitative result also suggested that symptoms, uneasiness to use, and production limitation, were negative experiences often cited by the students. For perception, only 23% of the students would like to use VR in future skills training. Contrarily, in Arents et al(42) a complementary approach, 83.4% of the students reported that more 360 VR videos should be used in future courses.

Limitations and strengths

The limitation in this study is, to begin with, the intervention was open to the student, and this could have alerted and give the impression of non-conformity to the new technology as a replacement for the established teaching method. This effect and performance bias could have been mitigated with a blinded study, but blinding was not feasible. Moreover, the 360 VR video was only content validated; the production was not validated for use. This could have also affected the students experience of the technology leading to production limitation. Additionally, all the students in our study are females; if the genders were mixed, there could be more generalization as gender factors in the acceptance of technology. Subsequently, our sample was a convenience sample of the nursing students enrolled in the course; a larger sample size could have achieved a normal distribution and mitigate the effect of using a non-parametric test. This could allow for better generalization of the outcomes.

Although face-to-face demonstration is the established method of teaching psychomotor skills to nursing students, the use of 360 VR video could achieve similar learning effect as an alternative approach. While this is true for learners’ performance, there is need for more studies to explore the students’ satisfaction when used as an alternative. The use of 360 VR video with HMD offers the best immersive experience; this should be used with cautions due to the VR sickness symptoms experienced by users.

CVI: Item-level content validity index

CVI/UA: Scale level content validity index of universal agreement

HMD: Head Mounted Display

ICU: Intensive Care Unit

OSCE: Objective Structured Clinical Exam

TAM: Technology Acceptance Model

VR: Virtual Reality

VLC: VideoLAN Client

2D: Two-dimensional

Ethics approval and consent to participate.

Consent for publication

Written informed consent for publication was obtained for use of the images

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interest

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Funding

The purchase of the HMDs and development of the 360 VR video content was funded by the Ministry of Education, Culture, Sports, Science and Technology, FY2021 Subsidy for Promotion of University Reform (Project for Fostering Medical Personnel for New Healthcare in the “With COVID-19 Era”).

Authors’ contribution

Concept and design: AOB, MK, CT, MO, MM; Development of educational content: AOB, MK, MO, YH, TS, MH, MM; Implementation: CT, MO, MM; Data collection: MK; Data analysis: AOB; Interpretation of data: AOB, SO, MM; Manuscript drafting: AOB, MM; Manuscript review: MK, CT, SO, TS, MH, MM. All authors read and approved the final manuscript.

Acknowledgement

We would like appreciate Hiroshima University Hospital Intensive Care Unit (ICU) Nurses and the students for their contribution. In addition, the nursing faculties and registered nurses that evaluated the psychomotor skills (Hiroyuki Sawatari, Tae Watanabe, Mizuho Kidani, Mikako Yoshihara, Haruka Yoshimaru, Emi Kawasaki, Kenji Matsuo)

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Face-to-face versus 360 VR video: a comparative study of two teaching methods in nursing education

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Abstract

Figures

Background

Method

Study design and Participants

Data collection procedure

Randomization and allocation

Development of the 360 VR Video

360 VR group

Face-to-Face group

Evaluation outcomes and Instrument

Closed tracheal suction checklist (including oral suction)

Knowledge test scores for suction in ventilated patients

Degree of satisfaction and confidence in learning

Perception of VR use

Ethical consideration

Data analysis

Results

Psychomotor skills of the students on closed endotracheal suctioning

Knowledge of the nursing students

The levels of satisfaction and confidence

The perception of the 360 VR use

VR sickness symptoms

Qualitative analysis of the open-ended questions

Discussion

Limitations and strengths

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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Journal Publication

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