Content area
Aim
The aim was to evaluate the effectiveness of an immersive 360° video-based VR simulation program for pressure injury management (VR-SIMPI) and explore new nurses’ perceptions and learning experiences qualitatively.
Background
Pressure injuries pose major healthcare challenge, causing patient discomfort, longer hospital stays and increased costs. Effective education for new nurses is essential, but traditional lecture-based training lacks hands-on experience. VR offers an innovative solution by providing immersive, interactive learning that enhances skill development and clinical decision-making.
Design
A quasi-experimental pretest-posttest design with a control group.
Methods
The study was conducted in a tertiary hospital in South Korea with 69 new nurses, divided into an experimental group (n = 35) receiving VR-SIMPI and a control group (n = 34) receiving lecture-based training. Nursing knowledge, performance confidence and clinical competency were assessed quantitatively; qualitative insights were collected through focus group interviews.
Results
The VR-SIMPI program significantly improved pressure injury nursing knowledge (z = -3.78, p < .001, ES = 0.90) and performance confidence (z = -8.40, p < .001, ES = 1.69) in the experimental group. Clinical competency also showed a large effect size (z = -7.00, p < .001, ES = 3.55) compared with the control group. Focus group interviews revealed that participants found the VR environment highly immersive and beneficial for mastering complex clinical scenarios.
Conclusions
VR-SIMPI significantly enhanced knowledge, confidence and competency among new nurses. These findings suggest that VR is a valuable nursing education tool. Future studies should explore its scalability and long-term impact.
1 Introduction
Pressure injuries, characterized by localized tissue damage from sustained pressure or shear, remain prevalent patient safety concerns globally ( European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance. 2025). These complications affect approximately 12–23 % of hospitalized patients globally and extend beyond mere discomfort, potentially resulting in severe, life-threatening conditions, such as deep infections and sepsis ( Li et al., 2020; Shiferaw et al., 2020; Tervo-Heikkinen et al., 2022). The prolonged hospital stays and additional medical expenses incurred per patient due to pressure injuries impose a substantial burden on healthcare systems ( Gould et al., 2024). Recognizing the critical nature of this issue, the United States has implemented financial incentive policies through Medicare and Medicaid, while the European Wound Management Association has introduced prevention strategies to mitigate the impact of pressure injuries ( European Wound Management Association, 2024; Gould et al., 2024).
Despite ongoing international efforts, pressure injuries remain a significant challenge. Moreover, in rapidly aging societies such as Korea, the increasing proportion of older adult patients necessitates a new approach to their management ( Song et al., 2023). Pressure injuries primarily occur in patients experiencing health deterioration or limited mobility, with advanced age identified as a major risk factor for their occurrence ( Gould et al., 2024). Therefore, innovative nursing interventions are essential to manage pressure injuries in Korea’s aging population.
Professional nursing knowledge is crucial for effectively preventing pressure injuries. However, a meta-analysis revealed an insufficient level of knowledge regarding pressure injury prevention among nurses, with an average score of only 51.5 % ( Wu et al., 2022). This knowledge gap increases the risk of patients developing pressure injuries and negatively affects quality of care ( Cieslowski et al., 2023). Systematic education on pressure injury management is even more critical for new nurses, as they may lack sufficient knowledge or skills when transitioning to clinical practice ( Horii et al., 2021).
Traditional educational methods emphasizing theoretical instruction have limited clinical applicability; simulation-based education effectively addresses these gaps by fostering learner engagement, critical thinking, problem-solving and teamwork ( Considine et al., 2021). With the recent integration of virtual reality (VR) technology into nursing education, VR-based simulations have gained attention as an innovative tool that offers immersion and realism to help compensate for the limitations of traditional simulation methods ( Jagatheesaperumal et al., 2024). VR simulations enable learners to practice complex clinical scenarios repeatedly and provide realistic experiences in a safe and controlled environment ( Cieslowski et al., 2023). Immersive 360° video VR, unlike fully simulated computer-generated environments, provides a realistic, cost-effective and emotionally engaging learning experience ( Kavanagh et al., 2025).
To date, research on nursing education using VR has predominantly focused on nursing students, with studies involving healthcare professionals, particularly newly employed nurses, notably scarce. New nurses often face challenges in acquiring the requisite knowledge and skills to adapt effectively to actual clinical environments during the early stages of their hospital tenure, which can have a negative impact on patient safety and quality of nursing care. Consequently, there is a critical need to develop a systematic and evidence-based educational program specifically designed for new nurses. This study aimed to design and implement an Immersive 360° Video-based VR Simulation Program for Pressure Injury Management (VR-SIMPI) to enhance the competency of new nurses in pressure injury care, thereby improving patient safety and the overall quality of healthcare services and rigorously evaluate its effectiveness.
