Pediatric OSCEs Within the Metaverse: A Virtual Reality Solution to Inefficiencies in Modern Nursing Education

Abstract

Background

The nurse practitioner (NP) objective structured clinical examination (NP-OSCE) is a cornerstone of nursing education, yet its traditional format is hindered by high costs, reliance on paid actors, limited pediatric scenarios, and increased instructor workload. The coronavirus disease 2019 pandemic amplified these challenges, necessitating innovative solutions for competency evaluation.

Method

A virtual reality NP-OSCE simulation was developed with a game engine and virtual reality headsets. Designed for nursing education, the simulation immerses NP students in a virtual clinical environment, enabling interactive patient care and auto-graded assessments to enhance efficiency.

Results

Compared with traditional manikins, the simulation significantly reduced costs, improved accessibility, and enabled realistic pediatric training. In addition, NP students reported increased engagement and motivation compared with traditional methods, and auto-grading reduced the administrative burden on nurse educators.

Conclusion

The use of virtual reality NP-OSCEs offers a cost-effective solution for continuing nursing education, supporting professional development educators in enhancing clinical competency and NP student preparedness across health care settings. [J Contin Educ Nurs. 2025;56(7):271–276.]

Graduate nursing schools around the world rely on nurse practitioner (NP) objective structured clinical examinations (OSCEs) to assess the clinical proficiency of NP students. An OSCE consists of a variety of highly versatile stations (generally 15–20) designed to evaluate a diverse assortment of skills the NP students should have mastered over the course of their education. To administer NP-OSCEs, nursing schools are generally required to hire actors, who are then trained to simulate real patients. The value of this implementation is that simulations are extremely realistic and also highly configurable by instructors. However, the unfortunate downside of this strategy is that many patient groups cannot be simulated, most notably, pediatric patients. Further, the recent coronavirus disease 2019 (COVID-19) pandemic made it difficult, if not impossible, to safely hold in-person NPOSCEs with paid actors and therefore motivated research in practical alternatives.

As part of preparation for the NP-OSCEs, nursing schools are often required to use a variety of highly detailed simulation manikins. These manikins are used to teach NP students an array of procedures, assess their mastery of certain techniques, and of course, prepare them for the OSCEs. Additionally, in recent years, because the pandemic limited in-person interaction for OSCEs, simulation manikins have been employed as a safe alternative to trained actors. Despite their undeniable value, several problems occur with these manikins. First, they are expensive, often costing more than $75,000 (^{Haerling & Miller, 2024}), and the cost is especially relevant for smaller institutions, which generally have less money available to spend on expensive equipment. As a result, colleges and universities often have a limited quantity and variety of manikins, resulting in limited NP student interaction with them. In parallel, and from a pedagogical perspective, assessment of NP student performance on an OSCE is time consuming and difficult for instructors because they must monitor and grade each NP student as they perform the various procedures for the assessment.

Although adult OSCEs often involve the use of paid adult actors as patients, pediatric OSCEs do not have this luxury, effectively restricting the options to either using a pediatric manikin or forgoing this particular version of the examination completely. Pediatric OSCEs typically have two phases: verbal and physical examination. The NP student begins by greeting the patient's parent or guardian, followed by handwashing and donning of appropriate personal protective equipment. The verbal phase involves introducing themselves, confirming patient identity, and gathering the medical history through a series of questions, including infant-specific risk assessments. The physical examination, conducted after the verbal phase, typically includes examination of the patient, measurement of vital signs, and examination of the head, neck, chest, and extremities. The specific order of examination may vary based on the setting, patient condition, and provider preference.

The Moc's Family Care Center (MFCC) is a high-fidelity, artificial intelligence-powered clinical simulation in virtual reality (VR), which addresses all of these issues. Although VR is a fairly new technology, it has quickly revolutionized a wide variety of industries. However, many nursing schools have yet to adopt it into their curricula. With use of a relatively inexpensive VR headset, users are immersed in a highly realistic three-dimensional world, wherein they can move around, explore, and interact with their surroundings by using the supplied hand-held controllers. This article discusses the development, implementation, and design of the MFCC, including a review of current literature, an overview of auto-grading functionality and examination types, and a discussion on the application of this technology.

