Development and evaluation of extracorporeal membrane oxygenation nursing education program for nursing students using virtual reality 

Development and evaluation of extracorporeal membrane oxygenation nursing education program for nursing students using virtual reality | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and evaluation of extracorporeal membrane oxygenation nursing education program for nursing students using virtual reality Hanna Lee, Jeong-won Han, Junhee Park, Soyoon Min, Jihey Park This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3588375/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jan, 2024 Read the published version in BMC Medical Education → Version 1 posted 8 You are reading this latest preprint version Abstract Background This study aims to improve nursing students’ ability to care for critically ill patients through education in extracorporeal membrane oxygenation (ECMO) nursing. Methods This study developed a virtual reality (VR) simulation program for the five-step ECMO nursing of the Analysis, Design, Development, Implement, and Evaluation (ADDIE) model and used an equivalent control group pre-test and post-test no-synchronized design to verify the effect. The participants of this study were fourth-year nursing students enrolled in nursing departments at three universities in Seoul, Gangwon, and Gyeonggi in South Korea; it included 66 participants, 33 in each of the experimental and control groups. The program consisted of pre-training, orientation, VR simulation, and debriefing. Results The interaction effect of the intervention and control groups with time points using the ECMO nursing VR simulation program was rejected due to no statistically significant difference in knowledge (F = 1.41, p = .251), confidence (F = 1.97, p = .144), and clinical reasoning capacity (F = 2.85, p = .061). However, learning immersion (t = 3.97, p < .001) and learning satisfaction (t = 4.25, p < .001) were statistically significantly higher in the experimental group than in the control group. Conclusion VR simulation program for ECMO nursing developed in this study is a potential educational method that positively affects the learning immersion and learning satisfaction of nursing students. This will also be an effective way to improve the performance of nursing students in ECMO nursing. clinical reasoning education nurse simulation student knowledge extracorporeal membrane oxygenation Figures Figure 1 Figure 2 Introduction COVID-19 can have a wide range of clinical manifestations, from asymptomatic to life-threatening acute respiratory distress syndrome (ARDS) and death [ 1 – 4 ]. Particularly, COVID-19 patients requiring intensive care are mostly accompanied by respiratory failure caused by ARDS [ 5 ]. ARDS treatment may start with a conservative method such as mechanical respiration, and extracorporeal membrane oxygenation (ECMO) may be considered if long-term mechanical respiration is required [ 6 ]. ECMO, also called extracorporeal life support (ECLS), refers to a device that temporarily helps the heart and lungs when their functions are declined and life support is difficult using conventional methods. As of November 2020, ECMO was performed on 83 domestic COVID-19 patients, and 48 patients were successfully treated [ 7 ]. The expertise and skills of healthcare providers with ECMO devices are critical. As the number of COVID-19 cases continues to rise, the number of critically ill patients is also soaring; thus, it is imperative to increase the number of hospitals and healthcare workers that can manage ECMO [ 8 ]. The Korean government selected the nationally designated hospitals for critical care management, expanded the intensive care units (ICUs), and trained students to secure dedicated critical care nursing personnel capable of ECMO nursing [ 9 ]. However, the supply and demand for nurses who can care for critically ill patients are not smooth; this is because training the personnel takes a long time, and in-depth education and specific training, such as movement management and changing protective clothing, is required for the special circumstances of COVID-19 [ 10 ]. During the COVID-19 pandemic, the Extracorporeal Life Support Organization (ELSO) developed the ECMO guidelines in the context of COVID-19 for the ECMO centers and medical staff around the world. The ELSO recommends that national governments should work with the private sector to secure resources during the COVID-19 pandemic; that networks are to be used at the local level to cooperate with equitable service delivery and staffing in the region; that ECMO training programs and staffing are important at the institutional level; that the ratio of patients to nurses should be 1:1; and that ECMO specialists should be deployed [ 11 ]. However, skilled nurses for the care of ECMO patients are substantially lacking, and education programs related to the management of ECMO patients are limited. In addition, ECMO training has been dominated by instructor-centered training methods such as lectures and skills training. However, some training using e-learning and high-fidelity simulators have been conducted recently [ 12 – 18 ]. Some preceding studies have shown that training using high-fidelity simulators has no difference in effectiveness when compared to traditional training [ 17 ]. In a previous study targeting nurses [ 19 ], a high-fidelity simulation was performed for nurses working in ICUs during a three-day workshop; however, there are limitations to conducting long hours of group education during the period of high transmission of COVID-19. Due to the prolonged COVID-19 pandemic, the training and education of prospective medical personnel has become an important issue in addition to securing specialized medical personnel; however, repeatedly educating the students who are pre-medical professionals in person during the pandemic is very difficult. The professionals such as ECMO nurses can not be trained in a short time; thus, generating interest and providing knowledge about ECMO nursing to nursing students is necessary. In addition, due to COVID-19, nursing students at many universities have been restricted from a practicum in ICUs, and they have lost the opportunity to even experience ECMO nursing indirectly; so, educational programs are needed to supplement their knowledge and experience. Many academics in various fields have been using virtual reality (VR) to educate students. VR is a cutting-edge technology that allows humans to interact with computers, which makes them feel that they are actually present in a virtual space [ 20 ]. By Incorporating these characteristics of technology into education, VR simulation creates a VR space that matches the nursing practice scenario, and allows students to make situational clinical decisions and perform nursing care accordingly [ 21 ]. VR simulations have the advantage of allowing students to experience real patient care vicariously in a safe environment without space constraints, enabling repetitive practice, and providing immediate feedback, especially during pandemics [ 20 ]. Thus, this study aimed to develop an ECMO nursing education program for nursing students who are pre-medical professionals and to evaluate its effect on education. Methods Study design This study developed a VR simulation program for ECMO nursing and evaluated the effects on ECMO nursing knowledge, confidence, clinical reasoning capacity, learning immersion, and learning satisfaction in fourth-year nursing students using an equivalent control group pre-test and post-test design (Fig. 1 ). Subjects This study was conducted on fourth-year nursing students from three universities in Seoul, Gangwon, and Gyeonggi in South Korea. In this study, the minimum number of samples applied to the implementation stage to test program effectiveness was determined as 26 participants per group with a 1:1 assignment, a test power of .80, a significance level of .05, and an effect size of .80 when using a two-tail test of the difference between two independent means (two groups) in the G*Power 3.1.2 program. The calculation of sample size was based on the effect size of learning satisfaction (effect size: d = 1.33) measured as the main variable in a previous study [ 22 ] that applied a VR simulation program to nursing students based on learning satisfaction, which is also one of the main variables of this study. This study set the effect size (f) as .80 (large) and had 66 participants as study subjects; 33 per group considering the dropout rate of 20.0%, given the social distancing due to COVID-19. Development of the program The program was developed according to the five-step ADDIE (Analysis, Design, Development, Implement, and Evaluation) model, which is used to develop teaching and learning methods [ 23 ]. Analysis stage The analysis stage involves the process of obtaining the basic data necessary to develop VR simulation scenarios and educational programs. Here, the educational needs were investigated through a literature review on ECMO nursing-related simulations, and through interviews with three nurses who had experience working in ICUs, two nursing professors, and two fourth-year nursing students. Data searches for literature reviews were performed on eight databases. The databases for foreign literature searches included PUBMED, Scopus, Proquest, and CINAHL, whereas DBpia, KISS, the National Assembly Library, and the Korea Education and Research Information Service were used for domestic literature searches. In the literature reviews and interviews, we identified what nursing students should learn for ECMO nursing through VR, as well as the operating hours of VR programs and the contents necessary for pre-training and debriefing configuration. Design stage In this stage, the learning goal is set based on the results of the analysis stage, and the study design and operation methods suitable for achieving the goal are decided. In this study, an ECMO nursing program was developed based on the case of a critically ill patient diagnosed with ARDS as a complication resulting from COVID-19, and the important nursing contents selected through the analysis stage were set as a scenario and algorithm of the VR program. Development stage In the development stage, algorithms and scenarios related to nursing care were developed for ECMO patients, and a pre-learning curriculum was constructed to help them acquire relevant knowledge before performing the VR simulation. To review the VR simulation algorithm, the composition of the scenario, the composition of prior learning, and the suitability and applicability of the learning objectives, opinions were collected from three nurses who had