Open access peer-reviewed chapter

The Use of Virtual Reality Simulations in Nursing Education, and Patient Safety

Written By

Sule Biyik Bayram and Nurcan Caliskan

Submitted: 29 August 2020 Reviewed: 18 September 2020 Published: 05 November 2020

DOI: 10.5772/intechopen.94108

From the Edited Volume

Contemporary Topics in Patient Safety - Volume 1

Edited by Stanislaw P. Stawicki and Michael S. Firstenberg

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Nursing education puts theory into practice. Patient safety is indispensable in nursing education. During clinical practice, nursing students make medication errors and have difficulty deciding on what interventions to perform in unusual situations and communicating with patients or other healthcare professionals. All these problems put patient safety at risk. However, “First, do no harm” is a fundamental human right and an ethical principle, which nurses should always consider when they perform interventions. Nursing students can help develop a culture of patient safety through experience in line with their knowledge, skills, and affective goals. Clinical settings can be equipped with real-life laboratories, mannequins, etc. Virtual reality simulations show nursing students what it is like to be in a real-world clinical setting and what problems and risks they may encounter there, and thus, helps them develop skills, build confidence, and prepare for clinical practice. This section addressed the effect of virtual reality simulations on skill development and patient safety in nursing education.


  • nursing education
  • patient safety
  • psychomotor skills
  • simulation
  • virtual reality

1. Introduction

Nursing education integrates theory and practice to help students develop cognitive, intellectual, affective (attitudes and beliefs), and psychomotor skills and prepare for professional life [1]. Errors in real clinical settings threaten patient safety. Therefore, nursing students should perform primary nursing interventions over and over in laboratories and develop basic psychomotor skills before they enter clinical practice. Simulations replicate real-world situations in which nursing students can gain clinical experience without putting patients at risk [1, 2, 3]. Simulations provide effective learning environments where nursing students can gain experience and develop collaboration, management, critical thinking, communication, clinical decision-making, and problem-solving skills without harming patients, and boost their confidence and readiness for real clinical practice [2, 4, 5, 6]. Virtual reality (VR), which is a type of simulation, consists of state-of-the-art equipment and augmented-reality interventions. The more similar the simulation is to the real clinical setting, the more motivated and better the students are at developing skills. VR simulations provide nursing students with the opportunity to perform high-risk and high-cost interventions on virtual patients and gain experience without jeopardizing the safety of real patients [7, 8].

1.1 Psychomotor skills and simulations

Psychomotor skills are coordinated muscle movements governed by conscious mental processes to complete certain tasks [9]. Students develop psychomotor skills by putting theory into practice in lab settings. Instructors first demonstrate the skills and then allow students to put them into practice by themselves and give them feedback on their performance until they become competent [10]. In lab settings, students analyze theoretical knowledge, learn to make observations, and establish a relationship between theory and practice, put their critical thinking and problem-solving skills into practice, and build up confidence [11, 12]. This training teaches them how to perform interventions before clinical practice without risking patient safety [3, 5]. Nursing students without psychomotor skills are more likely to feel insecure and inadequate and make medical errors in clinical practice than those with psychomotor skills [5]. To overcome those problems, it is necessary to help nursing students acquire knowledge and develop skills and put the theoretical knowledge of safe care into practice. Educational technologies are recommended to achieve that goal [13, 14, 15]. The students of Generation Z are particularly interested in technology and can easily access information via their personal devices. Therefore, simulations that appeal to the new generation of students have become widespread [5].

Simulations are a safe way for students to perform activities in environments that replicate actual or potential situations. It is effective and engaging because it helps students learn how to use equipment and develop problem-solving and decision-making skills before they step into real clinical settings where training is hard, dangerous, and costly. Simulations are used for pilot and astronaut training and medical education (e.g., cadaver) [16]. Simulations allow nursing students to practice whenever they want without jeopardizing patient safety [17, 18].

1.2 Types of simulations

Two types of simulations are used in nursing education; high-fidelity and low-fidelity. Low-fidelity simulations are three-dimensional organ models, human cadavers, animal models, and simulated and standardized patients. Three-dimensional organ models are anatomical models used to teach students about cardiac functions and how to insert a peripheral IV catheter and perform spinal anesthesia, first aid for injuries, and a breast examination. Simulated and standardized patients are used to help students develop communication skills and to teach them how to take a medical history and perform physical examinations [19]. High-fidelity simulations are image-based, realistic, and interactive patient simulations, VR, and haptic systems. Image-based simulations are computerized image-and video-based simulations that help students learn and develop critical thinking and decision-making skills by themselves [20]. Realistic and interventional simulations, also known as partial task trainers, imitate body parts to teach students particular skills. Some of the realistic and interventional simulations are models for intravascular and foley catheterization, and stitching, and eye and ear as well as ultrasound, clinical cardiology (auscultation), and invasive cardiology (catheterization) simulations. High-tech interactive simulations are computerized virtual patients replicating human anatomy and physiology. Such simulations can breathe, talk, and move their eyes, and have a pulse and heart rate [21]. VR and haptic systems are three-dimensional simulations that feel real and communicate with participants through computers [22]. Haptic systems are used to tutor students on laparoscopic and endoscopic interventions and to evaluate surgical skills [23].

1.3 Virtual reality

Virtual reality is a computer-generated 3-D simulation that delivers a wide range of sensory information to the user to allow them to interact with objects in a virtual environment and make them feel like they are physically there [15, 24]. VR can be used to help nursing students develop skills in virtual hospital settings.

