Nurse Education in Practice 15 (2015) 53e57

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Virtual reality disaster training: Translation to practice

Sharon L. Farra a, *, Elaine T. Miller b, Eric Hodgson c
a
Wright State University Miami Valley, College of Nursing and Health, Dayton, OH, USA
b
College of Nursing at the University of Cincinnati, Cincinnati, OH, USA
c
Miami University, Oxford, OH, USA

a r t i c l e i n f o a b s t r a c t

Article history: Disaster training is crucial to the mitigation of both mortality and morbidity associated with disasters.
Accepted 29 August 2013 Just as clinical practice needs to be grounded in evidence, effective disaster education is dependent upon
the development and use of andragogic and pedagogic evidence. Educational research findings must be
Keywords: transformed into useable education strategies. Virtual reality simulation is a teaching methodology that
Translation has the potential to be a powerful educational tool. The purpose of this article is to translate research
Disaster
findings related to the use of virtual reality simulation in disaster training into education practice. The
Virtual reality simulation
Ace Star Model serves as a valuable framework to translate the VRS teaching methodology and improve
disaster training of healthcare professionals. Using the Ace Star Model as a framework to put evidence
into practice, strategies for implementing a virtual reality simulation are addressed. Practice guidelines,
implementation recommendations, integration to practice and evaluation are discussed. It is imperative
that health educators provide more exemplars of how research evidence can be moved through the
various stages of the model to advance practice and sustain learning outcomes.
Ó 2013 Elsevier Ltd. All rights reserved.

The future of nursing in today’s world requires an examination
of how we educate and what content we impart to nurses (Benner
et al., 2010). Just as clinical practice needs to be grounded in evi-
dence, effective nursing education is dependent upon the devel-
opment and use of andragogic and pedagogic evidence (Institute of
Medicine, 2010). Educational research findings must be trans-
formed into useable education strategies. There is a need for
nursing education strategies that engage students in critical
thinking while allowing practice in safe environments. Opportu-
nities to train for some health-related events are severely limited.
For example, mass casualty incidents occur infrequently in any
given location, but practice is needed to prepare a well-trained
healthcare team to respond to these disasters. One innovative
teaching intervention is virtual reality simulation (VRS). The pur-
pose of this paper is to describe the translation of a VRS research
study findings into nursing education practice focusing on disaster
preparation.
The Ace Star Model is a conceptual framework set forth to sys-
tematically put evidence-based practice processes into operation
(Stevens, 2004). The model identifies five key stages to transform
knowledge (i.e. research) into practice. The first stage is that of
* Corresponding author. Tel.: þ1 937 554 7411.
E-mail address: Sharon.Farra@wright.edu (S.L. Farra).
knowledge discovery. Using scientific inquiry, both new qualitative
and quantitative knowledge is discovered. In stage two, evidence is
summarized into a meaningful statement. The third stage results in
the development of practice guidelines and recommendations. The
fourth stage of the model includes the integration of the strategy
into practice. In the final stage outcomes are evaluated (Stevens,
2004). This model will be applied to a study of VRS in disaster
training and translation of the teaching method to nursing educa-
tion practice.
Background and significance
Federally declared disasters occur at a rate of approximately one
per week across the United States (Federal Emergency
Management Agency, 2011). As a result, there is an ongoing need
to improve the education of healthcare workers training for
disaster response (Chapman and Arbon, 2008; Spleski and
Littleton-Kerney, 2010). Preparation for disasters may be hindered
by limited access to disaster training opportunities; live disaster
drills are costly and difficult to coordinate. An alternative method to
train responders is to simulate such disasters with VRS (Heinrichs
et al., 2010). Virtual Reality is a broad term encompassing a wide
range of technology (Blade and Padgett, 2002), which can vary from
desktop computer simulations to head-mounted displays with
sophisticated motion tracking to spatialized audio systems to

1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2013.08.017
54 S.L. Farra et al. / Nurse Education in Practice 15 (2015) 53e57
multi-wall 3D projection systems like a CAVE (Cave Automatic
Virtual Environment) (Strangman et al., 2003). While the technol-
ogy varies, the common theme of VRS is to provide a humane
computer interface that simulates an alternate three-dimensional
environment and presents multisensory stimulation to the user
(e.g., some combination of visual, auditory, haptic, olfactory, pro-
prioceptive, inertial, etc.) and allows the user to interact with the
synthetic environment in real time (Stanney and Cohn, 2009;
Stanney and Zyda, 2002). In the present work, VRS refers to an
interactive desktop computer simulation, which is preferred for its
low cost, wide accessibility and ability to embed such simulations
with a website for distribution. The same learning principles could
be applied to other types of specialized VRS.
