Keywords

1 Introduction

The development of new technologies has become more apparent over the last decade, especially with the development of mobile platforms (laptops, tablets, mobile phones), all of which connect to the Internet. How and whether technology improves learning are two big questions and the source of much debate. In this chapter, the authors will look at how the use of 360-degree videos, viewed through head-mounted displays (virtual reality headsets or HMDs), can become supplements to high-fidelity simulations using similar pedagogy. The role of 360-degree video in education is not yet clearly identified and understood, as little research has been done on this topic [1].

Since the introduction of the blackboard within education in the early eighteenth century, the development of technologies used in education has been many: overhead projectors, whiteboards, computers, and tablets, to mention a few. People more generally are faced with new opportunities that enable us to interact with anyone anywhere in the world, at any time; we can access any information through the touch of a button. These changes have occurred rapidly and affect how teaching and learning is viewed. How has this affected learning? The students themselves are now able to access information traditionally provided by the instructor and textbooks [2].

A bachelor’s degree in nursing must change in-step with new knowledge and new methods of learning. Students in the future may not have the same relationship to books as the previous generation but will perhaps have acquired other methods of gaining knowledge. Students now have a world of knowledge literally at the tip of their fingers and face the challenge of filtering the information to determine what is accurate. Teachers today aim to develop new didactical methods where students can focus on interpersonal interactions, especially in meetings with patients where they can practice professional relationship skills [3]. It is in encounters with patients that relational skills become evident. The authors believe that videos showing relevant scenarios in a 360-degree video format will be beneficial for students preparing for the clinical setting. Practice in mental health work can challenge students, as the practice brings with it new situations and unknown human encounters, which are often in combination with misguided assumptions about mental health issues [4].

Using VR technology in healthcare training is an important supplement when creating training and simulation programs [5]. It has become common in recent years to use 360-degree videos when creating relevant clinical settings and training. Themes with challenging topics such as suicide assessment, managing violence and threats, and the opportunities to train in demanding interpersonal situations are limited in healthcare simulation training [6]. Research in the field suggests that if we are affected emotionally, we learn better. With VR glasses, senses and emotions are activated, enabling students to learn in a completely different way than by reading or listening to a lecture [7]. Nursing requires creativity and a good ability for clinical decision-making processes. To practice this, playfulness can give students motivation and the opportunity to promote learning. 360-Degree video can be seen as a playful way to learn from new situations. “Play” in particular has the ability to unite imagination and intellect in that it acts as a tool for students to discover things at their own pace and in their own way [8]. Playful learning increases the levels of oxytocin, engages the students emotionally, and gives them a creative experience [9].

2 Technical Aspects of 360-Degree Video in Education

Virtual reality as a concept has acquired distinct meanings. The history began long before computers and modern technologies were invented. In the 1930s, the term “virtual reality” was first used by the French writer and philosopher Antonin Artaud in his book The Theatre and Its Double [10] when he tried to construct the illusion of being in other spaces [11]. The American inventor and film enthusiast Morton Heilig is perhaps the best known of these VR experimenters. He experimented with a project called multisensory theatre. In this performance, he used three-dimensional images imposed on physical facilities such as smell, wind, and movement. In 1962, he built a prototype of his vision called Sensorama Simulator [12]. In modern times, Heilig has been called the father of virtual reality (VR) technology. A few years later, in 1965, Ivan Sutherland and his students Danny Cohen, among others, constructed the first device that could be placed on the head, the head-mounted display (HMD), with head-tracking and stereoscopic glasses. The surroundings were updated in the glasses that also took into account the head position and direction [1].

Up until the 2000s, new phones and boards with higher resolution and motion detection were produced, as well as new types of headsets that made it possible to participate in simulations through VR headsets. This complete presence is often described as an immersive state [13]. Over the past 20 years, VR technology has been further developed in computer games, cars, and flight simulator training programs. In the mid-2010s and beyond, VR became more recognized as technology in educational research environments as well as in industry, military, and architecture. The concept of immersive learning was introduced and became more accessible with a new stand-alone headset in 2013. Within VR simulation, as in regular healthcare simulation with technical skills training on procedures, it is of great importance that the training takes place in a physical safe environment to prevent injury [14]. Over time, programmes have been developed to train technical skills (TS) on procedures in healthcare and in industrial enterprises. Immersive VR simulation with HMDs has been used since the early 2000s [13]. Today, VR technology has reached a point of technological maturity that makes it more accessible for both the consumer market and educational institutions [15].

