• academic electronic medical record (AEMR)
• assessment
• augmented reality (AR)
• augmented-reality game (ARG)
• avatar
• clinical information system
• database
• debrief
• dynamic web page shell
• edutainment
• enactment
• engage
• feedback
• fidelity
• game
• game mechanics
• gameplay
• immersive experience
• latex-based simulation
• massive multiplayer online role-playing game
• massive open online course (MOOC)
• Multimedia Educational Resource for Learning and Online Teaching (MERLOT)
• multiuser dungeon
• nonplayer character (NPC)
• object-oriented multiuser dungeon
• prebrief
• prebrief, enactment, debrief, and assessment (PEDA)
• reusable learning object (RLO)
• scaffolding
• Second Life (SL)
• serious game
• server
• simulated documentation
• simulation
• simulation scenario
• simulator
• three-dimensional (3D)
• virtual reality (VR)
• virtual simulation
• virtual world

The use of latex-based and virtual simulation (Figure 20-1), virtual worlds, and game mechanics in nursing education was increasing, but with the COVID-19 pandemic, their integration really escalated to meet the needs of students who could not attend clinical experiences or classes. Many schools and staff education departments have employed these techniques to provide efficient, effective, and engaging educational experiences for their students and staff. The schools and other educational entities began realizing the benefits of these educational modalities. The monumental National Council of State Boards of Nursing (NCSBN; Hayden et al., 2014) simulation study brought national attention to the need to enhance, extend, or replace clinical and practicum hours with other effective means, such as simulation. In this chapter, we will explore simulated documentation, simulation, virtual worlds, and game mechanics used in teaching nursing informatics competencies and nursing education.

Figure 20-1 Latex-Based Simulation

An illustration features a patient lying on a bed with an I V attached. A nurse checks the I V, and a doctor places a stethoscope on the patient's chest.

Even though there are many nursing students, nursing educators, and nurses using these technologies, no clear understanding of the terminology associated with these learning modalities exists. Therefore, it is important to define this terminology when discussing these technologies and their effect on nursing informatics and nursing education.

• Simulations are imitations of real-life events or circumstances; in nursing education, simulations are used to replicate a clinical scenario to provide an opportunity for practice in a mock situation. These simulations can be done with mannequins (latex-based simulation) or via role-play, web-based applications, or virtual simulation in a virtual world.
• A simulator is a mechanical or electronic device that provides an environment in which a simulation can occur.
• Simulated documentation refers to any simulated electronic format or electronic health record (EHR) that is accessed and used by the learner to actually document simulated nursing care for educational purposes.
• A simulation scenario is a situation or case developed in a simulation setting to mimic an actual practice situation.
• A game is a structured activity undertaken for enjoyment.
• In education, edutainment is the combination of education and entertainment to make learning fun.
• Game mechanics are the rules, instructions, directions, and constructs that the learner interacts with while playing the game. For educators, it is essential that any game mechanics they use be engaging and satisfying for the learner.
• Gameplay is how the learner interacts with or plays the game. This is extremely important to understand to be able to appreciate how the game functions and the learners function, play, and learn.

As you progress through the chapter, you will delve into simulated documentation, simulation, game mechanics, virtual worlds, and the realities.

The use of game mechanics in educational, or serious, games and virtual world simulation continues to grow, with a great deal of research effort and funds directed toward the discoveries of their best uses. Educational games and virtual world simulations share some characteristics, and it is difficult to find a pure experience in any of the genres. Simulations may have gamelike qualities, and virtual worlds may be used to present a simulation.

Following are two examples of using simulation in nursing informatics education. In the first example, the EHR is part of a larger simulation scenario that mimics a real-life clinical case, and in the second example, the EHR itself functions as a simulator and becomes a true-to-life learning tool.

In the first example, the patient call bell is ringing; you enter the room to find the patient verbalizing complaints of chest tightness. In a moment, the patient becomes unresponsive, and a code is called. The team quickly responds, initiating resuscitation measures per the advanced cardiac life support protocol. You review the EHRs with the attending physician while discussing your assessment before the code. After a short while, the resuscitation efforts are successful, and the patient is stable enough for transfer to the intensive care unit. You complete your documentation in the patient's EHR, the simulation scenario ends, and the debriefing begins. The instructor provides feedback not only on actions taken within the simulation scenario but also on the use of the EHR as an important resource for patient information and documentation.

In the second example, it is the first day of a new course, and rather than a lecture-based class with an accompanying textbook, the instructor uses an active learning approach with case studies delivered through an EHR interface to facilitate the learning and application of clinical concepts. In this example, rather than being part of an entire simulation scenario, the EHR itself is the learning tool providing learners with a hands-on learning opportunity centered on accessing and using the information contained within the patient record. Choi et al. (2016) concluded that academic electronic medical records (AEMRs) would improve students' understanding of clinical practice: “[T]he findings of this study will provide important developments by applying an AEMR, which will augment students' informatics competencies and critical thinking, into the nursing curricula to better prepare the future workforce” (p. 264).