1.1 Conceptual framework
This study adopted Kolb’s (1984) Experiential Learning Theory as the conceptual framework to evaluate the effectiveness of VR-SIMPI for new nurses. According to Kolb’s theory, learning is a process through which knowledge is created by transforming experience and comprises four stages: concrete experience, reflective observation, abstract conceptualization and active experimentation.
In the concrete experience stage, VR simulation can enable learners to engage in realistic pressure injury management scenarios in a safe environment. Studies have demonstrated that VR enhances learning effectiveness by providing immersive, hands-on experience ( Jung and Moon, 2024; Pande et al., 2021). The reflective observation stage is facilitated through structured debriefing, which allows learners to analyze their actions and improve their understanding based on immediate feedback, a critical factor for effective learning ( Bradley et al., 2020; Sapkaroski et al., 2022). During abstract conceptualization, learners can synthesize insights from their VR experiences with theoretical knowledge, promoting an integrated understanding of skills and concepts ( Hong and Wang, 2023; Kwon, 2019). The active experimentation stage involves applying learned knowledge and skills in clinical settings, enhancing practical competency and confidence in real-world applications ( Kiegaldie and Shaw, 2023).
In the present study, this framework was used to demonstrate how VR simulations can effectively facilitate the four stages of experiential learning by offering realistic scenarios, promoting reflection, integrating theory with practice and preparing learners for clinical application. VR-SIMPI provided new nurses with a structured and immersive environment where to practice pressure injury management. This study evaluated the program’s effectiveness in improving knowledge, performance confidence and clinical competency and supported the findings with qualitative feedback from focus group interviews (FGIs).
2 Methods
2.1 Study design
This study employed a mixed-methods design to develop and implement a VR-SIMPI tailored to new nurses and evaluate its effectiveness and to explore their perceptions and learning experiences through qualitative inquiry. A non-equivalent control group pretest-posttest design was employed for the quantitative component, while FGIs were conducted for the qualitative component (
2.2 Participants and allocation
The participants were new nurses who joined a university hospital in Korea between October 2023 and March 2024. The inclusion criteria were as follows: (1) new nurses who were willing to participate in a VR simulation-based pressure injury nursing education program; (2) understood the purpose of the study; and (3) provided written informed consent. The exclusion criteria were as follows: (1) individuals who had previously received VR or similar simulation training; (2) were unwilling to participate; and (3) had health conditions that could hinder full participation in the simulation training. The sample size was calculated using G*Power version 3.1.9.7. Based on the results of Chen et al. (2020) meta-analysis of the effectiveness of VR in nursing education, a large effect size (d = 0.8) was applied with a significance level (α = 0.05) and power (1-β = 0.9). A two-tailed independent sample t-test was used, yielding a minimum required sample size of 68 participants. Accordingly, 69 participants were recruited, with 35 assigned to the experimental group and 34 to the control group. Participants for the FGIs were selected from among those in the experimental group who expressed interest.
A post hoc power analysis was conducted using G*Power version 3.1.9.7. For pressure injury nursing knowledge, the analysis indicated a significance level of α = 0.05, an effect size of d = 0.73 and a power of 1-β = 0.83. For pressure injury nursing performance, the analysis showed a significance level of α = 0.05, an effect size of d = 3.55 and a power of 1-β > 0.99.
2.3 VR-SIMPI development
This study used the ADDIE (Analysis-Design-Development-Implementation-Evaluation) model ( Molenda, 2003) to develop and evaluate the effectiveness of VR-SIMPI. The ADDIE model offers a structured framework for creating systematic and effective educational programs and comprises five sequential stages: analysis, design, development, implementation and evaluation.
In the analysis phase, a structured survey was conducted among new nurses at the research hospital between March and July 2023 to identify training needs, focusing on pressure injury assessment, stage classification, prevention and management strategies and stage-specific debridement techniques. A comprehensive literature review of studies published between 2018 and 2023 and the 2019 international guidelines from the National Pressure Injury Advisory Panel and EPUAP informed the program content, ensuring it was evidence-based and clinically relevant. The learning environment was designed to minimize interruptions and enhance immersion. Two registered nurses with over five years of experience in pressure injury care and specialized training in simulation operations facilitated the VR-SIMPI sessions. This ensured the clinical and technical quality of the program.
In the design phase, explicit learning objectives were established, and the validity of the educational framework was confirmed by developing training content and scenario-based simulations. These scenarios were constructed based on the content items identified during the analysis phase. The learning objectives were designed to achieve the following competencies: 1) perform a comprehensive physical assessment of a patient presenting with pressure injuries; 2) accurately identify and describe the patient's pressure injury condition, including changes over time; 3) use the SBAR (Situation, Background, Assessment, Recommendation) communication framework to effectively report the patient’s pressure injury status to a physician and develop a nursing care plan prioritizing patient needs; and 4) demonstrate knowledge of the materials and procedures aligned with the pressure injury classification system, including the ability to explain the associated interventions. To facilitate these objectives, the training content was systematically aligned with the learning goals and organized into three progressive scenario stages: pressure injury assessment, pressure injury worsening and communication and intervention.