Videos tell their stories through an established language of cinema, using certain cues that the audience interprets [16]. However, 360-degree video is a relatively new experience to most people; only about 19% of US adults had tried VR in 2020 [15]. This means that the language of storytelling is not as established in this medium, and this must be considered when designing the 360-degree video. In a non-360-degree video, the director has full control of the audience’s attention: where they should focus and how they should experience the story being told. This is not the case with 360-degree videos as the user is in control of what they view in every moment. Creators need to design an engaging clinical situation where the student is guided, through visual and auditorial cues, to focus on the most relevant elements in order to learn [17].

Another aspect of student lack of experience with VR is the technical threshold that the HMDs present. The student will have a reduced experience if they do not know how to adjust them to their needs, for example, by adjusting the straps, volume, and focus. The technical frustration will be lessened with time as more students test them out and learn how to get the most out of them [18], but for now, ample time to introduce and explain the equipment to new users is recommended.

A great benefit to 360-degree video is the possibility of centralized distribution of produced content. Each produced simulation can be digitally distributed to any HMD. The more students that can use the same 360-degree video, the less the median cost of each produced experience. This allows institutions to work together on development and production and then share the final product. Maintenance on VR labs with self-contained HMDs involves keeping the HMD operational and replacing erroneous units.

3 Research on Virtual Reality and 360-Degree Video

VR for educational purposes has been researched for decades [12], with many compelling findings. The research on 360-degree video in education, however, seems to still be in an early exploratory phase [1], perhaps owing to only-recently dropping costs for the necessary technology. In this section, we will briefly discuss some findings of research on both topics to explore how the use of 360-degree video might benefit nursing simulation.

First, a note on the technical differences between 360-degree video and VR. Whereas VR puts the viewer in a virtual 3D-modeled environment, the environment of a 360-degree video is pre-recorded using a special camera that films in every direction. This means that the viewer can look around freely as in other VR experiences, but movement is limited because the camera only records from one position at a time, and interaction is limited because the environment is pre-recorded. Even so, 360-degree video is often referred to as VR [12], and some of the possible experiences of VR can be achieved using 360-degree video.

When researchers discuss the benefits of VR, they often highlight its ability to make the participant feel as if she is really present in a situation, the illusion of “presence,” rather than viewing the situation as a distanced observer [12]. This effect is apparent in many different VR experiments. For example, participants have been shown to feel pain and discomfort when their virtual body is subjected to certain stimuli [19], participants react to virtual characters with the same social instincts for personal distance as if they were real people [13] and, perhaps most importantly, participants themselves often report an experience of virtual presence [12].

This effect has been utilized in different ways that might prove useful for nursing simulation. Pan and Slater (2011) used VR to simulate ethical dilemmas and found that participants would sometimes respond differently to the dilemma after having experienced it virtually, rather than just as a theoretical problem [20]. Kleinsmith et al. found that VR could be used as empathy training with virtual patients [21], and Cook et al. concludes that VR can “provide training and many different scenarios that will help [doctors] toward gaining experience” [14]. Virtual experiences have also been shown to reduce anxiety from real experiences, for example, in VR-based exposure therapy for people suffering from arachnophobia [22].

The experience of “presence” can also involve being in a different body, which opens up whole new avenues of possibilities. Peck et al. found that virtually inhabiting a black person’s body for only 12 min made white participants less racist [23]. Ahn et al. let participants with normal vision virtually experience different forms of colour blindness, leading to more helpful behaviour toward people with colour blindness as compared to a control group [24]. VR is a promising tool for learning goals that are concerned with empathy, experience, and ethics.

Some Korean universities tested VR specifically in nursing education as a safe alternative to clinical practice during the COVID-19 pandemic. They found that VR, in combination with traditional simulation, gave the best learning results and highlighted the importance of a framework of learning activities before and after the VR session [25].

But do these findings translate to the use of 360-degree video? As mentioned, these technologies have fundamental differences, as well as similarities. In a scoping review of the research on 360-degree video, Snelson and Hsu found that an experience of “presence” was common among participants in experiments involving 360-degree video [1]. Virtual exposure therapy has also proven successful using 360-degree video [26], hinting that exposure to stressful nursing-related situations in 360-degree video might lead to reduced stress in real clinical situations. Overall, Snelson and Hsu found mixed results for the learning benefits of 360-degree video but noted that “there is some indication that learning with 360-degree VR video might be more appropriate for certain types of learning such as promoting empathy, reflection, or skill-based knowledge as opposed to factual or conceptual knowledge” [1]. These types of learning are a good fit with the goals of nursing simulation.