experience working in ICUs and two nursing professors, and the Content Validity Index [CVI] for experts was checked. Before applying the developed program to the subjects, its potential as a nurse education program was examined by simulating it to one clinical nurse, and the problems found were corrected. A preliminary investigation was also conducted to see if there was any difficulty in understanding the educational contents and whether any additional educational content was required, resulting in the final VR simulation education program. Then, two fourth-year nursing students and one nurse in an ICU tested the program as a simulation to increase the fidelity of the research. Implementation stage The control group had a pre-recorded lecture regarding the pre-learning contents to be applied to the experimental group, while the educational program (recorded pre-learning-VR experience-debriefing) developed in this study was applied to the experimental group. Considering that the contents delivered to the subjects may vary depending on the instructor, the time, and the student, a pre-recorded lecture was used so that the control group and the experimental group could learn the same content. In addition, the experimental group had three steps of learning, composed of pre-learning of the VR simulation program to be developed in this study, simulation operation, and debriefing. Before the VR experience, the trained research assistant gave an orientation on the VR program and equipment to a participant in the experimental group and then proceeded with the simulation. The researchers explained to the subjects about a precaution file for using Oculus products, and then, selected the subjects who indicated their intention to provide their consent for participation as the final study subjects. For the debriefing of the experimental group, a debriefing plan based on the algorithm of the scenario was prepared, and then, utilized to check the expected nursing performance from learners after the VR experience. The students performed VR programs while wearing VR headsets and controllers. The duration of the program was slightly different for each student and took a minimum of 5 min to a maximum of 15 min. The virtual patient was admitted to the intensive care unit on the second day after the diagnosis of ARDS. Hypoxemia (PO 2 47.0∼41.7mmHg) persisted despite mechanical ventilation control, and a venous-vein extracorporeal membrane oxidizer is being applied to improve lung oxygenation. For the virtual patient to maintain ECMO, mechanical ventilation was in assist-controlled mode, pressure-controlled mode (20-25cmH2O), tidal volume 500mL, respiration rate 12 times per minute, inhaled oxygen concentration 0.5, and positive end-expiratory pressure (5cmH2O) was maintained. Students experience various nursing interventions sequentially in the ICU. Students look at the patient monitor, check the V/S, ABP, and CVP values, and record them on the EMR. The balance of intake and output was also checked, and the amount of fluid injected for 1 h and the amount of urine excreted for 1 h were checked and recorded in the EMR. The students observed the patient's EKG monitor and checked for arrhythmias. In addition, students will observe lower-extremity ischemia on the side of the femoral artery into which the ECMO cannula is inserted. Students used the calculator to calculate whether the appropriate cardiac index was maintained according to ECMO flow, checked the ECMO charge state, and lubricated the sensor probe in the event of an alarm (Fig. 2 ). Evaluation stage of the program A pre-test was conducted with the experimental group and the control group on general characteristics, knowledge of ECMO nursing, confidence, and clinical reasoning capability before the VR program and lectures, and a post-test was also performed with both groups on the knowledge of ECMO nursing, confidence, clinical reasoning capability, learning immersion and learning satisfaction after the VR program and lectures. The participants were subjected to another post-survey after two weeks. Measurement Knowledge of ECMO nursing In this study, a tool comprising 15 questions based on the literature was developed by the researchers to test the knowledge of ECMO nursing. It was validated by two nursing professors with experience in teaching critical care nursing courses or working in ICUs, and three nurses with more than five years of ICU experience. Each question was scored as 0 points for a wrong answer and 1 point for a correct answer, and a higher score meant a higher degree of knowledge related to ECMO nursing. Confidence in ECMO nursing The confidence in ECMO nursing was evaluated on the basis of a five-point scale using the two questions proposed by Thomas, Chung, and Holt [ 24 ], in which a higher score indicated a higher degree of confidence in ECMO nursing. Clinical reasoning capability This study used the evaluation tool developed by Liou and his colleagues [ 25 ] for clinical reasoning capability. The Korean version was verified by Han & Jeong [ 26 ], which was composed of 15 questions (5-point scale), and a higher score meant a higher degree of clinical reasoning capacity. In the study by Liou et al. [ 25 ], the reliability of the tool was found with Cronbach's α = .94, whereas the study of Han and Jeong [ 26 ] showed Cronbach's α = .93. Cronbach's α in this study was .97. Learning immersion To measure nursing students’ immersion in learning, we used the 10-question 5-point Likert flow short scale, developed by Engeser and Rheinberg [ 27 ] and validated by Yoo [ 28 ] through translation and reverse translation into Korean. A higher score meant a higher level of learning immersion. Cronbach’s α was 0.92 at the time of development [ 27 ] and 0.84 in Yoo’s [ 28 ] study. Cronbach’s α in this study was .92. Learning satisfaction In this study, learning satisfaction was measured by NRS (numeral rating scale) with scoring 10 points for “very satisfied” and 0 points for “very dissatisfied,” in which a higher score meant a higher degree of satisfaction with learning. Data collection and analysis In consideration of COVID-19, the research team members trained in a state of daily quarantine met one-on-one with the study participants to explain the purpose and method of the research, and conducted the study. The data were analyzed using SPSS / WIN/23.0 (SPSS Data Solution. co), and the Shapiro-Wilk test was performed to test for normality on variables before program application. The general characteristics of participants and pre-homogeneity tests for variables were performed with the Chi-squared test, Fisher’s exact test, and t-test. After the intervention, a two-way repeated measures analysis of variance was performed to determine the effect on the variables including knowledge of ECMO nursing, confidence, and clinical reasoning capability in the experimental and control groups. Learning immersion and learning satisfaction were tested by independent t-test. Results Homogeneity test of subjects for general characteristics The majority of the participants comprised 55 females (93.3%), with an average age of 23.3 ± 4.3 years. A total of 14 (21.2%) participants had a religion while 52 (78.8%) had none. As for satisfaction with clinical practicum, 46 participants (69.7%) were “satisfied,” 18 (27.3%) were “average,” and 2 (3.0%) were “dissatisfied.” As for satisfaction with their majors, 45 participants (68.2%) were “satisfied” and 21 (31.8%) were “below average.” As for their satisfaction with school life, 45 participants (68.2 percent) were “satisfied” and 21 (31.8 percent) were “below average.” As for experience with ECMO education, 61 participants (92.4%) had experience, whereas 5 (7.6%) had no ECMO training experience. The students with ECMO training experience were surveyed about their training methods, and the following results were found: 46 (74.2%) had a lecture, 14 (22.6%) were from clinical practicum, and 2 (3.2%) were by simulation. No factors showed a statistically significant difference in the homogeneity test between the intervention and control groups according to general characteristics (Table 1 ). Tests for normality and homogeneity of the pre-dependent variables In this study, the pre-dependent variables including the knowledge and confidence in ECMO nursing and clinical reasoning capacity secured normality and homogeneity in both groups (Table 2 ). Verification of the effectiveness of the VR simulation program for ECMO nursing Knowledge of ECMO nursing Hypothesis 1 “There would be differences in the knowledge of ECMO nursing between the intervention group applying the ECMO nursing VR simulation program and the control group” was tested. The main effect found between the time points was that both the experimental group (F = 34.81, p < .001) and the control group (F = 29.47, p < .001) significantly increased their knowledge of ECMO nursing. However, there was no statistically significant difference among the pre-test (F = -1.320, p = .192), post-test 1 (F = .723, p = .472), and post-test 2 (F = .107, p = .915) in both the experimental and control groups. The effect of interaction between the group and the time point (F = 1.41, p = .251) was also not statistically significant; thus, the first hypothesis was rejected (Table 3 ). Confidence in ECMO nursing Hypothesis 2 “There would be differences in the confidence in ECMO nursing between the intervention group applying the ECMO nursing VR simulation program and the control group” was tested. The main effect identified between the time points was that both the experimental group (F = 65.48, p < .001) and the control group (F = 60.56, p < .001) significantly increased their confidence in ECMO nursing. However, there was no statistically significant difference in the main effect among the time points (pre-test: F = − .607, p = .546; post-test 1: F = .766, p = .446; and post-test 2: F = 1.182, p = .242) in both the experimental and control groups. The effect of interaction between the group and the time point (F = 1.97, p = .144) was also not statistically significant; thus, the second hypothesis was also rejected (Table 3 ). Clinical reasoning capability Hypothesis 3 “There would be differences in ECMO nursing-related clinical reasoning capacity between the intervention group applying the ECMO nursing VR simulation program and the control group” was tested. The main effect identified between the time points was that both the experimental group (F = 91.67, p < .001) and the control group (F = 66.03, p < .001) significantly increased their clinical reasoning capability in ECMO nursing. However, there was no statistically significant difference in the main effect among the time points (pre-test: F = − .711, p = .479; post-test 1: F = .799, p = .427; and post-test 2: F = .986, p = .328) in both the experimental and control groups. The effect of interaction between the group and the time point (F = 2.85, p = .061) was also not statistically significant; thus, the third hypothesis was rejected (Table 3 ). Learning immersion Hypothesis 4 “There would be differences in learning immersion between the intervention group applying the ECMO nursing VR simulation program and the control group” was tested, and the learning immersion of the experimental group was found to be statistically significantly higher than that of the control group (t = 3.97, p < .001); thus, the fourth hypothesis was accepted. Learning satisfaction Hypothesis 5 “There would be differences in learning satisfaction between the intervention group applying the ECMO nursing VR simulation program and the control group” was tested, and the learning immersion of the experimental group was found to be statistically significantly higher than that of the control group (t = 4.25, p < .001); thus, the fifth hypothesis was accepted. Discussion This study aimed to improve nursing students’ ability to care for critically ill patients through ECMO nursing VR learning in the pandemic situation resulting from infectious diseases such as COVID-19. The implications for the program’s effectiveness are as follows: First, the hypothesis that "There would be differences in the knowledge of ECMO nursing between the intervention group applying the ECMO nursing VR simulation program and the control group" was rejected. This result is similar to the study [ 29 ] in which four hospitals in the United States applied a screen-based pediatric ECMO simulation training program to medical professionals. Regarding the knowledge of mechanical ventilation nursing in the intervention group, which applied the mechanical ventilation nursing simulation program using VR in South Korea, and the control group, there was no significant difference in the interaction effect between the group and the time point [ 30 ]. However, the results were inconsistent in a study [ 31 ] in Taiwan that showed that the experimental group had higher knowledge than the control group after providing nursing students with educational materials related to chemotherapy administration using VR. As such, the effect on knowledge is not consistent in relation to simulation practice. It seems that the subjects tended to consider VR simulations as an opportunity to apply and combine existing knowledge rather than increase their knowledge by operating it for a long time because VR simulations with goggles have various difficulties in using the device. It was speculated that there was no significant difference, as this study also measured the basic knowledge of ECMO related to the scenario rather than a newly learned specific one. As simulation-based education is based on an integrated use of knowledge while participating in the process of solving problems in a given situation, it seems that there should be a limitation in measuring the effectiveness of education by measuring knowledge through simple questions. In addition, the knowledge measurement tool in this study was intended to simply measure if the subjects had correct or wrong knowledge, which might be unable to detect significant differences in the knowledge level between the experimental and the control groups. Several previous studies that trained medical staff on ECMO simulation and evaluated their performance have shown the effects on performance [ 13 – 15 , 17 ]. Thus, future studies should verify the effectiveness of the ECMO nursing VR simulation program using tools evaluating empirical knowledge and nursing performance skills. Second, the hypothesis, "There would be differences in ECMO nursing-related confidence between the intervention group applying the ECMO nursing VR simulation program and the control group" was rejected. This result was similar to the study [ 29 ] that applied the screen-based pediatric ECMO simulation training program, in which there was no statistically significant difference in self-efficacy. A study [ 32 ] that developed High-fidelity Extracorporeal Membrane Oxygenation Simulation in the UK reported that ECMO simulation allowed students to learn skills in an interactive environment without harming real patients, while giving them confidence. However, when analyzing the confidence score data in this study, the mean confidence of the experimental group increased from 6.30 in the prescore to 13.61, while the control group’s confidence increased from 6.94 to 12.61, which was not statistically significant though the difference in confidence increase in the experimental group appeared to be greater than that of the control group. These results suggest that, since ECMO is a difficult topic to understand in a short time period [ 33 ], it would be difficult to improve confidence with a single training as shown in this study. However, the ECMO VR simulation training developed in this study can be considered as a way to improve students’ confidence in that it allows for the safe and planned implementation of ECMO-related training [ 32 ]. It should be further studied to evaluate the improvement of confidence again through the iterative applications of the program in the future. Third, the hypothesis that "There would be differences in ECMO nursing-related clinical reasoning capacity between the intervention group applying the ECMO nursing VR simulation program and the control group" was rejected. This was contrary to the results of a study in South Korea, in which a simulation program using VR for nursing students was effective in clinical reasoning capabilities [ 30 ]. Clinical reasoning capability is a thought process for gathering and analyzing patient information, assessing the importance of analyzed information, and determining alternative behaviors [ 34 ]. Since simulation-based training is expected to enhance clinical reasoning capability in that it provides an opportunity for nursing students and nurses to develop and maintain technical proficiency in high-risk, rare events without the fear of harming the patients [ 32 ]. Nonetheless, clinical reasoning capability does not improve in a short period, which seems to be the reason why there was no significant difference between the experimental and control groups. However, previous studies [ 35 , 36 ] suggested that a program to educate medical staff using various simulation methods on all aspects related to ECMO is needed to improve the ability of medical staff to treat patients with ECMO. Likewise, if nursing students repetitively practiced various clinical situations using the ECMO nursing VR simulation program developed in this study, it would help them improve their clinical reasoning capacity. Fourth, the hypothesis that “There would be differences in learning immersion between the intervention group applying the ECMO nursing VR simulation program and the control group” was accepted, which is consistent with the results of the study [ 37 ] that the motivation to learn increased after applying the education program using VR. Due to the current COVID-19 pandemic, the demand for ECMO is unprecedented and its management is highly complex; however, nursing students have found it difficult to acquire the relevant skills [ 38 ]. The ECMO nursing VR simulation program developed in this study extends from traditional instructor-led learning methods to real-world clinical experiences that are rarely encountered, and we believe such experiences can be an effective way to improve nursing students’ learning immersion. In particular, the VR in this study used an HMD to seal the user’s audiovisual and other senses and used visual elements in the ICU and auditory elements such as the patient’s breathing sound and alarm, making the users feel as if they were in real virtual reality, which could ensure students’ learning immersion. Therefore, the provision of various teaching methods, including VR teaching methods, to help nursing students in their education, and to find ways to improve their immersion in learning are necessary. Fifth, the hypothesis that “There would be differences in learning satisfaction between the intervention group applying the ECMO nursing VR simulation program and the control group” was accepted. This is consistent with the study results [ 30 ], in which the experimental group had higher learning satisfaction than the control group in the mechanically ventilated nursing VR simulation program performed for nursing students in South Korea [ 30 ], and the HFS ECMO nursing training program for ICU nurses in France resulted in satisfaction from 95.2% of participants [ 19 ]. This is because the educational program developed in this study considered the learning needs of the subjects, and tried to maximize the educational element by realistically implementing scenarios and clinical situations with clinical and educational validity in VR. In addition, this result seemed to be due to the characteristics of the learning method, because the immersive VR simulation uses digital devices to learn in a situation completely different from reality, making it highly immersive and distinct from reality, which might have induced the learning interest and confidence enhancement in students [ 39 ]. High satisfaction with simulation education can improve learners’ internal motivation and, consequently, clinical performance [ 40 ]; thus, the program developed in this study is expected to be able to enhance students’ competence. Conclusion This study is an equivalent control pre-test and post-test design study, which developed a VR simulation program for ECMO nursing by applying the stages of the ADDIE model and determined the effects on ECMO nursing knowledge, confidence, clinical reasoning capability, learning immersion, and learning satisfaction in fourth-year nursing students. The ECMO nursing VR simulation program developed in this study was found to increase learning immersion and learning satisfaction in nursing students. ECMO education is a challenging issue in nursing education because of its unique nature of complex, high-risk, and low-frequency clinical activities that require dynamic decisions. If ECMO education is implemented with VR simulation education, students can learn in a safe clinical environment implemented in a virtual space compared to lecture-based learning methods, without being affected by time and place compared to HPS-based simulation. Therefore, the result is expected to be more effective if the ECMO nursing VR simulation program developed in this study is used together with the lecture in the classroom and HPS simulation. However, this study applied the VR simulation training program to the students only once, while the learning object of ECMO cannot be acquired in a short time period. The advantage of the VR simulation program is that it allows repeated practices; so, a future study should investigate the effect of an increased number of simulation training and its mid- to long-term intervention effects in a longitudinal study design. Abbreviations ADDIE: analysis, design, development, implement, and evaluation; COVID-19: Coronavirus Disease of 2019; ECLS: extracorporeal life support; ECMO: extracorporeal membrane oxygenation; VR: virtual reality Declarations Ethics approval and consent to participate The study was conducted from review by the Kyunghee University Institutional Review Board (KHSIRB-22-018(NA)). Informed written consent to participate was obtained from all students. Students participated in the study voluntarily. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000. Consent for publication Written informed consent was obtained from all participants to publish the data. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on request. Competing interests The authors declare that they have no competing interests. Funding This work has supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT; NRF-2020R1F1A1074448). Authors’ contributions All authors conceptualized the study. Han, Jeong-won, Lee, Hanna, Min, Soyon, Park, Junhee & Park, Jihey participated in data collection, analysis, interpretation of data and drafted the manuscript; All authors participated in interpretation of results. All authors have critically reviewed the manuscript and approved the final version. Acknowledgements We thank the students at nursing college for their participation in this study. References Maliszewska M, Mattoo A, Van Der Mensbrugghe D. The potential impact of COVID-19 on GDP and trade: A preliminary assessment. World Bank policy research working paper 2020(9211). World Health Organization. WHO COVID-19 dashboard. 2022; https://covid19.who.int/info/ . Accessed 1 Oct 2022. Korea Centers for Disease Control and Prevention Agency.COVID19 vaccination. 2021; https://www.kdca.go.kr/upload_comm/syview/doc.html?fn=163884126737300.hwp&rs=/upload_comm/docu/0015/ . Accessed 1 Oct 2022. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Cao B. 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Simulation training enables emergency medicine providers to rapidly and safely initiate extracorporeal cardiopulmonary resuscitation (ECPR) in a simulated cardiac arrest scenario. Resuscitation. 2019;138:68–73. Fouilloux V, Gran C, Guervilly C, Breaud J, El Louali F, Rostini P. Impact of education and training course for ECMO patients based on high-fidelity simulation: a pilot study dedicated to ICU nurses. Perfusion. 2019;34(1):29–34. Foreman N. Virtual reality in psychology. Themes in Science and Technology Education. 2010;2(1–2):225–52. Jenson CE, Forsyth DM. Virtual reality simulation: using three-dimensional technology to teach nursing students. CIN: Computers Informatics Nursing. 2012;30(6):312–8. Padilha JM, Machado PP, Ribeiro A, Ramos J, Costa P. Clinical virtual simulation in nursing education: randomized controlled trial. J Med Internet Res. 2019;21(3):e11529. Molenda M, Pershing JA, Reigeluth CM. Designing instructional systems. In The ASTD Training and Development Handbook, Edited by R. L. Craig, 266–293; 4th. New York: McGraw-Hill; 1996. Thomas F, Chung S, Holt DW. Effects of ECMO Simulations and Protocols on Patient Safety. J Extra Corpor. 2019;51:12–9. Liou S, Liu H, Tsai H, Tsai Y, Lin Y, Chang C, Cheng C. The development and psychometric testing of a theory-based instrument to evaluate nurses’ perception of clinical reasoning competence. J Adv Nurs. 2016;72(3):707–17. Joung J, Han JW. Validity and reliability of a Korean version of nurse clinical reasoning competence scale. J Korea Academia-Industrial Cooperation Soc. 2017;18(4):304–10. Engeser S, Rheinberg F. Flow, performance and moderators of challenge-skill balance. Motiv Emot. 2008;32(3):158–72. Yoo JH. Factors influencing nursing students' flow experience and clinical competency in simulation-based education: based on Jeffries's simulation model. Seoul: Sungshin University; 2016. Alsalemi A, Tanaka L, Ogino M, Disi MA, Alhomsi Y, Bensaali F, Alinier G. A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation. Perfusion. 2020;35(2):110–6. Lee HN, Han JW. Development and evaluation of a virtual reality mechanical ventilation education program for nursing students. BMC medical education. Chan H, Chang H, Huang T. Virtual reality teaching in chemotherapy administration: Randomised controlled trial. J Clin Nurs. 2021;30(13–14):1874–83. Lansdowne W, Machin D, Grant DJ. Development of the orpheus perfusion simulator for use in high-fidelity extracorporeal membrane oxygenation simulation. J Extra Corpor. 2012;44(4):250. Weems MF, Friedlich PS, Nelson LP, Rake AJ, Klee L, Stein JE, Stavroudis TA. The role of extracorporeal membrane oxygenation simulation training at extracorporeal life support organization centers in the United States. Simul Healthc. 2017;12(4):233–9. Simmons B. Clinical reasoning: concept analysis. J Adv Nurs. 2010;66(5):1151–8. Simmons B, Lanuza D, Fonteyn M, Hicks F, Holm K. Clinical reasoning in experienced nurses. West J Nurs Res. 2003;25(6):701–19. Labib A, Alinier G. Can simulation improve ECMO care? Qatar Medical Journal. 2017;2017(1-Extracorporeal Life Support Organisation of the South and West Asia Chap. 2017 Conference Proceedings):7. Lange A, Koch J, Beck A, Neugebauer T, Watzema F, Wrona KJ, et al. Learning with virtual reality in nursing education: qualitative interview study among nursing students using the unified theory of acceptance and use of technology model. JMIR Nurs. 2020;3(1):e20249. Banjas N, Hopf H, Hanisch E, Friedrichson B, Fichte J, Buia A. ECMO-treatment in patients with acute lung failure, cardiogenic, and septic shock: mortality and ECMO-learning curve over a 6-year period. J Intensive Care. 2018;6(1):1–9. Merchant Z, Goetz ET, Cifuentes L, Keeney-Kennicutt W, Davis TJ. Effectiveness of virtual reality-based instruction on students' learning outcomes in K-12 and higher education: A meta-analysis. Comput Educ. 2014;70:29–40. Cook NF, McAloon T, O'Neill P, Beggs R. Impact of a web based interactive simulation. game (PULSE). on nursing students' experience and performance in life support training—A pilot study. Nurse Educ Today. 2012;32(6):714–20. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Jan, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 12 Dec, 2023 Reviews received at journal 05 Dec, 2023 Reviewers agreed at journal 02 Dec, 2023 Reviewers invited by journal 01 Dec, 2023 Editor assigned by journal 01 Dec, 2023 Editor invited by journal 21 Nov, 2023 Submission checks completed at journal 21 Nov, 2023 First submitted to journal 09 Nov, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3588375","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":251606855,"identity":"03cda914-539f-43f1-bb91-ff67f2008c7f","order_by":0,"name":"Hanna Lee","email":"","orcid":"","institution":"Gangneung-Wonju National University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hanna","middleName":"","lastName":"Lee","suffix":""},{"id":251606856,"identity":"d620b052-03e6-43c9-8a5d-b46c96a57273","order_by":1,"name":"Jeong-won Han","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACA4YDDIf/VEjISUjABIjQwviA54yFMSlaGJgNeNsqEmcQrcWc8YyZhASbRPrM2T0GDD9qGIzNGwhosWwAajHgkcidLXPGgLHnGIOZzAFCDjtwdptEgoRE7jyJHAMG3gYGGwmCfgFpOWAgkS4H1ML4l0gtmw0bEiQSpIFamIG2mBGh5fzHxwwHJAxnzkgrOCxzTMKYsJYbxxIOM/6rk5e4kbzx4ZsaG8MZhLQwSBxAsIFMgnYAAX8DEYpGwSgYBaNgZAMAMTk9kptHFqcAAAAASUVORK5CYII=","orcid":"","institution":"Kyung Hee University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jeong-won","middleName":"","lastName":"Han","suffix":""},{"id":251606857,"identity":"13a8f072-abc1-4840-92c3-f32aae3cf805","order_by":2,"name":"Junhee Park","email":"","orcid":"","institution":"Dongnam Health University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Junhee","middleName":"","lastName":"Park","suffix":""},{"id":251606858,"identity":"a4c58f8c-b429-4c0c-8e8f-26a02d5605c5","order_by":3,"name":"Soyoon Min","email":"","orcid":"","institution":"Kyung Hee University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Soyoon","middleName":"","lastName":"Min","suffix":""},{"id":251606859,"identity":"8e1c52e6-e6d1-4807-866e-78f8636753cc","order_by":4,"name":"Jihey Park","email":"","orcid":"","institution":"Kyung Hee University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jihey","middleName":"","lastName":"Park","suffix":""}],"badges":[],"createdAt":"2023-11-10 04:14:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3588375/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3588375/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-05057-2","type":"published","date":"2024-01-26T15:17:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":47001731,"identity":"4e6e3ff5-1aa3-438e-a814-13cbe0afe9fb","added_by":"auto","created_at":"2023-11-24 00:15:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101862,"visible":true,"origin":"","legend":"\u003cp\u003eResearch subject\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3588375/v1/a8e7f4cee21f04eefc12f14e.png"},{"id":47001732,"identity":"2b842516-83ed-4e26-b3f6-d944e0a2f822","added_by":"auto","created_at":"2023-11-24 00:15:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1057677,"visible":true,"origin":"","legend":"\u003cp\u003eProgram implementation\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3588375/v1/4d7588fbbac72fd6006cd4d2.png"},{"id":50314101,"identity":"31b1ee18-b2ae-49cc-9607-62200af8d8c2","added_by":"auto","created_at":"2024-01-29 15:29:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1383825,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3588375/v1/f210283b-9b11-48b5-8487-fef7814a80a1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and evaluation of extracorporeal membrane oxygenation nursing education program for nursing students using virtual reality ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCOVID-19 can have a wide range of clinical manifestations, from asymptomatic to life-threatening acute respiratory distress syndrome (ARDS) and death [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Particularly, COVID-19 patients requiring intensive care are mostly accompanied by respiratory failure caused by ARDS [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. ARDS treatment may start with a conservative method such as mechanical respiration, and extracorporeal membrane oxygenation (ECMO) may be considered