During the development stage, a nursing plan for managing pressure injuries and a 360-degree VR educational video were created. The Meta Quest 2 head-mounted display and Virti platform were used to provide an interactive learning experience with 360-degree educational content (Supplementary 1). Six experts reviewed the program’s content validity, including two adult nursing professors, two wound care specialist nurses and two wound care nurse managers, achieving a content validity index (CVI) of 1.0. The program was then revised and refined based on expert feedback. These revisions included adjustments to the three-step pressure injury disinfection method used during the exacerbation stage to incorporate dressings designed to minimize pressure on wound base. Additionally, communication protocols with medical staff for managing pressure injuries were clarified and aspects of pain management, such as the need for pain control before dressing changes, were included to enhance clinical relevance. The finalized program reflected current best practices and addressed key areas identified during the development process. Knowledge, confidence and clinical performance were measured using items developed by four educational nurses at University Hospital with more than five years of clinical experience. The items were then modified and supplemented after validity evaluation by the expert panels with more than seven years of clinical experience at University Hospital and a master’s degree or higher (Supplementary 2).
During the implementation stage, the usability of the VR-SIMPI with 10 new nurses was assessed using the System Usability Scale (SUS) by
Brooke (1996), with a score of 54.5, categorized as good. Participant feedback prompted adjustments, such as repositioning the VR screen for better visual comfort, improving audio clarity and incorporating feedback mechanisms to promote engagement and participation. A standardized checklist was developed to address inconsistencies in evaluator judgments and ensure accurate and consistent assessments. The instruments were pilot tested with usability verification to ensure clarity, appropriateness and time feasibility. Minor revisions were made based on participant feedback. The finalized VR-SIMPI included three components: pre-briefing, VR simulation and debriefing. The pre-briefing introduced the program objectives, provided an overview of the VR experience and offered guidance on using the devices. The VR simulation covered three stages of pressure injury management: assessment, exacerbation and communication/intervention. The debriefing session encouraged reflection by helping participants review their experiences, analyze actions and apply the insights to clinical practice (
In the evaluation phase, participants were assigned to either the experimental or control group based on their preferences. The control group attended a traditional lecture on pressure injury nursing theory and participated in a single session of scenario-based group discussion, whereas the experimental group completed the VR-SIMPI. Both interventions were conducted as single sessions and used the same educational content. To address ethical considerations, the VR-SIMPI was offered to interested control group participants after data collection, ensuring equitable access to the program. Additional details on the content and scenario algorithms for VR-SIMPI are available in the
supplementary materials (
2.4 Data collection
Data collection and program implementation took place from April to August 2024. Quantitative data were collected using pre- and post-intervention questionnaires assessing participants’ demographic and professional characteristics, knowledge of pressure injury care, confidence in managing pressure injuries, clinical performance ability, learning immersion and educational satisfaction. The control group received a two-hour traditional lecture and scenario-based group discussion, whereas the experimental group participated in a two-hour VR-SIMPI session. Clinical performance ability was objectively assessed by a blinded clinical nurse educator using a standardized checklist.
Qualitative data were gathered through FGIs with 18 experimental group participants on 14 June, 21 June 21 and 12 July 2024. Four FGIs, each lasting 60–90 min and consisting of 4–5 participants, were conducted using a semi-structured format: introduction (5 min), transition (5 min), key questions (60–80 min), conclusion (5–10 min) (Supplementary 3). The main focus of FGIs was to explore participants’ learning experiences and perceptions about the simulation program. Discussions were moderated to encourage open dialogue. Audio recordings were transcribed verbatim and anonymized for analysis. This approach ensured ethical and reliable data collection.
2.5 Instruments
Knowledge of nursing care for patients with pressure injuries and confidence in performing related nursing tasks were assessed and compared. After completing the training, clinical performance ability, learning immersion and educational satisfaction were measured in the experimental and control groups.
2.5.1 Knowledge of nursing care for patients with pressure injuries
Knowledge of nursing care for patients with pressure injuries was assessed using a 10-item tool developed by the nursing education team at the research hospital. The expert panels (two nursing professors, two wound care managers and two wound specialist nurses) confirmed the tool’s content validity, achieving a CVI of 1.0. The vocabulary of some items and content of one item have been revised to reflect expert opinions. The items focus on key areas, including skin assessment, stage classification of pressure injuries, dressing methods and materials and prevention and management strategies. Each item is scored as 1 for a correct answer and 0 for an incorrect answer, with higher total scores indicating greater knowledge. The tool demonstrated a 95 % confidence interval (CI) of 6.81–7.48, reflecting a reliable estimation of the mean score.
