Review Article

Virtual Simulation in Nursing Education: A Systematic Review Spanning 1996

to 2018
Cynthia L. Foronda, PhD, RN, CNE, Summary Statement: As virtual simulation is burgeoning, faculty and administrators
CHSE, ANEF; are asking for evidence of its effectiveness. The objective of this systematic review was to
identify how virtual simulation impacts nursing student learning outcomes. Applying the Pre-
Margo Fernandez-Burgos, BA, ferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, 80 studies
were reviewed. Results indicate that most research (n = 69, 86%) supported virtual simula-
MS Ed;
tion as an effective pedagogy to support learning outcomes while highlighting gaps and
areas of bias. Adding search terms could have expanded the findings. The body of evi-
Catherine Nadeau, MSN, APRN-BC, dence supports virtual simulation as an effective pedagogy. Future studies should use more
FNP-BC, CCRN; robust research designs, prioritize curricular integration of virtual simulation, and deter-
mine best practices in virtual simulation methodology.
Courtney N. Kelley, MSN, APRN, (Sim Healthcare 15:46–54, 2020)
FNP-C, CCRN;
Key Words: Simulation training, nursing, virtual simulation, computer simulation.
Myrthle N. Henry, PhD(c), RN

A s the use of technology in nursing education is quickly

expanding, the science of virtual simulation is just beginning
• A simulation involving real people operating simulated systems.
Virtual simulations may include surgical simulators that are used
for on-screen procedural training and are usually integrated with
to emerge. The literature reveals a range of products, potential haptic device(s) (McGovern, 1994; Robles-De La Torre, 2011).
uses, and pilot studies related to virtual simulation; however, • A type of simulation that injects humans in a central role by
the outcomes of the intervention of virtual simulation as well exercising motor control skills (for example, flying an airplane),
as best practices for its use are yet to be thoroughly studied decisions skills (committing fire control resources to action), or
or established. In addition, faculty and researchers demon- communication skills (as members of an air traffic control team)
(Hancock et al, 2008).4
strate a lack of a clear understanding of the definition of virtual
simulation. No single terminology is used consistently within
This definition was a sound starting point, but as the sci-
the literature of games, serious games, virtual worlds, virtual
ence has expanded and evolved, so has the need to re-examine
patients, and virtual reality.1,2 A clear definition of virtual sim-
terminology to reveal society's interpretation.
ulation is needed to remove ambiguity, better guide education
Although the use and understanding of the “computer
efforts, and advance the science of simulation.
sense” of virtual simulation has been documented as early as
In 2013, Lopreiato3 led a working group to create the
1959,3 there is limited synthesized knowledge about the learn-
Healthcare Simulation Dictionary published by the Agency
ing outcomes that result from virtual simulation as a pedagogy
for Healthcare Research and Quality (AHRQ). The goal of this
in nursing. Therefore, a systematic review was undertaken to
landmark document was to enhance communication and clarity
examine, appraise, and synthesize the research about virtual
for health care simulationists in teaching, education, assessment,
simulation in nursing education to reveal the actualized stu-
research, and systems integration activities.3 This reputable
dent learning outcomes. This review used Preferred Reporting
resource has served as a key reference for those seeking un-
Items for Systematic Reviews and Meta-analyses (PRISMA)
derstanding of simulation terminology. In this dictionary,
2009 Guidelines.5
virtual simulation is currently defined as
OBJECTIVE
• The recreation of reality depicted on a computer screen
(McGovern, 1994). The objective of this review was to identify how virtual simu-
lation impacts nursing student learning outcomes.
From the School of Nursing and Health Studies (C.L.F., C.N., C.N.K., M.N.H.) and
School of Education and Human Development (M.F.-B.), University of Miami, Coral METHODS
Gables, FL.
Study Question
Reprints: Cynthia L. Foronda, PhD, RN, CNE, CHSE, ANEF, University of Miami School
The guiding question for the review was, “In nursing stu-
of Nursing and Health Studies, 5030 Brunson Dr, Suite 315, Coral Gables, FL 33146
(e‐mail: c.foronda@miami.edu). dents, how does virtual simulation impact learning outcomes?”
Supplemental digital content is available for this article. Direct URL citations appear in the Study Eligibility
printed text and are provided in the HTML and PDF versions of this article on the
journal’s Web site (www.simulationinhealthcare.com). Broad inclusion criteria were delineated with the intent of
Copyright © 2020 Society for Simulation in Healthcare casting the net widely, so to speak, to capture how virtual
DOI: 10.1097/SIH.0000000000000411 simulation has been used in nursing education to gather

