Being a nurse is rewarding, but the profession often involves challenging and demanding emotional experiences. On a daily basis, nurses encounter stressful situations of human suffering and pain that may trigger a variety of intense emotions.1 Nevertheless, nurses are socially expected to present a public image that is empathetic, caring, compassionate, and considerate and to manage their emotions. They are required to suppress and control unpleasant emotions such as anger, distress, fear, and frustration. This can be demanding and involves tremendous emotional effort.2 Smith,3 drawing on Hochschild's4 theory of emotion management, highlighted the cost of emotional involvement in human caring through the experiences of nursing students who struggle to suppress their emotions when caring for a dying child. Indeed, much of the research has shown that nursing students, as well as students from other health care professions, experience significant challenges in managing their own and others' emotions in clinical practice.5,6
According to Hochschild,4 who coined the term “emotion management” in her seminal work, when an experienced emotion is incompatible with a socially expected emotion, emotion work is conducted by deep or surface acting. Hochschild4 described deep acting as a type of emotion work that suppresses or evokes emotions that are appropriate or expected for the situation. For example, an expressive technique involves expressive gestures such as smiling to evoke the expected feeling of happiness; a physical technique works by regulating bodily sensations such as taking slow deep breaths to generate a more relaxed state; and a cognitive technique consists of actively altering thought processes to focus on a more appropriate emotion for the situation. Conversely, surface acting is simply appropriating a facade that is expected for the situation.7 Having realized that successful emotion management plays a central part in patients' healing process as well as being key to nurses' job satisfaction,1 the nature of emotion work should be studied further. This includes ensuring that nursing students, as part of their education, are supported and prepared with various strategies for emotion management in the clinical environment. Simulations, specifically virtual reality (VR) simulations, are ideally suited for this because they can provide a safe platform for students to reveal their own emotional tension and to acquire coping strategies.
Simulations provide a safe environment for students to learn new knowledge and skills. Much evidence shows that incorporation of simulations in nursing education helps students achieve learning objectives, increases their self-confidence, fosters clinical decision-making processes, and improves learning outcomes related to patient safety.8–10 As a result, simulations currently have a critical role in nursing education.11 The current study addresses VR-based simulations that are being increasingly adopted in nursing education12 in terms of emotional and cognitive learning.
VR is a computer-generated environment to model and simulate an artificial 3-dimensional (3D) visual experience and interaction. It supports an engaging illusion of being part of a simulated world where individuals are self-represented as avatars. VR is a responsive platform in which participants can maneuver the 3D representations of a physical location or of an occurrence, which, in turn, supports the sensation of being immersed in a real world.13 Such 3D VR simulations allow participants to experience a dynamic environment while being actively engaged in manipulating and obtaining information, thus providing educational designers the ability to facilitate constructivist learning experiences.14 VR-based simulations create a psychological sensory experience and illusion of being within the artificially created world as if it was a real place.15 This evokes the feeling of being there or a sense of presence.16
VR-based environments can be divided into 2 main categories, high-immersive and low-immersive VR. To provide a high-immersive experience, peripheral equipment such as headsets and controllers are often used to give an up close responsive high-fidelity display and sound is delivered through earphones. This allows users to visualize and feel mentally integrated into a virtual environment during which the awareness of time and the real world becomes disconnected. Conversely, low-immersive VR is based on lower immersion devices such as computer screens with interactions via a mouse, keyboard, or joystick, thus it is often called the desktop VR.17 Notably, studies show that learning with high-immersive environments is negatively associated with achievements, suggesting that high-immersive VR triggers higher levels of cognitive load.18,19 Consequently, the current study focused on learning with low-immersive desktop VR.
Because of the flexibility of the implementation afforded by asynchronous VR computer-based simulations, VR has been partly applied in K-12 educational settings and particularly in higher education.17 For example, VR technological advancements have been adopted by medical schools to teach and learn anatomy20 and surgery,21 showing clear learning benefits. In nursing, the educational incorporation of VR simulations is in its infancy and is mainly used to support the learning and training of procedures, skills, anatomy and physiology, as well as decision making in different clinical conditions.22–29 There is a general paucity of studies evaluating students' emotional experience when playing the role of a nurse in a VR hospital; hence, this study filled the gap by exploring students' emotional experiences and the emotional management involved.