Literature Review

Prompted by the occurrence of the COVID-19 pandemic and the physical safety limitations it introduced, Arrogante et al. (²⁰²¹) investigated the use of a computerized online NP-OSCE simulation. Their implementation involved a website wherein the various stations of a standard NP-OSCE were predesigned by the instructors. A series of computers would then be set up within a classroom, each representing a single station and displaying one of the virtual stations. The NP students would go through the stations in groups and interact with the computer at their respective stations.

The advantage of this implementation is that it provides a safe alternative to a standardized NP-OSCE as no actor is involved. However, this change comes at the expense of realism, as NP students could not actually perform the procedures the examination is designed to evaluate. Instead, they are instructed simply to explain how they would perform the procedures. Additionally, this implementation does not provide immersion, and NP students simply interact with a computer screen instead of speaking to a patient. Updike et al. (²⁰²¹) furthered this research by exploring various means of maintaining academic integrity throughout these virtual assessments. They examined the efficacy of browser lockdown software, plagiarism checkers, virtual proctoring, and a variety of other tools to aid in reducing academic dishonesty.

As an alternative to computer software, Quinlin et al. (²⁰²⁰) used virtual OSCE examinations that involved real actors and online conferencing software. One benefit of this method is that it exposes the NP students to tele-health and the ways that health care can be administered remotely. Hsia et al. (²⁰²¹) explored a similar implementation with online conferencing software to hold virtual OSCEs, which they referred to as VOSCEs. Their research focused on feedback from both the NP students and the actors, and the findings showed that although the VOSCE was a viable means of assessing clinical competence, it was severely limiting in terms of nonverbal communication and was insufficient to demonstrate the ability of NP students to physically perform a variety of procedures. However, examination scores from participants of the VOSCE were not significantly different from the scores of those who took the standard in-person OSCE.

Although earlier research, such as the work by Jenson and Forsyth (²⁰¹²), explored the use of specific haptic feedback devices to enhance the realism of procedural training such as intravenous line and catheter insertion for NP students, a significant limitation was the need for distinct instruments for each diverse skill required in NP practice. This need effectively presented a challenge in scaling haptic feedback across the breadth of the NPOSCE curriculum. However, more recent advancements in virtual reality offer promising solutions. Kim (²⁰²⁴) developed and evaluated VR educational content for perioperative nursing practice integrating haptic technology. Their program allowed nursing students to engage in immersive perioperative scenarios, overcoming the physical limitations of traditional clinical settings and providing multisensory feedback. The expert evaluation deemed the content suitable for education, and a usability assessment with nursing students showed high levels of presence, usability, and satisfaction. This development suggests a potential pathway for integrating haptic feedback into VR clinical simulations such as the MFCC, offering a more comprehensive and realistic training experience across a wider range of necessary skills without the constraints of individual physical instruments.

Although research specifically examining immersive VR with headset use in nursing education remains somewhat limited, other areas of medical education are actively integrating this technology for training. Mitha et al. (²⁰²³) developed a VR-based educational case to integrate age-friendly health system concepts into geriatric medical education. Their immersive simulation allowed medical students to care for a virtual elderly patient admitted with a hip fracture, reinforcing the four Ms—Mobility, Mentation, Medication management, and what Matters—through hands-on clinical decision-making from admission to discharge. The simulation was designed and iteratively refined by an interprofessional team and is now embedded within the medical school's geriatric curriculum. Their work highlights the growing recognition of the value of VR in providing students with a realistic, interactive environment for practicing complex competencies that are difficult to teach through traditional didactic methods. Although VR has been used successfully in a variety of academic disciplines, the more general reasons for leveraging VR involve the immersion users experience. Makransky and Lilleholt (²⁰¹⁸) investigated the emotional value of using VR in several education domains and how the level of immersion impacts learning outcomes, with significantly higher scores found among those using immersive VR simulations.

Method

Development

The MFCC was built with the Unity game/physics engine, version 2022.1.0 (Unity). The project was built with the end user in mind, and Quest 2 (Meta) was chosen as the VR headset of choice. The Quest 2 headset was picked because at the time it was the most popular VR headset available on the market and was available for less than $500, a fraction of the cost of a manikin. The simulation was built with the Input Package Manager (Input System), version 1.4.1 (Unity), and XR Interaction Toolkit, version 2.0.2 (Unity), to allow for interaction in the VR world. The teleport movement option was chosen as it appears to be less jarring to the user compared with continuous movement.

