Development and Usability Evaluation of a Virtual Reality Isolation Nursing Education Program for Nursing Students
Article information
Abstract
Purpose
This study developed a 360-degree virtual reality (VR) isolation nursing education program and evaluated its usability among nursing students in terms of flow, empathy, and satisfaction.
Methods
The 360-degree VR isolation nursing content was developed using the ADDIE model, which comprises analysis, design, development, implementation, and evaluation. The program was implemented with 20 second-year nursing students who had not yet completed clinical practicum. Usability was evaluated using structured questionnaires that assessed flow, empathy, and satisfaction.
Results
The 360-degree VR isolation nursing content consisted of nine phases: initial preparation, verification of the prescription and medication preparation, donning of personal protective equipment, patient identification, intravenous medication administration, position change and skin assessment, fundamental nursing assessment and interventions, administration of nebulization therapy, and post-treatment reassessment. The mean scores were 4.46±0.58 for flow, 4.28±0.66 for empathy, and 4.49±0.54 for satisfaction, all measured on a 5-point scale.
Conclusion
The 360-degree VR isolation nursing education program produced high scores for flow, empathy, and satisfaction among nursing students. These findings suggest that VR-based isolation nursing content can reproduce isolation-room environments that are difficult to access during routine clinical practicum and may serve as a complementary strategy for undergraduate isolation nursing and infection control education.
INTRODUCTION
With the recent increase in antibiotic‑resistant bacteria, preventing infections caused by multidrug‑resistant organisms (MDROs) has become a critical issue in clinical practice. Because nurses provide care in close proximity to patients, they must possess accurate knowledge of infection control to deliver safe and appropriate nursing care. In addition, as newly graduated nurses may be required to care for patients with infectious diseases immediately upon employment, undergraduate curricula need to equip students not only with theoretical knowledge of infection control, but also with practical competencies fostered through clinical practicum.
However, in Korean undergraduate nursing curricula, the time allocated for infection control education is limited, and such content is often embedded only as part of specific major courses or clinical practicum experiences [1]. In clinical practice settings, nursing students have very few opportunities to directly observe or perform isolation precautions for infectious patients [1,2]. Direct contact with isolated patients may place students at risk of acting as vectors for healthcare‑associated infection transmission or being exposed to infection themselves; therefore, safety concerns restrict their participation [1]. Consequently, there is a need for an educational method that allows nursing students to safely practice isolation precautions. Virtual reality (VR)-based simulation education may serve as an effective alternative.
VR-based simulation creates a three-dimensional virtual environment that reproduces clinical scenarios [3]. It has been used as an effective instructional strategy to develop practice-ready competencies, either complementing or replacing traditional manikin‑based simulations [4,5]. VR enables students to repeatedly practice skills within a limited physical space without jeopardizing patient safety, while allowing them to learn in a comfortable environment [6]. Because VR can overcome the spatial and temporal constraints associated with conventional simulation-based education, it is gaining recognition and demand as an innovative educational modality in nursing education settings [7].
VR-based infection-control programs and related simulation studies have addressed topics such as isolation education for COVID-19 [2,8-9], isolation of patients with tuberculosis [1], infection control for high‑risk newborns [10,11], and donning and doffing of personal protective equipment (PPE) [12-14]. These studies have reported significant improvements in flow [14], knowledge and problem-solving ability [10,13], as well as performance confidence, perceptions, and self-efficacy [1]. Nevertheless, VR-based infection control education programs for nursing students have predominantly evaluated cognitive and performance outcomes, such as knowledge, clinical performance, and self-efficacy [1,2,8-11], and have rarely examined experiential variables including flow, empathy, and satisfaction with VR-based education.
There are several approaches to implementing VR. Among them, 360-degree video is created using a specialized camera that records in all directions [15], allowing learners to experience the content within a virtual space at an observational level and to feel as though they are present in the actual environment [16]. A key advantage of 360-degree VR video is that, by using a wearable camera attached to the body to capture real scenes from the user's point of view [16], it enables learners to indirectly experience actual clinical environments from a nurse's perspective and to become immersed in the situation, rather than interacting with purely computer-generated virtual environments [17]. Furthermore, once appropriate equipment for viewing 360-degree video is available, education can be delivered anytime and anywhere, free from temporal and spatial constraints [17]. In recent years, 360-degree video has been increasingly used to develop VR-based educational content for various clinical environments [15], and such content has been reported to contribute to the development of students’ knowledge, skills, and attitudes [18]. A systematic review indicated that 360-degree video content in nursing education has predominantly focused on mental health nursing [18]. VR simulation using 360-degree video can foster both reflection and learning in a safe educational environment [15].