46 Virtual Simulation in Nursing Education Simulation in Healthcare

Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
knowledge about the learning outcomes. Inclusion criteria Study Selection
included the following: (a) peer-reviewed, (b) research study Two researchers worked independently to screen article
of any kind (all study designs included), (c) written in the titles and abstracts. When there was a discrepancy or uncer-
English language, (d) involving virtual simulation, (e) with tainty, a third researcher reviewed the title and abstract and
nursing students, and (f) from 1996 to 2018. The intervention helped establish consensus. The interrater agreement on the
examined was use of virtual simulation. Foronda's (2018) def- initial screening was calculated to be 75%. Only 50 relevant re-
inition of virtual simulation was applied: “clinical simulation search studies were selected. Next, an ancestral approach,
offered on a computer, the Internet, or in a digital learning meaning a search of the reference lists for additional poten-
environment including single or multiuser platforms.”6 This tially relevant articles based on titles, was then conducted. A
definition was applied because it was current and had been second ancestral approach of the newly identified articles was
used in the context of nursing education. Exclusion criteria conducted. These 2 searches identified an additional 163 arti-
included the following: (a) articles that were not primary re- cles. Duplicates were then removed. In total, 80 research studies
search studies, (b) dissertations, (c) language besides English, were included in the review (Fig. 1).
(d) did not involve virtual simulation, (e) participants that
did not include nursing students, and (f) articles that focused Data Extraction
on instrument development. Studies were read, and data were placed into summary
tables to assist with systematic documentation of the appraisal
and synthesis of findings. The summary tables included data
Study Identification reflecting various characteristics of the individual studies,
A team of 5 researchers sought the assistance of a library ranking and appraisal of the studies, and categorization of
scientist to guide the search process. Preferred Reporting Items the research findings. Two researchers independently ranked
for Systematic Reviews and Meta-Analyses guidelines were the articles on a hierarchy of 1 (high-quality evidence) to 7
followed.5 Data sources included articles retrieved from (low-quality evidence) using the Melnyk and Fineout-Overholt's
the databases of PubMed, CINAHL, Web of Science, and (2015) levels of evidence.7 Next, the researchers independently
ProQuest. Databases were searched using MeSH terms and a appraised each study for bias using the Critical Appraisal Skills
key word search of “virtual simulation,” “education,” and Programme (CASP) guidelines.
“nursing,” combined with the Boolean operator of “AND.” The Jeffries (2005) Simulation Framework was chosen as
Additional search limits were applied including publication the framework for analysis of data.8 Although the model has
date range of 1996 to 2018 to be consistent across databases more recent iterations including revision to a grand theory,9
as well as limits to include scholarly, peer-reviewed journals this previously developed, middle-range theory was more
or research studies. amenable to the purpose of the review—closely analyzing

FIGURE 1. Flow chart.

Vol. 15, Number 1, February 2020 © 2020 Society for Simulation in Healthcare 47
Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
and categorizing student learning outcomes. The 2005 frame- The virtual simulation technology used in these studies
work aptly demonstrated the relationship between student, the also highly varied. Virtual simulations included Second Life,
intervention of simulation, and learner outcomes.8 As the fo- Mooshak, Voki classroom, Digital Clinical Experience, The
cus of this review was on student learning outcomes achieved Neighborhood, virtual ward, computer-assisted learning mod-
through virtual simulation, the following 5 outcomes depicted ule, virtual game, vSim for Nursing, Pulse using Adobe Flash,
in the simulation model were placed in a data abstraction form FIRST2 ACTWeb, Web-based, screen-based computer simula-
as a foundation to analyze the outcomes of the existing research: tion, Microsoft Kinect, CliniSpace, Web-SP Virtual Patient
learning (knowledge), skill performance, learner satisfaction, system, Virtual Interactive Practice, CD ROM, CathSim, The
critical thinking, and self-confidence. Learning outcomes from Virtual Patient, Virtual Pediatric Patients, e-RAPIDS, virtual
each of the 80 studies were categorized into one or several of animations, VI-MED, virtual simulations using the platform
the 5 outcomes delineated in this framework.8 of Unity 3D, eWARD, Virtual Gaming Simulation (VGS),
Data Synthesis and Virtual Simulation Experience (VSE). Some technologies
were available for purchase and others were developed by the
To synthesize the data, the lead researcher read and re-
faculty member/researcher.
read through the summary tables noting the different learning
objectives and contexts, study characteristics, and learning
Impact of Virtual Simulation on Student Learning Outcomes
outcomes. Data from the CASP4 tools were aggregated to iden-
Most evidence (n = 69 studies, 86%) suggested that the
tify consistent areas of bias identified in the body of evidence.
intervention of virtual simulation resulted in improved
Studies were ranked based on Melnyk and Fineout-Overholt's
student learning outcomes. The amount of use or time
levels of evidence7 and categorized into high- or lower-quality
spent in virtual simulation correlated with greater learning
research. Data regarding learning outcomes were obtained
benefits.10–12 The learning outcomes captured were catego-
from the extraction table and aggregated in terms of frequency
rized within the outcomes of the Jeffries' (2005) Simulation
as well as effect on learning.
Framework (Fig. 4). Each study design, sampling strategy, type
RESULTS of virtual simulation used, sample characteristics, data collec-
tion methods, interventions, major results, and level of evidence
Study Characteristics
were extracted and consolidated into a summary table (see
The research studies (N = 80) reviewed spanned 22 years
Table, Supplemental Digital Content 1, which demonstrates
(Fig. 2) and represented the following 15 countries: Australia
key study features of all 80 articles reviewed, http://links.
(n = 2), Canada (n = 6), China (n = 1), Finland (n = 1), Iran
(n = 1), Malta (n = 1), Norway (n = 2), Portugal (n = 1), lww.com/SIH/A471).
Singapore (n = 2), Spain (n = 1), Sweden (n = 3), Thailand Learning (knowledge)
(n = 2), Turkey (n = 2), UK (n = 6), and the United States Forty-seven (59%) of the 80 studies specifically sought to
(n = 49). The studies included nursing students at the examine the outcomes of improving student learning or knowl-
preregistration/undergraduate/prelicensure/associate degree/ edge. This type of learning fell into the cognitive and affective
diploma level and graduate levels (Fig. 3). All studies involved domains. The learning outcomes were highly varied in terms
samples of nursing students to meet inclusion criteria, and sev- of context and settings. Learning outcomes were described in
eral studies (n = 7) also included participation of students from the following ways in a cognitive context: knowledge,1,13–29
outside disciplines such as medical, social work, occupational meaningful learning,30 cognitive gains,31,32 discovering,33 im-
therapy, physician assistant, physical therapy, and pharmacy proving learning,6,34 and improved academic performance.35
students. Most studies were conducted at a single site (n = 70), The learning occurred in a variety of contexts including health
several studies involved 2 sites (n = 5), and several studies in- assessment,18,36 life support and clinical deterioration,15,37
volved 3 or more sites (n = 5). disaster and decontamination training,37–39 leadership,22

FIGURE 2. Research study publications by year.