Interactivity is a key feature of VR, making it more effective than video demonstration. In VR simulations, users wear 3-D glasses and data suits and interact with one another haptically or via a keyboard and a mouse [24, 25, 26, 27, 28]. Second Life, Quest Atlantis, Active Worlds, Wonderland, World of Warcraft, and Opensim are 3D/VR platforms, with Second Life being the most popular one [15].

Virtual reality simulations provide students with the opportunity to put interventions into practice on models to overcome problems they may encounter in real clinics [29]. For example, VR can be used to teach nursing students tracheostomy care or urinary catheterization [17, 29]. In this way, they can develop nursing skills on virtual patients and perform interventions smoothly and confidently in real clinics without running the risk of harming real patients [15].

There are two types of VR technologies; immersive and non-immersive. Immersive means “the state of being surrounded, engrossed, and absorbed, the state of being three-dimensional,” as well as “plunging into something, and disassociating from reality and entering a virtual world [30]. Immersive VR provides experiences where the user wears a headset and motion-sensing gloves and loses all sense of the real world in a place no bigger than a room. Non-immersive VR is a computer-generated not-fully interactive 3D environment in which the user uses a keyboard, mouse, joystick, and haptic display to control and navigate [31].

1.4 What is virtual reality, and where is it used?

Virtual reality was first used in video games, followed by education, culture, arts, tourism, e-commerce, manufacturing, military and airline, construction, and production [22]. Three-dimensional virtual worlds in education make students more motivated to access information and use it in learning and help them adopt lifelong learning and develop collaboration skills [32]. Virtual reality also allows students to immerse themselves in virtual worlds that replicate the real world and use the materials there and interact with them. It appeals to all senses and promotes effective learning and learning retention. In the field of education, VR was first used in military, flight, and astronaut training [30]. Packy and Marlon was an educational video game developed in 1995 in Japan to teach self-care behavior to children with diabetes [33].

1.5 The use of virtual reality simulations in nursing education

Virtual reality in the field of medical education is defined as a type of computer-based 3D simulation that makes users feel like they are in clinical settings where they can practice skills without putting patients at risk [15]. VR used in physical therapy, and medical and nursing education [15, 17, 34, 35, 36, 37] allows students to practice as often as they want and see their own mistakes in safe lab settings [38]. Therefore, such simulations with active engagement improve learning retention and enable participants to learn interactively and analyze problems [39]. VR serves as a bridge between theory and practice in nursing education [40]. Research shows that VR makes learning fun and active participation possible through feedback and helps nursing students acquire knowledge and develop skills and makes them more motivated and confident [41, 42, 43, 44].

Nehring and Lashley [45] mentioned that Phillips [46] was the first to use VR in nursing. Afterward, Merril and Barker [47] developed a prototype for intravenous (IV) catheterization, and then, Skiba [48] used Internet-based interactive virtual environments [45]. The first example of VR in nursing is the CathSim Intravenous Training System (CathSim ITS) developed in 1998. Research shows that CathSim ITS makes participants more motivated and confident and results in a reduction in intervention-related pain, the incidence of hematoma formation, and the number of interventions [49, 50, 51]. Students with low anxiety and advanced skills are more likely to perform initiatives quickly and safely. Multiple interventions increase potential risks and jeopardize patient safety.

1.6 Advantages and disadvantages of virtual reality

Virtual reality simulations boost students’ concentration, engagement, confidence, motivation, and creativity, and allow them to put theory into practice and learn at their own pace [45]. It also provides them with the opportunity to practice whenever and how often they want in safe and realistic environments without fear of making mistakes and harming patients [52]. Students participating in VR simulations are more likely to become comfortable, confident, and successful in real clinical settings because they learn in an applied format [17, 29]. They can also practice dangerous, costly, and complex interventions that they are less likely to encounter in real clinics [22]. However, VR simulations require interdisciplinary collaboration, and time and money to design scenarios and to train instructors [28]. Besides, prolonged VR use causes dizziness, headaches, and pain when moving the eyes [53].

1.7 Impact of virtual reality simulations on patient safety

Patient safety is about eliminating preventable medical errors that cause harm to patients [54]. High-quality nursing education is a precondition of patient safety. Simulations, in general, and VR, in particular, improve the quality of nursing education and enables students to put theory into practice and develop skills and positive attitudes [15]. Those students are more likely to consider patient safety when performing clinical interventions [55].

Research shows that students who have developed fundamental nursing skills in virtual environments are likely to feel more comfortable and confident and minimize the harm that may result from interventions in real clinical settings [9, 10]. For example, Tag Team Patient Safety Simulation (TTPSS) enhanced nursing students’ knowledge and skills and enabled them to provide safe care [56]. VR simulation scenarios should emphasize the principles of patient safety to teach students how to provide safe care in clinics. The Joint Commission International outlines six principles of patient safety [57, 58]. The next section discusses the contribution of VR simulations to nursing education with reference to those principles.


2. Identifying patients correctly

Patient identity should be confirmed before all fundamental nursing interventions. The patient should have at least two of the four identifiers (name, surname, protocol number, and date of birth) as evidence for identification [59]. Skill tests and lists in nursing education emphasize the importance of patient identification. Henneman et al. [60] emphasized in his simulation study that verification of patient identity before drug administration is important in ensuring patient safety. In a VR simulation scenario on tracheostomy care, an avatar nurse verified the identity of a virtual patient from her wristband and explained to her the medical procedure to be carried out [61]. The scenario taught the participants how to identify patients correctly. It also highlighted the significance of patient identification as an essential stage of clinical interventions by not allowing the participants who failed to verify the patient’s identity to move on to the next stage. Therefore, such scenarios are an effective method for teaching nursing students how to identify patients correctly.