Defining terms is important to understanding the nature of
emergency and disaster response. Common terms for these emer-
gent situations include emergency, disaster, crises and critical in-
cidents. Emergencies, crises and critical incidents are often used
interchangeably and refer to sudden and usually unforeseen events
that require immediate action by a local agency or industry to
minimize consequences. These occurrences include adverse events
that do not have community wide impact or do not require
extraordinary use of resources or procedures to bring conditions
back to normal (Blanchard, 2008). For example, a power outage at a
local hospital would be a critical incident. The event calls for im-
mediate action by the agency, but does not usually require outside
resources or disrupt the community at large. Disasters occur on
larger scales and require resources beyond the local response. Ex-
amples include State or Federal response, multiple agency
involvement, and former declarations by government officials. A
disaster may be a manmade or natural event. Occurring with or
without warning and resulting in damages these events exceed the
local capacity to respond and external assistance. Examples of these
events include earthquakes, tsunamis, landslides, hurricanes, tor-
nadoes and wild fires. Damages may include environmental dam-
age, human casualties and result in mass disruption of society
(Center for Disease Control and Prevention, 2012).
Theoretical framework
The use of VRS as an education method is grounded in the
theory of situated cognition. Learners must apply and practice in
realistic environments. The theory is based upon concepts of
embodiment (cognition is dependent on the sensorimotor brain
and body), embeddedness (cognition is fixed in context specific
representations) and extension (cognitive systems exist in a phys-
ical and social environment) (Brown et al., 1989). The sense of self-
location, the sense of agency, and the sense of body ownership are
critical to learning (Gallagher, 2005; Mallot and Basten, 2009).
Meaningful learning will only take place if it is set in the culture of
the situation in which is it is intended to be used. Educational
technology, through virtual reality and interactive multimedia, is
supported as an avenue to bring situated learning into the class-
room (Harley, 1993). According to Herrington and Oliver (1995),
within the framework of situated cognition virtual simulations
provide a learning opportunity that has the critical characteristics
of a traditional apprenticeship. Interactivity is a key to learning
(Herrington and Oliver, 1995; Hansen, 2008; Hannafin and
Hannafin, 2010). Moreover, situated cognition fosters the expan-
sion of individual cognitive knowledge along with social and
physical interactions thus facilitating cognitive, affective and psy-
chomotor learning (Hansen, 2008; Hannafin and Hannafin, 2010).
Below is a visual representation of situation cognition applied to
VRS.
Situated cognition
The Ace Star Model
Point 1: discovery
In a longitudinal study using an experimental design, the effects
of disaster training with and without VRS were explored (Farra
et al., 2013). The subjects of the study, Associate Degree nursing
students in their second year, participated in disaster training using
web-based models. The control group used the web-based modules
alone while the treatment group completed the web-based mod-
ules along with a VRS to reinforce content. Learning and retention
were measured using a 20 question multiple-choice test. Content
validity of the tool was accomplished through review by both
disaster and education experts. Reliability of the assessment was
determined by test-retest consistency (r ¼ .72). Three measurement
points were assessed pre-training, immediately post-training, and
two months following training.
The results of the assessments were analyzed using the gener-
alized linear model and general estimating equations with overall
effect of the VRS was found to be strongly significant (p < .0001).
The post knowledge scores, and 2-month knowledge scores were
significantly different (p < .0001) with an effect size of d ¼ .676.
Although the two groups varied significantly on the immediate
posttest, differences were even greater between the groups at two
months (p < .0001), indicating greater retention of disaster training
content in the RS group. The control group that did not receive the
 S.L. Farra et al. / Nurse Education in Practice 15 (2015) 53e57
VRS demonstrated much greater decay in knowledge. Furthermore,
in evaluating the VRS experience learners reported feeling engaged
and that the VRS enhanced learning by providing a realistic op-
portunity to practice skills (Farra et al., 2013).
