Development of a training system for virtual reality trauma first aid nursing teamwork in central China

Abstract

Background

Virtual reality training can save resources and improve training efficiency. The cooperation of trauma team can shorten the treatment time and improve the treatment efficiency.

Methods

This study employed a quasi-experimental design to evaluate standardized trauma team performance scores among emergency nurses following VR training. Participants included 68 emergency department nurses from a tertiary Grade A hospital in Wuhan, China, who were divided into 17 groups (4 members per group) through convenience sampling. All teams underwent training using a virtual reality training system developed by the research team. Paired-sample t-tests were conducted to compare differences in standardized trauma team performance scores across all 17 groups between pre-intervention (March-May 2023) and post-intervention (September-November 2023) periods. Subsequently, qualitative research was implemented using semi-structured interviews to capture participants’ experiential feedback regarding the VR training system.

Results

Compared to traditional training, the use of the VR training system resulted in significantly enhanced teamwork performance among emergency nurses during simulated trauma first aid scenarios. Interview results indicated that the system’s novel format deepened professional understanding, conserved resources, increased practice opportunities, and enhanced the efficiency of trauma first aid nursing training. Moreover, it facilitated multi-role experiences, facilitating teamwork exercises.

Conclusion

The Virtual Reality training system for trauma first aid nursing teamwork enhances emergency nurses’ comprehensive trauma care capabilities, improves trauma training effectiveness, and is worthy of clinical promotion.

Introduction

“Trauma” refers to an acute injury caused by external mechanical forces or physical, chemical, or biological agents acting on the human body, resulting in structural disruption of tissues and organs or functional impairment [1]. Over the past two decades, trauma-related fatalities have increased by 46%, constituting 9% of the global mortality rate and standing as the leading cause of death among individuals aged 44 and younger [2]. In China, the trauma care landscape is particularly critical. According to the China Health Statistics Yearbook 2023 issued by the national authorities, over 300 million patients seek medical care for trauma-related injuries annually, including 12 million severe trauma cases, with a trauma-attributable mortality rate of 6.2% [3]. In June 2018, the National Health Commission of China issued a notice (National Health Commission Letter [2018] No. 477) [4]explicitly calling for the strengthening of regional trauma treatment systems centered around trauma centers to enhance trauma treatment capabilities further and bolster the training of trauma professionals. Given the strict time-dependency of trauma treatment, early intervention by trauma teams (a standardized first aid team of multidisciplinary medical professionals) within the “golden hour” can reduce mortality rates by 50% [5]. The urgent treatment of trauma patients is based on teamwork and division of labor, where proficient and cohesive teamwork can shorten treatment times and enhance treatment efficiency. Nurses, as integral members of trauma teams [6]play crucial roles in trauma patient treatment.

Currently, the most widely recognized training program globally is the Advanced Trauma Life Support System (ATLS) [7]which, however, emphasizes the learning and assessment of individual skills. While programs like the Advanced Trauma Care for Nurses (ATCN) [8] and the China Trauma Care Training-Nurse (CTCT-N) [9] involve teaching teamwork, their training methods still rely on non-clinical video-based learning, practice, and assessment. Due to the unique nature of trauma emergency care, traditional theoretical lectures and procedural drills fail to replicate the high-stress clinical environment of trauma management or the time-sensitive pressures inherent in real-life resuscitation scenarios. Consequently, trainees cannot experience authentic clinical tension or coordinate effectively with team members, thus impeding the translation of theoretical knowledge into practical competencies and compromising the efficacy of trauma nursing education. Furthermore, in CTCT-N, participants report limited hands-on practice opportunities despite workshop offerings, constrained by facility limitations, environmental factors, and material resource shortages [10].

Virtual Reality (VR) technology refers to the use of computer technology to create a virtual, realistic world where users can interact with objects using their real actions and behaviors via computer terminals. Currently, VR technology has been widely applied across various fields, including training in nursing operation processes and skills [11]. Several studies [11, 12] have indicated that immersive VR technology, when applied to nursing training, significantly enhances trainees’ operational skills and satisfaction. Consequently, our research team developed an immersive VR training system for trauma nurse. Its core innovations include: (1) constructing virtual environments replicating multiple common yet critical trauma scenarios; (2) designing a multi-user collaborative interaction module; (3) implementing a structured debriefing module to evaluate team performance in high-fidelity simulations. This system will enhance trauma nurses’ clinical management capabilities and emergency coordination competencies.

Methods

Study design

This study employed a quasi-experimental design to evaluate standardized trauma team performance scores among emergency nurses following VR training, supplemented by a qualitative component utilizing semi-structured interviews to explore their training experiences.