In the studies, the first step in the teaching of skill is the patient character verification process [43, 62, 63]. In a thesis study conducted by Biyik Bayram [62], one of the process steps in the simulation scenario is the patient verification step. Performing the student patient verification process in the VR game will enable him to focus on the same step in the clinic (Figure 1) [62]. Koivisto et al. [43], in their study with 166 nursing students, stated that students working with a simulation scenario were able to identify the descriptive characteristics of the patient and plan appropriate nursing interventions. Shibuy et al. [63] in his study with 36 nursing students, it is expected that the student will verify the patient identity in the first step in the 24-item tracheostomy aspiration skill. As seen in the studies, nursing skills practices start with the verification step of the patient identity and the student must ensure the competence in simulation practice to fulfill this task in clinical practice (Table 1) [63].

Figure 1.

Patient identify.

Patient safety principlesAuthor/yearDesignMethodConclusion
1. Identify patient correctlyShibuya et al./2019 [63]Three groupsVirtual Reality (VR group)
Traditional demonstration (TR group)
No intervention (NO group):
The checklist of tracheostomy suctioning skills (Identify patient using name)
Biyik Bayram/2017 [62]Randomized controlledGame Based Virtual Reality (experimental group)
Traditional method (control group)
The checklist of tracheostomy care skills (Identify patient using wristband)
Koivisto et al./2016 [43]Descriptive studyCareMe® Virtual Reality GameIt has been stated that simulation is effective patient identification.
Henneman et al./2010 [60]Retrospective studyTwo simulation scenariosIt has been determined that the nursing process game increases students’ concentration and experience.
2. Improving effective communicationFay-Hiller et al./2012 [55]ReviewHigh-fidelity simulationsHealth team communication.
Guise et al./2012 [65]ReviewHigh-fidelity simulationsSimulation help healthcare professionals develop communication skills.
Foronda et al./2016 [65]Descriptive and mix methodVirtual reality simulationStrengthens team communication
Liu et al./2018 [66]Pilot studyVirtual patientsVirtual patient improves students’ communication skills
3. Improving the safety of high-alert medicationsGu et al./2017 [67]Randomized controlledVirtual reality simulationsIt was stated that the IV drug infusion skills of the students increased. Prevents medication administration errors.
Lutckar-Flude et al./2012 [68]Experimental studyThe laboratory study (control group)
Virtual learning module (experimental group)
It was stated that the students’ self-confidence increased.
Dubovi et al./2017 [69]Quasi--experimental study (pre-post test)Virtual Reality SimulationLearned well about drug management
Vidal et al./2013 [49]Quasi--experimental studyIntravenous Virtual Reality SimulationIntravenous catheter interventions more successfully
4. Ensuring correct siteKruglikova et al./2010 [70]Experimental studyThe Accu Touch endoscopy simulatorVirtual Reality colonoscopy simulation performed it more accurately, safely, and quickly.
Weideman and Culleiton/2014 [71]ReviewVirtual patientVirtual patient improved students’ obstetrics skills.

Table 1.

The studies of contribution of virtual reality simulations on 1,2,3 and 4 patient safety principles.


3. Improving effective communication

All healthcare professionals should have effective communication skills to ensure patient safety. Research shows that a lack of or poor communication or miscommunication among patients, nurses, and other healthcare professionals puts patient safety at risk [56, 72]. A lack of communication leads to missing patient data and poor planning, which may result in misdiagnosis and inappropriate treatment [72]. High-fidelity simulations help healthcare professionals develop communication skills. Low-fidelity partial body manikins cannot give feedback, but high-fidelity Simman and virtual patients can speak [64]. VR simulations that can talk enable students to cooperate and make accurate and rapid clinical decisions [73]. Similarly, communicating with virtual patients improve students’ communication skills (Table 1) [56, 64, 65, 66]. VR can be used to teach students how to take patient history, welcome patients to the clinic, implement the protocol/procedure for discharge, and communicate with other healthcare professionals.


4. Improving the safety of high-alert medications

Nurses frequently administer medications based on the six rights: the right drug, the right patient, the right dose, the right route, the right time, and the right documentation. Nurses who do not comply with those principles or do not know how to administer drugs or have never practiced on a model are more likely to put patient safety at risk [74]. VR simulations give students feedback and help them learn by doing interactively [67]. VR simulations on intravenous drug infusion [67, 68] and administration [70] help students improve the ability to administer medications safely. Dubovi et al. [69] found that nursing students who participated in a VR simulation learned well about drug management. Gu et al. [67] also reported that a VR simulation helped nursing students acquire knowledge on the fundamental principles of asepsis, urinary catheterization, and drug management. Luctkar-Flude et al. [68] found that a VR simulation improved nursing students’ IV drug infusion skills. VR simulations are also used to teach nursing students how to notice possible complications after drug administration. For example, Vidal et al. [49] determined that nursing students performed IV interventions more successfully on fewer trials, inflicted less pain on patients, and observed lower incidence of hematoma formation after they participated in a VR simulation (Table 1). This result suggests that nursing students participating in VR simulations comply with the six rights of drug administration and intervention steps, and thus, prevent complications, resulting in improved patient compliance and shortened length of hospital stay.