2.5.2 Confidence in nursing care for patients with pressure injuries
Confidence in providing nursing care for patients with pressure injuries was assessed using a tool developed by the nursing education team at the research hospital. The expert panels evaluated the content validity, achieving a CVI of 1.0. The tool consists of 9 items, each rated on a 10-point scale ranging from 0 (completely disagree) to 10 (strongly agree). Higher scores indicate greater confidence in providing care for patients with pressure injuries. The tool demonstrated high reliability, with a Cronbach's α of.95.
2.5.3 Clinical performance in nursing care for patients with pressure injuries
Clinical performance in nursing care for patients with pressure injuries was assessed using a tool developed by the nursing education team at the research hospital. The expert confirmed the content validity, achieving a CVI of 1.0. The tool consists of 9 items, each rated as 0 (not performed), 1 (partially performed), or 2 (fully performed). Higher scores indicate greater clinical performance ability in managing pressure injuries. The tool demonstrated good reliability, with a Cronbach's α of.83.
2.5.4 Learning immersion
Learning immersion was assessed using a tool developed by Ko (2020), which was modified and supplemented for this study. The tool consists of 16 questions divided into the following sub-domains: cognitive assimilation (7 questions), presence (3 questions), attention (3 questions) and autotelic experience (3 questions). Each item is measured on a 5-point Likert scale ranging from 1 (not at all) to 5 (very much). Higher scores indicate greater levels of learning immersion. The reliability of the tool was Cronbach’s α = .89 at the time of development and Cronbach’s α = .94 in this study.
2.5.5 Educational satisfaction
Educational satisfaction was assessed using the tool developed by Jung (2005). This tool consists of 10 questions measured on a Likert scale ranging from 1 (“not at all”) to 5 (“very much”). Higher scores indicate higher levels of educational satisfaction. Reliability was measured as Cronbach’s α = .75 at the time of development, but was significantly higher in this study, with Cronbach’s α = .97.
2.6 Data analysis
2.6.1 Analysis of quantitative data
The data collected in this study were analyzed using SPSS/WIN 26.0 (IBM Corp., Armonk, NY, USA). The normality of the data distribution was assessed using the Shapiro-Wilk test. The general characteristics of the experimental and control groups were identified and frequency, percentages, chi-square tests and independent t-tests were used to verify preliminary homogeneity. To analyze changes in outcomes within each group before and immediately after the intervention, a paired t-test was performed for normally distributed data, and the Wilcoxon signed-rank test was used for non-normally distributed data. Post hoc comparisons between groups were conducted using independent t-tests or Mann–Whitney U tests, as appropriate. The threshold for statistical significance was set at p < 0.05 for all tests. The reliability of the measurement tools was confirmed using Cronbach's alpha coefficient.
2.6.2 Analysis of qualitative data
Qualitative data were analyzed using NVivo version 12 (QSR International, Burlington, MA, USA). Content analysis of the FGI data was conducted following the method outlined by Graneheim and Lundman (2004). First, an independent researcher assigned unique numbers to each participant and transcribed the FGI data while ensuring anonymity. The corresponding author and first researcher then cross-verified for accuracy transcriptions, comparing them to field notes and audio recordings. The corresponding author performed a detailed analysis by thoroughly reading the data to understand the context, identify meaningful units and generate codes. The generated codes were systematically categorized based on similarities and differences to reflect explicit and observable aspects of the text. To ensure the rigor of the analysis, the findings were verified and refined through discussions with a third party, a nursing professor with expertise in qualitative research.
2.6.2.1 Rigour
The rigor of this study was ensured by applying Lincoln and Guba’s (1985) qualitative research criteria: truth value, applicability, consistency and neutrality. Truth value was ensured by comparing the transcripts of the FGIs against the original recordings, with the analysis then confirmed by 2–3 participants per group. Applicability was supported through detailed context descriptions, purposive sampling of diverse departments and data collection until saturation. Consistency was maintained through methodical documentation and collaboration between two experienced researchers. Neutrality was achieved by anonymizing data, using reflective memos and maintaining a neutral stance during semi-structured interviews to minimize bias.
2.7 Ethical considerations
This study was conducted with the approval of the Bioethics Committee of C University Hospital in Korea (CNUH-2024-077) and written informed consent was obtained from all participants. The participants were informed about the voluntary nature of their participation, as well as the measures taken to ensure anonymity and confidentiality. It was emphasized that they could withdraw from the study at any time without facing penalties. Data confidentiality and anonymity were strictly maintained throughout the study and post-study processes.