Participants

Convenience sampling was employed to select emergency surgical nursing staff from a tertiary Grade A hospital in Wuhan, China, as research participants. Inclusion criteria: (a) Holding a valid nursing practice certificate; (b) Working in clinical nursing positions for a minimum of one year during the study period; (c)Informed consent and volunteered to participate in this study Exclusion criteria: Being on sick leave, maternity leave, or holding auxiliary or managerial positions. Prior to VR development, conventional training methods were administered to emergency surgical nursing personnel who met the inclusion criteria. The training regimen consisted of video-based learning and on-site guidance. The VR training system was implemented after system development.

The estimated sample size was calculated using G* Power version 3.0.10 software. The statistical test and model settings for the sample size estimation were as follows: paired-sample t-tests and a priori methods (parameter settings: α = 0.05, power = 0.8, and effect size d = 0.5). The recommended Cohen [13] medium effect size was used, as no similar study was found, and the research area of interest is unknown. Based on the a priori power analysis conducted, a minimum sample size of 34 participants was calculated. Accounting for a 20% anticipated attrition rate, the final enrollment target was adjusted to 43 participants to ensure statistical robustness. In this study, participants were first stratified according to their working years and numbered. Based on the computer-generated random number sequence, the participants within each stratum were randomly ordered using statistical software. Subsequently, in accordance with the preset number of groups, the participants in each stratum were evenly allocated to different groups. Participants for the qualitative interviews were recruited from the quantitative study cohort.

Training case

This case involves the resuscitation of a 45-year-old male patient with multiple injuries resulting from a wall collapse, who is being transferred to the emergency department following a call to emergency services. The patient’s injuries include open wounds to the hip and lower limbs, with a duration of 30 min since the incident. The patient presents with blood pressure of 83/56 mmHg, heart rate of 118 beats/min, respiratory rate of 22 breaths/min, and oxygen saturation of 93%. Emergency services have established one intravenous access and initiated oxygen therapy via nasal cannula, as well as urinary catheterization. The case scenario assigns roles L (Leader), A (Airway), B (Breathing), and C (Circulation) to four emergency trauma nursing personnel, requiring coordinated teamwork for the patient’s rescue.

VR system development and implementation

Team-Foundation

The project team consists of a total of eight members, including five medical staff from Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (one chief physician, two deputy chief nurses, and two head nurses), as well as three engineering and technical personnel from Nanjing Kuhe Information Technology Co., Ltd. Medical staff are responsible for case design and training, while engineering and technical personnel are responsible for providing technical support for the VR system, as well as system development and maintenance.

Development

The project employs a hybrid architecture combining B/S and C/S frameworks, utilizing professional software such as Maya, 3D Max, and Cinema-4D to construct physical objects and scenes. It leverages inside-out technology and Simultaneous Localization and Mapping (SLAM) technology to simultaneously establish maps and locations. This creates three terminal forms: teacher-end, administrator-end, and student-end, realizing an integrated system focused on the standardization of trauma first aid nursing, encompassing editing, management, assessment, and communication.

Teacher-end: Teachers conduct standardized trauma first aid nursing training online for multiple participants through this interface. Pre-configuration involves creating new training tasks, configuring training personnel and plans, and pairing equipment. Real-time configuration includes monitoring training progress, observing training personnel’s perspectives, and controlling training processes.

Administrator-end: Operated by engineering and technical personnel before training, this end utilizes structured databases to create three-dimensional models of instruments, environments, medications, tasks, etc., involved in VR training processes, constructing VR environments based on cases provided by teachers.

Student-end: Students enter the interface to simulate a role assigned for the current training task (LABC4 types), engaging in multi-player online trauma first aid teamwork with three other students based on VR environments and case information. During operations, they can access equipment information, patient feedback, and intervention results.

Implement

Preliminary Preparation

The teachers log into the teacher-end to configure the L, A, B, and C roles and select the cases to be used in training. The engineers log into the administrator-end to construct VR environments based on the cases chosen by teachers, configuring three-dimensional models of instruments, environments, medications, tasks, etc. Cases and learning tasks are distributed, and videos demonstrating trauma first aid teamwork are played. After watching the explanatory videos, students, grouped according to cases, perform operations on anatomical models, familiarizing themselves with the trauma team coordination process. The engineers introduce the immersive VR trauma first aid nursing training system, explaining and demonstrating the use of helmets, VR goggles, and controllers. Finally, students enter their names to log into the student-end and enter the training assessment scenario.