Point 2: evidence summary
The VRS research evidence is synthesized into one meaningful
statement: VRS provides a realistic environment for instruction
which increases retention of learned knowledge of disaster
training. Student nurses participating in a VRS had improved
learning retention (Farra et al., 2013). The work of Bergeron (2008)
supports these findings. In his study of disaster training using a VRS
group and control group he found that VRS participant scores on
pre/post and six-week tests demonstrated significantly greater
learning retention than the non VRS group (n ¼ 89). Similar find-
ings were found by Koh et al. (2010) and in Ke’s (2009) metanalysis
of computer games as learning tools.
Participant report of realism and immersion within the VRS
were also confirmed by other studies. VRS has consistently been
found to be a realistic and immersive environment for disaster
training. An integrative review of the literature describing partici-
pant reports of VRS offers high levels of realism, engagement and
immersion (Farra and Miller, 2013). A wide range of studies have
explored the use of VRS for disaster training with great success
(Heinrichs et al., 2008, 2010; Vincent et al., 2008). Using both
quantitative and qualitative methods, these studies report that
participants consistently find VRS a genuine and convincing
learning environment.
Point 3: translation
When implementing VRS content, education, content and
technology experts are needed. Content experts identify the
domain of learning for the simulation and work with technology
experts to implement realistic settings, details, actor behaviors, and
user interactions within the simulation. VRS may be used to
immerse learners in a wide variety of subject areas ranging from
healthcare as described here, to industrial manufacturing, military
drills, firefighting, and other healthcare applications Jayaram et al.,
1999; Rose et al., 2000; Bliss et al., 1997). VRS is valuable in applying
cognitive concepts in a realistic setting, both reinforcing content
and providing assessment. All three domains of learning (cognitive,
affective and psychomotor) can be addressed with VRS. After the
content domain is identified, appropriate measurable learning ob-
jectives are developed by both the content and education experts.
From these objectives, the specific content of the simulation is
determined. A storyboard is created for scripting of the scenarios
including: activities, challenges, redirection, narration and evalua-
tion of performance which facilitate learning and retention of
content (Van der Spek et al., 2010).
As the VRS is designed, education experts ensure that the
simulation 1) will support construction of knowledge, 2) scaffold
content to provide immediate availability of help, intentional
assisting and expert modeling (Zhao and Orey, 1999), 3) provide
coaching, 4) promote reflection and abstraction, and 5) integrate
assessment of learning tasks (Herrington and Oliver, 1995). After
the development of content and simulation scripting, the simula-
tion is articulated into the virtual environment and pilot testing
begins.
Consultation among these experts prior to and throughout
development process is required for a successful VRS. Early dis-
cussions regarding the method of VRS are critical to establish ex-
pectations and to select an appropriate technology toolset. Many
hardware and software systems are available for VRS delivery
55
including a range of sensory modalities from total immersion in
special rooms to less immersive environments using monitor,
keyboard and mouse (Stanney, 2002; Strangman, & Hall, 2003).
Choosing an appropriate set of technologies can optimize the
effectiveness of training. Case in point, a VRS intended to train
surgeons on a particular technique may necessitate a head-
mounted display coupled with a pair of motion-tracked stylus de-
vices with haptic feedback (e.g., the Phantom; Massie and Salisbury,
1994; Stanney, 2002). This approach would allow users to see their
hands and tools in the context of the virtual patient and to realis-
tically feel the resistance of different body tissues and structures, or
even to feel the pulsing of a crucial artery.
Such specialized hardware would not be necessary for a VRS
training scenario designed to teach nurses and staff proper evacu-
ation techniques during a disaster. In this case, it is more important
to focus on software rendering of particle effects like smoke and fire
that may obstruct vision of escape routes, and accurately simulating
3D spatial auditory cues. During a disaster, users may need to locate
unseen patients who are calling for help or orient themselves to-
wards an exit based on the direction of a police siren. Cost and
availability are also important when considering which technology
to use. Desktop simulations can often run on a portable laptop or
within a website, which minimizes hardware costs and makes
them widely available both in terms of time and location. Special-
ized immersive VRS systems, on the other hand, can increase the
realism, feedback, and the amount of data available to collect or
meet special requirements of the VRS. However, this comes at an
increased financial cost and typically requires users to travel to a
specific location for brief training sessions.