3 Results
3.1 Participant recruitment and baseline characteristics
Baseline characteristics were compared between the experimental (n = 35) and control (n = 34) groups. Most participants were female (87 %) and under the age of 24 (68.1 %). No significant differences were observed between groups in terms of age, gender, or marital status. By department, 52.2 % of participants worked in the intensive care unit, with no significant differences observed between groups. No significant differences were found between groups for the variables of pressure injury nursing knowledge and performance confidence, confirming homogeneity (
3.2 Differences in dependent variables between and within groups
The experimental group showed significant improvement in knowledge of nursing care for patients with pressure injuries in the post-test compared with the pre-test (z = -3.78,
p < .001, ES = 0.90, CI: 0.41–1.39). Additionally, the post-test scores of the experimental group were significantly higher than those of the control group (t = -2.91,
p = .004, ES = 0.73, CI: 0.24–1.22). The control group showed no significant changes. Both the experimental and control groups demonstrated significant improvements in confidence in performing pressure injury care from pre- to post-test; however, this was greater in the experimental group (z = -8.40,
p < .001, ES = 1.69). A post hoc comparison showed no significant differences between groups (p = .088). The experimental group showed a highly significant improvement compared with the control group (z = -7.00,
p < .001, ES = 3.55, CI: 2.79–4.31) for pressure injury nursing performance. However, the groups showed no significant differences in learning immersion and educational satisfaction (
3.3 Data analysis of FGIs
FGI participants included 18 new nurses (4 men and 14 women) aged 23–38 years. The participants were distributed across various departments, with 3 nurses (16.7 %) working on the internal medicine ward, 1 nurse (5.5 %) on the surgical ward, 4 nurses (22.2 %) in the internal medicine ICU, 3 nurses (16.7 %) in the surgical ICU and 7 nurses (38.9 %) in other departments. Content analysis of the FGIs resulted in eight subthemes and 24 codes across four main codes: (1) educational value of VR simulation, (2) improvement in clinical practice competency, (3) opportunities for self-reflection and improvement and (4) requirements for enhancing VR simulation training.
3.3.1 Theme 1: Educational value of VR Simulation
This theme highlights the educational benefits of VR simulation, emphasizing its role in enhancing nurses’ learning experiences by complementing actual clinical experiences and providing a realistic learning environment.
Compensating for limited clinical experience. VR simulation helps compensate for nurses’ limited clinical experience by presenting scenarios that are infrequent in actual practice. It reflects the reality that nurses may not have encountered certain stages or cases of pressure injuries in clinical settings. VR allows them to indirectly experience these situations, providing opportunities to practice and learn about scenarios they have not yet faced in real life. Furthermore, it broadens nurses' experiences by offering learning opportunities involving rare or uncommon cases.
Practical learning experience. This subtheme underscores the realistic and immersive learning experience VR simulation provides. Participants reported that VR creates an immersive environment that feels like being in an actual clinical situation, thereby enabling a hands-on experience. This realistic learning environment enhances the educational impact by allowing learners to directly practice clinical skills.
3.3.2 Improved clinical practice competency
This theme focuses on enhancing nurses' clinical practice skills through VR simulation.
Enhanced pressure injury assessment skills. VR simulation was reported to improve nurses' ability to assess pressure injuries effectively. Participants noted an increased ability to distinguish between different stages of pressure injuries and measure their size accurately. Additionally, learning comprehensive pressure injury assessment methods through VR was found to support better management of pressure injuries in clinical settings.
Improved dressing skills. VR simulation also enhanced nurses' skills in applying dressings for pressure injuries. Participants reported being better able to select appropriate dressing materials and follow correct dressing procedures and sequences. Furthermore, the use of aseptic techniques during dressing application was enhanced, leading to an overall improvement in dressing skills.
3.3.3 Theme 3: Opportunity for self-reflection and improvement
This theme explores how VR simulation experiences help nurses reflect on their abilities and identify areas for improvement.
Recognizing shortcomings. Through VR simulation, nurses were able to recognize their own limitations, including a lack of knowledge about pressure injury management and inexperience with techniques such as dressing application. This awareness highlighted the need to improve their overall skills and competencies in managing pressure injuries effectively.
Motivation to learn. The VR simulation experience motivated nurses to pursue further learning and skill enhancement. Participants expressed their realization that additional education was necessary and willingness to apply what they learned to clinical practice. They also reported a desire for continuous self-improvement, which served as motivation to enhance their expertise and professional growth.
3.3.4 Theme 4: Improvement needs in VR simulation education
This theme addresses the limitations of VR simulation education and identifies areas for improvement. Technical limitations. This subtheme highlights the challenges related to VR technology. Participants reported issues such as insufficient resolution or screen clarity, dizziness or discomfort during VR use and difficulties operating the VR devices or systems. These technical challenges were noted as factors that could have a negative impact on learning experience quality.
Demand for the expansion of educational content. Participants emphasized the need to improve and expand the educational content and scenarios available for VR simulation training. They noted that the scenarios provided were limited and VR simulations differed from actual patient cases. The need for more diverse and complex scenarios was raised, highlighting the importance of expanding educational content to better align with real-world clinical practice.