if long-term mechanical respiration is required [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. ECMO, also called extracorporeal life support (ECLS), refers to a device that temporarily helps the heart and lungs when their functions are declined and life support is difficult using conventional methods. As of November 2020, ECMO was performed on 83 domestic COVID-19 patients, and 48 patients were successfully treated [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The expertise and skills of healthcare providers with ECMO devices are critical. As the number of COVID-19 cases continues to rise, the number of critically ill patients is also soaring; thus, it is imperative to increase the number of hospitals and healthcare workers that can manage ECMO [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The Korean government selected the nationally designated hospitals for critical care management, expanded the intensive care units (ICUs), and trained students to secure dedicated critical care nursing personnel capable of ECMO nursing [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the supply and demand for nurses who can care for critically ill patients are not smooth; this is because training the personnel takes a long time, and in-depth education and specific training, such as movement management and changing protective clothing, is required for the special circumstances of COVID-19 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e During the COVID-19 pandemic, the Extracorporeal Life Support Organization (ELSO) developed the ECMO guidelines in the context of COVID-19 for the ECMO centers and medical staff around the world. The ELSO recommends that national governments should work with the private sector to secure resources during the COVID-19 pandemic; that networks are to be used at the local level to cooperate with equitable service delivery and staffing in the region; that ECMO training programs and staffing are important at the institutional level; that the ratio of patients to nurses should be 1:1; and that ECMO specialists should be deployed [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, skilled nurses for the care of ECMO patients are substantially lacking, and education programs related to the management of ECMO patients are limited. In addition, ECMO training has been dominated by instructor-centered training methods such as lectures and skills training. However, some training using e-learning and high-fidelity simulators have been conducted recently [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Some preceding studies have shown that training using high-fidelity simulators has no difference in effectiveness when compared to traditional training [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a previous study targeting nurses [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], a high-fidelity simulation was performed for nurses working in ICUs during a three-day workshop; however, there are limitations to conducting long hours of group education during the period of high transmission of COVID-19.\u003c/p\u003e \u003cp\u003eDue to the prolonged COVID-19 pandemic, the training and education of prospective medical personnel has become an important issue in addition to securing specialized medical personnel; however, repeatedly educating the students who are pre-medical professionals in person during the pandemic is very difficult. The professionals such as ECMO nurses can not be trained in a short time; thus, generating interest and providing knowledge about ECMO nursing to nursing students is necessary. In addition, due to COVID-19, nursing students at many universities have been restricted from a practicum in ICUs, and they have lost the opportunity to even experience ECMO nursing indirectly; so, educational programs are needed to supplement their knowledge and experience. Many academics in various fields have been using virtual reality (VR) to educate students. VR is a cutting-edge technology that allows humans to interact with computers, which makes them feel that they are actually present in a virtual space [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. By Incorporating these characteristics of technology into education, VR simulation creates a VR space that matches the nursing practice scenario, and allows students to make situational clinical decisions and perform nursing care accordingly [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. VR simulations have the advantage of allowing students to experience real patient care vicariously in a safe environment without space constraints, enabling repetitive practice, and providing immediate feedback, especially during pandemics [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Thus, this study aimed to develop an ECMO nursing education program for nursing students who are pre-medical professionals and to evaluate its effect on education.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study developed a VR simulation program for ECMO nursing and evaluated the effects on ECMO nursing knowledge, confidence, clinical reasoning capacity, learning immersion, and learning satisfaction in fourth-year nursing students using an equivalent control group pre-test and post-test design (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003eThis study was conducted on fourth-year nursing students from three universities in Seoul, Gangwon, and Gyeonggi in South Korea. In this study, the minimum number of samples applied to the implementation stage to test program effectiveness was determined as 26 participants per group with a 1:1 assignment, a test power of .80, a significance level of .05, and an effect size of .80 when using a two-tail test of the difference between two independent means (two groups) in the G*Power 3.1.2 program. The calculation of sample size was based on the effect size of learning satisfaction (effect size: d\u0026thinsp;=\u0026thinsp;1.33) measured as the main variable in a previous study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] that applied a VR simulation program to nursing students based on learning satisfaction, which is also one of the main variables of this study. This study set the effect size (f) as .80 (large) and had 66 participants as study subjects; 33 per group considering the dropout rate of 20.0%, given the social distancing due to COVID-19.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of the program\u003c/h2\u003e \u003cp\u003eThe program was developed according to the five-step ADDIE (Analysis, Design, Development, Implement, and Evaluation) model, which is used to develop teaching and learning methods [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis stage\u003c/h2\u003e \u003cp\u003eThe analysis stage involves the process of obtaining the basic data necessary to develop VR simulation scenarios and educational programs. Here, the educational needs were investigated through a literature review on ECMO nursing-related simulations, and through interviews with three nurses who had experience working in ICUs, two nursing professors, and two fourth-year nursing students. Data searches for literature reviews were performed on eight databases. The databases for foreign literature searches included PUBMED, Scopus, Proquest, and CINAHL, whereas DBpia, KISS, the National Assembly Library, and the Korea Education and Research Information Service were used for domestic literature searches. In the literature reviews and interviews, we identified what nursing students should learn for ECMO nursing through VR, as well as the operating hours of VR programs and the contents necessary for pre-training and debriefing configuration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDesign stage\u003c/h2\u003e \u003cp\u003eIn this stage, the learning goal is set based on the results of the analysis stage, and the study design and operation methods suitable for achieving the goal are decided. In this study, an ECMO nursing program was developed based on the case of a critically ill patient diagnosed with ARDS as a complication resulting from COVID-19, and the important nursing contents selected through the analysis stage were set as a scenario and algorithm of the VR program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment stage\u003c/h2\u003e \u003cp\u003eIn the development stage, algorithms and scenarios related to nursing care were developed for ECMO patients, and a pre-learning curriculum was constructed to help them acquire relevant knowledge before performing the VR simulation. To review the VR simulation algorithm, the composition of the scenario, the composition of prior learning, and the suitability and applicability of the learning objectives, opinions were collected from three nurses who had experience working in ICUs and two nursing professors, and the Content Validity Index [CVI] for experts was checked. Before applying the developed program to the subjects, its potential as a nurse education program was examined by simulating it to one clinical nurse, and the problems found were corrected. A preliminary investigation was also conducted to see if there was any difficulty in understanding the educational contents and whether any additional educational content was required, resulting in the final VR simulation education program. Then, two fourth-year nursing students and one nurse in an ICU tested the program as a simulation to increase the fidelity of the research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eImplementation stage\u003c/h2\u003e \u003cp\u003eThe control group had a pre-recorded lecture regarding the pre-learning contents to be applied to the experimental group, while the educational program (recorded pre-learning-VR experience-debriefing) developed in this study was applied to the experimental group. Considering that the contents delivered to the subjects may vary depending on the instructor, the time, and the student, a pre-recorded lecture was used so that the control group and the experimental group could learn the same content. In addition, the experimental group had three steps of learning, composed of pre-learning of the VR simulation program to be developed in this study, simulation operation, and debriefing. Before the VR experience, the trained research assistant gave an orientation on the VR program and equipment to a participant in the experimental group and then proceeded with the simulation. The researchers explained to the subjects about a precaution file for using Oculus products, and then, selected the subjects who indicated their intention to provide their consent for participation as the final study subjects. For the debriefing of the experimental group, a