Points to consider when selecting the VRS system include: 1)
The simulation needs to be built in a manner that facilitates
embeddedness (cognition is fixed in content specific representa-
tions), extension (individuals exist in social and physical environ-
ments) and embodiment (cognition is linked to the sensorimotor
brain and body (Robbins and Aydede, 2009). 2) What is the depth
and breadth of sensory information that needs expressed (audio,
visual, touch, etc.; Steuer, 1992)? 3) What element of immersion
within the simulation is needed? 4) What types of data need to be
collected (e.g., time-to-completion, precise motion trails, de-
cisions)? 5) What is the target platform for end-users (e.g., mobile
device, website, specialized facility)? These considerations are not
mutually exclusive, and may require some tradeoffs. For instance, if
it is desirable to have sophisticated motion tracking but also to
permit users to train at home via a web-based VRS, then some
compromises will need to be made in the final design.
Point 4: integration
Integration of VRS into disaster training poses some challenges.
Creation of VRS may be costly and requires specialized training to
develop, but once produced these scenarios can be used repeat-
edly by many participants. Learners must also have access to
appropriate technology to take part in the VRS and both educators
and students must be trained in the use of the VRS. In exploring
the extensive numbers of systems available for delivery of VRS
questions should be considered: What level of immersion is
desired to accomplish learning objectives? What is the cost of the
system and equipment required to participate in the VRS? Hard-
ware costs can range from free e when repurposing existing
computers e to several million dollars for specialized display and
motion tracking systems. How expensive will the design and
implementation be?
The creation of a VRS will typically require the creation or
purchase of 3D models with which to build the virtual environment
as well as extensive computer programming to build appropriate
56 S.L. Farra et al. / Nurse Education in Practice 15 (2015) 53e57
behaviors, animations, data collection, and user interactions. Costs
of quality-assurance testing, documentation, deployment, updating
and maintenance, and training-of-the-trainers should also be
considered. Will participants benefit from social interaction within
the VRS; should a single player or multiplayer system be used?
What will be the perspective of the learner, first person or third
person? The viewer’s perspective plays a role in the subjective
experiences within the VRS. In first person the participant sees the
virtual world through the “eyes” of the avatar, from the third person
perspective the participant sees the world from behind or above
the avatar. Schuurink and Toet (2010) found no difference in par-
ticipant’s affective appraisal of engagement in VRS in either first or
third person when completing a search and find task in the online
virtual world Second Life, but found higher perceptions of envi-
ronment in those participating in a third-person perspective. Other
tasks, such as finding an evacuation route through simulated
smoke, may be more suited to a first-person perspective.
Point 5: evaluation
Although VRS has been demonstrated as an effective education
modality in disaster training, it requires further investigation with
larger samples. Given that most hospitals have mandatory annual
staff training, knowledge retention studies spanning at least one
year in length are highly recommended. In addition, research
must be performed that examines whether the knowledge pre-
sented in VRS translated into actual performance behaviors in real
disasters.
Other aspects pertaining to VRS that need scrutiny are analysis
of the efficiency, effectiveness, and cost of the various types of VRS
delivery systems (e.g., CAVE total immersion versus keyboard and
mouse). Because VRS is an active learning strategy allowing stu-
dents to learn by doing in a controlled environment, any environ-
ment (real or imagined) can be manufactured in a VRS. Plus,
students are safe to explore in a digital environment where repe-
tition of experience can easily be accomplished. With the increased
emphasis on digital media, social networks, and gaming as viable
teaching strategies, it is imperative that nurse researchers perform
targeted investigations to expand the body of evidence regarding
these educational approaches.
In summary, the Ace Star Model serves as a valuable framework
to translate the VRS teaching methodology and improve disaster
training of healthcare professionals. It is imperative that health
educators provide more exemplars of how research evidence can
be moved through the various stages of the model to advance
practice and sustain learning outcomes.
Acknowledgment
The authors gratefully acknowledge Sigma Theta Tau and the
METI Corporation for their support of this research through the
Sigma Theta Tau METI Simulation, Nursing Research Grant.