48 Virtual Simulation in Nursing Education Simulation in Healthcare

Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
 Skill Performance
Twenty-nine (36%) of the studies examined the outcomes
of skills resulting from simulation. Skills included handwashing,13
health assessment,18,36 life support and deterioration training,15–36,61,64
surgery,62 decontamination,38,39 communication perfor-
mance,22,65 intravenous insertion,25 nasogastric tube insertion,60
catheter insertion,66 medication administration,63 critical nursing
tasks or functions,1,67 and clinical and team performance,29–50,61,64
and Objective Structured Clinical Examination perfor-
mance.1,13,15,29 Five studies examined student perceptions
of skill acquisition rather than demonstrated skills performance.
Cohorts that were taught via virtual simulation compared with
traditional methods demonstrated a decreased time to perform
skills.1,38 Of 13 RCT's that examined skill performance, 8 stud-
ies showed statistically significant improvements in skills in
the virtual simulation cohort compared with the traditional
methods cohort. Most studies demonstrated skill improve-
ment resulting from virtual simulation.

Learner Satisfaction
Forty-one studies (51%) examined learner satisfaction
after use of virtual simulation. Studies examined the student
experience, appreciation, and perceived benefits of virtual
FIGURE 3. Level of learner of the reviewed studies. simulation. Students described the virtual simulation expe-
rience as enjoyable,68–70 fun,19,39 easy to use,71,72 great,73 re-
alistic,74,75 engaging,10,19,35,39,68,74,76 and express a high level
communication,40–42 evidence-based practice,14 poverty,43 of satisfaction.6,15,18,20,24,25,37,41,58–60,63,76–80 Students enjoyed
patient interviewing,44 mental health,45,46 pediatrics,28,47 chronic the ability to interact with others and work in groups.70 Students
care,48 public health,49 and interprofessional education.42,50,51 appreciated the ability to study at home and felt that the virtual
In addition to learning within the cognitive domain, simulations helped more than just reading from textbooks.28 Af-
learning was described in the affective domain. Learning that ter virtual simulation, they felt better prepared.44,76,81 Gerdprasert
encompassed attitudes, values, or student engagement was et al28 found that the more the time students spent on the Web
placed in this domain. Virtual simulation was found to improve site, the higher the student satisfaction scores. Of 12 RCT's that
cultural awareness and competency,52–54 attitudes,18,28,42,43,50,55 examined satisfaction, 10 studies incorporating virtual simulation
value for evidence-based practice,14 emotional connection,56 reported high student satisfaction.
perceived utility,15 and engagement.14,15,34,57–59 Twelve studies
examined student perceptions of learning as opposed to dem- Critical Thinking
onstrated learning outcomes. Of the randomized controlled Ten (12.5%) studies examined the outcome of critical
trials (RCTs) that examined learning (knowledge), 13 of the thinking. As this term is interpreted differently and has many
15 studies demonstrated increases in learning (Table 1). The forms of measurement, a broad interpretation was applied.
remaining 2 studies did not examine a pre-post effect of virtual For example, terms reflecting critical thinking included clinical
simulation on learning so this could not be determined from decision-making,1,12,24,34,47,57,62 clinical judgment,24 critical
the data reported. Most evidence indicated that virtual simula- nursing tasks,1 recognizing clinical deterioration,15 recogniz-
tion lead to improved learning outcomes. ing poverty,43 and clinical problem-solving.75 Of the 5 RCT's

FIGURE 4. Number of times the outcomes were investigated in the reviewed studies.

Vol. 15, Number 1, February 2020 © 2020 Society for Simulation in Healthcare 49
Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
 Less than traditional group
that examined critical thinking, 3 demonstrated a result of no
difference in critical thinking compared with traditional
Self-confidence

Increased, nd

Increased, sd
methods,43,47,62 whereas 2 studies suggested a statistically sig-
nificant increase in the virtual simulation cohort.1,15

nd

nd

sd
Self-confidence
Thirteen (16%) studies examined the outcome of self-confidence
resulting from virtual simulation.24–26,29,32,33,36,38,40,47,54,59,72
The terms of self-confidence and self-efficacy both were in-
cluded in this interpretation. Most studies demonstrated an
increase of self-confidence resulting from virtual simula-
tion.24,26,29,33,54,59,72 When comparing virtual simulation to
Critical Thinking

Increased, sd
Increased, sd
traditional methods, several studies found that no significant
nd

nd
nd

differences in self-confidence were obtained.25,36,38,47 Of the

RCT's examining self-confidence, the results were mixed with
2 of 6 studies demonstrating an increase in self-confidence,38,64
2 studies reporting no difference compared with the tradi-
tional methods cohort,37,47 and 1 study demonstrating lower
self-confidence scores in comparison with the traditional
Less than traditional group

methods group.32
Mixed satisfaction
Learner Satisfaction

Satisfied, nd
Satisfied, sd
Satisfied
Satisfied

Satisfied

Satisfied

Satisfied
Satisfied

Satisfied

Satisfied

Synthesis of the Results, Biases, and Gaps

Summary of Evidence
When applying the Levels of Evidence defined by Melnyk
and Fineout-Overholt (2015),7 18 studies were rated level 2, 22
studies were rated level 3, 5 studies were rated level 4, and 35
Abbreviations: nd, no difference compared with the traditional method cohort; sd, significant difference compared with the traditional method cohort.

studies were rated as level 6. Therefore, half (n = 40, 50%) of

the evidence was of high quality and the other half (n = 40,
50%) was of lower quality. When honing in on only the level
Less than traditional group
Less than traditional group

2 studies or the highest levels of evidence that examined the in-

tervention of virtual simulation (n = 17), RCTs, most studies
Skill Performance

Increased, nd
Increased, sd
Increased, sd

Increased, sd

Increased, sd

Increased, sd
Increased, sd

Increased, sd
increased, sd

(n = 13, 76%) demonstrated that virtual simulation lead to

nd

nd

statistically significant gains in outcomes when compared with

traditional methods. One RCT was not included in the syn-
thesis because it compared debriefing methods as opposed
to the intervention of virtual simulation versus traditional
methods.26 One study, conducted in 2003, indicated that
traditional methods lead to better learning outcomes when
compared with virtual simulation.32
Less than traditional group
TABLE 1. Results of RCTs Applied to Jeffries' (2005) Framework