5. Ensuring correct-site, correct-procedure, correct-patient surgery

Surgical errors are among the most common errors that jeopardize patient safety. Virtual patients can be used to inform students on patient safety based on the Surgical Safety Checklist. Students can practice filling out the name and location of the surgery and receiving informed consent before surgery. In this way, they can see their shortcomings and evaluate patient outcomes and learn better through experience [53]. Medical students can manage or perform surgeries on virtual patients that replicate human anatomy and cope with complications [40]. Nurses practicing colonoscopy [70] and obstetric [68] interventions on virtual patients are likely to have better skills and make fewer errors. Kruglikova et al. [70] found that nurses participating in a VR colonoscopy simulation performed it more accurately, safely, and quickly. Weideman and Culleiton [71]. reported that practicing obstetrics on a virtual patient improved students’ skill (Table 1). This result shows that virtual patients can be used to help surgical nursing students see their shortcomings and patient outcomes and develop skills.


6. Reducing the risk of health care-associated infections

Infections are the most common cause of death in hospitals. Hand and skin hygiene before each intervention breaks the chain of infection [75]. VR simulations can be used to help nurses develop positive attitudes towards hygiene, resulting in a reduction in the rate of infections. Hand washing is the most effective way to prevent the spread of infections. Nakamura et al. [76] found that simulation scenarios raised students’ awareness of hand hygiene and reduced the incidence of catheter-infection. VR simulations improve students’ knowledge and skills on decontamination [44, 77] and urinary [4, 17] and intravenous catheterization [10, 34, 78, 79], port catheter injection [35], tracheostomy aspiration [80] and care [29] and nasogastric (NG) tube insertion (Table 2) [50, 83]. Failure to comply with asepsis rules in such invasive procedures may cause the spread of infections. Besides, students rarely find themselves in situations where they have to perform those procedures in clinics. They should, nevertheless, practice them in VR simulations so that they would not have anxiety and difficulties in case they have to perform them in clinics [15]. This enables them to put their knowledge and skills into practice more efficiently, resulting in higher-quality care and reduced rates of infections and complications.

Patient safety principlesAuthor/YearDesignMethodConclusion
5. Reducing the risk of infectionsSmith and Hamilton/2015 [44]Experimental studyComputer-based virtual realityThe urinary catheterization skills have increased.
Farra et al./2015 [77]Quasi--experimentalVirtual realityThe decontamination skills of the students increased.
Kardong-Edgren et al./2019 [4]Pilot studyHaptik and virtual realityVirtual reality is fun and effective in teaching.
Butt et al./2018 [17]Pilot studyİmmersive virtual realityStudents’ level of knowledge is increased
Tsai et al./2008 [34]Pilot studyVirtual realityIntravenous catheter application skill was advanced.
Jung et al./2012 [78]Experimental studyArm model(A group)
Virtual reality (B group)
Virtual reality and arm model (C group)
C group was successful compared to other groups.
Engum et al./2003 [79]Randomized controlled (Pre-post test)Arm model (control group)
Virtual reality (experimental group)
There was an increase in the intravenous catheter application knowledge scores of the students who used the virtual reality method.
Tsai et al./2008 [35]Experimental study (Pre-post test)Traditional (control group)
Virtual reality (experimental group)
Port catheter injection knowledge and skill increased.
Noyudom et al./2011 [80]Experimental (Pre-post test)Virtual RealityTracheostomy suctioning knowledge and skill increased.
Biyik Bayram and Caliskan/2019 [29]Randomized controlledTraditional (control group)
Virtual reality (experimental group)
Tracheostomy care knowledge and skill increased.
Chiang et al./2017 [50]Quasi--experimentalTraditional (control group)
Virtual reality (experimental group)
NG tube insertion skill increased.
Choi et al./2015 [78]Pilot studyVirtual realityThought to guide nurses.
6. Reducing the risk of patient fallsBursiek et al./2020 [81]Pilot studyVirtual scenarioPatient falls decreased.
DeBourg and Prion/2011 [82]Quasi-experimental study (per-post test)SimulationSimulation ensuring a culture of patient safety and preventing falls.

Table 2.

The studies of contribution of virtual reality simulations on 5 and 6 patient safety principles.

In the experimental study conducted by Smith and Hamilton [44] with 20 nursing students, it was stated that computer-based VR application increased urinary catheter skills. In the study conducted by Kardong-Edgren et al. [4] with 31 nursing students, it was stated that haptic VR application increased urinary catheterization skills. These studies highlight the asepsis conditions that the student must comply with in the urinary catheterization procedure. It is aimed that the student fulfills the requirements of asepsis while performing this procedure on the patient. Butt et al. [17] performed urinary catheterization skills with 20 nursing students in a VR environment with a device and gloves they wore on their heads. In a study conducted by Farra et al. [77] with 106 nursing students, it was stated that students’ decontamination skills increased. Thus, attention was paid to the prevention of infections. Tsai et al. [34] stated that the frequency of errors of students decreased in the intravenous catheter application they performed in virtual environment with 10 students. In the study conducted by Jung et al. [78], it was stated that the success of the group working with intravenous catheter application and arm model was higher than the others. Tsai et al. [35] increased the knowledge level of port catheter injection of 77 nurses using VR application. Noyudom et al. [80] increased tracheostomy aspiration skills of 35 nursing students working in a virtual environment.