In the late 1990s, researchers identified that healthcare professionals needed to possess both skills in and knowledge of informatics (American Association of Colleges of Nursing, 1999; Gassert, 1998; Pew Health Professions Commission, 1998). In addition, information technology was identified as a key measure in improving patient safety and quality of care (American Academy of Nursing, 2003; Institute of Medicine, 2000). In response to the increasing demand for practitioners to become skilled in this area, coupled with the absence of research-based informatics competencies, a Delphi study was used to identify informatics competencies for nurses at four levels of practice (Staggers et al., 2002). In essence, this seminal study created informatics competencies for entry-level nurses through informatics specialists and innovators, with a focus on computer skills, informatics knowledge, and informatics skills.

Although informatics competencies for nurses have been identified, the degree to which schools of nursing have woven them into the curriculum varies greatly (Carty & Ong, 2006). In a study conducted by Fetter (2009), a survey of graduating senior nursing students ranked the following competencies with which they had no experience or minimal skill: (1) using applications to document, (2) creating an electronic care plan, (3) valuing informatics knowledge for practice, (4) valuing informatics knowledge for skill development, and (5) using applications for data entry. Hunter et al. (2013) developed an online self-assessment tool, the TIGER-Based Assessment of Nursing Informatics Competencies (TANIC); this instrument assesses the Level 1 Beginning Nurse and Level 2 Experienced Nurse competencies. McGonigle et al. (2013) developed the Nursing Informatics Competency Assessment (NICA) for Level 3 Informatics Nurse Specialist and Level 4 Informatics Innovator, based on the seminal work of Staggers, the current literature, and expert input. This online self-assessment was noted in the 2014 American Nurses Association Nursing Informatics: Scope and Standards of Practice, Second Edition. These self-assessment tools are discussed in Chapter 7, Nursing Informatics as a Specialty.

The question then becomes, Which best practices will ensure that students become prepared in informatics? The National League for Nursing (2015) realized the need to prepare students for the technology-rich healthcare environments. Nursing educators and administrators indicated the need to make sure that informatics is integrated throughout the curriculum and that experience with nursing informatics is provided during clinical rotations as well. Little clinically related informatics content and few such learning experiences were provided in nursing programs. Technology tools containing care planning software and clinical information systems were least likely to be incorporated into the courses, and the lack of these tools continues to be an issue. Another area of concern is the preparation of the nursing informatics faculty in the use of these tools. Rajalahti et al. (2014) made several recommendations about competencies, including the following: “A description of nursing informatics competencies for nurse educators is needed at a national and global level. Advanced nursing informatics programmes are needed in the nurse educators' training programme” (p. 64). Nursing faculty must be prepared to use these technologies. With emerging technologies in nursing and healthcare education, the use of these technologies, including simulation, to allow students to use informatics in an active manner and in an authentic and realistic learning context is one potential approach to remedying these shortcomings.

A simulation recreates a real-life set of conditions or events with as much fidelity as possible (Alessi, 1988). Aldrich (2010) contended that simulations develop cognition (i.e., learning-to-know skills), ethics and roles (i.e., learning-to-be skills), and application capabilities (i.e., learning-to-do skills). Unlike games, however, simulations are not necessarily designed to be fun.

Simulations contain four major components: prebrief, enactment, debrief, and assessment (PEDA) (refer to Table 20-1). Every simulation should have these elements in order to prepare and assess students while also facilitating learning through doing and reflection. The most important translational PEDA components are the prebrief and debrief. It is imperative that learners know exactly what is expected and be prepared for the enactment in the prebriefing. When done well, debriefing helps learners reflect on the authentic experience and solidifies the learning by facilitating the transfer of theory and skills to their real practice setting. Graduate nursing education is an area that is expanding learners' simulated learning episodes. Woroch et al. (2018) described a drug-seeking telephone triage scenario simulation in which family nurse practitioner (FNP) students collaborated with psychiatric mental health nurse practitioner students. Robinson-Reilly et al. (2020) stated that “[s]imulated telehealth allows students to engage in a learning environment that closely reflects real-life experiences without posing a threat to either the student or the patient” (p. 49). Harris (2020) simulated lacerations, abscesses, and suspicious lesions with nurse practitioner students. Harris et al. (2016) believed that simulation could assist FNP students with their role transition from generalist to advanced practice by doing the following:

Developed by Dee McGonigle.

• “Allowing FNP students opportunities to gain confidence in a risk-free environment.
• Providing FNP students an entire comprehensive office-based or acute patient care experience.
• Reinforcing classroom content and bridging the theory to practice gap” (p. 14).

Simulations may be experiential and task based, in which the learner takes on a first-person role and executes a self-chosen series of decisions by manipulating the variables in the simulation toward a desired outcome (Aebersold & Tschannen, 2013; Gredler, 1996). Simulations may also be symbolic scenarios in which the learner directly manipulates variables, sees the results of changes, and then makes decisions on how to continue in the simulation. Spreadsheets are often used for this type of simulation. Symbolic simulations are good choices for discovering principles, misconceptions, and relationships and for fostering understanding, prediction, and solution development (Mastrian et al., 2011).