debriefing plan based on the algorithm of the scenario was prepared, and then, utilized to check the expected nursing performance from learners after the VR experience. The students performed VR programs while wearing VR headsets and controllers. The duration of the program was slightly different for each student and took a minimum of 5 min to a maximum of 15 min. The virtual patient was admitted to the intensive care unit on the second day after the diagnosis of ARDS. Hypoxemia (PO\u003csub\u003e2\u003c/sub\u003e 47.0\u0026sim;41.7mmHg) persisted despite mechanical ventilation control, and a venous-vein extracorporeal membrane oxidizer is being applied to improve lung oxygenation. For the virtual patient to maintain ECMO, mechanical ventilation was in assist-controlled mode, pressure-controlled mode (20-25cmH2O), tidal volume 500mL, respiration rate 12 times per minute, inhaled oxygen concentration 0.5, and positive end-expiratory pressure (5cmH2O) was maintained. Students experience various nursing interventions sequentially in the ICU. Students look at the patient monitor, check the V/S, ABP, and CVP values, and record them on the EMR. The balance of intake and output was also checked, and the amount of fluid injected for 1 h and the amount of urine excreted for 1 h were checked and recorded in the EMR. The students observed the patient's EKG monitor and checked for arrhythmias. In addition, students will observe lower-extremity ischemia on the side of the femoral artery into which the ECMO cannula is inserted. Students used the calculator to calculate whether the appropriate cardiac index was maintained according to ECMO flow, checked the ECMO charge state, and lubricated the sensor probe in the event of an alarm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation stage of the program\u003c/h2\u003e \u003cp\u003eA pre-test was conducted with the experimental group and the control group on general characteristics, knowledge of ECMO nursing, confidence, and clinical reasoning capability before the VR program and lectures, and a post-test was also performed with both groups on the knowledge of ECMO nursing, confidence, clinical reasoning capability, learning immersion and learning satisfaction after the VR program and lectures. The participants were subjected to another post-survey after two weeks.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eKnowledge of ECMO nursing\u003c/h2\u003e \u003cp\u003eIn this study, a tool comprising 15 questions based on the literature was developed by the researchers to test the knowledge of ECMO nursing. It was validated by two nursing professors with experience in teaching critical care nursing courses or working in ICUs, and three nurses with more than five years of ICU experience. Each question was scored as 0 points for a wrong answer and 1 point for a correct answer, and a higher score meant a higher degree of knowledge related to ECMO nursing.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eConfidence in ECMO nursing\u003c/h2\u003e \u003cp\u003eThe confidence in ECMO nursing was evaluated on the basis of a five-point scale using the two questions proposed by Thomas, Chung, and Holt [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], in which a higher score indicated a higher degree of confidence in ECMO nursing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinical reasoning capability\u003c/h2\u003e \u003cp\u003eThis study used the evaluation tool developed by Liou and his colleagues [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] for clinical reasoning capability. The Korean version was verified by Han \u0026amp; Jeong [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which was composed of 15 questions (5-point scale), and a higher score meant a higher degree of clinical reasoning capacity. In the study by Liou et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], the reliability of the tool was found with Cronbach's α\u0026thinsp;=\u0026thinsp;.94, whereas the study of Han and Jeong [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] showed Cronbach's α\u0026thinsp;=\u0026thinsp;.93. Cronbach's α in this study was .97.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLearning immersion\u003c/h2\u003e \u003cp\u003eTo measure nursing students\u0026rsquo; immersion in learning, we used the 10-question 5-point Likert flow short scale, developed by Engeser and Rheinberg [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and validated by Yoo [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] through translation and reverse translation into Korean. A higher score meant a higher level of learning immersion. Cronbach\u0026rsquo;s α was 0.92 at the time of development [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and 0.84 in Yoo\u0026rsquo;s [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] study. Cronbach\u0026rsquo;s α in this study was .92.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLearning satisfaction\u003c/h2\u003e \u003cp\u003eIn this study, learning satisfaction was measured by NRS (numeral rating scale) with scoring 10 points for \u0026ldquo;very satisfied\u0026rdquo; and 0 points for \u0026ldquo;very dissatisfied,\u0026rdquo; in which a higher score meant a higher degree of satisfaction with learning.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eData collection and analysis\u003c/h2\u003e \u003cp\u003eIn consideration of COVID-19, the research team members trained in a state of daily quarantine met one-on-one with the study participants to explain the purpose and method of the research, and conducted the study. The data were analyzed using SPSS / WIN/23.0 (SPSS Data Solution. co), and the Shapiro-Wilk test was performed to test for normality on variables before program application. The general characteristics of participants and pre-homogeneity tests for variables were performed with the Chi-squared test, Fisher\u0026rsquo;s exact test, and t-test. After the intervention, a two-way repeated measures analysis of variance was performed to determine the effect on the variables including knowledge of ECMO nursing, confidence, and clinical reasoning capability in the experimental and control groups. Learning immersion and learning satisfaction were tested by independent t-test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003eHomogeneity test of subjects for general characteristics\u003c/h2\u003e\n \u003cp\u003eThe majority of the participants comprised 55 females (93.3%), with an average age of 23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 years. A total of 14 (21.2%) participants had a religion while 52 (78.8%) had none. As for satisfaction with clinical practicum, 46 participants (69.7%) were \u0026ldquo;satisfied,\u0026rdquo; 18 (27.3%) were \u0026ldquo;average,\u0026rdquo; and 2 (3.0%) were \u0026ldquo;dissatisfied.\u0026rdquo; As for satisfaction with their majors, 45 participants (68.2%) were \u0026ldquo;satisfied\u0026rdquo; and 21 (31.8%) were \u0026ldquo;below average.\u0026rdquo; As for their satisfaction with school life, 45 participants (68.2 percent) were \u0026ldquo;satisfied\u0026rdquo; and 21 (31.8 percent) were \u0026ldquo;below average.\u0026rdquo; As for experience with ECMO education, 61 participants (92.4%) had experience, whereas 5 (7.6%) had no ECMO training experience. The students with ECMO training experience were surveyed about their training methods, and the following results were found: 46 (74.2%) had a lecture, 14 (22.6%) were from clinical practicum, and 2 (3.2%) were by simulation. No factors showed a statistically significant difference in the homogeneity test between the intervention and control groups according to general characteristics (Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u003cbr\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1700689741.png\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003eTests for normality and homogeneity of the pre-dependent variables\u003c/h2\u003e\n \u003cp\u003eIn this study, the pre-dependent variables including the knowledge and confidence in ECMO nursing and clinical reasoning capacity secured normality and homogeneity in both groups (Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1700688940.png\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\"\u003e\n \u003ch2\u003eVerification of the effectiveness of the VR simulation program for ECMO nursing\u003c/h2\u003e\n \u003cdiv id=\"Sec22\"\u003e\n \u003ch2\u003eKnowledge of ECMO nursing\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;There would be differences in the knowledge of ECMO nursing between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was tested. The main effect found between the time points was that both the experimental group (F\u0026thinsp;=\u0026thinsp;34.81, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the control group (F\u0026thinsp;=\u0026thinsp;29.47, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) significantly increased their knowledge of ECMO nursing. However, there was no statistically significant difference among the pre-test (F = -1.320, p\u0026thinsp;=\u0026thinsp;.192), post-test 1 (F\u0026thinsp;=\u0026thinsp;.723, p\u0026thinsp;=\u0026thinsp;.472), and post-test 2 (F\u0026thinsp;=\u0026thinsp;.107, p\u0026thinsp;=\u0026thinsp;.915) in both the experimental and control groups. The effect of interaction between the group and the time point (F\u0026thinsp;=\u0026thinsp;1.41, p\u0026thinsp;=\u0026thinsp;.251) was also not statistically significant; thus, the first hypothesis was rejected (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1700689683.png\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\"\u003e\n \u003ch2\u003eConfidence in ECMO nursing\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;There would be differences in the confidence in ECMO nursing between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was tested. The main effect identified between the time points was that both the experimental group (F\u0026thinsp;=\u0026thinsp;65.48, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the control group (F\u0026thinsp;=\u0026thinsp;60.56, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) significantly increased their confidence in ECMO nursing. However, there was no statistically significant difference in the main effect among the time points (pre-test: F\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.607, p\u0026thinsp;=\u0026thinsp;.546; post-test 1: F\u0026thinsp;=\u0026thinsp;.766, p\u0026thinsp;=\u0026thinsp;.446; and post-test 2: F\u0026thinsp;=\u0026thinsp;1.182, p\u0026thinsp;=\u0026thinsp;.242) in both the experimental and control groups. The effect of interaction between the group and