All scripts were coded with the C# programming language, as C# is the chosen development language of Unity. Many aspects of the interactive objects require scripts to ensure the simulation is different each time. Heart rate, blood pressure, temperature, and heart sound are all chosen by a randomly seeded number each time the simulation is run. This was all done to ensure that the NP students would have a unique experience every time they ran the simulation. This code is mostly executed with coroutines, a method of writing asynchronous nonblocking code snippets that can run in parallel. Parallelism is important because many actions may be occurring at the same time.

A variety of plug-ins and assets were used to create the MFCC. The room and entryway were built with pieces from the Hospital Package (Hospital Medical Office Kit), version 3.1 (Soja Exiles/Brick Project Studio), asset. The room was then fitted with all the assets needed to perform an OSCE. To better stylize the room and hallway, the Soja Exiles asset was used. The parent was brought in from the Stylized Office (Ultimate Stylized Business Women), version 4.0 (Stephanie Maslen), pack, and her animations were created with the Mixamo (Mixamo) plug-in. The parent's voice was simulated with the SpeechBlend LipSync, version: 1.1 (Tiny Angle Labs), plug-in, which used voice clips recorded from a voice actor. Interaction was possible through a plug-in called Recognissimo: Offline Speech Recognition, version 2.0.4 (bluezzzy), a speech recognition library designed to interpret keywords from the questions the NP students ask. The physics and kinematics of the interactions are handled by the plug-in AutoHand-VR Interaction, version 3.2 (Earnest Robot).

Finally, objects that needed to be tweaked or custom designed were built with Blender, version 3.1 (Blender Foundation), or AutoDesk Maya, version 2023.1 (AutoDesk, Inc.).

User Experience

The simulation begins outside the patient's room, where the NP student inputs assessment information and chooses between summative and formative assessment types. Once inside the room, the NP student encounters the pediatric patient and their parent. According to standard practice, the NP student greets the family, washes their hands, and dons personal protective equipment before starting the verbal portion of the examination with the parent.

The NP student retrieves a tablet from the desk to document the information collected during the examination. They are required to ask a series of questions aloud, sourced from the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (^{Hagan et al., 2017}), as if conducting the examination in person. The artificial intelligence-powered virtual parent responds to the questions appropriately. If the student struggles to recall a question or progress in the verbal portion, they can use the virtual tablet to access the correct prompts.

After completing the verbal segment, the NP student transitions to the physical examination of the child. Essential equipment is available in the room: a thermometer and pulse oximeter are located in the cabinets, a stethoscope is accessible via the interact option near the student's neck, and a sphygmomanometer with a basket of various blood pressure cuff sizes is located near the patient's table. The NP student applies the appropriate cuff to the child, records the findings, and ensures all information is accurate. The simulation concludes with a comprehensive assessment of the NP student's documentation and performance.

Results

Cost Savings

Offering more than 99.3% in cost savings, the MFCC is a highly economical alternative to traditional nursing training equipment. As mentioned previously, more advanced simulation manikins cost more than $75,000, whereas the only cost associated with this product is $500 for a Quest 2 headset. The MFCC software itself is fully open source and free to use. For larger institutions, this may not be entirely necessary, as they may be able to afford large volumes of simulation manikins to support the needs of their respective nursing schools. However, for smaller institutions with financial restrictions, these savings are important. Although a simulation manikin costing $75,000 can be used by approximately 10 NP students at once, the use of $75,000 worth of Quest 2 headsets could allow 150 NP students to be training in more realistic virtual clinics, where they can examine virtual living patients and interact with people, instead of manipulating a plastic manikin.

Student Evaluation

The NP students in the study were provided access to the MFCC virtual reality software as a supplementary tool to their traditional educational modalities, which included practice with simulation manikins. To assess the impact of the MFCC software, students were asked to complete the same formative assessment scenarios using both the simulation manikins and the VR software. After these assessments, participants were asked to evaluate their learning experiences through surveys. The results of these surveys indicated a notable increase in student motivation to use the MFCC software for practice compared with the traditional manikins. Specifically, 82% of the NP students reported increased engagement with the learning material when using the MFCC software. Further, all participating NP instructors provided overwhelmingly positive feedback, expressing significant enthusiasm about the potential of the MFCC software as an educational tool.