Simulations may use a process known as scaffolding (Jonassen, 1999; Podolefsky et al., 2013) to assist in acquiring the accepted level of proficiency. An example of scaffolding is when corrective feedback is initially used to correct user mistakes and ensure success and then the feedback fades away when it is no longer needed.

Medical simulations use realistic three-dimensional computer models of humans to investigate new medical possibilities and test assumptions (i.e., learning-to-know skills). Simulations of drawing blood and performing complex medical operations are used to teach learning-to-do skills.

In general terms, a simulator can perhaps best be described as a tool designed to emulate some aspect of the clinical practice environment, which may be focused on a single task or designed to mimic a complete patient care situation (Gaba & DeAnda, 1998). At its essence, it is any device that is used to create a realistic learning experience for the learner but that removes the risk associated with learning during hands-on patient care. A simulator offers the unique ability to create a realistic learning environment that is safe, structured, and supportive for the learner (Bligh & Bleakley, 2006).

Simulators encompass a broad range of devices, such as partial task trainers (e.g., an IV insertion arm); screen-based simulations, including simulated EHRs, documentation, and environments that replicate a realistic patient-care area (virtual simulation); and complex computer-driven human-patient simulation mannequins (i.e., latex-based simulation). Web-based virtual standardized patients are also increasing in use. It is important to understand which of these products you are using, one in which you enter and interact in a virtual world, access a web-based product, or interact in a latex-based lab. Although each of these simulation modalities can be used alone, they can be powerful learning tools when used together to create a realistic patient care scenario. When designing simulation learning environments, “[i]nnovative educators design learning environments that encourage active engagement in the learning process. . . . Active engagement creates a personal connection with the learning experience and motivates the learner to take greater responsibility in the learning process” (Fisher, 2016, p. 9). According to Gaba (2004), the goal of simulation is a seamless immersion into the simulated practice environment during which learners are drawn into the reality of the environment or task at hand. Hertel and Millis (2002) noted that this is a cooperative process whereby learners come together in an authentic setting and begin to learn from one another. Darragh et al. (2016) recommended realistic scenarios that elicit autonomous problem-solving and decision-making to immerse and engage the participants in active learning and critical thinking (Figure 20-2).

Figure 20-2 Simulation Can Bridge the Gap

An illustration depicts a suspended cable bridge linking two columns; one column represents education, and the other signifies practice. The simulation bridges the gap between the two columns.

Considering the realistic nature of simulation and its hands-on active approach to learning, it seems that the use of simulation modalities can be a powerful tool in moving student nurses-indeed, any practitioners-toward achieving the informatics competencies. Recall the examples given at the beginning of this chapter. In both examples, simulation is used to incorporate nursing informatics into the context of patient care, thereby giving students an authentic learning experience that can be applied in clinical practice.

According to the NCSBN national simulation study (Hayden et al., 2014), 50% simulation can be effectively used in various program types, in different geographic areas, and in urban and rural settings with good educational outcomes. The NCSBN study results and the lack of available quality clinical and practicum placements are prompting the move to integrate more simulation into nursing education. Virtual and latex-based simulations are valuable educational assets at all levels of nursing education. They provide a safe, authentic environment in which to develop knowledge, skills, and attitudes before interacting with actual patients. There is no risk to patients, and students can practice and receive assessment and feedback for controlled episodes, including unusual events. Simulation relates well to adaptive learning methods, such as branching logic, that allow the learner to guide the learning. The nurse educator can tailor the simulation to the learning needs of the students and provide deliberate practice with feedback. The learner can learn, relearn, and hone skills while safely practicing in dynamic and complex situations with a view to decreasing and eliminating mistakes.

There are two main approaches to the incorporation of an EHR into the learning environment, whether used within a simulated clinical environment as part of a patient care scenario or as a stand-alone learning tool. First, the EHR can be created specifically for simulation purposes; options range from a well-developed Microsoft Access database to commercially available products designed specifically for simulation purposes. Second, the simulation may use a real EHR system either within a hospital-based simulation center or through a partnership with a healthcare facility or an EHR vendor. Raths (2020) found that many health centers are using commercial EHRs.

There are certain advantages and disadvantages to each simulated documentation solution (Figure 20-3). Live documentation systems provide learners with a realistic experience and can be incorporated into the learning environment, but they also present certain drawbacks: (1) They are designed for the patient care environment, not the learning environment, and therefore lack an efficient feedback mechanism for learners; (2) they are designed to work in real time, not simulated time, which creates issues with data recall, especially when a record may be used repeatedly over a period of months or years; and (3) if a system is overly complex, it may unintentionally focus the learning on the specific system rather than on the process of data retrieval and documentation. Refer to Research Brief 1 for more on the challenges of teaching clinical documentation skills in an EHR.