Biyik Bayram and Caliskan [29] stated that 86 nursing students increased tracheostomy aspiration skills with the use of VR. In the study conducted by Chiang et al. [50] with 79 students, it was stated that NG tube insertion application skills increased. NG tube insertion skill is a procedure that must be complied with medical asepsis conditions. Thus, the student understands the distinction between medical and surgical asepsis rules. Similarly, VRapplications are designed to improve NG tube insertion skills in the design study by Choi and his friends.


7. Reducing the risk of patient harm resulting from falls

Nurses are responsible for providing safe care, which is an indicator of the quality of care [70]. Making sure the bed brakes are locked and raising the bed rails are preventive measures against accidental falls. Therefore, VR simulations are used to teach them. Biyik Bayram and Caliskan [61] used a tracheostomy care scenario in which the student was supposed to lower the bed rails before the intervention and raise them back after the intervention, and if the student skipped the step, she failed to complete it. Such simulations teach students what kind of preventive measures to take against falls. Bursiek et al. [81] reported a decrease in patient falls in clinics with nurses working in virtual scenarios. It was also emphasized that teamwork is effective in preventing patient falls [81]. DeBourg et al. [82] stated that simulation studies were effective in providing patient safety culture of 285 students and preventing falls (Table 2). VR simulations have scenarios in which students can keep practicing preventive measures against falls. In this way, they know what to do when they encounter such situations in real clinics. Students should put virtual patients in VR simulations at risk so that they will not jeopardize the safety of real patients because the former can afford the risk, but the latter cannot.


8. Conclusions

Nursing education is an applied type of education. Therefore, students must perform both lab and clinical practice. However, students may put patients at risk because they are inexperienced. Nurses are responsible for establishing a culture of patient safety and protecting patients. Nursing students should participate in activities and lab interventions to become aware of patient safety. Nursing students who do not have much opportunity to participate in lab activities can be provided with VR simulations. Research shows that VR simulations help students gain knowledge and develop collaboration and critical thinking skills, and recognize rare clinical situations, and communicate effectively with patients. Nursing students with those skills can provide safe care, administer medications correctly, and notice changes in their patients. In conclusion, students who participate in VR simulations can provide patient safety in real clinics.


Conflict of interest

No conflict of interest has been declared by the authors.