Although VR and 360-degree video interventions in nursing education have reported improvements in learning flow [8,17], educational satisfaction [19,20] and empathy [17,21], evidence remains limited regarding how these experiential responses are manifested in VR-based isolation nursing education and how they relate to learners’ evaluation of the program. In the present study, flow, empathy, and satisfaction with VR-based education were conceptualized as key experiential variables for evaluating the usability and educational acceptability of a VR-based isolation nursing education program. Accordingly, a VR based educational content incorporating 360-degree video of an actual isolation room was developed and applied to nursing students, and their flow, empathy, and satisfaction were measured to assess the educational utility and potential applicability of this approach to infection control education.
METHODS
1. Study Design
This study employed a methodological approach with a descriptive survey design. A VR-based isolation nursing education program using 360-degree video was developed based on the ADDIE (Analysis, Design, Development, Implementation, Evaluation) instructional design model and applied to nursing students to examine their flow, empathy, and satisfaction with the program.
2. Participants and Data Collection
The participants were 20 nursing students enrolled in the department of nursing at a university located in C province, South Korea. They had completed a fundamental nursing course but had not yet participated in clinical practice. They understood the purpose of the study and agreed to participate. The sample size of 20 was determined with reference to previous studies that evaluated the usability of VR educational content in small groups [19,20].
After the purpose of the study was explained, permission was obtained from the head of the university nursing department, and the students were then recruited to participate in the usability evaluation of the 360-degree VR isolation nursing content. Information regarding the study's purpose, participation procedures, and the right to withdraw at any time during participation was provided through social networking services (SNS) commonly used among students. Those who voluntarily agreed to participate were included in the study.
Data were collected on March 4, 2025. After participants were provided with instructions on how to operate the Oculus Quest head‑mounted display (HMD), they were guided to experience the 360‑degree VR isolation‑nursing education content.
3. Development of VR-Based Educational Content
The VR‑based isolation nursing education content was developed using the ADDIE model, which is widely used in educational program development.
1) Analysis
A literature review was conducted to examine nursing students’ knowledge, perceptions, confidence in performing, and educational needs regarding isolation precautions. In addition, to analyze learners’ educational needs, in‑depth interviews were conducted with two groups: an expert group comprising six nurses from the infection control department of a university hospital and a learner group comprising six third and fourth‑year nursing students with clinical practicum experience. The group size for the in-depth interviews (6∼10 participants) was determined based on prior recommendations for facilitating smooth discussion and manageable group dynamics [22]. Accordingly, two focus groups of six participants each—one comprising infection control nurses (ICNs) and the other nursing students—were formed, for a total of 12 participants.
Participants for the in-depth interviews were selected using purposive sampling [23]. For the ICNs, the principal investigator and co-investigators recruited participants by recommendation. For the nursing students, permission was first obtained from the head of the university nursing department after the study purpose had been explained, and students were then recruited via SNS commonly used among them. During recruitment, the purpose of study, participation procedures, and the right to withdraw at any time without penalty were fully explained, and only students who voluntarily agreed were included. Written informed consent was obtained prior to the start of the study. Participants were reminded that they could discontinue participation at any point and that doing so would not result in any disadvantages. All interviews were conducted in a quiet and comfortable seminar room at the researchers’ institution.
Key interview questions for the ICNs included: "Which pathogens related to isolation precautions pose the greatest problem in the clinical setting?", "What are common examples of incorrectly applied isolation precautions observed in clinical setting?", and "What isolation precautions do you believe should be emphasized in education for newly graduated nurses?". For nursing students, key questions included: "What types of isolation precautions have you observed or experienced during clinical practice?", "Have you ever observed incorrect application of isolation precautions in the clinical setting?", and "If you were to start working on a ward as a newly graduated nurse, what aspects of isolation precautions would you find most difficult or feel least confident about?". Each in-depth interview lasted approximately 60 minutes. With participants’ consent, all interviews were audio-recorded and later transcribed verbatim for analysis.
From the interviews, nurses reported that carbapenem‑ resistant Enterobacterales (CRE) were the most problematic organisms with respect to isolation precautions in the clinical setting, and that contact and airborne precautions were the types of transmission-based precautions requiring priority education. They also emphasized the need to educate nurses about appropriate methods and timing for donning and doffing personal protective equipment (PPE), designated locations for doffing, environmental management of isolation rooms, safe injection practices, and appropriate moments for hand hygiene. Nursing students, on the other hand, expressed educational needs related to indications and rationales for PPE use during isolation, correct methods of donning and doffing PPE, the timing of PPE changes and the designated areas for PPE removal, specific hand‑hygiene moments, disinfection and sterilization of equipment used for isolated patients, management of medical waste, and education for caregivers of isolated patients.