4 Preparing for Psychiatric Nursing

Students who are preparing for practice within psychiatric nursing must be able to meet patients who are struggling with depression, extensive anxiety problems, psychoses, substance abuse disorders, and, potentially, an inability to self-care [27]. Nursing students must learn to deal with a field that is at times complex, which requires a dynamic approach. In the face of mental health work, one can see how health professionals become emotionally involved in patient’s difficulties. Interaction with the patients may trigger adverse interactions such as rejection, quarrelling, neglect, and opposition. In order to maintain a professional relationship, nursing students are required to accept, validate, and use communication skills to promote health [27]. Nursing students are taught various techniques for communication, such as active listening, and affirmative and exploratory skills. Practicing mentalization, seeing others from the inside and yourself from the outside, is one such method. Mentalization as a perspective is universal and can be used in many types of consultations with patients [5]. It is, however, difficult to prepare for the complex, unique, and delicate nature of each meeting, as each interaction involves complex, subtle verbal and nonverbal cues [28, 29]. Simulation is a pedagogical method that has been used to prepare students for patient interactions, which enables students to put already-acquired skills and knowledge to use in a setting that is as close to reality as possible. This provides students with valuable experience and knowledge into how their own reactions may influence their situational awareness [3, 4].

Students in nursing are trained in knowledge-based practice. This requires making assessments based on both research, experience, and promoting shared decisions, which requires unbiased assessment [30]. Students must be able to meet demanding clinical situations in a tactful way. It is an advantage if students have emotionally trained for this, which 360-degree video offers. Being able to identify where there is a lack of knowledge by mapping current knowledge is important. How these challenges are met and how capability and flexibility are shown to integrate new with existing knowledge are key prerequisites for knowledge advancement [31].

5 Why Is 360-Degree Video Suitable for Promoting Nursing Students’ Competence in Psychiatric Nursing?

The pedagogy of simulation aims to create a safe environment for reflection and learning, enabling the students to apply already acquired skills, knowledge, and values in a clinical setting. Simulation has traditionally been an arena where the student is able to combine technical skills and non-technical skills (communication, teamwork, decision-making, and critical thinking) [32,33,34]. Simulation utilizes a combination of pedagogy and technology to achieve the desired learning outcome, which is covered in other sections.

Skills training has been a part of nursing education since 1910 [34], when the first lifelike mannequin was developed for nurses to practice their clinical skills. It was a doll with no other functions, which can be defined as a low-fidelity simulator. Since then, the technology has made leaps. Today’s modern mannequins can give clinical signs and symptoms as well as talk. These mannequins are expensive and are regarded as high-fidelity simulators [32, 34].

Clinical simulation in a somatic setting has the unique ability to imitate real-life scenarios, as mannequins can give clinical signs and symptoms. Students act on the clinical signs and symptoms and get real-time feedback from their interventions. However, the nature of the psychiatric setting, where one or two nurses are faced with conversations of a delicate or volatile nature, makes it exceedingly difficult to use mannequins [3, 28]. Mannequins lack the ability to provide the complex nonverbal cues, such as facial expression, eye movement, and body posture, which are all important aspects in communication. The learning outcomes in simulations within the psychiatric setting might address how the nursing student or nurse applies specific mental health tools to assess for suicide risk, depression, or symptoms of other illnesses.

Nursing is a profession where skills, knowledge, and experience, combined with professional attitudes and values, play crucial parts. Nursing students need to make the journey form novice to clinician over a period of 3 years. Students must develop skills within the psychomotor, cognitive, and affective domain. The psychomotor and cognitive domains may be covered through several didactive methods such as PBL (problem-based learning) and TBL (team-based learning) [35, 36]. Although student active methods, like those mentioned above, address the psychomotor and cognitive domains, the affective domain “remains undiscovered country” [37]. The affective domain addresses the students’ perspectives, emotions, feelings, and attitudes that the student needs to be able to understand the motivation for action and inaction [38].

In the reality of clinical life, students are faced with the complexity of applying already-acquired clinical skills and knowledge in real-life situations. Although there is a growing body of research addressing student awareness of their own feelings, the challenge is how this is transferred to students [3]. Students who are preparing for clinical placements in the psychiatric setting need to be aware of the sensitive, unpredictable, and sometime volatile nature of this part of nursing. By experiencing certain scenarios, students may start to develop new awareness and a deeper understanding of how they may interact with the patients [33].