The aims of this research were 3-fold: (1) to evaluate the impact of the perceived sense of presence while learning with VR on emotional experiences; (2) to reveal whether emotion work is triggered during emotional dissonance between perceived and expected emotions; and (3) to assess whether emotion work impacts knowledge acquisition outcomes.
Research Design and Participants
A prospective pretest-posttest design was employed. Undergraduate sophomore nursing students at an Israeli university were invited to participate in the study. The university's ethics committee approved the study.
The low-immersive desktop VR simulation was designed in a previous study.30 The simulation was designed to model a hospital ward with 2 main spaces (see Supplemental Digital Content, Figure 1, available at: https://links.lww.com/NE/B168). The first space represented the patient room, and the second space represented the medicine room with various medical equipment and medications. A student participant enters the VR simulated hospital ward as a nurse-avatar. First, the student is able to explore their avatar-body and become familiar with performing VR actions such as moving around, opening cabinets, lifting equipment, and reading charts. After this familiarization with the environment, the student is presented with clinical scenarios to support procedure training and development of clinical reasoning. During these clinical scenarios, which include different patients with different health conditions and medical orders, the student learns the medication administration guidelines via embedded interactive tutorial directions and videos and then applies knowledge by administering medications to the patient. During these steps, the VR technology provided individual feedback on the student's performance together with video directions.
Data Collection Instruments
Emotion Work Questionnaire
Based on the questionnaire devised by Furman et al2 on nurses' emotion work, the questionnaire used in this research included 3 subscales: (1) Experienced Emotions, (2) Expected Emotions, and (3) Emotion Work Strategies (see Supplemental Digital Content, Questionnaire, available at: https://links.lww.com/NE/B169). The Experienced Emotions subscale was originally taken from the Medical Emotion Scale31 used to measure emotions in medical studies. This part incorporated 7 positive and negative activating emotions. The participant rates their experienced emotions while playing the role of a nurse in the VR simulation on a Likert scale ranging from 1 (not at all) to 5 (to a great extent). The internal consistency, as determined by a Cronbach α, was high: α= 0.88 for negative emotions and α= 0.91 for positive emotions.
The Expected Emotions subscale included the same 7 emotions as in the Experienced Emotions scale. The participants rated the level of emotions they think that nursing educators and clinical instructors expected them to feel while playing the role of a nurse in the VR simulation, on a Likert scale ranging from 1 (not at all) to 5 (to a great extent). The internal consistency, as determined by a Cronbach α, was high: α= 0.84 for negative emotions and α= 0.85 for positive emotions.
The Emotion Work Strategies subscale included the strategies used for emotion work based on the questionnaire by Furman et al.2 The participants marked their level of agreement with each of 8 items referring to their emotional coping while playing the role of a nurse in the VR simulation, on a Likert scale ranging from 1 (not at all) to 4 (to a great extent). For example: “I bit my lip so as not to feel frustrated” as a physical strategy of emotion work, and “I reminded myself how important it is these days to use advanced technology in order to evoke a sense of pride” as a cognitive strategy. Two questions refer to cognitive strategies of emotion work, 2 to expressive strategies, 2 to physical strategies, and 2 to surface acting. The final score was obtained by averaging all the answers. The Cronbach α score was 0.88. The Emotion Work Questionnaire was administered immediately after learning with the VR simulation.
Medication Administration Test
The Medication Administration Test (MAT) evaluates students' understanding of medication administration procedures and clinical reasoning skills.30 The test is composed of 2 domains: (1) 8 items assess knowledge of basic medication administration procedures and (2) 5 items evaluate clinical decision-making capabilities related to medication administration procedures. For instance, students were asked to reason how they should respond if they are being asked to administer medication that was not prepared by them but by their nurse colleague who was urgently called to assist with resuscitation. The internal consistency, as determined by a Cronbach α, was good at α= 0.74. The MAT was administered twice: at the beginning of the semester (nearly 3 months before) and then immediately after learning with the VR simulation.
The Presence Questionnaire (PQ) was used to assess students' levels of presence while learning with VR. Witmer and Singer developed the PQ to estimate the degree to which the participant is “experiencing the computer-generated environment rather than the actual physical locale.”16(p225) The PQ incorporates 3 subscales: (1) Involved/Comparison (11 items) on the level of VR responsiveness to the initiated actions; (2) Natural (3 items) on the level to which the VR interactions felt natural; and (3) Interface Quality (3 items) on the quality of the interface. The internal consistency, Cronbach α= 0.88, was comparable with a previous report.16 The PQ was administered immediately after learning with the VR simulation.