Technical Issues
Learning (Knowledge)

As virtual simulation involves technology, technical

Increased, nd
Increased, nd

Increased, nd

Increased, nd

Increased, nd
Increased, nd

Increased, nd
Increased, sd

Increased, sd

Increased, sd
Increased, sd
Increased, sd

Increased, sd

issues were noted as a common problem. Ten studies reported

nd

that technical issues were an interference to the learning

experience.22,39,46,47,49–51,71,82,83 The technical issues caused
anxiety,22 frustration,40,71 and dissatisfaction47 for students.
Risk of Bias Across Studies
To assess risk of bias, specific CASP tools were used based
on the type of study conducted. For cohort studies, the areas of
most potential for bias were reflected in (a) lack of large sam-
Cobbett and Snelgrove-Clarke (2016)47

ples, (b) lack of the identification of confounding factors, and

Fernández, Alemán et al (2011)31

(c) lack of reporting confidence intervals. For randomized

Ismailoglu and Zaybak (2018)25

controlled studies, there was risk for bias most often with
Kaveevivit-chai et al (2009)18

respect to (a) failing to identify the effect size as well as (b)

Bloomfield et al (2010)13
60

Durmaz et al (2012)62
Aebersold et al (2018)

Verkuyl et al (2017)64

not blinding study personnel to the intervention. In the

Menzel et al (2014)43
Engum et al (2003)32

Farra, et al. (2015)38

LeFlore et al (2012)
Cook et al (2012)61

Farra et al (2013)37

Liaw et al (2014)15

qualitative studies reviewed, the most common areas with

Gu et al (2017)17

Jeffries (2001)63

potential for bias were that (a) the relationship between re-
searcher (who was often the teacher) and participants was
Authors

not adequately considered and (b) the data analyses lacked

sufficient rigor.

50 Virtual Simulation in Nursing Education Simulation in Healthcare

Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
 Conflicting Findings DISCUSSION
Although evidence demonstrated virtual simulation as su- The results of this review suggest that most evidence (86%) in-
perior to traditional methods in relation to improving learning dicated that virtual simulation positively impacted student
(knowledge) outcomes, 8 of the 15 RCTs examining learning learning outcomes. This review demonstrated that virtual sim-
(knowledge) found no statistically significant differences in out- ulation has been used effectively to improve learning (knowl-
comes between the control group and intervention group. Although edge), skills/performance, critical thinking, self-confidence,
virtual simulation was effective in improving learning outcomes, the and provide learner satisfaction. The remaining 14% of studies
effectiveness, at times, was equivalent to the traditional methods. did not necessarily indicate that virtual simulation decreased
There were also conflicting findings regarding the reten- learning outcomes; rather, some lower level studies such as de-
tion of learning over time. Two studies found that the virtual scriptive studies or feasibility studies did not examine an out-
simulation group demonstrated improved retention of learn- come variable of learning; thus, they could not be included.
ing over time in comparison with the control group.13–37,61,64 In addition, some studies found no difference between virtual
Two different studies found no differences in retention of simulation and a comparative traditional method; however,
learning over time when virtual simulation was compared with ultimately, both modalities resulted in improved learning. Only
traditional methods.15,31 Therefore, it remains unclear whether one study demonstrated that traditional methods performed
virtual simulation leads to improved retention over time. As the better than virtual simulation.32 Overall, the supportive body
amount of time and doses of virtual simulation highly varied of evidence unveiled may be helpful to guide faculty, administra-
throughout the literature, there was limited information tors, and policymakers in decisions regarding virtual simulation.
about the amount of time of virtual simulation needed to
achieve desired learning outcomes. Summary of Evidence
The learning that occurred as well as the offered contexts
Gaps and modalities was very broad and highly varied making it
As virtual simulation is a relatively new science, a number challenging to mathematically synthesize or determine best
of gaps were noted with respect to the current body of evi- practices or standards in virtual simulation at this time. More
dence. Only one study was located that examined the cost consistent methods in terms of learning objectives, virtual
of virtual simulation compared with manikin-based simula- simulation modality, and virtual simulation exposure time in
tion.24 Haerling24 (2018) calculated that manikin-based simula- relation to select desired learning outcomes are necessary to
tion costs were US $36.55 per student, whereas virtual simulation forward the science. Effect sizes and confidence intervals were
costs were US $10.89 per student yielding a cost/utility ratio of rarely reported. Given the current state of the science, multisite,
US $3.62 for manikin-based simulation and US $1.08 for vir- longitudinal studies using randomized controlled designs are
tual simulation. The literature was scant with respect to cost- needed. We also suggest comparative studies to examine the ef-
benefit analyses in the realm of virtual simulation. fectiveness of different forms of education on learning outcomes.
As debriefing is a major part of simulation and learning, In comparison with manikin-based simulation, the learn-
the literature in virtual simulation demonstrated high var- ing outcomes were similar. Most of the learning outcomes
iability with respect to debriefing practices. Most studies were in the cognitive domain, although several studies demon-
did not mention debriefing practices, although, with some strated that virtual simulation corresponded with an improved
virtual simulation products, students are debriefed by the psychomotor skill performance afterward. Because of the
game. Verkuyl et al26 (2018) conducted a randomized controlled computer-based nature of virtual simulation, it is not surpris-
study comparing 3 debriefing methods after a virtual simulation. ing to see that many studies examined cognitive outcomes in-
They found that all groups made significant knowledge and self- cluding communication and test performance. Interestingly,
efficacy gains with no statistically significant differences in out- nearly 20 studies examined learning in the affective domain.
comes among in person, virtual, and self-debriefing. There is Learner attitudes, perceived utility and engagement, and value
little evidence regarding debriefing virtual simulation. for the virtual simulation were affected in various studies. This
After examining what was known about virtual simula- is an important benefit as affecting students' feelings and values
tion, there was a noted lack of knowledge regarding best prac- is likely to affect future actions—a domain that could be easily
tices in the methods of administering virtual simulation as well missed in nursing education. Critical thinking was the least
as the adequate exposure time (dose) to result in significant measured of the Jeffries' 5 outcomes—perhaps, because of the
learning outcomes. Second, there was very little information difficulty of measuring this complex phenomenon. On the
reported about differences in learning depending on the age other hand, several studies used Objective Structured Clinical
or generation of the learner, despite known differences in Examination1,13,16,29 performance as a learning outcome, which
learning styles and generational learning preferences. Third, arguably includes a subcomponent of critical thinking.
it is unknown whether using virtual simulation in conjunction In the evaluation of learning outcomes, the term “engage-
with traditional simulation is advantageous. Fourth, there is ment” was placed under the category of learning/knowledge.
little evidence evaluating use of virtual simulation at a program Although many would argue that engagement and learning
level. Fifth, it is unknown whether virtual simulation could be are completely different concepts, engagement was placed
substituted for clinical practicum with comparable outcomes. under learning/knowledge because learning occurs best when
Finally, there is a lack of studies investigating whether learning one is engaged and engagement reflects the affective domain
achieved through virtual simulation translates to clinical prac- of recognizing the importance or value of the simulation—
tice or ultimately impacts patient outcomes. another facilitator of learning. Engagement may have been