4 Discussion
This study evaluated the effectiveness of VR-based pressure injury management education for new nurses, designed based on Kolb’s experiential learning theory. The VR simulation enhanced learners' knowledge, confidence and clinical performance by systematically applying the four stages of experiential learning, yielding meaningful results at each stage.
First, in the concrete experience stage, VR simulation allowed participants to directly engage in pressure injury management within a realistic environment, like actual clinical settings. The experimental group reported high learning immersion and educational satisfaction, demonstrating the effectiveness of this realistic learning environment. Similarly, Chang et al. (2022) identified immersion in VR simulations as a key factor in enhancing learning effectiveness, particularly in acquiring complex clinical skills. The findings from the FGI further support this, with participants acknowledging that the hands-on experience provided by VR offers practical learning opportunities not available in traditional theory-based education. However, some participants noted VR limitations like dizziness and screen clarity, expected to improve with technological advancements ( Sapkaroski et al., 2022).
Second, the reflective observation phase was conducted systematically through structured debriefing. In the FGIs, participants reported that the debriefing process enabled them to reflect on their performance and identify specific areas for improvement. This aligns with the findings of Bradley et al. (2020) highlighting that structured debriefing is crucial for fostering reflective thinking and enhancing learning effectiveness. Notably, the immediate feedback feature of the VR simulation effectively promoted self-reflection among learners. The VR program also helped prepare participants for real-world clinical performance by offering experiences that closely resembled actual clinical situations in a safe and controlled environment ( Kiegaldie and Shaw, 2023).
Third, in the abstract conceptualization stage, the experimental group showed significant improvement in knowledge of pressure injury management compared with the control group. This improvement reflects not only the accumulation of knowledge but also an integrated understanding of its application in practical contexts. Providing empirical support for this study’s findings, Hong and Wang (2023) highlighted that VR simulation facilitates the integration of theory and practice. FGI participants further noted that the VR experience helped them develop a deeper understanding of how to apply textbook knowledge in real clinical situations. This aligns with the concept of “bridging the theory-practice gap through VR,” as suggested by Kim et al. (2024).
Fourth, in the active experimentation phase, clinical performance significantly improved in the experimental group compared with the control group. These findings indicate that VR simulation is highly effective in enhancing practical clinical skills. Kiegaldie and Shaw (2023) reported that VR simulation effectively improves clinical performance and the present study demonstrates that the effect is especially pronounced in the area of pressure injury management. The observed improvement in performance confidence further suggests increased readiness for application in actual clinical settings, which aligns with the confidence-enhancing effect of simulation training reported by Considine et al. (2021).
Notably, the VR simulation program facilitated professional development and encouraged self-directed learning among new nurses. The FGI theme of “self-reflection and improvement opportunities” revealed that participants developed professional attitudes, enabling them to objectively assess their own abilities and seek continuous improvement. This aligns with the “promotion of professional growth” effect of VR simulation identified by Jung and Moon (2024) and represents an important finding that could enhance the overall quality of nursing care.
This study had some limitations. First, the study was conducted at a single medical institution, limiting the generalizability of the findings. Second, the one-time training format prevented verification of the long-term intervention effects. Third, the current limitations of VR technology may have reduced participants’ immersion. Fourth, this study did not control for differences in departmental characteristics or severity. Despite these limitations, this study empirically demonstrated that VR simulation can effectively implement Kolb’s experiential learning cycle and enhance new nurses' capabilities in pressure injury management.
Future studies should investigate generalizability, cumulative effects of repeated training, long-term clinical outcomes and broader applicability of VR simulation through multicenter research. Additionally, examining changes in educational effectiveness resulting from advancements in VR technology and the development of new educational methodologies will be important areas for further investigation.
5 Conclusion
This study developed a VR simulation-based education program to enhance new nurses’ skills in managing pressure injuries, using Kolb’s experiential learning theory as its foundation. The program was designed to provide realistic learning experiences, structured opportunities for reflection and a platform to bridge theoretical knowledge with practical skills. The results showed significant improvements in new nurses’ clinical performance, knowledge and confidence related to pressure injury management. The value of the program lies in its ability to provide safe, controlled and immersive scenarios, thus addressing limitations associated with traditional training methods. The FGI findings emphasized that VR simulation not only supports skill acquisition but also promotes critical thinking and professional development by encouraging learners to reflect on their practice and identify areas for improvement. To further enhance the effectiveness of VR simulation, future research should explore its application across clinical scenarios and healthcare settings. Longitudinal studies are also needed to evaluate the durability of its impact on clinical competencies. As VR technology continues to evolve, it has the potential to revolutionize nurse training by offering tailored and advanced educational programs, ultimately contributing to improved patient outcomes and nursing care quality.
CRediT authorship contribution statement
Hwi Gon Jeon: Writing – original draft, Visualization, Methodology, Investigation, Formal analysis, Data curation. JEONG Hye Won: Writing – review & editing, Writing – original draft, Validation, Supervision, Project administration, Funding acquisition, Formal analysis, Conceptualization.