ID#6330
References
Benner, P., Sutphen, M., Leonard, V., Day, V., 2010. Educating Nurses: a Call for
Radical Transformation. Jossey-Bass, San Francisco.
Bergeron, B.P., 2008. Learning & retention in adaptive serious games. Studies in
Health Technology and Informatics 132, 26e30. Retrieved from EBSCOhost.
Blade, R.A., Padgett, M.L., 2002. Virtual environments standards and terminology.
In: Stanney’s, K.M. (Ed.), Handbook of Virtual Environments: Design Imple-
mentation, and Applications. Lawrence Erlbaum Associates, Mahwah, New
Jersey, pp. 15e27.
Blanchard, B.W., 2008. Guide to Emergency Management and Related Terms, Def-
initions, Concepts, Acronyms, Organizations, Programs, Guidance, Executive
Orders & Legislation. Retrieved from http://training.fema.gov/EMIWeb/edu/
docs/terms%20and%20definitions/Terms%20and%20Definitions.pdf.
Bliss, J.P., Tidwell, P.D., Guest, M.A., 1997. The effectiveness of virtual reality for
administering spatial navigation training to firefighters. Presence: Teleoper.
Virtual. Environ. 6, 73e86.
Brown, J.S., Collins, A., Duguid, P., 1989. Situated cognition and the culture of
learning. Educ. Res. 18 (1), 32e41. Retrieved from http://www.exploratorium.
edu/IFI/resources/museumeducation/situated.html.
Center for Disease Control and Prevention, 2012. Preparedness for Response for
Public Health Disasters. Retrieved from http://www.cdc.gov/nceh/hsb/disaster/
training.htm.
Chapman, K., Arbon, P., 2008. Are nurses ready? Disaster preparedness in the acute
setting. Australasian Emerg. Nur. J. 11 (3), 135e144. http://dx.doi.org/10.1016/
j.aenj.2008.04.002.
Farra, S.L., Miller, E.T., 2013. Integrative review: Virtual disaster training. J. Nur. Edu.
Pract. 3 (3), 93e101.
Farra, S.L., Miller, E.T., Timms, N., Schafer, J.C., 2013. Improved training for disasters
using 3-D virtual reality simulation. West. J. Nur. Res. (available online preview).
Federal Emergency Management Agency, 2011. Federal Disaster Declarations.
Retrieved from http://www.fema.gov/news/disasters.fema?year¼2011. Health-
care workers need training to respond to disasters.
Gallagher, S., 2005. How the Body Shapes the Mind. Oxford University Press, New
York.
Hannafin, M.J., Hannafin, K.M., 2010. Cognition and student-centered, web based
learning: issues and implications for research and theory. In: Speator, J.M., et al.
(Eds.), Learning and Instruction in the Digital Age doi 10.10007/978-1-4419-
1551-1_2.
Hansen, M. Versatile, 2008. Immersive, creative and dynamic virtual 3-D healthcare
learning environments: a review of the literature. J. Med. Internet. Res. 10 (3).
http://dx.doi.org/10.2196/jmr.1051.
Harley, S., 1993. Situated learning and classroom instruction. Educ. Technol. 33 (3),
46e51.
Heinrich, L.W., Youngblood, P., Harter, P.M., Dev, P., 2008. Simulation for team
training and assessment: case studies with virtual worlds. World J. Surg. 32 (2),
161e170. http://dx.doi.org/10.1007/s00268-007-9354-2D S.
Heinrichs, W.L., Youngblood, P., Harter, P., Kusumoto, L., Dev, P., 2010. Training
healthcare personnel for mass-casualty incidents in a virtual emergency
department: VED II. Prehospital. Disaster. Med. 25 (5), 424e431.
Herrington, J., Oliver, R., 1995. Critical Characteristics of Situated Learning: Implica-
tions for the Instructional Design of Multimedia [PDF]. Edith Cowan University.
Retrieved from http://methodenpool.uni-koeln.de/situierteslernen/herrington.
Institute of Medicine, 2010. A Summary of the February 2010 Forum on the
Future of Nursing: Education. The National Academies Press, Washington,
D. C.
Jayaram, S., Jayaram, U., Wang, Y., Tirumali, H., Lyons, K., Hart, P., 1999. VADE: a
virtual assembly design environment. IEEE Comp. Graph. Appl. 19 (6), 44e50.