the time point (F\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;.144) was also not statistically significant; thus, the second hypothesis was also rejected (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\"\u003e\n \u003ch2\u003eClinical reasoning capability\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;There would be differences in ECMO nursing-related clinical reasoning capacity between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was tested. The main effect identified between the time points was that both the experimental group (F\u0026thinsp;=\u0026thinsp;91.67, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the control group (F\u0026thinsp;=\u0026thinsp;66.03, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) significantly increased their clinical reasoning capability in ECMO nursing. However, there was no statistically significant difference in the main effect among the time points (pre-test: F\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.711, p\u0026thinsp;=\u0026thinsp;.479; post-test 1: F\u0026thinsp;=\u0026thinsp;.799, p\u0026thinsp;=\u0026thinsp;.427; and post-test 2: F\u0026thinsp;=\u0026thinsp;.986, p\u0026thinsp;=\u0026thinsp;.328) in both the experimental and control groups. The effect of interaction between the group and the time point (F\u0026thinsp;=\u0026thinsp;2.85, p\u0026thinsp;=\u0026thinsp;.061) was also not statistically significant; thus, the third hypothesis was rejected (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv id=\"Sec25\"\u003e\n \u003ch2\u003eLearning immersion\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;There would be differences in learning immersion between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was tested, and the learning immersion of the experimental group was found to be statistically significantly higher than that of the control group (t\u0026thinsp;=\u0026thinsp;3.97, p\u0026thinsp;\u0026lt;\u0026thinsp;.001); thus, the fourth hypothesis was accepted.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\"\u003e\n \u003ch2\u003eLearning satisfaction\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 5\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;There would be differences in learning satisfaction between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was tested, and the learning immersion of the experimental group was found to be statistically significantly higher than that of the control group (t\u0026thinsp;=\u0026thinsp;4.25, p\u0026thinsp;\u0026lt;\u0026thinsp;.001); thus, the fifth hypothesis was accepted.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to improve nursing students\u0026rsquo; ability to care for critically ill patients through ECMO nursing VR learning in the pandemic situation resulting from infectious diseases such as COVID-19. The implications for the program\u0026rsquo;s effectiveness are as follows:\u003c/p\u003e \u003cp\u003eFirst, the hypothesis that \"There would be differences in the knowledge of ECMO nursing between the intervention group applying the ECMO nursing VR simulation program and the control group\" was rejected. This result is similar to the study [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] in which four hospitals in the United States applied a screen-based pediatric ECMO simulation training program to medical professionals. Regarding the knowledge of mechanical ventilation nursing in the intervention group, which applied the mechanical ventilation nursing simulation program using VR in South Korea, and the control group, there was no significant difference in the interaction effect between the group and the time point [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, the results were inconsistent in a study [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] in Taiwan that showed that the experimental group had higher knowledge than the control group after providing nursing students with educational materials related to chemotherapy administration using VR. As such, the effect on knowledge is not consistent in relation to simulation practice. It seems that the subjects tended to consider VR simulations as an opportunity to apply and combine existing knowledge rather than increase their knowledge by operating it for a long time because VR simulations with goggles have various difficulties in using the device. It was speculated that there was no significant difference, as this study also measured the basic knowledge of ECMO related to the scenario rather than a newly learned specific one. As simulation-based education is based on an integrated use of knowledge while participating in the process of solving problems in a given situation, it seems that there should be a limitation in measuring the effectiveness of education by measuring knowledge through simple questions. In addition, the knowledge measurement tool in this study was intended to simply measure if the subjects had correct or wrong knowledge, which might be unable to detect significant differences in the knowledge level between the experimental and the control groups. Several previous studies that trained medical staff on ECMO simulation and evaluated their performance have shown the effects on performance [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Thus, future studies should verify the effectiveness of the ECMO nursing VR simulation program using tools evaluating empirical knowledge and nursing performance skills.\u003c/p\u003e \u003cp\u003eSecond, the hypothesis, \"There would be differences in ECMO nursing-related confidence between the intervention group applying the ECMO nursing VR simulation program and the control group\" was rejected. This result was similar to the study [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] that applied the screen-based pediatric ECMO simulation training program, in which there was no statistically significant difference in self-efficacy. A study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] that developed High-fidelity Extracorporeal Membrane Oxygenation Simulation in the UK reported that ECMO simulation allowed students to learn skills in an interactive environment without harming real patients, while giving them confidence. However, when analyzing the confidence score data in this study, the mean confidence of the experimental group increased from 6.30 in the prescore to 13.61, while the control group\u0026rsquo;s confidence increased from 6.94 to 12.61, which was not statistically significant though the difference in confidence increase in the experimental group appeared to be greater than that of the control group. These results suggest that, since ECMO is a difficult topic to understand in a short time period [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], it would be difficult to improve confidence with a single training as shown in this study. However, the ECMO VR simulation training developed in this study can be considered as a way to improve students\u0026rsquo; confidence in that it allows for the safe and planned implementation of ECMO-related training [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. It should be further studied to evaluate the improvement of confidence again through the iterative applications of the program in the future.\u003c/p\u003e \u003cp\u003eThird, the hypothesis that \"There would be differences in ECMO nursing-related clinical reasoning capacity between the intervention group applying the ECMO nursing VR simulation program and the control group\" was rejected. This was contrary to the results of a study in South Korea, in which a simulation program using VR for nursing students was effective in clinical reasoning capabilities [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Clinical reasoning capability is a thought process for gathering and analyzing patient information, assessing the importance of analyzed information, and determining alternative behaviors [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Since simulation-based training is expected to enhance clinical reasoning capability in that it provides an opportunity for nursing students and nurses to develop and maintain technical proficiency in high-risk, rare events without the fear of harming the patients [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Nonetheless, clinical reasoning capability does not improve in a short period, which seems to be the reason why there was no significant difference between the experimental and control groups. However, previous studies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] suggested that a program to educate medical staff using various simulation methods on all aspects related to ECMO is needed to improve the ability of medical staff to treat patients with ECMO. Likewise, if nursing students repetitively practiced various clinical situations using the ECMO nursing VR simulation program developed in this study, it would help them improve their clinical reasoning capacity.\u003c/p\u003e \u003cp\u003eFourth, the hypothesis that \u0026ldquo;There would be differences in learning immersion between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was accepted, which is consistent with the results of the study [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] that the motivation to learn increased after applying the education program using VR. Due to the current COVID-19 pandemic, the demand for ECMO is unprecedented and its management is highly complex; however, nursing students have found it difficult to acquire the relevant skills [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The ECMO nursing VR simulation program developed in this study extends from traditional instructor-led learning methods to real-world clinical experiences that are rarely encountered, and we believe such experiences can be an effective way to improve nursing students\u0026rsquo; learning immersion. In particular, the VR in this study used an HMD to seal the user\u0026rsquo;s audiovisual and other senses and used visual elements in the ICU and auditory elements such as the patient\u0026rsquo;s breathing sound and alarm, making the users feel as if they were in real virtual reality, which could ensure students\u0026rsquo; learning immersion. Therefore, the provision of various teaching methods, including VR teaching methods, to help nursing students in their education, and to find ways to improve their immersion in learning are necessary.