Vol. 15, Number 1, February 2020 © 2020 Society for Simulation in Healthcare 51
Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
better placed as a separate outcome of learning outside of technology that offers a fully immersive experience through
the 5 delineated outcomes in Jeffries' (2005) framework the use of a headset that covers the eyes, whereas the term aug-
as this framework is not intended to be exhaustive of all mented reality has evolved to mean the juxtaposition or over-
learning outcomes. lay of a digital learning environment with real life. Although
A large number of studies examined perceptions of learn- early literature demonstrates interchangeable use of these terms,
ing and learner satisfaction rather than demonstrated learning the science of simulation has since advanced. Better distinction
outcomes. As the science of virtual simulation is relatively and clarity of these terms in the Healthcare Simulation Dictio-
new compared with manikin-based simulation, this finding is nary are warranted to deepen our current understanding.
not surprising as these types of descriptive studies are often
Future Research
starting points. Moving forward, simulation researchers
Given the gaps identified from this review, the following
should consider evaluating more objective evidence using
areas for research are encouraged as priorities: (a) examine
quantitative methods. the effects of virtual simulation when integrated throughout
Various studies described challenges with the
the curriculum; (b) examine the effects of virtual simulation
technology.22,39,46,47,49–51,71,82,83 Log-in problems, inability to
when used in conjunction with manikin-based simulation;
multitask, lag time, lack of realism, and other issues caused
(c) determine adequate amounts of time and dosing of virtual
student anxiety and frustration. Therefore, when conducting
simulation to result in desired learning outcomes; (d) examine
virtual simulation research, providing ample technological
retention of learning resulting from virtual simulation longitu-
support, orientation, time to “play,” and troubleshoot is im-
dinally; and (e) examine whether virtual simulation may be
portant on the front-end to avoid a disappointing and ineffec-
substituted for a select amount of clinical practicum. Further-
tive learning experience. more, although stakeholders in simulation and nursing educa-
Based on the analysis of bias across studies, virtual
tion may benefit from the results of a meta-analysis, the high
simulation researchers should consider the following when
number of exploratory, descriptive, feasibility, and usability
designing future studies:
studies as well as the high variability of study objectives, condi-
tions, equipment, and samples present significant barriers. We
• Anticipate challenges with technology
• Identify the effect size/s urge simulation researchers to conduct RCTs when possible to
• Conduct a power analysis to determine adequate sample size elevate the science of virtual simulation.
• Blind study personnel
• Identify confounding factors Limitations
• Report confidence intervals This review was limited in several ways. Adding search
• Examine hard metrics related to student learning as opposed to terms such as “serious games,” “videogames,” and “screen-
perceptions of learning based learning” could have expanded the findings. However,
these terms were not used as the goal was to focus on society's
To conduct more robust simulation research in the field, interpretation of virtual simulation. Moreover, no gray lit-
applying guidelines set by Issenberg et al84 and Cheng et al85 erature searches were conducted. Thus, because only peer-
are recommended. reviewed research studies were included, findings may
overreport positively significant findings. Because of the vast
Definition of Virtual Simulation breadth of this review, the various study designs combined,
It is apparent that there lies discrepancy in the meaning of and various contexts in the use of virtual simulation, a meta-
the term virtual simulation. Kardong-Edgren et al (2019) de- analysis could not be conducted. The focus on nursing educa-
scribe the confusion resulting from the various definitions tion as opposed to health professions education may be
and call for more precise definitions.86 The breadth of this determined a limitation as well as a strength.
term may lead to various interpretations. We noted that the
terms virtual simulation and virtual reality were used inter- CONCLUSIONS
changeably in the earlier literature but have since evolved to Virtual simulation is a relatively new pedagogy in the context
signify different concepts. As the nomenclature of virtual of nursing education that has been demonstrated to improve
simulation is unclear, Cant et al (2019) recommend that ter- student learning outcomes. The body of evidence indicates
minologies be refined to include expressive description of the that virtual simulation improves learning outcomes. As the rel-
simulation components including (a) level of fidelity, (b) im- atively new science of virtual simulation progresses, more evi-
mersion, and (c) bodily form of the patient.2 dence is needed to substantiate best practices in methodology
After this extensive review of the literature, we propose of virtual simulation-based education. Comparative studies in-
that the simulation community better differentiate the terms volving virtual simulation versus other learning modalities are
of virtual simulation, virtual reality, mixed reality, and aug- indicated to inform evidence-based teaching. Virtual simula-
mented reality. These terms all have distinctly different mean- tion researchers may consider the analysis of bias across stud-
ings. We suggest that virtual simulation should no longer be ies from this review and work to better decrease risk for bias in
used as an umbrella term to describe any and every virtual mo- future work through improving study design and applying
dality; rather, it should be used to refer to partially immersive, simulation research guidelines.85 As future generations of stu-
screen-based experiences as this is the interpretation most dents emerge as digital natives and technology continues to
reflected in the current literature. On a different note, virtual progress, virtual simulation is a promising pedagogy of the
reality or virtual reality simulation has evolved to represent now and the future.