Ethical Approval
The study was approved by the Chonnam National University Hospital Institutional Review Board (Approval number: CNUH-2024–077).
Funding
This was supported by
Declaration of Competing Interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Hye Won Jeong reports financial support was provided by Korea National University of Transportation. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper
Acknowledgments
I would like to express our appreciation to the nurses and clinical nurse educators for participating in our study and for their valuable responses.
Appendix A Supporting information
Supplementary data associated with this article can be found in the online version at
Appendix A Supplementary material
Supplementary material
Supplementary material
Supplementary material
Table 1
| Subjects | Content |
| Pre-briefing
(10 min) |
⦁Orientation
⦁Learning objectives ⦁Introduction of simulation lab setting ⦁Provide operation method of lab equipment |
| Simulation
(10–15 min) |
⦁Practice simulation
1) Initial phase 2) Deterioration phase |
| Debriefing
(30 min) |
⦁Description phase
⦁Analysis phase ⦁Application phase |
| VR = virtual reality |
Table 2
| Variables | Total |
Experimental group
(n = 35) |
Control group
(n = 34) |
χ 2 | p | |
| n (%) | n (%) | n (%) | ||||
| Age (years) | ≤ 24 | 47 (68.1) | 23 (65.7) | 24 (70.6) | 0.19 | .664 |
| > 24 | 22 (31.9) | 12 (34.3) | 10 (29.4) | |||
| M (SD) | 24.55 (3.16) | |||||
| Gender | Male | 9 (13.0) | 4 (11.4) | 5 (14.7) | 0.16 | .686 |
| Female | 60 (87.0) | 31 (88.6) | 29 (85.3) | |||
| Marital status | Single | 67 (97.1) | 34 (97.1) | 33 (97.1) | 0.00 | 1.000 † |
| Married | 2 (2.9) | 1 (2.9) | 1 (2.9) | |||
| Department | ICU | 36 (52.2) | 17 (48.6) | 19 (55.9) | 0.48 | .788 |
| Medical/Surgical ward | 12 (17.4) | 7 (20.0) | 5 (14.7) | |||
| Others (OR, ER, Delivery room) | 21 (30.4) | 11 (31.4) | 10 (29.4) | |||
| M (SD) | M (SD) | M (SD) | t | p | ||
| Nursing knowledge of patients with pressure injuries | 7.15 (1.41) | 7.31 (1.51) | 6.97 (1.29) | 1.02 | .314 | |
| Confidence in caring for patients with pressure injuries | 5.29 (1.94) | 5.22 (1.95) | 5.36 (1.96) | −0.29 | .771 | |
| M = mean; SD = standard deviation; ICU = intensive care unit; OR = operation room; ER = emergency room.
†Fisher’s exact test. |
Table 3
Wilcoxon signed-rank test.
Mann–Whitney U test.
| Variables | Experimental group (n = 35) | Control group (n = 34) | Experimental vs. Control | |||||||
| Pre-test | Post-test | ES | t/Z ( p) | Pre-test | Post-test | ES | t/z ( p) | Post-test only
t/ Z ( p) |
ES
(CI) | |
| M (SD) | M (SD) | (CI) | M (SD) | M (SD) | (CI) | |||||
| Nursing knowledge of patients with pressure injuries | 7.31 (1.51) | 8.57 (1.29) | 0.90
(0.41–1.39) |
−3.78 (<.001) a | 6.97 (1.29) | 7.56 (1.48) | 0.43
(−0.06–0.91) |
−1.67 (.095) a | −2.91 (.004) b | 0.73
(0.24–1.22) |
| Confidence in caring for patients with pressure injuries | 5.22 (1.95) | 8.15 (1.49) | 1.69
(1.14–2.23) |
−8.40 (<.001) | 5.36 (1.96) | 7.58 (1.23) | 1.36
(0.83–1.88) |
−6.68 (<.001) | 1.73 (.088) | 0.42
(−0.06–0.89) |
| Clinical performance for patients with pressure injuries | - | 15.40 (1.79) | - | - | - | 8.56 (2.06) | - | - | −7.00 (<.001) b | 3.55
(2.79–4.31) |
| Learning engagement | - | 4.25 (0.52) | - | - | - | 4.10 (0.60) | - | - | −1.16 (.248) b | 0.27
(−0.21–0.74) |
| Learning satisfaction | - | 4.70 (0.42) | - | - | - | 4.76 (0.42) | - | - | −0.69 (.489) b | −0.14
(−0.62–0.33) |
Table 4
| Themes | Categories | Codes | Examples of quotations |
| Educational value of VR simulation | Compensating for limited clinical experience | Experiencing situations difficult to encounter directly | “
I have never encountered a bedsore beyond stage 2 before, so I had only used foam dressings. However, through this experience, I was able to learn about and practice using stage 3 filling dressings.” (Group 1-Participant 3)
“ On our ward, we have never managed patients with high-stage pressure injuries. Through VR, we were grateful to have the opportunity to learn and gain valuable knowledge.” (Group 3-Participant 2) |
| Opportunity to learn about rare cases | “
I rarely have the opportunity to observe the dressing process directly on the ward, so it was great to be able to see it through VR.” (Group 2-Participant 1)
“ I have never encountered pressure injuries this severe in real life, but I think I will be able to perform dressing well if I encounter such severe cases in the future.” (Group 4-Participant 3) | ||
| Practical learning experience | Realistic educational environment | “
It felt realistic because it was similar to an actual situation, and it gave me an opportunity to check what I was doing wrong.” (Group 1-Participant 4)
