Nurse Education in Practice (2005) 5, 103–108

NurseEducation

www.elsevierhealth.com/journals/nepr

in Practice

Bringing problem based learning to lifeusing virtual reality

Linda Nelson*, Lynne Sadler1, Geoffrey Surtees

Senior Lecturers, Adult Nursing, School of Health and Social Care, University of Teesside, MiddlesbroughTS1 3BA, UK

Accepted 18 May 2004

Summary Recent UK government policy advocates the need for a more flexibleapproach to nurse education and ‘Fitness for Practice’ stresses the importance ofinformation technology and computer mediated learning facilities in the future ofnursing education [Department of Health, Making a Difference, Strengthening theNursing, Midwifery and Health Visiting Contribution to Health Care, Department ofHealth, 1999; The United Kingdom Central Council For Nursing, Fitness for Practice,The UKCC Commission for Nursing and Midwifery Education, 1999]. In response tothis recommendation, a virtual reality package has been designed as a learningresource within adult pre-registration nursing education. This learning and teachingstrategy is used in conjunction with problem based learning, enabling students tovisualise individual/family life in a community setting. Students are encouraged toconsider wider issues such as social and environmental factors and their impact uponhealth. The virtual reality package acts as one of a number of triggers. This paperwill discuss the early development and offer an example of its use as a learning andteaching strategy within year two of a three year programme.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSCollaborative learning;Problem-based learning;Triggers;Virtual reality

Introduction

The University of Teesside was one of the leadpartnership sites for the implementation of ‘Makinga Difference’ (Department of Health, 1999). Thisdocument together with ‘Fitness for Practice’(UKCC, 1999) aimed to strengthen and widenaccess to nursing and midwifery pre-registration

* Corresponding author. Tel.: +44-1642-384-964; fax: +44-1642-384-105.

E-mail addresses: linda.nelson@tees.ac.uk; l.sadler@tees.ac.uk

1 Tel.: +44-1642-384-967; fax: +44-1642-384-105.

1471-5953/$ - see front matter �c 2004 Elsevier Ltd. All rights reserdoi:10.1016/j.nepr.2004.05.001

education. The Governments priorities were toprovide more flexible career pathways, to increasethe level of practical skills, and for education to bemore adaptable to the needs of the National HealthService. This provided Nursing academics with theopportunity to design a new curriculum and adopt amore student centred approach to learningwith the integration of both theory and practicemodules.

Today’s health care climate requires students tobe able to collaborate and participate in multi-professional working to become competent prac-titioners in health care delivery (Miller et al.,1999). The overall aim of the curriculum design was

ved.

104 L. Nelson et al.

that students upon qualification would be ‘fit forpurpose’ equipped with the skills, knowledge andability to meet the ever increasing and changingdemands in health care (Barrow et al., 2002).

Following a common foundation year studentscontinued on the adult pathway. In year two therewere two theoretical modules and one practicalskills:

• Care of the acutely Ill adult.• Continuing care of the adult client in diverse

Settings.• Developing core practice skills in adult nursing.

The focus of the modules was to prepare stu-dents for clinical practice within primary and crit-ical care settings.

Problem based learning approaches are claimedto be more effective than traditional educationmethods in preparing student nurses for registra-tion. (Creedy and Alavi, 1997; Frost, 1996). Thepurpose of problem based learning is not to teachstudents everything they will ever need to know,but to furnish them with the means to be able tolearn and discover. The increasing use of problembased learning in the educational preparation ofthe health professional offers a window of oppor-tunity for enhancing the capacity of staff to useinformation technology in ways that are engagingand meaningful (Polson and Farmer, 2002). Nicholsand Renwanz-Boyle (2001) suggested that newstrategies must be found to educate students for anew era. The integrated use of technology offersmany educational opportunities when driven bysound visions of learning. Students’ ability to cre-ate knowledge can be enhanced when educatorsuse varied instructional delivery formats to providea richer environment (Berge, 1995), virtual realityis one such format.

