The effect of virtual reality on cognitive, affective, and psychomotor outcomes in nursing staffs: systematic review and meta-analysis

This meta-analysis showed that all three domains of Bloom’s taxonomy, comprising cognitive, affective, and psychomotor aspects, were improved to a statistically significant level by the application of VR for training the nursing workforce. A significantly higher score for learning satisfaction in the VR groups also was revealed. In terms of moderator analysis, the level of immersion, study design, use of head tracking, and the intervention context, our moderator analysis found no significant difference in the effect sizes of the cognitive, affective, and psychomotor aspects in nurses. Finally, meta-regression also showed that interventions comprising total sessions and total minutes’ duration did not affect cognitive, affective, and psychomotor outcomes.

This VR study can be used as a reference with a low quality of evidence. Though the Egger’s test indicated no publication bias, high risk of bias was found in the reporting of RCT studies. Information on blinding or masking between the intervention and control groups was not available. The report of the randomization allocation technique was also not explained by the researchers. Not all RCT study protocols registered, leading to a lack of information for risk assessment of reporting bias. Prospective registration of clinical trials is important because of the issue of publication bias and selective reporting [65]. The publication status of the listed RCTs would provide clarity for readers to assess the research report [65]. The result of I² also performed substantial heterogeneity among two outcomes. This may due to the variation of intervention, duration, and media used. Furthermore, this review also includes the four quasi-experimental studies which may interfer internal validity of the data pooling.

VR training considerably raised the cognitive level of the nursing staffs. Although they did not assess the cognitive aspect based on Bloom’s categories, previous studies have evaluated the effect of VR on knowledge outcomes as one part of the cognitive domain [43, 66]. This result is consistent with earlier reviews and meta-analyses that examined the impact of VR training and reported an increase in the applied knowledge of registered nurses and nursing students [67]. In addition, other studies focusing on nursing students revealed the same result [25, 68, 69]. The realism and immersion of the simulated VR world boosted pupil comprehension. Students believed that the ability to modify an avatar’s viewpoint enhanced their ability to learn [70]. On the other hand, VR showed more efficacy in nursing than conventional or other simulation-based education modalities. Virtual patients helped students to understand better the ideas taught and how to apply their new knowledge [71].

As evidenced by the previous study, Bloom’s taxonomy has provided a basis for learning in a VR environment [70]. Bloom’s taxonomy helps examine the process by which VR promotes knowledge acquisition. Bloom’s taxonomy has been extensively used in educational contexts to help students think and solve problems through the learning process. VR presents educational ideas of higher-level thinking in Bloom’s cognitive domains, such as creative and critical thinking, problem-solving, and multiple intelligences [70, 72]. It is also directly related to technological integration [70]. Bloom’s theory proposes that the acquisition of cognitive knowledge will proceed in three ways: comprehension, application, and analysis [43]. During VR simulations, the participants comprehend how to handle the problem in the most applicable method feasible, and they assess whether their knowledge is adequate to provide this clinical care [73]. VR programs may be essential for enhancing learning material as a supplement to conventional training [74].

Pooled data showed the effectiveness of VR in improving nurses’ affective aspect, compared to other traditional methods. This result is in line with a systematic review investigating the impact of VR intervention on nursing students’ and registered nurses’ emotional skills compared to other training method [75]. VR has the potential to foster empathy and help nurses visualize situations from the perspective of patients and in an affective domain [76]. Ouzouni and Nakakis [77] concluded that a nurse’s empathy is a two-pronged term that encompasses both emotional and mental reactions. Thus, using VR in education can improve nurses’ ability to detect another person’s emotions, comprehend their significance, and respond appropriately. A benefit of VR for influencing human emotions is that it simulates complex real-world situations [78].

According to Bloom’s taxonomy, in the affective domain, the behaviors of receiving and reacting must be used throughout the pre-simulation, pre-briefing or briefing, and participation phases [73, 79]. Previous research uncovered gaps and deficiencies in developing nursing students’ emotional domains for trust, decision-making, and patient care. The clinical simulation approach was planned and supported using Bloom’s taxonomy for competence building. The simulation linked with Bloom’s taxonomy might transcend the learning of cognitive and psychomotor domains, producing congruence between knowledge and the affective and psychomotor aspects in the nursing student [73, 80]. The affective domain is established during the first phases of the clinical simulation, when the person’s determination and drive to learn are appreciated and heightened during debriefing, which includes all the behaviors described by Bloom’s taxonomy throughout the reflective process. This supports the significance of debriefing for the development of clinical nursing competence [73].