“ I appreciated being able to learn in a realistic way.” (Group 4-Participant 2) | |
| High immersion | “
I think it will be very helpful for actual nursing because you can perform it as if it were a real situation.” (Group 2-Participant 3)
“ I believe I was able to practice in a realistic way.” (Group 4-Participant 22) | ||
| Improvement in clinical practice competency | Enhanced pressure injury assessment skills | Ability to distinguish between stages | “
We need to carefully assess the size of pressure injuries, communicate with patients, and provide education on preventing of pressure injuries.” (Group 1-Participant 2)
“ When assessing pressure injuries, I learned the importance of carefully checking whether the patient is experiencing any pain and applying a filling dressing for patients with stage 3 or higher pressure injuries.” (Group 3-Participant 4) |
| Accurate measurement methods | “
Through the education program, I learned how to assess the size and depth of pressure injuries.” (Group 2-Participant 2)
“ We were able to accurately assess the size and stage of the pressure injury.” (Group 4-Participant 1) | ||
| Improved dressing skills | Selection of appropriate dressing material | “
The dressing materials were selected appropriately, and the dressing was performed using the correct process.” (Group 1-Participant 1)
“ I need to examine pressure injuries and study more about what types of dressings are required.” (Group 3-Participant 3) | |
| Application of aseptic technique | “
I learned how to use new forceps to sterilely prepare dressing sets.” (Group 2-Participant 4)
“ I realized the importance of being mindful of contamination while performing dressing” (Group 2-Participant 4) | ||
| Opportunity for self-reflection and improvement | Recognizing shortcomings | Recognition of lack of knowledge | “ Currently, I feel the need to study more about the nursing care required due to my lack of knowledge about dressings.” (Group 1-Participant 3) |
| “ I realized I need to study more about pressure injury dressing formulations.” (Group 3-Participant 2) | |||
| Recognition of poor skills | “
The most basic sterility was not maintained. I did not wear gloves and attempted to reuse forceps that were already contaminated.” (Group 2-Participant 1)
“ It was my first time using a filling dressing, so it felt awkward, and I missed some preparation. But from what I learned today, I believe I can provide more accurate nursing care to actual patients.” (Group 4-Participant 22) | ||
| Motivation to learn | Willingness to learn more | “
I felt the need to study dressing preparation, dressing sequence, and pressure injury assessment.” (Group 1-Participant 4)
“ I thought we should better adhere to dressing preparation and aseptic techniques appropriate for the stage of pressure injuries” (Group 3-Participant 1) | |
| Willingness to apply clinically | “
I tried to approach it as if it were a real patient, but it was disappointing because it left out a lot of preparations and explanations.” (Group 2-Participant 3)
“ I will also be organizing dressings in the future, and I think this experience will help me decide which dressings to use in different situations.” (Group 4-Participant 3) | ||
| Improvement needs in VR simulation education | Technical limitations | Inconvenience related to VR devices | “
It was a bit dizzying, but the fact that I could observe the situation firsthand and even try it myself will stay in my memory for a long time.” (Group 1-Participant 2)
“ I felt a little dizzy after doing it, but I recovered quickly.” (Group 3-Participant 4) |
| Perception of screen clarity | “
It was hard to get an accurate understanding because the image was not clear.” (Group 2-Participant 2)
“ It was more helpful than explaining it with words or pictures because I could see it right in front of me as if it were real.” (Group 4-Participant 1) | ||
| Demand for expansion of educational content | Lack of scenario variety | “ It was disappointing that the scenarios were limited. I did not really feel much difference between VR and simply watching a video.” (Group 1-Participant 1) | |
| “ Since it is an educational video and not an actual pressure injury, I might find the stage classification confusing when encountering a real patient’s pressure injury.” (Group 3-Participant 3) | |||
| Differences from actual patients | “ It looks realistic, but there are aspects that differ from reality, which is unfortunate.” (Group 2-Participant 4) | ||
| “ If it were a real patient, there would be pressure to do it accurately without making mistakes, but since it was a mannequin, it was nice to be able to learn and proceed slowly.” (Group 4-Participant 4) |
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