Figure 20-3 Simulated Documentation Nurse/Patient. You are working as a team. This is Mr. Poli, and as your simulated patient, you will be saving him from falling when you assist him to the restroom and determining why he is unsteady. At the end of your shift, you will document the nursing care you provided to this patient. When you leave, Mr. Poli will tweet about his experience with each of you as his nurse and post comments about the care you provided. It is important to simulate not only what the nurse must document but also what the patients document and how they use social media to describe their care experience. It is important that you realize that patients take note of your actions and use social media to share their opinions and observations. Think about your best and worst experiences in health care. They might be something you experienced yourself or with a loved one. Where and what would you share through social media?

A healthcare practitioner observes a monitor that depicts a three-dimensional simulated healthcare scenario. In the simulation, a patient is portrayed standing at a hospital reception area.

One system designed specifically for simulation is the web-based medical chart (WMC). This system requires four components: (1) a database, (2) dynamic web page shells, (3) a server, and (4) computers with access to the internet. With this system, a Microsoft Access database is created to hold administrative information about the simulation scenario and other pertinent overview information accessible by only the instructor and the simulated patient data, simulated patient documentation, student documentation entries, and learner feedback from instructors. Each time a learner logs in to the WMC system via the internet, the server custom creates the requested page using the existing database information, user-specific information, and web page shells to create a realistic EHR for use by the student. Although this type of system offers a great deal of flexibility because it is custom created by the end user (and is certainly a cost-effective solution), it requires that the simulation instructor have a strong background in computer science and information technology to create and maintain the database and supporting materials.

Research Brief 1

Faculty perceptions of the challenges of teaching undergraduate students proper clinical documentation in both paper-based and electronic systems are described in a qualitative research study by Mahon et al. (2010). In this study, participants (N = 25) were interviewed using both open- and closed-ended questions, and results were analyzed using a constant comparative method. The most common method of teaching documentation skills was some variation of the demonstration-return-demonstration method. Faculty members were concerned about the amount of time it took to hone documentation skills in the actual clinical area, indicating that a median of 2 hours of an 8-hour clinical day were consumed by this task, and shared that there was seemingly little documentation taught in the classroom or laboratory. Faculty relied heavily on experts in the clinical setting and used their documentation as models for students to emulate. In the case of the EHR documentation, on-site nursing experts proficient in the use of the system were especially useful as role models. However, faculty remained concerned that using the electronic system and the endless drop-down menus might actually interfere with the development of nursing expertise and critical thinking. One crucial issue that was shared by faculty regarding electronic documentation was that the clinical facility provided the instructor with only one access code so that all the students in the clinical group used the same code to document and there was limited access to computers on the clinical unit. The faculty was very concerned about the legal and ethical issues for appropriate documentation and the provision of care, such as on-time medication administration in a group of 8 to 10 students with one access code. The authors suggested the need to integrate information competencies throughout the curricula and provide opportunities for faculty development in informatics. They suggested that “faculty competencies in the area of informatics must be identified and standardized” and faculty must learn to “model self-efficacy: the patience, support and persistence that characterize individual development within a professional discipline” (p. 620). The full article appears in: Mahon, P. Y., Nickitas, D. M., & Nokes, K. M. (2010). Faculty perceptions of student documentation skills during the transition from paper-based to electronic health records systems. Journal of Nursing Education, 49(11), 615-621. https://doi.org/10.3928/01484834-20100524-06. A qualitative research study by Kennedy et al. (2009) described the experiences and development of nursing process skills in nursing students (N = 5) using the Simulated E-hEalth Delivery System (SEEDS) learning innovation. In the SEEDS learning innovation, students were given written case studies and asked to enter the patient data in a simulated EHR and generate a care plan for the patient and family. The authors concluded that “[t]he technology provided an interactive venue for developing nursing process skills by linking assessment data from case studies with foundational concepts in nursing. . . . The exercise was authentic, dynamic, and learner centered” (p. 99). As a result of the themes discovered in this qualitative study, the authors proposed two hypotheses for future research to explore learning outcomes resulting from the use of a simulated e-health system: Interaction is greater among technologically competent students who use electronic documentation for patient data during clinical conferences. These students interact more freely with other students and their faculty members and experience enhanced learner satisfaction. These students also demonstrate superior nursing process skills compared to students using traditional post clinical group discussion about patient care. Technologically competent students also have higher test scores on specific topics compared to students who use paper-and-pencil means to organize the assessment data and develop care plans. The full article appears in: Kennedy, D., Pallikkathayil, L., & Warren, J. J. (2009). Using a modified electronic health record to develop nursing process skills. Journal of Nursing Education, 48(2), 96-100. https://doi.org/10.3928/01484834-20090201-07.