Glossary of abbreviations


Virtual Reality






Tag Team Patient Safety Simulation


  1. 1. Oermann MH, Gaberson KB. Evaluation and Testing In Nursing Education. 4th ed. New York; Springer Publishing Company; 2014. 12-305p.
  2. 2. Cant RP, Cooper SJ. Simulation based learning in nurse education: systematic review. Journal of Advanced Nursing. 2010;66(1):3-15. DOI: 10.1111/j.1365-2648.2009.05240.x
  3. 3. Silveira MDS, Cogo ALP. The contributions of digital technologies in the teaching of nursing skills: an integrative review. Revista gaucha de enfermagem. 2017;38(2). DOI: 10.1590/1983-1447.2017.02.66204
  4. 4. Kardong-Edgren S, Breitkreuz K, Werb M, Foreman S, Ellertson A. Evaluating the usability of a second-generation virtual reality game for refreshing sterile urinary catheterization skills. Nurse educator. 2019;44(3):137-141. DOI: 10.1097/NNE.0000000000000570
  5. 5. Terzioğlu F, Kapucu S, Özdemir L, Boztepe H, Duygulu S, Tuna Z, et al. Nursing students’ opinions about simulation method. Hacettepe University Nursing Faculty Journal. 2012;19(1):16-23 (in Turkish)
  6. 6. Khalaila R. Simulation in nursing education: an evaluation of students’ out comes at their first clinical practice combined with simulations. Nurse Education Today. 2014;34(2):252-258. DOI: 10.1016/j.nedt.2013.08.015
  7. 7. Raman S, Labrague LJ, Arulappan J, Natarajan J, Amirtharaj A, Jacob D. Traditional clinical training combined with high-fidelity simulation-based activities improves clinical competency and knowledge among nursing students on a maternity nursing course. In Nursing Forum. 2019;54(3):434-440. DOI: 10.1111/nuf.12351
  8. 8. Fealy S, Jones D, Hutton A, Graham K, McNeill L, Sweet L, et al. The integration of immersive virtual reality in tertiary nursing and midwifery education: A scoping review. Nurse Education Today. 2019;79:14-19. DOI: 10.1016/j.nedt.2019.05.002
  9. 9. Morgan R. Using clinical skills laboratories to promote theory–practice integration during first practice placement: an Irish perspective. Journal of Clinical Nursing. 2006;15(2):155-161. DOI: 10.1111/j.1365-2702.2006.01237.x
  10. 10. Baillie L, Curzio J. A survey of first year student nurses’ experiences of learning blood pressure measurement. Nurse Education in Practice. 2009;9:61-71. DOI: 10.1016/j.nepr.2008.05.003
  11. 11. Mete S, Uysal N. Implementatıon of an Education Model for Nursing Skills Development Dokuz Eylül University High School Nursing E-journal. 2009;2(3), 115-123. (in Turkish).
  12. 12. Eker F, Açıkgöz F, Karaca A. Occupational Skill Training through the Eyes of Nursing Students. Dokuz Eylül University High School Nursing E-journal. 2014;7(4):291-294 (in Turkish)
  13. 13. Kelly M, Lyng C, McGrath M, Cannon G. A multi-method study to determine the effectiveness of, and student attitudes to, online instructional videos for teaching clinical nursing skills. Nurse Education Today. 2009;29(3):292-300. DOI: 10.1016/j.nedt.2008.09.004
  14. 14. Aleman JLF, De Gea JMC, Mondejar JJR. Effects of competitive computer-assisted learning versus conventional teaching methods on the acquisition and retention of knowledge in medical surgical nursing students. Nurse Education Today. 2011;31(8):866-871. DOI: 10.1016/j.nedt.2010.12.026
  15. 15. Jenson CE, Forsythm DM. Virtual reality simulation: using three-dimensional technology to teach nursing students. Computers Informatics Nursing. 2012;30(6):312-318. DOI: 10.1097/NXN.0b013e31824af6ae
  16. 16. Tan Ş. Öğretim Ilke ve Yöntemleri. 13rd ed. Ankara: Pegem Akademi; 2016. pp. 2-307 (in Turkish)
  17. 17. Butt AL, Kardong-Edgren S, Ellertson A. Using game-based virtual reality with haptics for skill acquisition. Clinical Simulation Nursing. 2018;16:25-32. DOI: 10.1016/j.ecns.2017.09.010
  18. 18. Şendir M, Doğan P. Hemşirelik eğitiminde simülasyonun kullanımı: Sistematik inceleme. Florence Nightingale Nursing Journal. 2015;23(1):49-56 (in Turkish)
  19. 19. Ziv A, Small SD, Wolpe PR. Patient safety and simulation-based medical education. Medical Teacher. 2000;22(5):489-495. DOI: 10.1080/01421590050110777
  20. 20. Lane JL, Slavin S, Ziv A. Simulation in medical education: A review. Simulation & Gaming. 2001;32(3):297-314. DOI: 10.1177/104687810103200302
  21. 21. Mıdık Ö, Kartal M. Simulation-based medical education. Marmara Medical Journal. 2010;23(3):389-399
  22. 22. Bayraktar E, Kaleli F. Virtual reality on commercial applications Akademik Bilişim 2007. 1-6.
  23. 23. Çoban S. Uzaktan ve teknoloji destekli eğitimin gelişimi. 2012. Available from: [Accessed: 2020-06-30]
  24. 24. Bulu ST, İşler V. Second life ODTÜ kampüsü. Akademik Bilişim Kongresi’nde sunulan bildiri. İnönü Üniversitesi, Malatya: Kasım, 15, 2011.
  25. 25. Aydın ED. Üç boyutlu sanal gerçeklik ortamında mimari mekan temsilinin geliştirilmesi: temel anlam ve yan anlam yaratma, [thesis]. Fen Bilimleri Enstitüsü, İstanbul: Yıldız Teknik Üniversitesi; 2012
  26. 26. Kaufman D, Sauve L. Educational gameplay and simulation environments: case studies and lessons learned: Case studies and lessons learned. New York: Information Science Reference; 2010. pp. 231-250p
  27. 27. Sherman WR, Craig AB. Understanding virtual reality: Interface, application, and design. USA: Elsevier. 2003. 24-37p.
  28. 28. Kayabaşı Y. Sanal gerçeklik ve egitim amaçlı kullanılması. The Turkish Online Journal of Educational Technology. 2005;4(3):151-166
  29. 29. Biyik Bayram S, Caliskan N. Effect of a game-based virtual reality phone application on tracheostomy care education for nursing students: a randomised controlled trial. Nurse Education Today. 2019;79:25-31. DOI: 10.1016/j.nedt.2019.05.010