2) Design
Based on the findings from literature review and focus group interviews, the topic of the 360-degree VR isolation nursing education content was defined as the care of patients isolated for MDROs, specifically CRE. The scenario was designed to incorporate key elements such as the selection, donning, and doffing of PPE, hand hygiene, safe injection practices, and medical waste management.
3) Development
A scenario was developed around the theme of nursing care for a patient isolated due to a CRE infection, and 360-degree VR isolation nursing education content was produced using a 360-degree camera. To ensure that the VR-based isolation nursing education content adequately reflected infection-control practices for CRE-isolated patients, the scenario was structured to include hand hygiene, the appropriate selection, donning, and doffing of PPE, medical waste disposal, and core nursing skills. Content validity was reviewed by a panel of five experts: three infection control advanced practice nurses (ICAPNs), one professor of fundamentals of nursing, and one nursing faculty member certified as an ICAPN. The scenario was revised and finalized based on their feedback.
In accordance with the finalized scenario, the educational video content was recorded using a 360-degree camera. The recorded VR isolation nursing content was then evaluated for content validity by two ICNs and one nursing faculty member certified as an ICAPN. After incorporating their suggested revisions, the final version of the educational content was produced. Subsequently, the user interface was implemented in collaboration with a professional developer, and the completed content was installed on the HMD device.
4) Implementation
Following a previous study [20], the VR‑based isolation nursing education program incorporating 360-degree VR content was implemented for 20 nursing students who had no clinical practicum experience.
5) Evaluation
After experiencing the finalized 360-degree VR isolation nursing educational content, the participants completed a questionnaire measuring their levels of flow, empathy, and satisfaction with the program.
4. Instruments
1) Flow
Flow refers to a state in which individuals lose their sense of time and space and become fully absorbed in the mediated environment [26]. It was measured using a five-item scale developed by Oh [26] based on the work of Novak et al. [24] and Whang [25], with permission obtained from the author prior to use. The original instrument employed a 7-point Likert scale (1=strongly disagree, 7=strongly agree); however, verbal anchors were provided only for points 1, 4, and 7, with no specific descriptors for points 2, 3, 5, and 6. This raised the possibility of heterogeneous interpretations of the intermediate response categories. Therefore, to enhance the clarity of response options and reduce ambiguity in interpreting the scale, the response format in this study was modified to a 5-point Likert scale (1=strongly disagree, 5=strongly agree), considering the ease in which participants could discriminate among categories. Higher scores indicate higher levels of flow. Cronbach's ⍺ was .86 in Oh's study [26] and .81 in the present study.
2) Empathy
Empathy refers to understanding a given situation or character and identifying with them [25]. It was measured using a four-item scale modified by Oh [26] which was developed with reference to items used in the studies of Escalas and Stern [27], Lee and Cook [28], and Cook [29], and it was used with the author's permission. The original instrument used a 7-point Likert scale (1=strongly disagree, 7=strongly agree), but, as with the flow scale, only points 1, 4, and 7 were verbally anchored, leaving points 2, 3, 5, and 6 without explicit descriptors and potentially leading to inconsistent interpretations of intermediate categories. For the same reasons as for the flow scale, the response format was revised to a 5-point Likert scale (1=strongly disagree, 5=strongly agree) in this study. Higher scores indicate a higher level of empathy. Cronbach's ⍺ was .88 in Oh's study [26] and .88 in the present study.
3) Satisfaction
Satisfaction was measured using a 5-point Likert‑type instrument employed in the study by Cha et al. [1], with permission obtained from the author. This scale consists of four items assessing overall satisfaction, intention to participate in VR-based education on other topics, willingness to recommend the program to other students, and perceived helpfulness for understanding infection control practices. Each item is rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree), and higher scores indicate higher satisfaction. Cronbach's ⍺ was .94 in the study by Cha et al. [1] and .86 in the present study.
5. Ethical Considerations
This study was conducted after obtaining approval from the Institutional Review Board (IRB) of the researchers’ affiliated university (IRB No.CBNU-2024-A-0079). Participation was entirely voluntary, and participants were informed that they would not be disadvantaged in any way if they chose not to participate and that they could withdraw from the study at any time if they no longer wished to continue. Data collection was initiated only after written informed consent had been obtained from all participants.