Debriefing a simulation scenario is enhanced when a fully functional EHR is included. The EHR is linked to the simulation scenario and contains all the pertinent patient information for learners to access before or during the simulation scenario. It is imperative that the system incorporate the ability for learners to document just as they would in an actual clinical setting, with the capability of submitting the documentation to the instructor for evaluation and feedback. Being able to do this helps students feel practice ready. A major strength of this type of system is that it is a prepackaged, web-based solution that does not need to be created from scratch. Vanderbilt University Medical Center went with Epic. According to Raths (2020), “A decade ago, many academic medical centers built homegrown EHRs based on the innovative work of their own informaticians. Now, by and large, those same health centers use commercial EHRs from Epic or Cerner” (para. 1). Vanderbilt wants to guarantee that students, faculty, and clinicians can access data, investigate and test innovations, and assess the results.

In addition, many learning systems designed for simulation contain all the necessary tools for the instructor or simulation center staff to build the simulation scenario, including but not limited to programming guides, staging and scripting information for the scenario, and debriefing guides. Two potential disadvantages with any commercially available solution, however, are the cost to purchase it, which varies depending on the product and vendor, and the ability for or cost associated with customization.

Although the main disadvantages of a live system were discussed at the beginning of this section, the use of a real EHR system clearly provides learners with a truly authentic experience. One innovative solution to bridge this gap was developed out of an academic-business partnership between the Cerner Corporation and the University of Kansas School of Nursing. The SEEDS incorporated the use of Cerner Corporation's clinical information system and PowerChart application (Connors et al., 2002). This system was specifically adapted for educational purposes to address the learner's informatics needs. Similar to the WMC system, discussed previously, instructors developed the patient data stored within the Cerner Corporation's clinical information system database to create virtual patients within the system. Students could navigate through the system to view pertinent patient data and then document assessment information and create a plan of care within the PowerChart application. In addition, the instructor could access student documentation for evaluation and feedback. The SEEDS marked the first time a clinical information system was used in a simulated way for teaching curriculum content to health professional students (Kennedy et al., 2009). Refer to Research Brief 1 for a discussion of a study on the use of the SEEDS approach.

The adoption and use of simulation technologies present unique advantages and disadvantages. Using simulated medical records, either as a stand-alone learning tool or in conjunction with a complete simulation scenario, provides the learner with an opportunity for a realistic, hands-on learning experience. Major considerations when looking to adopt a simulated EHR include (1) cost, (2) ease of use for the instructor and learner, (3) technical support from the vendor, (4) time to build or develop the patient database, (5) additional simulation materials included with the package, (6) flexibility of the system to be customized and used as a stand-alone tool or in the setting of a full-scale simulation scenario, and (7) overall fidelity (i.e., realism).

In 2006, a coalition consisting of experts from the fields of health care, informatics, business and industry, and nursing proposed the Technology Informatics Guiding Education Reform (TIGER) initiative (Healthcare Information and Management Systems Society [HIMSS], n.d.). The aim of this group is to advance the integration of informatics core competencies into nursing education to provide better and safer care to patients. Of particular interest is the call to take an active role in the design and integration of informatics tools that are intuitive, affordable, usable, responsive, and evidence based (HIMSS, n.d.). This approach promotes truly new and innovative strategies for informatics education and creates significant opportunities for collaboration among industry, academia, and clinical practice.

Simulation will clearly play an important role in the development of informatics competencies for student nurses and practitioners. One theme of simulation-based learning is practicing just as a nurse would in the actual clinical setting. Regarding facilitating the growth of informatics competencies, it is no different. If there are expectations regarding the use of clinical information systems and EHRs in the clinical setting, then the opportunity also exists for the incorporation of such tools into the classroom and simulated clinical setting.

Aside from using the simulated EHR in the setting of a clinical simulation scenario, opportunities also exist to incorporate the simulated EHR into the classroom in new and innovative ways. As mentioned at the beginning of the chapter in the second simulation example, the EHR can be used as an active learning tool within the classroom. Rather than requiring students to absorb information from a book, the EHR can become a powerful way for learners to make important connections about caring for patients with a specific disease process or to learn concepts of pathophysiology or pharmacology.

Game mechanics are, simply put, the rules and limitations in which a game takes place. It is imperative that the rules be clearly stated in the instructions so that the players know what is expected of them and what the rules are that the game itself must follow. The mechanics determine how the players interact with the rules and the game responds to the players' moves or behaviors within the game, thus connecting the players' actions to the purpose of the game. People voluntarily play games because they are fun and embody many motivational aspects (Mastrian et al., 2011). Great games provide an optimally challenging state between boredom and frustration (Csikszentmihalyi, 1990). Games exist within a set of rules (Kelley, 1988; Salen & Zimmerman, 2003), and players receive feedback from their interactions in the game and rule space. According to Chen (2012), the rule space model facilitates the cognitive assessment and breakdown of a learner's skill and provides an understanding of the learning topics or concepts that are weaknesses or strengths for each learner.