  30. 30. Tepe T, Kaleci D, Tüzün H. Eğitim teknolojilerinde yeni eğilimler: sanal gerçeklik uygulamaları. Paper presented at the 10th International Computer and Instructional Technologies Symposium. 2016. Rize, Türkiye.
  31. 31. Lee EAL, Wong KW. A review of using virtual reality for learning. Heidelberg: Springer; 2008
  32. 32. Erbaş Ç, Demirer V. Eğitimde sanal ve artırılmış gerçeklik uygulamaları. Online Books: Eğitim Teknolojileri Okumaları; 2015. pp. 131-148p
  33. 33. Lupton D. Health promotion in the digital era: a critical commentary. Health promotion international. 2014;30(1):174-183. DOI: 10.1093/heapro/dau091
  34. 34. Tsai WW, Fung CP, Tsai SL, Jeng MC, Doong JL. The assessment of stability and reliability of a virtual reality-based intravenous injection simulator. Computers Informatics Nursing. 2008;26(4):221-226. DOI: 10.1097/01.NCN.0000304804.46369.5a
  35. 35. Tsai SL, Chai SK, Hsieh LF, Lin S, Taur FM, Sung WH, et al. The use of virtual reality computer simulation in learning Port-A cath injection. Advances in Health Sciences Education. 2008;13(1):71-87. DOI: 10.1007/s10459-006-9025-3
  36. 36. Loukas C, Nikiteas N, Kanakis M, Moutsatsos A, Leandros E, Georgiou E. A virtual reality simulation curriculum for intravenous cannulation training. Academic Emergency Medicine. 2010;17(10):1142-1145. DOI: 10.1111/j.1553-2712.2010.00876.x
  37. 37. Shin JH, Park SB, Jang SH. Effects of game-based virtual reality on health-related quality of life in chronic stroke patients: A randomized, controlled study. Computers in Biology and Medicine. 2015;63:92-98. DOI: 10.1016/j.compbiomed.2015.03.011
  38. 38. Boz Yüksekdağ B. Hemşirelik eğitiminde bilgisayar teknolojisinin kullanımı. Açıköğretim Uygulamaları ve Araştırmaları Dergisi. 2015;1(1):103-118 (in Turkish)
  39. 39. Huang HM, Rauch U, Liaw SS. Investigating learners’attitudes toward virtual reality learning environments: Based on a constructivist approach. Computers & Education. 2010;55(3):1171-1182. DOI: 10.1016/j.compedu.2010.05.014
  40. 40. Simpson RL. The virtual reality revolution: Technology changes nursing education. Nursing Management. 2002;33(9):14-15
  41. 41. Chia P. Using a virtual game to enhance simulation based learning in nursing education. Singapore Nursing Journal. 2013;40(3):21-26
  42. 42. Lancaster RJ. Serious game simulation as a teaching strategy in pharmacology. Clinical Simulation in Nursing. 2014;10(3):129-137. DOI: 10.1016/j.ecns.2013.10.005
  43. 43. Koivisto JM, Niemi H, Multisilta J, Eriksson E. Nursing students’ experiential learning processes using an online 3D simulation game. Education and Information Technologies. 2015:1-16. DOI: 10.1007/s10639-015-9453-x
  44. 44. Smith PC, Hamilton BK. The effects of virtual reality simulation as a teaching strategy for skills preparation ın nursing students. Clinical Simulation in Nursing. 2015;1(11):52-58. DOI: 10.1016/j.ecns.2014.10.001
  45. 45. Nehring WM, Lashley FR. Nursing simulation: A review of the past 40 years. Simulation & Gaming. 2009;40(4):528-552. DOI: 10.1177/1046878109332282
  46. 46. Phillips JR. Virtual reality: A new vista for nurse researchers? Nursing Science Quarterly. 1993;6(1):5-7
  47. 47. Merril GL, Barker VL. Virtual reality debuts in the teaching laboratory in nursing. Nurse Educator? 1996;19:182-187
  48. 48. Skiba D. Nursing education 2.0: Second life. Nursing Education Perspectives. 2007;28:156-157
  49. 49. Vidal VL, Ohaeri BM, John P, Helen D. Virtual reality and the traditional method for phlebotomy training among college of nursing students in Kuwait: implications for nursing education and practice. Journal of Infusion Nursing. 2013;36(5):349-355. DOI: 10.1097/NAN.0b013e318243172f
  50. 50. Chiang VCL, Choi TKS, Ching SSY, Leung, KLK. Evaluation of a virtual reality based interactive simulator with haptic feedback for learning NGT placement. Journal of Problem-Based Learning. 2017; 4(1), 25-34. DOI: 10.24313/jpbl.2017.4.1.25
  51. 51. Jamison RJ, Hovancsek MT, Clochesy JM. A pilot study assessing simulation using two simulation methods for teaching intravenous cannulation. Clinical Simulation in Nursing. 2006;2(1):9-12. DOI: 10.1016/j.ecns.2009.05.007
  52. 52. Çavaş B, Çavaş PH, Can BT. Eğitimde sanal gerçeklik. TOJET: The Turkish Online Journal of Educational Technology. 2004;3(4):110-116
  53. 53. Aslan R. Uluslararası rekabette yeni imkanlar: sanal gerçeklik, artırılmış gerçeklik ve hologram. Ayrıntı Dergisi. 2017;5(49):21-26
  54. 54. National Patient Safety Foundation. Patient safety. 2016. Available from: [Accessed: 2020-06-30]
  55. 55. Fay-Hillier TM, Regan RV, Gallagher GM. Communication and patient safety in simulation for mental health nursing education. Issues in mental health nursing. 2012;33(11):718-726. DOI: 10.3109/01612840.2012.709585
  56. 56. Guinea S, Andersen P, Reid-Searl K, Levett-Jones T, Dwyer T, Heaton L, et al. Simulation-based learning for patient safety: The development of the Tag Team Patient Safety Simulation methodology for nursing education. Collegian. 2019;26(3):392-398. DOI: 10.1016/j.colegn.2018.09.008
  57. 57. Joint Commission International. Available from: [Accessed: 2020-07-28]
  58. 58. National Patient Safety Foundation. Patient safety. 2016. Available from:, [Accessed: 2020-07-28]
  59. 59. Gurlek O, Kanber NA, Khorshid L. Investigating the use of identity wristbands in hospitals and patients’ opinions/Hastanelerde kimlik tanimlayici bileklik kullanimina iliskin uygulamalarin ve hasta gorüslerinin incelenmesi. Journal of Education and Research in Nursing. 2015;12(3):195-204