Though the included articles comprised a range of participants and types of psychomotor skills, this meta-analysis showed that VR intervention could improve the psychomotor domain in nurses. These results support the findings of several studies [67, 81, 82]. On the other hand, in a meta-analysis that encompassed nursing student participants, VR was not more effective than traditional methods in improving nursing skills [23]. This finding is consistent with other reviews that VR was not proven to influence skill development in nursing students and registered nurses [16]. From this point, it can be argued that the conclusions of some recent studies are inconsistent. This might be because there were various participant characteristics, such as years of experience and level of education. It cannot be overlooked that these variables affect the clinical skills of nurses.

In Bloom’s taxonomy, the psychomotor aspect is in the second phase of clinical simulation, which is initiated by the cognitive and affective domains in the first phase [83]. In other words, the performance of psychomotor skills is affected by the pre-knowledge and motivation of nurses, and these aspects are gained from the experience of environment exposure. Our analysis of the studies showed that VR significantly improved nurses’ cognitive and affective aspects. Thus, initiating psychomotor improvement in nursing staffs by the affective and cognitive aspects is guaranteed in this study. The role of VR is imperative to help nurses get closer to the real environment [84]. Thus, VR is presumed to provide positive benefits in improving clinical skills.

This review concluded that VR could significantly improve nursing staff’s learning satisfaction compared to other training modalities. Compared to the three domains of Bloom’s taxonomy, the number of included studies on learning satisfaction was relatively small. Nonetheless, the four included studies were remarkably similar. This finding is not supported by Chen, Leng [68] who found no significant increase in learning satisfaction among students of nursing and other health professions. However, it is essential to consider the homogeneity of immersion levels across studies, which is likely to influence the results.

Researchers have shown strong positive associations between student motivation and academic performance [85, 86]. Based on anatomical arrangement, Moro, Štromberga [87] discovered that one-third of participants found the VR approaches disorienting and annoying. Using VR may result in cybersickness, including nausea, dizziness, and headache. Thus, future research should concentrate on the detrimental impacts of VR, such as impaired vision and confusion [85, 88].

The statistical test of moderator analysis of the subgroups of the categorical and continuous variables in the meta-analysis and meta-regression showed that there was no significant difference in the effectiveness of VR at various levels of attenuation (high, moderate, or low), the presence or absence of head tracking, study design (RCT or quasi-experimental), intervention context (emergency or not emergency), total sessions of interventions, and total minutes’ duration. The cognitive, affective, and psychomotor domains showed the same results from the moderator analysis. This finding is consistent with a previous meta-analysis, which reported that content covariates, level of immersion, length of sessions, and the number of sessions did not affect knowledge outcome scores [25]. However, it cannot be concluded that there is no effect of covariate variables on the effectiveness of VR because the studies included in this meta-analysis were mostly conducted on small samples, and the bias of most studies was assessed as high risk. According to Woon, a low to medium level of immersion is more effective in providing a learning environment than a high level of immersion [25]. Further exploration is needed to determine the effect of VR on the levels of immersion, interactivity [27], VR devices, and intervention context.

As far as the authors know, this study is the first to evaluate the effectiveness of VR in nursing staff populations. There was no publication bias from the 12 studies. This work provides three outcomes of VR intervention, which are inspired by Bloom’s taxonomy. The cognitive, affective, and psychomotor domains are deemed to be the pedagogic mechanism for the development of nursing competence in clinical settings [83]. Moreover, this work conducted a sensitivity analysis that showed the robustness of the results. However, risk of bias was high in most of the study included. The heterogeneity among two outcomes were considered substantial. In addition, the quasi-experiment method was still included in this review because of the lack of studies focused on nursing staffs. The other shortcomings were the exclusion of potential appropriate study related engineering area due to the conference proceedings were excluded in this study.Lastly, most of the analyzed studies were conducted on small sample sizes. Therefore, the analysis of study bias should be treated with careful caution.

This work strengthened the prospect of involving VR in training nurses and improving their nursing competency. There is high confidence in the effectiveness of VR in increasing the cognitive, affective, and psychomotor dimensions of nurses’ knowledge, which can lead to improved patient safety and increased patient satisfaction. Nevertheless, using VR has been presumed to be expensive and demanding. Fortunately, the literature has shown that VR has lower costs than traditional simulation [89]. Therefore, cost should not be a major concern of hospital management. However, technological issues may be a challenge for nursing departments. The use of VR should be understood comprehensively by the users so that the equipment is run properly. In addition, regular updates and maintenance of the programs are necessary to avoid glitches [90]. Thus, the existence of a special team that handles such technology is required.