Role assignment

Following traditional training groupings, groups discuss and assign L, A, B, C roles. Subsequently, students select the corresponding helmets and controllers. Wearing the helmets, students can see simulated standard trauma resuscitation unit scenes, equipped with various instruments such as ventilators and monitors, as well as various medications and consumables like saline solution, balanced solution, tourniquets, cotton pads, and pelvic belts. The team leader assumes the role of L, responsible for injury assessment and guiding and coordinating team members in first aid teamwork. Role A is responsible for airway establishment and management, oxygen administration, and ventilator adjustment. Role B is responsible for circulation establishment and management, medication administration, and electrocardiogram monitoring. Role C is responsible for assisting in limb immobilization, passing first aid supplies, controlling bleeding, and maintaining nursing records.

Operational coordination

Students follow voice prompts from the system to select corresponding tasks. Using different buttons on the controllers, they move to virtual physical locations and perform relevant patient operations according to the actual trauma team coordination process, such as cardiac monitoring, applying hemostatic agents, bandaging, and immobilization. All maneuvers have specific positional and temporal requirements. If tasks are not completed within the countdown or if errors occur, the system records them and automatically proceeds to the next step to avoid disrupting the entire process.

Summary and feedback

From the moment students put on VR goggles to entering the VR scene until the entire trauma first aid teamwork process is completed, the engineers and teachers cannot be interrupted. The VR training system integrates existing trauma first aid coordination process evaluation standards, setting corresponding deduction rules based on the time and completion of each step, and objectively evaluating students’ actual operations. Finally, the teachers log into the teacher-end to review the overall scores of each group of students, as well as the time spent and issues encountered by each student in each operational step of L, A, B, and C roles, providing targeted guidance and feedback.

Improvement

Addition of practice mode

The original system only featured an assessment mode, where once in the VR scene, regardless of whether the operations were correct, the entire process could not be interrupted. The system recorded any issues encountered, ultimately yielding an assessment score. In contrast, the practice mode allows the process to be paused if a student makes an erroneous operation, prompting them to continue the trauma first aid teamwork process correctly. The goal is to enable students to acquire the correct operational skills and become familiar with the entire trauma first aid teamwork process.

Design of missing role simulation training

In the study case, the VR training system was configured for simultaneous operation by four roles. However, if a role is missing, individuals, pairs, or trios can also select roles for practice and assessment. Students can independently train on weak areas without the need to form a group. Once the appropriate role is selected, the system automatically fills in for other roles to assist in training, and students can observe the execution process.

Outcome measurements

An online platform, Questionnaire Star, was used to collect trauma emergency coordination scores before and after VR system training. Scoring criteria for trauma emergency coordination consists of six components: Role allocation (3 points), Primary assessment (ABCDE) (48 points), Comprehensive head-to-toe assessment (31 points), Critical patient transport (5 points), Diagnostic discussion (3 points), and Teamwork coordination (10 points), totaling 100 points. Higher scores on the scale demonstrate enhanced emergency coordination proficiency among trauma nurses. Scoring criteria for trauma emergency coordination was self-developed for this study. Clinical reliability tests demonstrated that the scale achieved a Cronbach’s α coefficient of 0.761, indicating good internal consistency reliability. The detailed scoring criteria are provided in Appendix 1.

Interview outline

This study utilized scoring criteria for trauma emergency coordination and trainees’ subjective evaluations of the VR training system’s effectiveness. The research team finalized the interview guide, then conducted a pilot interview with one emergency surgical nurse. After revising based on the feedback received, the finalized version of the interview outline was developed, including the following questions: What are your thoughts and experiences regarding the VR training? How do you perceive the effectiveness of the VR training? What suggestions do you have?

Techniques such as probing, active listening, and feedback were employed during the interview process to ensure data accuracy. Each interviewee was assigned a numerical code from 1 to 9, and the duration of each interview ranged from 30 to 45 min. Interviews were conducted with 9 trainees until saturation was reached. Among them, there were 6 females and 3 males, comprising 2 deputy chief nurses, 3 head nurses, 2 nurses, and 2 nursing assistants.

Data analysis

Data analysis for the quantitative part was conducted using SPSS version 22.0 software, employing paired-sample t-tests and one-way analysis of variance (ANOVA), with a significance level set at α = 0.05.

The data were transcribed verbatim into Chinese and analyzed using Colaizzi’s 7-step analysis method. First, two researchers independently and repeatedly read the original interview transcripts to familiarize themselves with the content, generating initial codes based on predetermined interview questions and new insights emerging from the data. Subsequently, team members engaged in extensive discussions on the initial codes, systematically categorizing them into potential themes and subthemes. In cases where disagreements arose between the two independent coders, they were resolved through team discussions until a consensus was reached, ensuring consistency and clarity in the coding process. The final analysis results were returned to the interviewees to validate the authenticity of the content.