  60. 60. Henneman EA, Roche JP, Fisher DL, Cunningham H, Reilly CA, Nathanson BH, et al. Error identification and recovery by student nurses using human patient simulation: Opportunity to improve patient safety. Applied Nursing Research. 2010;23(1):11-21
  61. 61. Bayram ŞB, Çalışkan N. Using a game-based virtual reality application in psychomotor skills acquisition: An experience sharing Oyun tabanlı sanal gerçeklik uygulamasının psikomotor beceri öğretiminde kullanımı: Bir deneyim paylaşımı. Journal of Human Sciences. 2019; 16(1), 155-163. DOI: 10.14687/jhs.v16i1.5508
  62. 62. Biyik Bayram S. Effect of game based virtual reality application on tracheostomy care learning of nursing students, phd. thesis, Gazi University Institute of Health Sciences, december 2017
  63. 63. Shibuy H, Eto C, Suzuki M, Imai R, Yamashita A, Nakano R, et al. Exploring the Possibility of Virtual Reality in Nursing Skills Education: A Preliminary Study Using a First-Person Video. Open Journal of Nursing. 2019;9(02):163. DOI: 10.4236/ojn.2019.92015
  64. 64. Guise V, Chambers M, Välimäki M. What can virtual patient simulation offer mental health nursing education? Journal of psychiatric and mental health nursing. 2012;19(5):410-418. DOI: 10.1111/j.1365-2850.2011.01797.x
  65. 65. Foronda CL, Swoboda SM, Hudson KW, Jones E, Sullivan N, Ockimey J, et al. Evaluation of vSIM for Nursing™: A trial of innovation. Clinical Simulation in Nursing. 2016;12(4):128-131. DOI: 10.1016/j.ecns.2015.12.006
  66. 66. Liu T, Luo J, He H, Zheng J, Zhao J, Li K. History-taking instruction for baccalaureate nursing students by virtual patient training: A retrospective study. Nurse Education Today. 2018;71:97-104. DOI: 10.1016/j.nedt.2018.09.014
  67. 67. Gu Y, Zou Z, Chen X. The effects of Vsim for nursing™ as a teaching strategy on fundamentals of nursing education in undergraduates. Clinical Simulation in Nursing. 2017;13(4):194-197. DOI: 10.1016/j.ecns.2017.01.005
  68. 68. Luctkar-Flude M, Pulling C, Larocque M. Ending infusion confusion: evaluating a virtual intravenous pump educational module. Clinical Simulation in Nursing. 2012;8(2):39-48. DOI: 10.1016/j.ecns.2010.06.001
  69. 69. Dubovi I, Levy ST, Dagan E. Now I know how! The learning process of medication administration among nursing students with non-immersive desktop virtual reality simulation. Computers & Education. 2017;113(16-27):16-27. DOI: 10.1016/j.compedu.2017.05.009
  70. 70. Kruglikova I, Grantcharov TP, Drewes AM, Funch-Jensen P. Assessment of early learning curves among nurses and physicians using a high-fidelity virtual-reality colonoscopy simulator. Surgical Endoscopy. 2010;24(2):366-370. DOI: 10.1007/s00464-009-0555-7
  71. 71. Weideman YL. Culleiton AL Innovation Center A Virtual Pregnancy for Pre-Licensure Nursing Students: Nine Months Up and Close. Nursing Education Perspectives. 2014;35(6):410-413. DOI: 10.5480/11-601.1
  72. 72. Rice MM. Teams and teamwork in emergency medicine. Croskerry P, Cosby KS, Schenkel SM, Wears RL, editors. In: Patient safety in emergency medicine. 1st Ed., Philadelphia. Lippincott Williams & Wilkins, 2009;174-187p.
  73. 73. Green J, Wyllie A, Jackson D. Virtual worlds: A new frontier for nurse education? Collegian. 2014;21(2):135-141. DOI: 10.1016/j.colegn.2013.11.004
  74. 74. Uslusoy EÇ, Duran ET, Korkmaz M. safe injection practices. Hacettepe UniversitY Nursing Faculty Journal. 2016;3(2):50-57
  75. 75. Potter PA, Perry AG. Fundamentals of nursing. (8th ed). St. Lous Missouri: Mosby Inc. 2013. 821-882p.
  76. 76. Nakamura I, Fujita H, Tsukimori A, Kobayashi T, Sato A, Fukushima S, et al. Scenario-based simulation health care education for performance of hand hygiene. American journal of infection control. 2019;47(2):144-148. DOI: 10.1016/j.ajic.2018.07.024
  77. 77. Farra SL, Smith S, Gillespie GL, Nicely S, Ulrich DL, Hodgson E, et al. Decontamination training: With and without virtual reality simulation. Advanced Emergency Nursing Journal. 2015;37(2):125-133. DOI: 10.1097/TME.0000000000000059
  78. 78. Jung EY, Park DK, Lee YH, Jo HS, Lim YS, Park RW. Evaluation of practical exercises using an intravenous simulator incorporating virtual reality and haptics device technologies. Nurse Education Today. 2012;32(4):458-463. DOI: 10.1016/j.nedt.2011.05.012
  79. 79. Engum SA, Jeffries P, Fisher L. Intravenous catheter training system: computer-based education versus traditional learning methods. The American Journal of Surgery. 2003;186(1):67-74. DOI: 10.1016/S0002-9610(03)00109-0
  80. 80. Noyudom AN, Ketpichainarong W. Ruenwongsa, P. Development of a computer-based simulation unit on tracheal suctioning to enhance nursing students’ knowledge and practical skills. The Thai Simulation 2011-TS’11-3rd Annual International Conference. 2011. Thailand.
  81. 81. Bursiek AA, Hopkin MR, Breitkopf DM, Grubbs PL, Joswiak ME, Klipfel JM, et al. Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls. Journal of patient safety. 2020;16(3):245-250
  82. 82. DeBourgh GA, Prion SK. Using simulation to teach prelicensure nursing students to minimize patient risk and harm. Clinical Simulation in Nursing. 2011;7(2):47-56. DOI: 10.1016/j.ecns.2009.12.009
  83. 83. Choi KS, He X, Chiang VCL, Deng Z. A virtual reality based simulator for learning nasogastric tube placement. Computers in Biology and Medicine. 2015;57:103-115. DOI: 10.1016/j.compbiomed.2014.12.006

Written By

Sule Biyik Bayram and Nurcan Caliskan

Submitted: 29 August 2020 Reviewed: 18 September 2020 Published: 05 November 2020