For simulations in the psychiatric setting, actors may be used to imitate a patient, which provides students with valuable interaction and experience. It does, however, require the actor to be provided with sufficient direction. The task of the actor is not to act for the students but with the students to such an extent that they are able to address the learning outcome. Some simulation centres employ trained actors, while others use other unskilled actors. If the actor overplays or is unable to understand the desired learning outcome, the whole simulation experience might be affected. Although the use of 360-degree video lacks the interaction that high-fidelity simulations have, it has the advantage that by using 360-degree video, the quality of the recording and the actor can be controlled giving a consistency to the learning outcomes. Few studies [3, 29] have been done on the use of 360-degree video in this type of setting, but this method has the possibility of creating a private room environment free from distractions. This method provides an opportunity to reflect openly and equally without concern for other participants, as the students have one common experience, though different perceptions. Furthermore, this differs from an experience on a flat screen, as the participant is immersed, but not by environmental distractions like other electronic devices, noise, light, and/or other factors [39].

The types of skills nurses need in the psychiatric clinic is complex and should not be reduced to communication skills. Anderson and colleagues have operationalized a set of facilitative interpersonal skills that are meaningful and useful [40]. These skills are used by helpers in various professions and are believed to motivate a person with emotional or mental difficulties to initiate change toward better emotional and mental health. The core of facilitating interpersonal skills can be defined by the fact that the helper, i.e. nurse, is able to capture, understand, and communicate a wide range of interpersonal messages to a person seeking help. The nurse can then convince the person seeking help to adopt proposed solutions to the problem and let go of more inappropriate coping strategies [40]. How one learns these skills is often based on both practical and theoretical knowledge. Mass training becomes possible with the use of 360-degree video, which constructs a form of experiential knowledge.

6 VR-360-Degree Model: “VR-SIMI Model”

VR-SIMI is a model used to describe a specific VR-training method for health professionals developed at the Centre for Simulation and Innovation at SIMInnlandet, Innlandet Hospital Trust in Norway [41]. The terms used at SIMInnlandet, to describe the specific stages of the method, are Briefing, E-Motion, and Debriefing as shown in Fig. 1.

Fig. 1
An illustration depicts three terms used at S I M Innlandet to describe the specific stages. It includes briefing (information learning outcomes), Emotion (360-degree experiences), and debriefing.

Three terms involved in the VR-SIMI model

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The VR-SIMI model combines pedagogical principles from medical simulation with the 360-degree VR scenarios, exposing and preparing health professionals for clinical situations in the psychiatric nursing setting, by training their ability to reflect on and learn from relevant situations. Figure 2 shows examples of situations that students can practice increasing their competence in psychiatric nursing. VR-SIMI involves embodied multimodal learning by offering theoretical knowledge, immersive 360-degree video experience, and reflection in the same exercise.

Fig. 2
A box depicts example situations in students' practice in mental health work. It reads about violence and threats, suicidal thoughts, and concerns about child welfare.

Examples of situations students can practice in preparation for practice in mental health work

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Psychological safety is based on trust and will help students reduce their interpersonal risk. This will promote certainty and a will to change in the next phase [42]. Psychological safety can be seen as a strategy which helps people overcome their defensiveness or learning anxiety. Schein argues that psychological safety allows people to focus on collective goals and problem prevention, rather than on self-protection. We can see this in the light of the use of 360-degree video as a tool that allows the students to be free without defence and self-focus [43].

E-motion describes the student viewing experience and refers to the feeling of “presence,” as discussed in the previous section [7].

6.1 Briefing

In VR-SIMI, psychological safety is of great importance for the training experience. The building blocks for a “safe room” are laid in the pre-simulation phase. In addition to establishing a flat group structure through the “sharing is caring” attitude, factors such as clarifying expectations, closeness to the collaborative exploration of the theoretical input and learning outcomes. The friendly fostering of diversity is important in VR-SIMI to ensure the psychological safety for the participants. Maintaining a psychologically and physically safe learning environment is crucial for the student experience. It is therefore important that the number of participants experiencing the scenario does not exceed ten students. This enables all students to actively participate in the debriefing and may reduce a fear of feeling exposed. In the pilot stages of the VR-SIMI experience, some students experience dizziness and nausea, which can result in students falling over. Students expressed feeling safer when sitting down in an office chair with arm rests equipped with a swiveling option (e.g. gaming chairs). The briefing phase ensures the theoretical and emotional warm-up through the presentation of the model, the technology, learning goals, and theory relevant to the learning goals. Furthermore, the participants are invited to share and contribute with their own knowledge and experience from their education and work as healthcare professionals.