Ethical considerations

The study was approved by the Research Ethics Committee of Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (Ethical approval number TJ-IRB20210920).

Results

A total of 68 eligible emergency department nurses were enrolled and allocated into 17 groups, with each group comprising four participants. The actual sample (68 participants) substantially exceeded the minimum requirement (34 participants), which significantly enhanced the statistical power, enabling a more sensitive detection of pre-post intervention differences and improving the reliability of the findings. Furthermore, the expanded sample diversity reduced sampling errors, thereby strengthening the generalizability and external validity of the results within the target population. Comprehensive demographic and baseline clinical characteristics of all participants are systematically presented in Table 1.

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Pre- and post- training scoring for trauma emergency coordination

Compared to traditional training, the use of VR training resulted in significant improvements in emergency nurses’ scores across four modules in the trauma first aid teamwork coordination process, including total scores, initial assessment, comprehensive assessment, and diagnostic discussion. These improvements were statistically significant (P < 0.05). Although no statistically significant differences were found in the pre- and post-training scores for “Role division” and “Patient transport”, an upward trend was observed. These findings demonstrated a positive impact of VR training on emergency department nurses. (Table 2)

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Interview results Theme 1

The novel format of VR trauma first aid nursing teamwork coordination training deepens understanding of the profession.

The immersive VR training is innovative and realistic, offering a stronger sense of immersion and realism compared to traditional offline and video-based training methods. It attracts trauma nursing personnel more effectively and enhances their understanding of the profession.

“The format is particularly innovative…It grabs my attention, and I may prefer this method of training…” (Trainee 6).

“Overall, it’s quite impressive, with full 3D effects simulating rescue environments and realistic patient wounds and scenarios…I can immerse myself in real-life rescue scenarios and collaborate effectively with others.” (Trainee 3).

“It deepens understanding of professional knowledge and leaves a more lasting impression…“(Trainee 5).

Theme 2

The VR trauma first aid nursing teamwork coordination training system saves resources, increases practice opportunities, and enhances training efficiency.

Interviewed trainees indicated that the immersive VR training system effectively recreates real-life rescue environments in a 1:1 manner without the need for any equipment or consumables, thus saving manpower, material resources, and financial resources. Moreover, trainees can practice repeatedly, which is highly efficient.

“… we don’t need everyone to prepare a set of materials, as each trainee can achieve the training goals through headsets and controllers.” (Trainee 1).

“It’s very convenient, saves manpower and material resources, and allows for repeated practice…. VR training does not require material preparation, saving a lot of time and energy…“(Trainee 8).

Theme 3

The VR trauma first aid nursing teamwork coordination training system enables multi-role experiences, facilitating teamwork coordination exercises.

Interviewed trainees stated that the immersive VR training system sets up four roles (L, A, B, and C) based on trauma cases. Trainees can learn the responsibilities, tasks, and how to coordinate with other members for each role according to the process and system prompts, making it suitable for teamwork coordination, teaching, and training.

“… I can experience different roles, such as airway management, circulation management, and even a recorder role…“(Trainee 2).

“…This system allows us to practice teamwork coordination repeatedly, constantly discover and improve problems, so that we can provide the best rescue for trauma patients in actual cases.“(Trainee 4).

Theme 4

The VR trauma first aid nursing teamwork coordination training system needs improvement in tactile perception.

Interviewed trainees indicated that the immersive VR training system needs further improvement in tactile perception.

“At the same time, I also found some shortcomings, such as when we need to control the strength during hemostasis and bandaging…“(Trainee 9).

“…If we could perceive them realistically or have a real sense of touch, I think it would be better…“(Trainee 7).

Discussion

The quantitative results of this study demonstrate that post-training, nurses’ trauma first aid coordination ability scores, including preliminary assessment, comprehensive assessment, and diagnostic discussion modules, all improved. This suggests that the system effectively enhances nurses’ assessment capabilities, optimizes patient transfer processes, and strengthens clinical thinking abilities, consistent with findings by Rushton et al. [14] Trainee interviews revealed that nurses perceive the training system as innovative, deepening their understanding of the profession and enhancing their skills. Additionally, multiple studies [15, 16] indicate that immersive VR technology can improve nursing operational skills and emergency skills compared to traditional teaching methods. The immersive VR trauma first aid nursing teamwork coordination training system effectively engages nurses in learning trauma-related knowledge by utilizing visual, auditory, and tactile senses, stimulating their enthusiasm and interest in learning. Nurses can repeatedly practice trauma nursing teamwork coordination within the system, becoming familiar with the instruments, equipment, items, and medications required, mastering emergency skills such as hemostasis, bandaging, and immobilization, and anticipating changes in patient conditions, thereby enhancing predictive thinking abilities. Integrating immersive VR technology into hospital trauma nursing training and developing immersive trauma first aid nursing teamwork coordination training systems based on VR technology significantly improve emergency nurses’ comprehensive trauma treatment capabilities and enhance training effectiveness.