6. Data Analysis
The collected data were analyzed using SPSS/WIN 28 (IBM Corp., NY, USA). Participants’ general characteristics were analyzed using frequencies and percentages. Mean scores and standard deviations were calculated for satisfaction, flow, and empathy after experiencing the 360-degree VR isolation nursing educational content.
RESULTS
1. 360-Degree VR Isolation Nursing Educational Content
The 360-degree VR isolation nursing educational content was developed as a scenario-based program in which learners first review the patient's condition, relevant clinical information, and prescribed orders before proceeding (Figure 1). The scenario incorporated elements such as the selection, donning and doffing of PPE; hand hygiene; safe injection practices; medical waste management in the isolation room; and fundamental nursing skills (e.g., measurement of vital signs, oxygen therapy, medication administration, and position changes) (Table 1).
360-degree VR isolation nursing content screen.
Scenario for 360-degree VR Isolation Nursing Content
2. Usability Evaluation
1) General characteristics of participants
All students who participated in the usability evaluation were second‑year nursing students. Five participants (25.0%) were men and 15 (75.0%) were women. Ninety-five percent of the students had a grade point average of 3.5 or higher. Eighty-five percent had previously received VR-related education, and they had participated in such education once (Table 2).
General Characteristics of Participants (N=120)
2) Flow
The mean flow score for the 360-degree VR isolation nursing content was 4.46±0.58 out of 5 (Table 3). At the item level, relatively high scores were observed for statements such as "I was deeply absorbed in the VR video" (4.60±0.68) and “While watching the VR video, I felt as if I were actually there”(4.50±0.69).
Flow in the 360-degree VR Isolation Nursing Content (N=20)
3) Empathy
The mean empathy score for the 360-degree VR isolation nursing content was 4.28±0.66 out of 5 (Table 4). High scores were observed for items such as "I felt as if I had become the character in the VR video" (4.40±0.60) and "I felt the same emotions as the people in the VR video" (4.30±0.87).
Empathy Related to the 360-degree VR Isolation Nursing Content (N=20)
4) Satisfaction
The mean satisfaction score with the 360-degree VR isolation nursing content was 4.49±0.54 out of 5 (Table 5). Among the items, high scores were reported for "Compared to traditional lectures or practicum, this education helped me better understand isolation nursing" (4.65± 0.49) and "I would like to recommend this program to other students" (4.50±0.69).
Satisfaction with the 360-degree VR Isolation Nursing Content (N=20)
DISCUSSION
This study developed a VR-based isolation nursing education program using 360-degree camera technology grounded in the ADDIE model and evaluated its usability in terms of flow, empathy, and satisfaction. These findings suggest that reproducing an actual isolation room environment using 360-degree VR technology has considerable potential as an educational modality for infection control training.
A key strength of this study is that VR technology was not employed as a mere technical trial, but rather that the isolation nursing content was systematically developed by following the sequential phases of the ADDIE model. In the analysis phase, learners’ educational needs and clinical demands related to isolation precautions were identified. In the design and development phases, realistic clinical elements—such as the isolation room setting, donning and doffing of PPE, patient identification and assessment, and fundamental nursing interventions—were integrated into the scenario. This systematic process ensured that the VR content was constructed as a structured learning experience rather than as simple "viewing material."
Although nursing studies utilizing 360-degree video remain relatively limited, and a previous study of nursing students that employed Oh's flow scale [26] used a 7‑point response format whereas the present study used a 5-point scale [17], prior research has reported that VR provides a more immersive experience than traditional two‑dimensional video‑based media.
In this study, the mean flow score for the 360-degree VR isolation nursing content was 4.46±0.58 on a 5-point scale (corresponding to 6.24±0.81 on a 7-point scale). This reflects a high level of flow, similar to the flow score (6.02±0.84) reported in a previous study that investigated the effects of 360-degree VR content for intravenous infusion education using the 7-point version of the same scale [17]. In addition, the item "I was deeply absorbed in the VR video" showed a higher mean score in the present study (6.44±0.95) than in the previous study (6.22±0.77) [17], further supporting the strong immersive experience elicited by this content. The particularly high score for the item "While watching the VR video, I felt as if I were actually there" (4.50±0.69) suggests that the 360-degree video technology provided learners with visual and spatial experiences similar to actually being present in an isolation room. This implies that nursing students were able to identify with the nurse in the video, immerse themselves in the patient's situation, and experience deep engagement with the content, leading to positive learning experiences. Given that isolation rooms are difficult to access during routine clinical practicum, these findings suggest that VR-based indirect exposure can serve as an effective means of enhancing learners’ sense of presence in such specialized environments. The present findings are consistent with this body of evidence and further suggest that 360-degree VR technology can safely and effectively immerse nursing students in specialized environments, such as isolation rooms.