A 3D virtual world often mimics a real-world environment, although it may also include supernatural abilities, such as flying unaided (Mastrian et al., 2011). Users of virtual worlds are often quick to stress that these creations are not games, although this confusion is easy to understand because virtual worlds share many of the same interface characteristics as 3D action and role-playing games.

The best use of virtual worlds for educational purposes may occur when there is a need for an immersive experience coupled with a need for social interaction. For example, in the virtual world of Second Life, one university has developed a virtual hacienda for students learning Spanish (Clark, 2009). Students interact with the environment and the objects in the hacienda while speaking to one another in Spanish, thereby participating in authentic learning activities. Some of the Second Life scenarios used by a college of nursing include a real human resources representative whom the student must call; the pair must discuss the situation, and the student then determines a solution based on the representative's input. This activity immerses the students in their role and fully engages them in the learning episode. Cohen et al. (2012) tested the use of a virtual world as a training site for emergency preparedness and coordination for first responders in major incidents (e.g., a terrorist attack) and concluded that

Simulations; educational, or serious, games; and virtual worlds overlap a great deal. Games may be placed in virtual worlds, and simulations may have gamelike elements. Yet these three tools also have distinctive characteristics. By examining several of these key characteristics (i.e., goal orientation, competition, fun factor, exploratory learning, and social interaction), choosing the correct tool for teaching purposes becomes easier.

Games are goal oriented and may be competitive in nature. They should be fun and perhaps a bit fantastical and lighthearted. A particular game may or may not include exploratory learning and social interaction. Although simulations are also goal oriented, the competition is generally subdued. Simulations are typically more realistic and not necessarily fun to use. A particular simulation may or may not include exploratory learning and social interaction. Virtual worlds do not intrinsically have goals or competition; it is up to the player to construct them and add them to the world. Virtual worlds may include fantastical elements. Virtual worlds generally lend themselves to exploratory learning and social interaction. When educators develop virtual worlds for education, they can control the scenarios or activities that the learners experience. Virtual worlds used for simulation also include a debriefing process for their learners, which solidifies the learning.

The use of simulations, games, and virtual worlds in Western society continues to increase. The combination of best practices supported by sound research, the ever-growing power of technology, and learners who grew up using these environments will lead to greater use of these tools for learning (New Media Consortium, 2007).

In addition, games are becoming less expensive to produce and consume. Game development engines, which were long the exclusive domain of major game development companies, are now available at a cost that many users and organizations can afford. Some games come with built-in development tools, which are the game producers' attempt to use free labor to extend their products (Dyer-Witheford & de Peuter, 2009). The growth of indie (i.e., independent) game companies is leading to a plethora of cheap yet high-quality games. The same holds true for virtual worlds. New virtual worlds spring up all the time. Many offer free (sometimes with limited functionality) accounts, and educators are exploring these spaces with increasing regularity for building fantastic learning environments.

Companies are tapping mobile devices as another avenue to push out their games. These devices are already used for a variety of communication and social functions, so why not expand that platform with casual games that rely on social interactions? Expect to see much more happening in this space in the near future.

Another related area of growth is in augmented-reality games (ARGs). Augmented reality occurs when one uses a device, such as a smartphone, to overlay additional information on the real world (Klopfer & Squire, 2008). For example, one might use the camera in the phone to view the stars at night and see on the phone's screen both the stars and the constellation labels and linking lines between the stars in a constellation. ARGs exploit this concept in gamelike ways, bringing people together physically and virtually to solve a series of challenges. In education, ARGs may be used to provide a fun way to collect and analyze data, collaborate with other students, and access information resources and a new way to look at the world.

Serious games may also have a place in helping practicing nurses maintain or hone skills. Baker (2009) suggested that gaming has a place in continuing education. The science of nursing practice encourages nurses to ask questions, promote dialogue, share lessons learned willingly and openly, and make the outcomes of their patients constructive and positive. Rigorous, high-quality evaluation and research into the teaching and learning techniques offered by serious games can offer insight into future changes not currently conceived of. For example, if a serious game could effectively assist nurses in maintaining the skill set required to care for a patient who is experiencing hypothermia, would that be worth the investment? If a serious game could reduce medication errors in the operating room by 50% to 75% compared to what has been demonstrated in the past, would that have value? If it were found that after implementation of a serious game, a facility experienced zero errors in right-site, right-procedure, and right-patient events during a 10-year period, would this be of value (Baker, 2009, p. 173)?

Serious games can be used to educate health professionals or use their collective knowledge. Foldit (2018) was designed to solve puzzles for science. Foldit had a crowdsourcing computer game that challenged its players to create a protein that could be used as a vaccine for malaria.

The best uses of all these technologies and approaches related to nursing education remain a bit murky (Bauman, 2016, p. 110). Fortunately, the findings of a great deal of research that is currently underway will guide future educators toward the most effective uses of educational games, simulations, and virtual worlds. In an ideal world, educators would have a plethora of available, well-designed, and educator-certified games from which to choose that mesh with the educational objectives of their classes, courses, and curricula.