This questionnaire gathered personal data such as gender, age, and ethnicity.
Responses to items in the MAT were calculated as a proportion of all correct responses. Descriptive statistics (mean, SD) compared using t tests were applied to analyze the pre- and postsimulation results, including the overall score for the subscales of medication administration Basic Procedures and Clinical Reasoning. Bivariate intercorrelations were calculated to assess the association between emotional dissonance, emotion work strategies, and learning scores. The analysis was conducted with SPSS software (version 25; IBM Corporation, Armonk, New York).
Overall, 75 students completed the study's pre- and posttest analyses. The majority of the participants were female (91%), and the mean age of the study sample was 22.5 ± 1.9 years.
To evaluate the participants' experienced emotions while learning with the VR simulation, they rated the intensity and valence (the extent to which an emotion is positive or negative) of their experienced emotions (Table 1). The results showed that participants experienced significantly more positive emotions than negative emotions (3.69 ± 0.97 vs 1.69 ± 0.74, respectively; t = 14.79, P < .001). Curiosity was the most experienced and perceived expected emotion. Of the negative emotions, the most common experienced was frustration. In addition, participants reported a high sense of presence while playing the role of a nurse in the VR hospital. The 3 PQ subscales were Involved/Comparison (4.7 ± 1.0), Natural (4.7 ± 1.3), and Interface Quality (5.2 ± 1.4), comparable with the previous work of Witmer and Singer with immersive VR. Perceived sense of presence was positively correlated with positive experienced emotions (satisfaction: r = 0.233, P < .05; pride: r = 0.233, P < .05; curiosity: r = 0.345, P < .01; joy: r = 0.393, P < .01) and negatively correlated with negative emotions such as fear (r =−0.320, P < .01) and stress (r =−0.403, P < .001).
Table 1. -
Experienced, Expected Emotions and Emotional Dissonance While Playing the Role of a Nurse in Virtual Reality
Simulation (N = 75)
||Experienced Emotions, Mean ± SD
||Perceived Expected Emotions, Mean ± SD
||Emotional Dissonance,a Mean ± SD
|Paired t test
||Effect Size, Cohen's d
|Positive activating emotions
||3.53 ± 1.18
||4.33 ± 0.94
||0.80 ± 1.38
t = 5.00b
||3.36 ± 1.37
||4.16 ± 0.95
||0.80 ± 1.18
t = 5.84b
||4.00 ± 0.96
||4.53 ± 0.70
||0.53 ± 0.90
t = 5.10b
||3.88 ± 1.03
||4.19 ± 0.96
||0.30 ± 0.98
t = 2.69c
|Negative activating emotions
||2.17 ± 1.39
||1.95 ± 1.33
||−0.22 ± 0.87
||1.36 ± 0.81
||1.96 ± 1.44
||0.60 ± 1.25
t = 4.15b
||1.55 ± 0.84
||2.08 ± 1.07
||0.53 ± 1.17
t = 3.92b
aEmotional dissonance was computed for differences between perceived expected emotions and experienced emotions (expected – experienced).
bP < .001.
cP < .01.
dP < .05.
Emotional dissonance, which is the gap between the participants' expected and experienced emotions, was found. This was significantly greater for positive emotions than for negative emotions (F1,74 = 46.185, P < .001). Interestingly, for negative emotions, such as fear and stress, the experienced emotions were lower than expected, suggesting that students felt they were meeting the expectations. Consequently, the dissonance between positive expected emotions and expressed emotions was associated with higher levels of emotion work (see Supplemental Digital Content, Table, available at: https://links.lww.com/NE/B170), specifically for the cognitive deep acting (r = 0.301, P < .05) and surface acting (r = 0.260, P < .05). The cognitive deep acting strategy was the most common strategy used by the participants.