Virtual reality entails the use of advancedtechnologies to produce simulated environmentsthat users perceive as comparable to real worldobjects and events (Weiss and Jessel, 1998). Theinteractive three-dimensional image technologycan be quite dramatic to health care learning andpractice (Hodson Carlton, 1996). The virtual realitypackage designed provides educators with a tool toenhance the learning process. Conrick (1998) pro-poses that the possibilities of virtual reality as amedium for learning and teaching in nurse educa-tion are endless. This innovative strategy providesopportunities for the learner to explore and ques-tion emerging issues, thus promoting problem-based learning, self direction, critical thought anddecision making skills as recommended by theUKCC (1999).

Problem based learning

Morales-Mann (2001) believes problem basedlearning is a method of group learning which usestrue-to-life problems that enables students tolearn problem-solving skills. It is believed that thisapproach is the most significant innovation in ed-ucation for many years (Boud and Feletti, 1997).Problem based learning shifts the focus of educa-tion from teacher delivery to the student becomingan active participant in the learning process.

The benefits of problem based learning havebeen well documented in the literature. Morales-Mann (2001) suggests that students learn teamworkand effective interaction with peers. This is sup-ported by collaborative working, communicationskills, respect for differing opinions and cognitiveskills (Biley and Smith, 1999). A recent study byMok et al. (2002) concluded that graduate nursesfrom a problem based learning programme have astrong sense of responsibility for widening theirown learning and are adaptable to change and in-novation. Therefore, problem based learning pro-vides students with opportunities to acquire asense of their own authority and power in thelearning process (Creedy and Hand, 1994). Aweakness of problem based learning is that it reliesfor its success on group dynamics and this canpresent problems (Biley and Smith, 1999). Groupco-operation and cohesiveness have been identi-fied as significant factors in the learning process(Barrow et al., 2002).

Triggers

The focus of problem based learning is the actualproblems or triggers that form the starting pointfor the students learning (Wilkie, 2000). It is im-portant that the triggers are well constructed be-cause their purpose is to guide the studentslearning. Triggers must stimulate the student toengage in the materials and actively learn (Drum-mond-Young and Mohide, 2001).

Triggers need to be broad and complex enoughto allow the students to explore the wider deter-minants of health and social care. If the focus is toonarrow, it restricts the exploration and creativityof the students and has the potential to limit theirlearning.

The triggers developed for the adult pathwaywere not subject specific but centred on familiesand individuals thus making them person centred inorder to provide a holistic approach to the nurse’srole. Triggers must be realistic and reflect current

Table 1 Examples of triggers used in year two

Patient scenariosCommunity mapVirtual reality presentation of communityPictures, photographsDiagnostic results – ECG, blood resultsQuestionsDocumentation

Figure 1 A home in the virtual community.

Bringing problem based learning to life 105

health and social care issues as well as futuretrends within these domains. As nurses do not workin isolation the design of the triggers needed toaddress this by engaging students in a multi-pro-fessional approach. The modules had to includepatients/clients that the students would actuallycare for in clinical practice in order to achieverealism. This would encourage students to makethe connections between their study and real lifesituations (Cooke and Moyle, 2002), thus facilitat-ing theory to practice.

A trigger can be anything that provides a cue tothe direction that the students learning could take.(Table 1).

If constructed appropriately the trigger shouldencourage questions and the need to elicit furtherinformation. A lot of problem based learning iscentred on patient scenarios or case studies al-lowing students to explore issues within the infor-mation provided (Mok et al., 2002). Scenariosreflect real-life practice and are designed to en-courage the active solution of a problem or situa-tion (Biley and Smith, 1999).

Figure 2 A parade of shops.

Virtual community

In collaboration with colleagues from the VirtualReality Centre within the University of Teesside, avisual representation of a community was designedand developed. This was created using real-timemodelling software. The community consists of awide variety of homes in which individuals live,ranging from conventional houses to a traveller’scaravan (Fig. 1). Amenities include a school,churches, children’s play area, public houses, mo-bile library, care home, health centre, police sta-tion and leisure facilities. A parade of shopsreflects current trends including general stores,video shop, pharmacy, betting shop and a com-plementary health clinic. In reality, the wholecommunity would cover an area of approximately8 km.