VR users can feel as if they have become the main character in the virtual world from a first-person perspective, and may experience emotions similar to those of that character [26]. In this study, empathy levels after the 360-degree VR isolation nursing content experience were 4.28± 0.66 (5.99±0.93 on a 7-point scale), and this was comparable to the empathy score reported in a prior study using the same instrument (5.32±0.88) [17], which was also relatively high. This result suggests that the VR content in this study may be effective in promoting empathic engagement with patients in isolation. The high scores for items such as "I felt as if I had become the character in the VR video" and "I felt the same emotions as the people in the VR video" indicate that 360-degree VR facilitated not only observation but also emotional resonance through indirect experience. This suggests that learners were able to more vividly assume the nurse's role via VR. Chen et al. [21] reported that in a 360-degree VR dementia education program for nursing students, those who received immersive VR education in addition to traditional lecture and case-based discussion showed significantly higher empathy toward patients with dementia than those who received conventional education alone. Such findings indicate that 360-degree VR education can go beyond simple cognitive information delivery to foster learners’ emotional and empathic responses. The high empathy scores observed in the present study can be interpreted as consistent with this potential.
The mean satisfaction score was 4.49 out of 5, with the highest ratings given to the statement that the VR content enhanced understanding of isolation precautions compared with traditional lectures or practicum. This may be because the scenario‑based 360‑degree video effectively compensated for aspects that are difficult to convey through traditional teaching methods, namely the complexity of isolation‑nursing procedures and the sense of realism in the clinical environment. Previous studies [17,30] have also reported high satisfaction with 360-degree VR, consistent with the present findings. In the study by Kim and Kim [30], a VR-based class on the hospital environment resulted in significantly higher satisfaction compared with lecture-based instruction. VR-based isolation nursing content can serve as a valuable supplementary educational tool, particularly in settings such as isolation rooms where clinical practicum opportunities are limited, by enabling safe and repeated exposure to isolation nursing scenarios without temporal or spatial constraints. Moreover, the high willingness to recommend the program to peers suggests that participants were positively receptive to VR-based education.
The 360-degree VR video content used in this study was designed to allow learners to provide care to a patient isolated for CRE from the nurse's point of view. It included activities such as donning and doffing PPE, performing hand hygiene, safe injection practices, and medical waste management. It also included core fundamental skills such as measuring vital signs, providing oxygen therapy, administering medications, and performing position changes. Accordingly, this VR content is expected to function as an effective means of enabling learners to experience the actual isolation room setting.
This study has several limitations. First, it focused on the development and usability evaluation of VR-based isolation nursing content, and therefore did not systematically verify objective learning outcomes such as knowledge, confidence in performance, self-efficacy, and actual performance competence. Second, because the study was conducted with a small number of nursing students from a single institution, the generalizability of the findings is limited. Thus, future research should apply educational programs that utilize the VR-based isolation nursing content developed in this study and rigorously evaluate their effects on a wide range of educational outcomes related to isolation‑nursing and infection control competencies.
CONCLUSION
This study developed a 360-degree VR-based isolation nursing education content grounded in the ADDIE model and evaluated its usability among undergraduate nursing students. The participants reported high levels of flow, empathy, and satisfaction. These results indicate that the content developed in this study effectively reproduces the isolation‑room environment, which is difficult to experience directly during clinical practicum, and serves as a useful educational medium that promotes learner engagement and empathic involvement.
The findings suggest that VR-based nursing education, beyond the mere application of technological tools, can provide vivid on-site-like experiences in a safe environment, enhance flow in learning, and ultimately contribute to improved learning satisfaction. Accordingly, VR-based isolation nursing education programs, such as that developed in this study holds promise as a complementary educational strategy for isolation nursing and infection control education in undergraduate nursing curricula.
Notes
CONFLICTS OF INTEREST
Kyung Mi Kim is an editorial board member of the Journal of Fundamental Nursing Science. She was not involved in the review process of this manuscript. Otherwise, there was no conflict of interest.
AUTHORSHIP
Study conception and design acquisition - Choi SY and Kim KM; Data collection - Choi, SY, Oh S-W, Oh SJ, Yun HJ, Son, HY, Chung MH and Kim KM; Data analysis & Interpretation – Oh, S-W, Son, HY and Kim KM; Drafting & Revision of the manuscript - Choi SY and Kim KM.