52 Virtual Simulation in Nursing Education Simulation in Healthcare

Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
ACKNOWLEDGMENTS with nursing students before clinical placements (report). Paediatr Nurs
The activities reported here were supported (in part) by the Josiah 2009;21(8):32.
Macy Jr. Foundation. 22. Foronda C, Budhathoki C, Salani D. Use of multiuser, high-fidelity virtual
simulation to teach leadership styles to nursing students. Nurse Educ
2014;39(5):209–211.

REFERENCES 23. Borg Sapiano A, Sammut R, Trapani J. The effectiveness of virtual

simulation in improving student nurses' knowledge and performance
1. Leflore JL, Anderson M, Zielke MA, et al. Can a virtual patient trainer during patient deterioration: a pre and post test design. Nurse Educ Today
teach student nurses how to save lives—teaching nursing students about 2018;62:128–133.
pediatric respiratory diseases. Simul Healthc 2012;7(1):10–17.
24. Haerling KA. Cost-utility analysis of virtual and mannequin-based
2. Cant R, Cooper S, Sussex R, Bogossian F. What's in a name? Clarifying the simulation. Simul Healthc 2018;13(1):33–40.
nomenclature of virtual simulation. Clin Simul Nurs 2019;27:26–30.
25. Ismailoglu EG, Zaybak A. Comparison of the effectiveness of a virtual
3. Lopreiato JO. Heathcare Simulation Dictionary. Rockville, MD: Agency for simulator with a plastic arm model in teaching intravenous catheter
Healthcare Research and Quality; 2016:1–48. insertion skills. Comput Inform Nurs 2018;36(2):98–105.
4. Critical Appraisal Skills Programme. CASP checklist. Updated 2017. 26. Verkuyl M, Atack L, McCulloch T, et al. Comparison of debriefing
Available at: https://casp-uk.net/. Accessed December 11, 2017. methods after a virtual simulation: an experiment. Clin Sim in Nurs
5. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. 2018;19:1–7.
Preferred reporting items for systematic reviews and meta-analyses: the 27. Tschannen D, Aebersold M, McLaughlin E, Bowen J, Fairchild J. Use of
PRISMA statement. PLoS Med 2009; 6(7):e1000097. virtual simulations for improving knowledge transfer among baccalaureate
6. Foronda CL, Swoboda SM, Henry MN, Kamau E, Sullivan N, Hudson nursing students. J Nurs Educ Pract 2012;2(3):15–24.
KW. Student preferences and perceptions of learning from vSim for 28. Gerdprasert S, Pruksacheva T, Panijpan B, Ruenwongsa P. An interactive
nursing. Nurs Educ Pract 2018;33:27–32. web-based learning unit to facilitate and improve intrapartum nursing care
7. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and of nursing students. Nurse Educ Today 2011;31(5):531–535.
Healthcare: A Guide to Best Practice. 3rd ed. Philadelphia: Wolters Kluwer
29. Cooper S, Cant R, Bogossian F, Kinsman L, Bucknall T. Patient
Health; 2015.
deterioration education: evaluation of face-to-face simulation and
8. Jeffries PR. A framework for designing, implementing, and evaluating e-simulation approaches. Clin Simul Nurs 2015;11(2):97–105.
simulations used as teaching strategies in nursing. 2005;26(2):96–103.
30. Poikela P, Ruokamo H, Teräs M. Comparison of meaningful learning
9. Jeffries PR. The NLN/Jeffries Simulation Theory. Philadelphia: Wolters characteristics in simulated nursing practice after traditional versus
Kluwer; 2015. computer-based simulation method: a qualitative videography study.
Nurse Educ Today 2015;35(2):373–382.
10. Carlson Sabelli, Linnea L, Giddens JF, Fogg L, Fiedler RA. Challenges and
benefits of using a virtual community to explore nursing concepts among 31. Fernández Alemán JL, Carrillo de Gea JM, Rodríguez Mondéjar JJ. Effects
baccalaureate nursing students. Int J Nurse Educ Scholarsh 2011;8(1):1–14. of competitive computer-assisted learning versus conventional teaching
11. Giddens J, Fogg L, Carlson-Sabelli L. Learning and engagement with a methods on the acquisition and retention of knowledge in medical surgical
virtual community by undergraduate nursing students. Nurs Outlook nursing students. Nurse Educ Today 2011;31(8):866–871.
2010;58(5):261–267. 32. Engum SA, Jeffries P, Fisher L. Intravenous catheter training system:
12. Kleinheksel AJ. Transformative learning through virtual patient computer-based education versus traditional learning methods. Am J Surg
simulations: predicting critical student reflections. Clin Simul Nurs 2003;186:67–74.
2014;10(6):e301–e308. 33. Verkuyl M, Lapum JL, Hughes M, et al. Virtual gaming simulation:
13. Bloomfield J, Roberts J, While A. The effect of computer-assisted learning exploring self-debriefing, virtual debriefing, and in-person debriefing. Clin
versus conventional teaching methods on the acquisition and retention of Simul Nurs 2018;20:7–14.
handwashing theory and skills in pre-qualification nursing students: a 34. Mccallum J, Ness V, Price T. Exploring nursing students' decision-making
randomised controlled trial. Int J Nurs Stud 2010;47(3):287–294. skills whilst in a second life clinical simulation laboratory. Nurse Educ
14. Foronda CL, Hudson KW, Budhathoki C. Use of virtual simulation to Today 2011;31(7):699–704.
impact nursing students' cognitive and affective knowledge of
35. Giddens J, Hrabe D, Carlson-Sabelli L, Fogg L, North S. The impact of a
evidence-based practice. Worldviews Evid Based Nurs 2017;14(2):168–170.
virtual community on student engagement and academic performance
15. Liaw SY, Chan SW, Chen F, Hooi SC, Siau C. Comparison of virtual among baccalaureate nursing students. J Prof Nurs 2012;28(5):284–290.
patient simulation with mannequin-based simulation for improving
36. Bryant R, Miller CL, Henderson D. Virtual clinical simulations in an
clinical performances in assessing and managing clinical deterioration:
online advanced health appraisal course. Clin Simul Nurs
randomized controlled trial. J Med Internet Res 2014;16(9):e214.
2015;11(10):437–444.
16. Mosalanejad L, Shahsavari S, Sobhanian S, Dastpak M. The effect of virtual
versus traditional learning in achieving competency-based skills. Turk 37. Farra S, Miller E, Timm N, Schafer J. Improved training for disasters using
Online J Dist Educ 2012;13(2):69–75. 3-D virtual reality simulation. West J Nurs Res 2013;35(5):655–671.