In relation to problem based learning, Drum-mond-Young and Mohide (2001) identify the needto give the problem a broad title. An outline wasprovided about eight families/individuals who livedin the fictitious community called Bellwood.Through a written scenario the students are intro-duced to the families/individuals. Other triggersprovide further information about their personalcharacteristics and lifestyles. This design was im-portant to learning, as it encouraged students toconsider issues such as social and environmentalfactors and their impact upon health. Having beenintroduced to the families that lived in the com-munity students could now visualise the neigh-bourhood, the amenities, and social conditions.(Fig. 2).

Virtual reality is not new in nursing and tech-nology such as this can have a complementary rolein educating nurses (Hodson Carlton, 1996). Multi-media is recognised as providing nurse educatorswith a tool to enhance the teaching and learningprocess of students (Ribbons, 1998). Due to thefacilities available within the university the virtual

Figure 3 Interior of a home.

106 L. Nelson et al.

community could be viewed in a hemispherium. Ithas been suggested that the work-related applica-tions that appear most promising are those thatemploy virtual reality for visualisation and naviga-tion (Weiss and Jessel, 1998). Students could betaken on a tour of the neighbourhood, via anyroute, at any speed and stops could be made on theway around the community, rather like being in acar. It is also possible to look at the aerial lay out ofthe community. The virtual community is designedso that students can pilot and navigate the packageby entering the homes of the families that theyhave been introduced to, again making it morerealistic and meaningful to their learning. Althoughthis sounds ideal virtual reality can be expensive toproduce. In addition, a problem that was not an-ticipated was that some students and staff devel-oped motion sickness when viewing the package inthe hemispherium. Cybersickness has been high-lighted in the literature as a potential problem forthis type of technology (Hodson Carlton, 1996).

An example of how the approach is used

One individual within the virtual community whothe students are introduced to is Fiona. The writtenscenario informs students that Fiona is a 36 yearold hairdresser who shares a rented house with afriend. She has recently developed diabetes mell-itus. Students are introduced to a variety of trig-gers within each of the modules which areunderpinned by the virtual reality package. Stu-dents are able to tour Fiona’s neighbourhood andexplore the interior of her house. The designedpackage provides the opportunity to obtain closeups of smaller objects within the homes. Examplesare medication and food packaging which can beviewed in more detail (Fig. 3). Further triggers forFiona include:

• Acute care module. GP’s letter of referral tohospital due to problems of poor metabolic con-trol.

• Continuing care module. Pictorial representa-tion of Fiona’s lifestyle and a posed question.

• Skills. Theory and practice of Blood GlucoseMonitoring.

Staff and students always referred to the res-idents by name throughout all of the modules,which keeps the focus and interest. Skills ob-tained from one family were transferable to an-other and students continued to refer to previousfamilies.

Students explored the triggers by means of col-laborative groupwork facilitated by a nurse edu-cator. Berge (1995) suggested that what makes adifference in content retention and transfer is notso much what is done by teachers, but what stu-dents as learners can be encouraged to do forthemselves. It has been acknowledged that the roleof the educator must change from bearer and re-pository of knowledge to facilitator of learning(Wallace et al., 1999). When using a problem basedlearning approach with computer-mediated com-munication the nature of learning almost inevitablyimplies that the locus of control shifts from teacherto active student participation (Magee and Wheel-er, 1997).

Feedback related to each family/individual wasdelivered through student led sessions. The infor-mation was presented in a variety of ways, whichwere often dynamic and innovative. The method offeedback was decided by the students consisting ofpresentations, role play, discussions and debate.Using differing resources enhanced their learningfor example: powerpoint, demonstrations, hand-outs and video. The quality of the work did varywith some students doing better than others, whichis acknowledged in the literature (Juwah, 2002).