\u003c/p\u003e \u003cp\u003eFifth, the hypothesis that \u0026ldquo;There would be differences in learning satisfaction between the intervention group applying the ECMO nursing VR simulation program and the control group\u0026rdquo; was accepted. This is consistent with the study results [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], in which the experimental group had higher learning satisfaction than the control group in the mechanically ventilated nursing VR simulation program performed for nursing students in South Korea [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and the HFS ECMO nursing training program for ICU nurses in France resulted in satisfaction from 95.2% of participants [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This is because the educational program developed in this study considered the learning needs of the subjects, and tried to maximize the educational element by realistically implementing scenarios and clinical situations with clinical and educational validity in VR. In addition, this result seemed to be due to the characteristics of the learning method, because the immersive VR simulation uses digital devices to learn in a situation completely different from reality, making it highly immersive and distinct from reality, which might have induced the learning interest and confidence enhancement in students [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. High satisfaction with simulation education can improve learners\u0026rsquo; internal motivation and, consequently, clinical performance [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]; thus, the program developed in this study is expected to be able to enhance students\u0026rsquo; competence.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study is an equivalent control pre-test and post-test design study, which developed a VR simulation program for ECMO nursing by applying the stages of the ADDIE model and determined the effects on ECMO nursing knowledge, confidence, clinical reasoning capability, learning immersion, and learning satisfaction in fourth-year nursing students. The ECMO nursing VR simulation program developed in this study was found to increase learning immersion and learning satisfaction in nursing students.\u003c/p\u003e \u003cp\u003eECMO education is a challenging issue in nursing education because of its unique nature of complex, high-risk, and low-frequency clinical activities that require dynamic decisions. If ECMO education is implemented with VR simulation education, students can learn in a safe clinical environment implemented in a virtual space compared to lecture-based learning methods, without being affected by time and place compared to HPS-based simulation. Therefore, the result is expected to be more effective if the ECMO nursing VR simulation program developed in this study is used together with the lecture in the classroom and HPS simulation. However, this study applied the VR simulation training program to the students only once, while the learning object of ECMO cannot be acquired in a short time period. The advantage of the VR simulation program is that it allows repeated practices; so, a future study should investigate the effect of an increased number of simulation training and its mid- to long-term intervention effects in a longitudinal study design.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADDIE: analysis, design, development, implement, and evaluation; COVID-19: Coronavirus Disease of 2019; ECLS: extracorporeal life support; ECMO: extracorporeal membrane oxygenation; VR: virtual reality\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted from review by the Kyunghee University Institutional Review Board (KHSIRB-22-018(NA)).\u0026nbsp;Informed written consent to participate was obtained from all students. Students participated in the study voluntarily. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants to publish the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work has supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT; NRF-2020R1F1A1074448).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors conceptualized the study. Han, Jeong-won, Lee, Hanna, Min, Soyon, Park, Junhee \u0026amp; Park, Jihey participated in data collection, analysis, interpretation of data and drafted the manuscript; All authors participated in interpretation of results. All authors have critically reviewed the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the students at nursing college for their participation in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eMaliszewska M, Mattoo A, Van Der Mensbrugghe D. The potential impact of COVID-19 on GDP and trade: A preliminary assessment. World Bank policy research working paper 2020(9211).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Seoul: Sungshin University; 2016.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAlsalemi A, Tanaka L, Ogino M, Disi MA, Alhomsi Y, Bensaali F, Alinier G. A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation. Perfusion. 2020;35(2):110\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLee HN, Han JW. Development and evaluation of a virtual reality mechanical ventilation education program for nursing students. BMC medical education.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChan H, Chang H, Huang T. Virtual reality teaching in chemotherapy administration: Randomised controlled trial. J Clin Nurs. 2021;30(13\u0026ndash;14):1874\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLansdowne W, Machin D, Grant DJ. Development of the orpheus perfusion simulator for use in high-fidelity extracorporeal membrane oxygenation simulation. 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Qatar Medical Journal. 2017;2017(1-Extracorporeal Life Support Organisation of the South and West Asia Chap. 2017 Conference Proceedings):7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLange A, Koch J, Beck A, Neugebauer T, Watzema F, Wrona KJ, et al. Learning with virtual reality in nursing education: qualitative interview study among nursing students using the unified theory of acceptance and use of technology model. JMIR Nurs. 2020;3(1):e20249.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBanjas N, Hopf H, Hanisch E, Friedrichson B, Fichte J, Buia A. ECMO-treatment in patients with acute lung failure, cardiogenic, and septic shock: mortality and ECMO-learning curve over a 6-year period. J Intensive Care. 2018;6(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMerchant Z, Goetz ET, Cifuentes L, Keeney-Kennicutt W, Davis TJ. Effectiveness of virtual reality-based instruction on students\u0026apos; learning outcomes in K-12 and higher education: A meta-analysis. Comput Educ. 2014;70:29\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCook NF, McAloon T, O\u0026apos;Neill P, Beggs R. Impact of a web based interactive simulation.\u0026nbsp;\u003cspan\u003egame (PULSE). on nursing students\u0026apos; experience and performance in life support training\u0026mdash;A pilot study. Nurse Educ Today. 2012;32(6):714\u0026ndash;20.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"clinical reasoning, education, nurse, simulation, student, knowledge, extracorporeal membrane oxygenation","lastPublishedDoi":"10.21203/rs.3.rs-3588375/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3588375/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aims to improve nursing students\u0026rsquo; ability to care for critically ill patients through education in extracorporeal membrane oxygenation (ECMO) nursing.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study developed a virtual reality (VR) simulation program for the five-step ECMO nursing of the Analysis, Design, Development, Implement, and Evaluation (ADDIE) model and used an equivalent control group pre-test and post-test no-synchronized design to verify the effect. The participants of this study were fourth-year nursing students enrolled in nursing departments at three universities in Seoul, Gangwon, and Gyeonggi in South Korea; it included 66 participants, 33 in each of the experimental and control groups. The program consisted of pre-training, orientation, VR simulation, and debriefing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe interaction effect of the intervention and control groups with time points using the ECMO nursing VR simulation program was rejected due to no statistically significant difference in knowledge (F\u0026thinsp;=\u0026thinsp;1.41, p\u0026thinsp;=\u0026thinsp;.251), confidence (F\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;.144), and clinical reasoning capacity (F\u0026thinsp;=\u0026thinsp;2.85, p\u0026thinsp;=\u0026thinsp;.061). However, learning immersion (t\u0026thinsp;=\u0026thinsp;3.97, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and learning satisfaction (t\u0026thinsp;=\u0026thinsp;4.25, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) were statistically significantly higher in the experimental group than in the control group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eVR simulation program for ECMO nursing developed in this study is a potential educational method that positively affects the learning immersion and learning satisfaction of nursing students. This will also be an effective way to improve the performance of nursing students in ECMO nursing.\u003c/p\u003e","manuscriptTitle":"Development and evaluation of extracorporeal membrane oxygenation nursing education program for nursing students using virtual reality ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-24 00:15:12","doi":"10.21203/rs.3.rs-3588375/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-12-12T06:32:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-12-06T04:53:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2b77b55c-439a-4548-a598-7dcda3baa950","date":"2023-12-03T01:06:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-12-01T18:07:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-01T17:41:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-11-21T07:48:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-11-21T07:47:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2023-11-10T04:12:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3928cf13-d570-4569-bc6a-132a66da32ac","owner":[],"postedDate":"November 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-29T15:25:44+00:00","versionOfRecord":{"articleIdentity":"rs-3588375","link":"https://doi.org/10.1186/s12909-024-05057-2","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-01-26 15:17:32","publishedOnDateReadable":"January 26th, 2024"},"versionCreatedAt":"2023-11-24 00:15:12","video":"","vorDoi":"10.1186/s12909-024-05057-2","vorDoiUrl":"https://doi.org/10.1186/s12909-024-05057-2","workflowStages":[]},"version":"v1","identity":"rs-3588375","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3588375","identity":"rs-3588375","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}