17. Gu Y, Zou Z, Chen X. The effects of vSIM for nursing™ as a teaching 38. Farra SL, Smith S, Gillespie GL, et al. Decontamination training. Adv
strategy on fundamentals of nursing education in undergraduates. Clin Emerg Nurs J 2015;37(2):125–133.
Simul Nurs 2017;13(4):194–197. 39. Ulrich D, Farra S, Smith S, Hodgson E. The student experience using
18. Kaveevivitchai C, Chuengkriankrai B, Luecha Y, Thanooruk R, Panijpan B, virtual reality simulation to teach decontamination. Clin Simul Nurs
Ruenwongsa P. Enhancing nursing students' skills in vital signs assessment 2014;10(11):546–553.
by using multimedia computer-assisted learning with integrated content of 40. Foronda C, Lippincott C, Gattamorta K. Evaluation of virtual simulation
anatomy and physiology. Nurse Educ Today 2009;29(1):65–72. in a master's-level nurse education certificate program. Comput Inform
19. Chia P. Using a virtual game to enhance simulation based learning in Nurs 2014;32(11):516–522.
nursing education. Singapore Nurs 2013;40(3):21–26.
41. Gobbi M, Monger E, Watkinson G, et al. Virtual interactive practice:
20. Tschannen D, Dorn R, Tedesco C. Improving knowledge and behavior of a strategy to enhance learning and competence in health care students.
leadership and followership among the interprofessional team. Int J Med Stud Health Technol Inform 2004;107:874.
Educ 2018;9:182–188.
42. Sweigart LI, Umoren RA, Scott PJ, et al. Virtual TeamSTEPPS(®)
21. Broom M. Using online simulation in child health nurse education: simulations produce teamwork attitude changes among health
Mark broom and colleagues report on using a computerised 'virtual' ward professions students. J Nurs Educ 2016;55(1):31–35.