The two realities of AR and VR are revamping nursing education. They can enhance critical thinking, clinical judgment, and competency and skill attainment. These realities are typically available to the student 24/7 for exploration and practice. As disruptive innovations, they are transforming our educational paradigms and providing interactive, experiential learning. In the future, what is now innovative will be mainstream. Please refer to Chapter 25, Our Expanding Realities and the Metaverse, for more about reality and the realities.

The realities have been described as disruptive innovations (see the Disruptive Innovations box). Using virtual realities in education requires immersion. The expectation of immersive learning is that learners will become absorbed, engrossed, and engaged in the learning activity to the point that they suspend their own reality and truly experience the virtual scenarios and simulations as if they were real; they feel that they are actually participating in a physical setting instead of the virtual, synthetic, artificially generated environment. Augmented reality (AR) and virtual reality (VR) are technological examples of immersive environments used in learning episodes to enhance the learning experience in a safe setting.

Augmented Reality

Augmented reality (AR) is an interactive experience within a real-world environment that enhances real-world objects using virtually simulated, or computer-generated, perceptual information. Integrating AR into educational venues provides stimulation, or input, for multiple senses, including olfactory, visual, auditory, haptic, and somatosensory (e.g., pressure, pain, or warmth). It comprises apps; wearable technologies, such as glasses; and software that not only interacts with users but also enhances their senses with data, information, audio, and images.

Disruptive Innovations
Disruptive innovations are new developments that radically change, or disrupt, the way structures or industries function. They are the introductions of products or services into well-known or established industries that outperform all other products or services (i.e., are more efficient and lower priced), thereby obtaining competitive advantages, which capture the market share and alter and transform those industries. Thinking about the internet, how did it disrupt education? Examples of disruptive innovations that are game changers follow. Reflect on each of them, the disruption they have caused as they evolved and how their disruption affects nursing education.
Surgeon using VR to practice a surgery using the patient's own anatomy so that in the actual surgery, the risk of the surgeon being met with an unanticipated event is minimized. Will this preparation be the norm for all surgeries going forward? If so, how do we educate current practitioners and students who will be the future healthcare professionals in the workforce? Artificial intelligence (AI) Internet of Things (IoT) and Artificial Intelligence of Things (AIoT) Blockchain technology Robotics What other disruptive innovations can you think of, and why were or are they disruptive, or game changers?

AR does not require specialized equipment; the digital information is overlaid on an image of something being viewed through a smart device's camera. AR has been integrated into nursing curriculums to help nursing students achieve and improve clinical skill proficiency. AR improves the abstract, or conceptual, comprehension of phenomena. Faculty members can bring abstract concepts to life with AR expeditions in which they and the students actively explore. Learners can view and manipulate digital animations, such as a beating heart or human brain, by bringing them into their real background. This helps nursing students understand the relationships of diseases and normal pathophysiology. Nursing students can also better understand the effect of procedures in relation to the anatomy and physiology of their patients. AR is a learning experience that enhances critical thinking skills and clinical judgment.

Virtual Reality

Virtual reality (VR) is infiltrating health care to improve plans of care and patients' outcomes. Heady (2019) described the use of VR at the University of California at Los Angeles to explore the patient's own anatomy prior to surgery. VR “models to prepare for kidney tumor surgeries resulted in substantial improvements, including shorter operating times, less blood loss during surgery and a shorter stay in the hospital afterward” (para. 1). VR is also being used to distract patients during painful and/or lengthy procedures, such as helping patients stay relaxed and comfortable while receiving chemotherapy (Pratt, 2017), and for pain management. Brody (2019) said that for pain management, it is more than a distraction: “It's more like a brain hack that occupies the brain so fully that it has no room to process pain sensations at the same time” (para. 1). “Through the hospital's [Stanford Medicine Children's Health] CHARIOT program [www.stanfordchildrens.org/en/innovation/chariot], Packard Children's is one of the only hospitals in the world to have VR available on every unit to help engage and distract patients undergoing a range of hospital procedures” (Stanford Medicine Children's Health, n.d., para. 2). VR integrations such as these demand that nurse educators prepare nurses to function in environments that expand into VR so that they can actively participate in the evolution of the technologies being used to enhance patient care.

See Research Brief 3, which discusses VR airway research. Dr. McGonigle worked with the students and faculty as they experienced the VR airway lab during this research project; she felt their excitement and how they reacted to the immersive VR environment. Based on this type of research, innovative nurse educators and experts in nursing education and informatics are designing VR scenarios and simulations for nursing students. The VR learning episodes exist in a controlled virtual environment that immerses nursing students in the educational experience. They are able to practice and learn by doing in VR and are being familiarized to this technology.