Discussion

Major Findings

This article describes the development of a highly advanced and realistic VR simulation for nursing education. Preliminary feedback from NP students indicated a positive user experience. The user interface is easily understandable and intuitive, allowing for greater ease of access. After only a few minutes of using the simulation, the movement becomes natural, and the NP students can navigate the scene efficiently. This quality, along with the previously discussed information, leads to a unique and highly versatile simulation that benefits both NP students and educators.

Optimization of Simulation Performance

In general, VR simulations are highly resource intensive, requiring NP students to be connected via a wire to a highly powerful (and expensive) computer. An advantage of the MFCC is that the simulation runs well when exported to a standalone VR app. This capability is the result of the method used to reduce the number of polygons rendered. Computer graphics are rendered via a series of triangles, which form polygons. Increasing the number of vertices, and thus the number of triangles, improves visual quality while reducing performance. The inverse proportionality has made it difficult to maintain graphical realism while being constrained to the physical space (and therefore the inability to use powerful graphics cards) of a standalone VR headset. To remedy this situation, all of the three-dimensional models (called GameObjects) were brought into a three-dimensional modeling software called Blender, where they were individually adjusted to provide the best graphics-to-performance ratio. This process of adjusting objects for their visual quality and performance is an imperative step for VR development as the headsets have a limited amount of random access memory (the “working memory” for a computer). Good performance is needed for the application as, if the frame rate declines, the simulation becomes significantly less realistic.

Assessment Types and Auto-Grading

Another significant value of the MFCC is its auto-grading functionality. In general, when NP students perform various procedures on simulation manikins, instructors must monitor each NP student individually and yet simultaneously, making grading difficult. The MFCC addresses this problem with the provided auto-grading technology. When an NP student first launches the simulation and enters their information, they must select between summative and formative assessment. The formative assessment simply provides general feedback to the NP student on completion of the simulation and is primarily used for practice and studying. In contrast, if the NP student selects the summative examination, one of the script controllers within the simulation monitors the NP student's activity and assigns grades, based on the accuracy of recorded data, whether they asked all of the required questions, used the appropriate technology and equipment to perform the relevant procedures, and performed the individual procedures correctly. These grades are then formatted and exported into a text file, along with the NP student's name, identification, and the current date. Instructors can then retrieve the files from the Quest 2 headset by simply plugging it into their computer and accessing the export folder.

Applications of the Moc's Family Care Center

Although this article focuses primarily on graduate nursing education, the applications of the MFCC extend far beyond this scope. In particular, the MFCC shows significant potential for application within transition to practice programs, which bridge the gap between academic training and independent clinical practice for newly graduated nurses. By simulating complex, realistic scenarios, including pediatric care, the MFCC allows participants to meet core competencies such as clinical judgment, critical thinking, patient safety, effective communication, and technical skills. The pediatric OSCEs within the MFCC offer structured opportunities to develop specialty competencies such as recognizing developmental milestones, providing age-appropriate care, and managing pediatric emergencies. Incorporating the MFCC into these programs could enable new nurses to gain hands-on experience in a safe, controlled environment, enhancing their confidence and readiness for real-world settings. Further, the ability to document performance outcomes through auto-grading ensures that both core and specialty competencies are rigorously evaluated, aligning with the goals of transition to practice programs to deliver competent, patient-centered care.

Another potential application of the MFCC is in advanced practice registered nurse (APRN) graduate programs. These programs often face challenges in providing consistent and comprehensive competency documentation, particularly given the limited number of APRNs hired in most institutions, which can make large-scale approaches cost prohibitive. The MFCC offers a scalable, cost-effective alternative, enabling APRN students to demonstrate advanced competencies in clinical judgment, patient management, and specialty care through immersive, high-fidelity simulations. By tailoring VR scenarios to advanced practice roles, such as primary care or acute care specialties, the MFCC can support APRN programs in addressing these challenges without requiring substantial financial or logistical resources. This flexibility not only enhances training outcomes but also ensures alignment with institutional goals for efficient resource use and comprehensive competency evaluation.