Vol. 15, Number 1, February 2020 © 2020 Society for Simulation in Healthcare 53
Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
43. Menzel N, Willson LH, Doolen J. Effectiveness of a poverty simulation in 64. Verkuyl M, Romaniuk D, Atack L, Mastrilli P. Virtual gaming
second life: changing nursing student attitudes toward poor people. Int J simulation for nursing education: an experiment. Clin Simul Nurs
Nurse Educ Scholarsh 2014;11(1):1–7. 2017;13(5):238–244.
44. Sweigart L, Hodson-Carlton R, Campbell BR, Lutz DR. Second life 65. Strekalova YA, Krieger JL, Kleinheksel AJ, Kotranza A. Empathic
environment: a venue for interview skill development. CIN communication in virtual education for nursing students. Nurse Educ
2010;28(5):258–263. 2017;42(1):18–22.
45. Sunnqvist C, Karlsson K, Lindell L, Fors U. Virtual patient simulation in 66. Smith PC, Hamilton BK. The effects of virtual reality simulation as a
psychiatric care—a pilot study of digital support for collaborate learning. teaching strategy for skills preparation in nursing students. Clin Simul Nurs
Nurse Educ Pract 2016;17:30–35. 2015;11:52–58.
46. Kidd L, Knisley S, Morgan K. Effectiveness of a second life® simulation 67. Carman M, Xu S, Rushton S, et al. Use of a virtual learning platform for
for undergraduate mental health nursing students. Clin Simul Nurs distance-based simulation in an acute care nurse practitioner curriculum.
2012;8(8):e408. Dimens Crit Care Nurs 2017;36(5):284–289.
47. Cobbett S, Snelgrove-Clarke E. Virtual versus face-to-face clinical 68. Anderson J, Page A, Wendorf DM. Avatar-assisted case studies. Nurse Educ
simulation in relation to student knowledge, anxiety, and self-confidence 2013;38(3):106–109.
in maternal-newborn nursing: A randomized controlled trial. Nurse Educ
Today 2016;45:179–184. 69. Evans DA, Curtis AR. Animosity, antagonism, and avatars: teaching
conflict management in second life. J Nurs Educ 2011;50(11):653–655.
48. Tilton KJ, Tiffany J, Hoglund BA. Non-acute-care virtual simulation:
preparing students to provide chronic illness care. Nurs Educ Perspect 70. Schmidt B, Stewart S. Implementing the virtual world of second life into
2015;36(6):394–395. community nursing theory and clinical courses. Nurse Educ
2010;35(2):74–78.
49. Schaffer MA, Tiffany JM, Kantack K, Anderson LJW. Second life(®) virtual
learning in public health nursing. J Nurs Educ 2016;55(9):536–540. 71. Foronda CL, Swoboda SM, Hudson KW, et al. Evaluation of vSIM for
50. Caylor S, Aebersold M, Lapham J, Carlson E. The use of virtual simulation nursing™: a trial of innovation. Clin Simul Nurs 2016;12(4):128–131.
and a modified TeamSTEPPS™ training for multiprofessional education. 72. Tait M, Tait D, Thornton F, Edwards M. Development and evaluation of a
Clin Simul Nurs 2015;11(3):163–171. critical care e-learning scenario. Nurse Educ Today 2008;28(8):970–980.
51. Seefeldt TM, Mort JR, Brockevelt B, et al. A pilot study of interprofessional 73. Pittiglio LI, Harris MA, Mili F. Development and evaluation of a
case discussions for health professions students using the virtual world three-dimensional virtual hospital unit: VI-MED. CIN 2011;29(5):
second life. Curr Pharm Teach Learn 2012;4(4):224–231. 267–271.
52. Tiffany JM, Hoglund BA. Using virtual simulation to teach inclusivity: 74. Forsberg E, Georg C, Ziegert K, Fors U. Virtual patients for assessment of
a case study. Clin Simul Nurs 2016;12(4):115–122. clinical reasoning in nursing—a pilot study. Nurse Educ Today
53. Giddens JF, North S, Carlson-Sabelli L, Rogers E, Fogg L. Using a virtual 2011;31(8):757–762.
community to enhance cultural awareness. J Transcult Nurs
75. Kiegaldie D, White G. "The virtual patient"—development,
2012;23(2):198–204.
implementation and evaluation of an innovative computer simulation for
54. Weideman YL, Young L, Lockhart JS, Grund FJ, Fridline MM, Panas M. postgraduate nursing students. J Educ Multimedia Hypermedia
Strengthening cultural competence in prenatal care with a virtual 2006;15(1):31–47.
community: building capacity through collaboration. J Prof Nurs
2016;32(5):S53. 76. Verkuyl M, Hughes M, Tsui J, Betts L, St-Amant O, Lapum JL. Virtual
gaming simulation in nursing education: a focus group study. J Nurs Educ
55. Strang Zook S, Hulton LJ, Dudding CC, Stewart AL, Graham AC. 2017;56(5):274.
Scaffolding interprofessional education: unfolding case studies,
virtual world simulations, and patient-centered care. Nurse Educ 2018; 77. Johannesson E, Olsson M, Petersson G, Silen C. Learning features in
43(2):87–91. computer simulation skills training. (report). Nurse Educ Pract
2010;10(5):268.
56. Shuster G, Giddens JF, Roehrig N. Emotional connection and integration:
dominant themes among undergraduate nursing students using a virtual 78. Merritt LS, Brauch AN, Bender AK, Kochuck D. Using a web-based e-visit
community. J Nurs Educ 2011;50(4):222–225. simulation to educate nurse practitioner students. 2018;57(5):304–307.

57. Burke SM. Cultivating critical thinking using virtual interactive case 79. Padilha JM, Machado PP, Ribeiro AL, Ramos JL. Clinical virtual
studies. J Pediatr Nurs 2017;33:94–96. simulation in nursing education. Clin Simul Nurs 2018;15:13–18.
58. Fowler T, Phillips S, Patel S, et al. Virtual interprofessional learning. J Nurs 80. Tjoflat I, Brandeggen TK, Strandberg ES, Dyrstad DN, Husebo SE.
Educ 2018;57(11):668–674. Norwegian nursing students' evaluation of vSim for nursing. Adv Simul
2018;3(10):1–6.
59. Verkuyl M, Romaniuk D, Mastrilli P. Virtual gaming simulation
of a mental health assessment: a usability study. Nurse Educ Pract 81. Sweigart L, Hodson-Carlton K. Improving student interview skills: the
2018;31:83–87. virtual avatar as client. Nurse Educ 2013;38(1):11–15.
60. Aebersold M, Voepel-Lewis T, Cherara L, et al. Interactive 82. Aebersold M, Tschannen D, Stephens M, Anderson P, Lei X. Second
anatomy-augmented virtual simulation training. Clin Simul Nurs life®: a new strategy in educating nursing students. Clin Simul Nurs
2018;15:34–41. 2012;8(9):e475.
61. Cook NF, Mcaloon T, O'Neill P, Beggs R. Impact of a web based 83. Tiffany J, Hoglund BA. Teaching/learning in second life: perspectives of
interactive simulation game (PULSE) on nursing students' experience and future nurse-educators. Clin Simul Nurs 2014;10(1):e24.
performance in life support training—a pilot study. Nurse Educ Today
2012;32(6):714–720. 84. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features
and uses of high-fidelity medical simulations that lead to effective learning:
62. Durmaz A, Dicle A, Cakan E, Cakir Ş. Effect of screen-based computer a BEME systematic review. Med Teach 2005;27(1):10–28.
simulation on knowledge and skill in nursing students' learning of
preoperative and postoperative care management: a randomized 85. Cheng A, Kessler D, Mackinnon R, et al. Reporting guidelines for health
controlled study. CIN 2012;30(4):196–203. care simulation research: extensions to the CONSORT and strobe
statements. Simul Healthc 2016;11(4):238–248.
63. Jeffries PR. Computer versus lecture: a comparison of two methods of
teaching oral medication administration in a nursing skills laboratory. J 86. Kardong-Edgren SS, Farra SL, Alinier G, Young HM. A call to unify
Nurs Educ 2001;40(7):323–329. definitions of virtual reality. Clin Simul Nurs 2019;31:28–34.

54 Virtual Simulation in Nursing Education Simulation in Healthcare

Copyright © 2020 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.