6.2 E-Motion Phase: 360-Degree VR Experience

During this phase, students put on the HMDs, as can be seen in Picture 1. The facilitator conducts a “start-up ritual,” making sure equipment is ready. The facilitator then starts the scenario simultaneously on all HMDs. Though all students watch the same recording, the experience will depend on each participant’s personal and professional values, as well as lived experience. The subjective experience of each individual participant may therefore vary considerably, which creates the foundation for reflection and learning. The group takes this diversity of embodied experiences into the reflection phase. Ideally, the facilitator participates in the VR experience.

Picture 1
Four people sitting on chairs wearing V R glasses.

A VR simulation group carrying out the 360-degree VR experience viewed through head-mounted displays, in the E-Motion phase. (Photo: Marius Huse)

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6.3 Debriefing–Reflection Phase

In addition to opening to the participants’ bodily experiences, thoughts, and feelings related to the virtual scenario, the consideration of diversity among the participants is of importance. A variety of experiences and perspectives within the group after the same VR-scenario is of special interest. The facilitator encourages the students to be active participants throughout this phase, emphasizing the process of reflection, rather than right or wrong answers. The importance of the reflection process has been covered earlier in this book.

6.4 Exercises

The VR-SIMI model was used in a project called “VR-SIMI Acute” that included four exercises with playful learning in mind. The group members viewed the same VR-experience with the following frames:

  • Exercise 1: How does working with mental illness affect us? How do we embody other people’s suffering?

  • Exercise 2: Mentalization: How can we see ourselves from the outside?

  • Exercise 3: Mentalization: How can we see the patient from the inside? Which model of understanding do we use?

  • Exercise 4: “Change glasses”: Experience the virtual situation as a unit leader, a therapist, a chief physician, or a new employee, and use your new experience in the reflection.

In exercise 1, the staff work on the understanding of mental illness and how it affects them. This exercise challenges perceptions and aims to increase knowledge of student’s own understanding and awareness. In exercises 2 and 3, participants work on the theoretical perspective mentalization and how this can function as a good scenario for improving relations skills.

Mentalizing is the capacity to understand ourselves and others in terms of intentional mental states, such as feelings, desires, wishes, attitudes, and goals. It is a fundamental capacity in our social environment: Without this capacity, we would be completely lost in a world that is determined by complex and ever-changing interpersonal relationships that require a high degree of collaboration and mutual understanding [44, p. 366].

When students work to see themselves from the outside and others from the inside, relational competence will increase, especially through an increased awareness of how complicated but also important relational compassion is. Exercise 4 titled “Change Glasses” challenges perspectives on student’s own and others’ roles and aims to increase understanding for others in order to prevent misunderstandings.

6.5 Potential Clinical Situations: Suitable as Preparation for Clinical Practice

A nurse is committed to promoting hope and change in the case of creating health-promoting behaviours [45], among many relational skills, some of which are mentioned here in the chapter. How nursing students can pass on and create empathy in interactions with the patient is dependent on the nurses’ professional attitudes and clinical experience. A nursing student naturally lacks clinical experience and certain types of training that a nurse needs to and wants to practice. It is not unknown for nursing students to meet patients who have complex health challenges [30]. VR simulations are reflective of clinical situations in psychiatric nursing and give possibilities for practice.

7 Conclusions

By looking for new methods that can be used in educational institutions, we can elevate students’ perspective and activation so that learning is formed, especially learning that is needed for the specific fields in the clinic. The potential of 360-degree VR video gives flexibility to create systematic experiential learning as well as playful emotional learning in collaboration with students. This chapter has provided knowledge about the practical use of 360-degree VR video, technical potential, and challenges. We have also discussed why this method is suitable for improving nursing students’ competence in the psychiatric clinic. The chapter is an introduction to inspire use of 360-degree VR video in professional education, with a focus on nursing education. 360-Degree video simulations will not replace real-life situations but can act as a complement. What 360-degree video simulation offers is a tool that allows nursing students to have increased time in relevant situations that can contribute to quicker and better decision-making in real, clinical situations. This chapter argues that using 360-degree video creates a playful and safe learning environment, promoting reflection and learning. The VR- SIMI model shows more explicitly how 360-degree VR video can be used as a tool for nursing students in a psychiatric simulation. The 360-degree VR simulation of a clinical situation is a highly immersive experience and gives the participants a feeling of “being there,” a feeling of presence.