Limitations of Virtual Reality and the Moc's Family Care Center

Although the MFCC offers numerous advantages, it is important to recognize several limitations. Despite their immersive qualities, VR simulations are inherently constrained by the hardware capabilities of standalone headsets, such as the Quest 2. Although extensive optimization efforts, such as polygon reduction and model refinement, have successfully improved performance, standalone headsets remain limited in their ability to replicate the tactile realism and procedural nuance available through physical simulation manikins. Additionally, although the MFCC is highly effective in delivering structured, competency-based simulations, certain challenges exist in scalability and scenario development. Creating and validating new clinical simulation modules requires significant time, technical expertise, and content knowledge, which can initially limit rapid expansion into new specialty areas. However, because the MFCC is built as an open source platform, once a scenario has been developed, it can be freely shared, adapted, and implemented across multiple institutions without incurring additional licensing or development costs. This open source model significantly mitigates long-term scalability concerns and supports broader dissemination and collaborative improvement. To further address existing limitations, future iterations of the MFCC should prioritize ongoing asset optimization, continuous scenario development, and integration of user feedback to enhance educational fidelity and responsiveness. Through these efforts, the MFCC can continue to evolve as a robust and scalable solution for health care education and competency assessment.

Conclusion

The NP-OSCE, although undeniably valuable, introduces problems in terms of feasibility, cost, and safety. Additionally, the simulation manikins that are historically used to train for the NP-OSCE are very costly and present their own challenges. The use of VR resolves these issues and more. It improves on cost more than 150-fold, provides very high levels of realism, increases NP student access to resources, and potentially reduces instructor workload through the ability for auto-grading. Further, the MFCC provides an invaluable asset to NP students, the ability to practice and perform realistic pediatric simulations.

References

Arrogante, O., López-Torre, E. M., Carrión-García, L., Polo, A., & Jiménez-Rodríguez, D. (2021). High-fidelity virtual objective structured clinical examinations with standardized patients in nursing students: An innovative proposal during the COVID-19 pandemic. Healthcare(Basel), 9(3), 355. 10.3390/healthcare9030355 PMID: 33804700

Haerling, K. A., & Miller, C. W. (2024).Acost-utility analysis comparing traditional clinical, manikin-based simulation, and screen-based virtual simulation activities. Journal of Nursing Education, 63(2), 79–85. 10.3928/01484834-20231205-04 PMID: 38316155

Hagan, J. F., Shaw, J. S., & Duncan, P. M.(Eds.). (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents(4th ed.). Bright Futures/American Academy of Pediatrics.

Hsia, S. L., Zhou, C., Gruenberg, K., Trinh, T. D., & Assemi, M. (2021). Implementation and evaluation ofavirtual objective structured clinical examination for pharmacy students. Journal of the American College of Clinical Pharmacy: JAACP, 4(7), 837–848. 10.1002/jac5.1448

Jenson, C. E., & Forsyth, D. M. (2012). Virtual reality simulation: Using three-dimensional technology to teach nursing students. Computers, Informatics, Nursing: CIN, 30(6), 312–320. 10.1097/NXN.0b013e31824af6ae

Kim, H.-Y. (2024). Development and usability assessment of virtual reality- and haptic technology-based educational content for perioperative nursing education. Healthcare(Basel), 12(19), 1947. 10.3390/healthcare12191947 PMID: 39408127

Makransky, G., & Lilleholt, L. (2018).Astructural equation modeling investigation of the emotional value of immersive virtual reality in education. Educational Technology Research and Development, 66(5), 1141–1164. 10.1007/s11423-018-9581-2

Mitha, S., Dezine, M., Tewary, S., Guida, V., Masri, H., Pandya, N., & Oviawe, E. (2023). Design and development of virtual reality application: Age-friendly health system scenario. Innovation in Aging, 7(Suppl. 1), 809–810. 10.1093/geroni/igad104.2612

Quinlin, L., Clark Graham, M., Nikolai, C., & Teall, A. M. (2020). Development and implementation of an e-visit objective structured clinical examination to evaluate student ability to provide care by telehealth. Journal of the American Association of Nurse Practitioners, 33(5), 359–365. 10.1097/JXX.0000000000000409 PMID: 32304481

Updike, W. H., Cowart, K., Woodyard, J. L., Serag-Bolos, E., Taylor, J. R., & Curtis, S. D. (2021). Protecting the integrity of the virtual objective structured clinical examination. American Journal of Pharmaceutical Education, 85(6), 8438. 10.5688/ajpe8438 PMID: 34315707