Medication Administration Test
The results of the MAT pre- and postsimulation, administered before and immediately after learning with VR, are presented in Table 2. Overall, the postsimulation MAT score was significantly higher than the presimulation score, with a large effect size. When analyzing the MAT subscales, the postsimulation score was significantly higher than the presimulation score only for the Clinical Reasoning subscale (81 ± 17 vs 49 ± 24), whereas for the Basic Procedures subscale the difference between pre- and postsimulation scores was not significant (Table 2). The surface acting emotion work strategy was negatively associated with participants' postsimulation MAT scores (r =−0.34, P < .05; see Supplemental Digital Content, Table, available at: https://links.lww.com/NE/B170).
Table 2. -
Comparisons Between Pre- and Postsimulation Scores on the Medication Administration Test (N = 75)a
||Pre, Mean ± SD
||Post, Mean ± SD
||Paired t Test
||66 ± 16
||82 ± 15
||77 ± 17
||82 ± 16
||49 ± 24
||81 ± 17
aData in percentages; range, 0-100.
bP < .001.
To ensure that nursing students have sufficient knowledge and can safely provide patient care upon graduation, nursing education is constantly embracing innovative teaching methods such as VR-based simulations.23 The findings of this study clearly show that VR-based simulation is beneficial for students' learning, particularly in acquiring clinical reasoning skills. Although knowledge of basic medication administration procedures remained relatively unchanged, the findings demonstrated a significant change in clinical reasoning knowledge posttest compared with pretest. Building on this finding, it can be suggested that being able to actively apply this knowledge in a meaningful VR simulation fostered higher-order thinking skills of clinical reasoning. This finding is supported by a recent neuroimaging study, which showed that learning with a VR simulation enhances critical thinking more than a video lecture or hands-on learning.32 Indeed, virtual learning simulations are designed not merely to replace or amplify real-world learning environments but rather the immersed experience activates and reinforces the cognitive system due to the multiple modes of visual-spatial representations.33
An important insight of this study related to the disclosure of students' emotions and emotional management strategies activated while learning with the VR simulation. The realistic experience of playing the role of a virtual nurse, supported by the students' perception of a high sense of presence, caused them to experience a variety of emotions. Specifically, the results show that higher levels of sense of presence were associated with higher levels of positive emotions, whereas lower levels of presence were associated with higher levels of negative emotions. There are studies in the research literature that support this finding concerning the relationship between the feeling of presence and one's emotional state34,35; however, the current study is the first, to our knowledge, to examine the emotion work involved. Namely, the study found that the emotional dissonance was stronger for positive emotions than for negative emotions and that a great deal of emotion work, specifically cognitive deep acting and surface acting, was required to bridge the emotional discrepancy.
We found that the surface acting strategy had a negative effect on participants' postsimulation knowledge achievements. Namely, the more participants used surface acting strategies, the lower their postsimulation knowledge scores. Previous studies have demonstrated the negative psychological consequences of surface acting, such as emotional exhaustion, burnout, and physical ill-health, among nurses and other health care professions.5,36,37 The current study thus adds to the existing body of research by suggesting the negative impact of surface acting on learning outcomes.
To characterize learning with VR simulations and related advantages or disadvantages, future studies should focus on various clinical scenarios beyond medication administration procedures, including the incorporation and evaluation of high-fidelity and standardized patient simulations.
Over the years, emotional processes and emotional dissonance have remained significant among health care providers. However, the ability to better prepare nursing students for clinical practice by supporting the training of management strategies has evolved. The current study extends Hochschild's emotion management theory to suggest that emotion work techniques can be accomplished in a safe VR-based simulated environment. As we have discussed, the present study illustrates that simulation-based learning can activate emotions to reveal students' management strategies. This suggests that simulations such as VR can serve as a platform for preparing nursing students for clinical practice, both cognitively by fostering learning and knowledge acquisition and emotionally by recognizing and then refining students' emotion management strategies.
When students play the role of a nurse in a virtual hospital to practice and learn clinical procedures, educators can leverage this opportunity to recognize and discuss the emotion work required in the nursing profession. This includes building students' awareness of their own emotions, legitimizing the sharing of emotions, and allowing them to learn from each other how to overcome negative emotions and how to deal with them by using management strategies. All these learning experiences, followed by the training of deep acting, may contribute to nursing students' learning achievements and further effectively prepare them for the emotional demands involved in relating to patients, families, and colleagues. Until now, emotion work has been learned on the job in the process of working in the clinical environment37; the current study suggests that students can be taught emotion work techniques as part of their studies in a safe simulated environment.
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