Toward a Virtual Future of Medical Simulation
Medical simulation is a vitally important learning modality and has been proven to reduce errors, improve patient outcomes, and save lives. However, access remains relatively expensive and dependent on the physical hardware space of simulation centers and high-fidelity mannequins. Virtual technologies offer the opportunity to massively expand access to medical simulation to anyone, anywhere, anytime. Following the trend of so many industries touched by virtualization, medical simulation is beginning to realize a similar trajectory. The physical infrastructure required to support industries such as film, newspapers, music, and magazines is an example of this transcendence into digital counterparts. In each case, this transition substantially lowered costs and increased access while introducing explosive new growth opportunities that were never before possible. The same will be true of medical simulation. Virtual counterparts to the physical “stuff” of simulation are already growing rapidly as numerous studies validate their efficacy. Perhaps most importantly, those who never before had access will soon enjoy expansive libraries of digital environments, equipment, patients, and scenarios to advance their hands-on and critical thinking skills. Virtual simulation also introduces powerful network effects by building bridges between experts and participants joining from rural or remote locations. The simulation center of the future is no longer an isolated physical location but rather an interconnected node with real-time access to a perpetually evolving library of expertise and validated best practices. Virtualization also enables simulation to take lateral steps and expand beyond an isolated scenario narrative into a broader chronology of events that are more akin to the realities of clinical experience. It can more easily bridge between professions, thus enabling cross-disciplinary training on a level that has never before been possible. Looking ahead to the future of virtual simulation, we may begin to completely rethink and expand its role far beyond what is familiar today. Moving beyond the mere simulation, we might envision fictitious patients and scenarios transitioning into a mirror world of real-time patient interactions that span the entire spectrum of health care. Patients in the future might opt in to maintain a real-time, digital counterpart of themselves and thus enable procedures to be rehearsed virtually. Imagine an emergency room team rehearsing lifesaving procedures on a patient's virtual replica, trying different approaches and realizing potential complications long before the ambulance arrives.
A three-dimensional simulated scenario portrays three healthcare professionals watching over a patient lying on a bed in a room. An E C G monitor is present beside the patient. A three-dimensional simulated healthcare scenario depicts two healthcare professionals overseeing a patient lying in a semi-Fowler's position on a bed in a room. Screens on the walls display E C G, heart and other medical data. A three-dimensional simulated healthcare scenario depicts two healthcare professionals having a discussion in a hospital room, standing in front of a ventilator and an E C G monitor. A three-dimensional simulated healthcare scenario depicts a healthcare team attending to a child patient lying on a bed in an operating theater. A three-dimensional simulated healthcare scenario depicts a healthcare team having a discussion in an empty operating theater, with surgical tools and equipment neatly laid out on a table. Actual image from Acadicus. Inclusion in this text was permitted by Jon Brouchoud, CEO, Arch Virtual, Developers of Acadicus

Research Brief 3 Teaching Airway Insertion Skills to Nursing Faculty and Students Using VR: A Pilot Study
Purpose of Investigation
To examine whether an educational intervention with a pilot contemporary immersive virtual reality simulation (CIVRS) builds knowledge and is feasible to implement among nursing students and faculty.
Intervention
VR airway lab intervention with six adjunct narrated lessons:
Bag valve mask Oropharyngeal airway Nasopharyngeal airway King laryngeal airway tube Laryngeal mask airway Endotracheal tube
Survey Sampling
N = 31 (10 faculty members and 21 students)
Theoretical Framework
Bauman's Layered-Learning model Situated and multimodal approach Knowledge building occurs by leveraging contemporary educational technologies Scaffolding knowledge transfer for learners Faculty roles shift to facilitate users' discovery of knowledge Technology enhances opportunities for mastery learning, moving learners from didactic preparation to and through the simulation to the practice pathway
Methodology
Survey sampling Quasi-experimental One-group pre- and posttest design
Approach
Enact the VR intervention Virtual Presence Questionnaire Virtual Reality Sickness Questionnaire Knowledge test
Results
Faculty and students rated the VR airway lab as having a high level of virtual presence and reported no cybersickness and significant improvement of knowledge of airway management (p 0.0001).
Conclusions
The VR airway lab was an efficacious means of teaching difficult airway management skills to nursing students. A VR airway intervention was presented to teach difficult airway management using six different airway adjuncts. Students and faculty widely accepted the intervention. The researchers recommended that further research be conducted to evaluate this immersive, educational delivery medium.

Simulated experiences in nursing education contain the PEDA elements, which provide important opportunities for students to hone critical thinking and clinical judgment skills in a safe and supportive environment. Simulation scenarios may also provide a better variety of clinical and practicum experiences than those available in a real setting, and they also provide nursing faculty the opportunity to track student progress and development against specific learning objectives. Nurse educators can share simulation scenarios and experiences and thus contribute to the body of nursing education knowledge to improve education practice. Simulations; games; virtual worlds; and the realities, AR and VR, have a great deal of potential as educational tools for augmenting, supplementing, or even replacing traditional methods of teaching as well as clinical experiences. As educators become more skilled in the use of these tools; designers share their creative works with others; and nurse informaticists lead, collaborate, and support these efforts, we can expect to see these tools blended, honed, integrated, and leveraged more frequently in the coming decade.