The interview results indicate that the VR training system facilitates the enhancement of teamwork awareness and abilities. Nurses deeply understand and master trauma first aid teamwork coordination skills and processes in the immersive system, optimizing teamwork coordination processes. During training, nurses can also try different roles, gaining a deeper understanding of the responsibilities of other team members. Moreover, the system provides multiple training opportunities for the same group of members, with trainees believing that repeated cooperative exercises will help improve teamwork coordination. Research by Benjamin et al. [17] shows that VR training may improve the effectiveness of teamwork in surgery. However, the quantitative results of this study show that teamwork abilities were not effectively improved, possibly because trainees only participated in immersive VR training once, resulting in unfamiliarity with virtual colleagues in the virtual environment, leading to poor cooperation. There were no statistical differences in role division training before and after, likely because the same group of trainees played the same role before and after VR training, having a clear understanding of their respective tasks. Subsequent efforts should involve continuous immersive VR trauma first aid nursing teamwork coordination training, with each trainee experiencing different roles. Studies by Smith et al. [18] on VR found that skill scores decline 6 months after VR technology is acquired. Therefore, it is recommended to provide 2-week VR first aid teamwork coordination training every 6 months to enhance teamwork cooperation awareness and familiarity with each other’s knowledge background, values, and working styles, thereby improving teamwork coordination abilities.

Some participants indicated that enhanced haptic feedback could potentially improve efficacy, highlighting a current limitation of the VR technology employed in this study. Future research should prioritize integrating advanced haptic feedback systems, such as wearable haptic gloves embedded with high-precision tactile sensors and actuators, into existing VR platforms. These devices could dynamically simulate real-time tactile sensations (e.g., texture discrimination, pressure gradients) during virtual interactions, thereby resolving the identified deficiency and optimizing immersive experiential fidelity. The study indicates that nurses believe immersive VR trauma first aid nursing teamwork coordination training systems reduce resource costs. Compared to skills laboratories, VR is more affordable [19]reducing manpower resources investment. The training system requires fewer teaching staff and logistical support resources while allowing for emergency treatment training tailored to different disease patients. VR training systems save financial resources, are not limited by location or time [19]have lower economic and time costs [20]enabling trainees to practice repeatedly in a safe and risk-free environment, saving resource costs and improving training efficiency.

Implication

Our findings demonstrated that compared to traditional trauma emergency care training methods, the use of VR could improve the competencies of emergency nurses, particularly in the areas of preliminary assessment, comprehensive assessment, and diagnostic discussion. Results from the qualitative study also revealed that emergency nurses expressed greater interest in VR training, reported more positive training experiences, and perceived more benefits. This suggests that VR is a promising approach to improving nursing competencies. Therefore, where feasible, we encourage the adoption of innovative training methods for nurses in clinical practice. We also call for policymakers, professional associations, and healthcare institutions to collaboratively establish a VR training support system to extend these benefits to a wider population of healthcare workers. However, it is critical to note that outcomes such as cost-effectiveness and the sustainability of training effects remain unclear and warrant further investigation. Consequently, additional large-scale, high-quality studies are needed to strengthen the evidence base in this field.

Limitations

This study has several limitations. First, immersive VR technology is less utilized in trauma first aid nursing training, with this study only implemented in a tertiary Grade A hospital in China. The teaching training duration was short, and the frequency was limited. Future research should increase the intervention sample size and training frequency, expand the scope and intensity of clinical practice. In addition, there are still some potential biases in study, such as self-selection bias (voluntary participation) or learning curve effects in VR technology. Future studies could mitigate these biases by implementing randomized participant recruitment and employing repeated-measures designs to disentangle the effects of technical proficiency from true emergency coordination capabilities. Third, although our findings are positive, there remain several crucial metrics that have not been thoroughly examined, such as the psychological impact of VR on nurses, nurses’ adaptability to the technology, implementation costs, and whether the improvement in teamwork is sustainable. Therefore, further controlled and long-term studies are still necessary in the future.

Conclusions

The VR trauma first aid nursing teamwork coordination training system significantly enhances emergency nurses’ awareness of teamwork coordination and comprehensive trauma treatment capabilities, while also reducing training costs and improving training effectiveness. These findings suggest it is worthy of clinical promotion.

Data availability

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

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