The way forward

Initial feedback from students suggests that thevirtual community brought problem based learningalive and was stimulating and different to otherteaching methods. The use of this technology hasbrought advantages to student learning and quali-tative data highlights the realism’ of the project toactual clinical care. Students considered they wereable to ‘view patients care holistically’ and had

Bringing problem based learning to life 107

improved their confidence in problem solving anddecision making skills. This is supported by Amosand White (1998) who proposed that seven out-comes emerge from problem based learning whichare critical thinking, learning how to learn, crea-tivity in learning, the link to the community,teamwork, research skills and personal growth.

Weaknesses of the project identified by bothstudents and academic staff centre around thepresentation and use of the package. As previouslymentioned the hemispherium resulted in motionsickness for some students. As a result of this, thevirtual community has now been installed on adedicated computer within the School of Healthand Social Care. Students interact with displayedimages, moving around the virtual community in away that engenders the feeling of actual presencein the simulated environment (Weiss and Jessel,1998). The use of technology brings many advan-tages to education and training which include, in-creased access time and convenience for studentsto suit their learning needs (Juwah, 2002). It alsopermits students to have a degree of control overthe simulation that would not be possible in thereal-life situation, affording the student the op-portunity to learn by trial and error in a controlledenvironment (Weiss and Jessel, 1998; Connorset al., 2002). This encourages students to revisitthe community individually or in small groupsthroughout the year as they meet different resi-dents. A joystick will also be installed to replacethe 3-button mouse which has caused some prob-lems with navigation.

Academic staff recognised that not all studentshave IT skills. Students who have grown up in theelectronic age may already have the skills or behighly motivated to acquire them but for othersthere may be a resistance or fear to using tech-nologies (Magee and Wheeler, 1997). If the projectwas to encourage and develop student participa-tion and IT skills then it needed to be user friendlyand not act as a deterrent to their learning. Unfa-miliarity or anxiety about technology can decreasea learner’s motivation for the subject matter(Magee and Wheeler, 1997). This could have influ-enced the philosophy of the problem based learn-ing approach within the adult pathway as thevirtual community is the starting point of a numberof triggers. Videos are also available for classroomwork however in this format the route is set andstudents lose the ability to navigate independently.

Further planned changes include a sound track ofresidential noise such as traffic and children playingto replace the present music background. Ribbons(1998) suggests that sound effects are essential andcanbeused to attract attention or set the scene.The

interior of some of the properties will be developedfurther to make the homes more ‘lived in’. Pres-ently, they are too sterile and bare and could bemore realistic to reflect a home environment.

Conclusion

The virtual community moves away from a pre-scriptive approach to learning allowing students toconsider all aspects of a person’s health and socialcare and all members of the multi-disciplinaryteam who could be involved with the package ofcare. Being problem based rather than subjectbased means that the student’s learning is notfragmented into different specialities or teachingsessions. Students critically question and drawtheir own conclusions about what they have seen inthe virtual community together with other triggers.They reflect upon prior learning, analyse and syn-thesise the contextual information, acquire furtherknowledge and assimilate into their existingknowledge base (Wong et al., 2001).

Problem based learning has proven to be anenergising, dynamic and creative teaching meth-odology with positive outcomes for students andstaff (Amos and White, 1998). There is an abun-dance of recent literature to support the use ofscenarios as triggers based on ‘real life situation’(Mok et al., 2002; Cooke and Moyle, 2002). How-ever in addition, the virtual community broughtproblem based learning alive with an innovativestimulus not previously seen in traditional teachingparadigms. The arrival of the virtual environmenthas introduced a new teaching approach into thecurriculum. Advances in technology have poweredparadigmatic shifts in education (Berge, 1995). Theuse of advanced technologies as a learning andteaching strategy required us as nurse educators todevelop new skills ourselves. While there is nodoubt that much work still needs to be done to fullyappreciate the impact of integrating the virtualcommunity into the nursing curriculum, the earlysigns are very promising. Teaching in the 21stCentury is going to be very different as the tech-nology that can help provide these new environ-ments for education emerges (Berge, 1995).

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