Ke, F., 2009. A qualitative meta-analysis of computer games as learning tools.
Handbook Res. Effect. Elect. Gaming Edu. 1, 1e32.
Koh, C., Tan, H.S., Tan, K.C., Fang, L., Fong, F.M., Kan, D., Lye, S.L., Wee, M.L., 2010.
Investigating the effect of 3D simulation-based learning on the motivation and
performance of engineering students. J. Eng. Edu. 99, 237e251.
Mallot, H.A., Basten, K., 2009. Embodied spatial cognition: biological and artificial
systems. Image Vision Comput. 27, 1658e1670.
Massie, T.H., Salisbury, J.K., 1994, November. The phantom haptic interface: a device
for probing virtual objects. In: Proceedings of the ASME Winter Annual
Meeting, Symposium on Haptic Interfaces for Virtual Environment and Tele-
operator Systems, vol. 55. IOS Press, pp. 295e300, 1.
Robbins, P., Aydede, M., 2009. In: Robbins, P., Aydede, M. (Eds.), The Cambridge
Handbook of Situated Cognition. Cambridge University Press, Cambridge, NY.
Rose, F.D., Attree, E.A., Brooks, B.M., Parslow, D.M., Penn, P.R., 2000. Training in
virtual environments: transfer to real world tasks and equivalence to real task
training. Ergonomics 43 (4), 494e511.
Schuurink, E.L., Toet, A., 2010. Effects of their person perspective on affective
appraisal and engagement: findings from Second life. Simul. Gaming 41 (5),
724e742. http://dx.doi.org/10.1177/1046878110365515.
Spleski, L.A., Littleton-Kerney, M.T., 2010. Disaster nursing educational compe-
tencies. In: Powers, R., Daily, E. (Eds.), Disaster Nursing. Cambridge University
Press, New York, NY, pp. 549e561.
Stanney, K.M., 2002. Handbook of Virtual Environments: Design, Implementation,
and Applications. Lawrence Erlbaum Associates, Mahwah NJ.
Stanney, K.M., Zyda, M., 2002. Virtual environments in the 21st century. In:
Stanney’s, K.M. (Ed.), Handbook of Virtual Environments: Design Implementa-
tion, and Applications. Lawrence Erlbaum Associates, Mahwah, New Jersey,
pp. 1e14.
Stanney, K., Cohn, J., 2009. Virtual environments. In: Jacko’s, J.A. (Ed.), Humane
computer Interaction: Design Issues, Solutions, and Applications, pp. 293e310.
Stevens, K.R., 2004. Ace Star Model of EBP: Knowledge Transformation. Academic
Center for Evidence-Based Practice. The University of Texas Health Science
Center at San Antonio.
Strangman, N., Hall, T., Meyer, A., 2003. Virtual Reality/simulations with UDL. National
Center on Accessing the General Curriculum, Wakefield, MA. Retrieved from http://
aim.cast.org/learn/historyarchive/backgroundpapers/virtual_simulations_udl.
Strangman, N., Hall, T., 2003. Virtual Reality/simulations. National Center on
Accessing the General Curriculum, Wakefield, MA. Retrieved from http://aim.
cast.org/learn/historyarchive/backgroundpapers/virtual_simulations.
 S.L. Farra et al. / Nurse Education in Practice 15 (2015) 53e57 57

Steuer, J., 1992. Defining virtual reality: dimensions determining telepresence.
J. Commun. 42 (4), 73e93.
Van der Spek, E.D., Wouers, P., van Osterdendorp, H., 2010. Code red: triage or
cognition-based design rules enhancing decision making training in a game
environment. British J. Educ. Technol. 42 (3), 441e455. http://dx.doi.org/
10.1111/j.1467-8535.2009.0121.x.
Vincent, D.S., Sherstyuk, A., Burgess, L., Connolly, K.K., 2008. Teaching mass casualty
triage skills using immersive three-dimensional virtual reality. Acad. Emerg.
Med. 15 (11), 1160e1165.
Zhao, R., Orey, M., 1999. The Scaffolding Process: Concepts, Features, and Empirical
Studies. Unpublished manuscript. University of Georgia.