Journal of Nursing Education

Major Article 

The Effects of Augmented Reality on Prelicensure Nursing Students' Anxiety Levels

Sarah Ball, PhD, RN, RNC-OB, C-EFM; Leslie C. Hussey, PhD, RN, CNE

Abstract

Background:

Prelicensure nursing students experience high anxiety as they enter the clinical setting, which can have a negative impact on learning care performance and critical thinking. This study explored the viability of an innovative technological teaching strategy, augmented reality (AR), as a platform to prepare students and decrease their anxiety levels when entering a new environment.

Method:

A pretest/posttest quasiexperimental design was used to assess the effect of AR 360 photosphere on preli-censure nursing students' anxiety levels as they entered a new clinical environment compared with anxiety levels of prelicensure nursing students who participated in the traditional faculty-led orientation method.

Results:

Students from three midwestern colleges of nursing completed the State-Trait Anxiety Inventory before and after completing the AR 360 photosphere orientation or a faculty-led orientation. An independent t test revealed no difference in students' anxiety levels between the two methods of orientation.

Conclusion:

Although there were no significant differences in nursing students' anxiety levels between the two methods of clinical orientation, the AR 360 can be a valuable method of orientation that saves faculty time and ensures more consistent and uniform content compared with the traditional faculty orientation method. [J Nurs Educ. 2020;59(3):142–148.]

Abstract

Background:

Prelicensure nursing students experience high anxiety as they enter the clinical setting, which can have a negative impact on learning care performance and critical thinking. This study explored the viability of an innovative technological teaching strategy, augmented reality (AR), as a platform to prepare students and decrease their anxiety levels when entering a new environment.

Method:

A pretest/posttest quasiexperimental design was used to assess the effect of AR 360 photosphere on preli-censure nursing students' anxiety levels as they entered a new clinical environment compared with anxiety levels of prelicensure nursing students who participated in the traditional faculty-led orientation method.

Results:

Students from three midwestern colleges of nursing completed the State-Trait Anxiety Inventory before and after completing the AR 360 photosphere orientation or a faculty-led orientation. An independent t test revealed no difference in students' anxiety levels between the two methods of orientation.

Conclusion:

Although there were no significant differences in nursing students' anxiety levels between the two methods of clinical orientation, the AR 360 can be a valuable method of orientation that saves faculty time and ensures more consistent and uniform content compared with the traditional faculty orientation method. [J Nurs Educ. 2020;59(3):142–148.]

First-time clinical experience brings apprehension and anxiety to undergraduate nursing students, compromising their ability to maximize their learning (Foley, 2016). Increased anxiety negatively impacts student learning, care performance, and critical thinking in a clinical environment (Cheung & Au, 2011; Khalaila, 2014). Nursing faculty must provide techniques to help students overcome the uncertainties that bring on the apprehension and anxiety, allowing adaptation to the setting and enabling students to maximize their learning experience to be able to provide patient care effectively (Foley, 2016).

Innovative methods can be adapted to address the needs of nursing students such as augmented reality (AR), which has been used by other professions (O'Shea & Elliott, 2015). AR is the technological ability to combine reality with virtual experiences allowing individuals to connect to experiences in a real-time three-dimensional (3D) panoramic atmosphere (Azuma, 1997; Dunleavy, 2014). The use of AR as a clinical orientation tool may be beneficial in decreasing nursing students' anxiety levels as AR is available for nursing students to autonomously virtually enter clinical settings multiple times to orient themselves to the clinical site prior to the clinical experience. Because there is minimal literature on the use of AR in nursing education, evaluating the use of AR and the added value it brings by decreasing students' anxiety levels before their clinical experience could provide an innovative methodology for nursing academia.

Background

Anxiety in a New Clinical Environment

New clinical environments can be viewed by nursing students as threatening stimuli. An evaluation of nursing students' perceived anxiety levels in the clinical environment revealed that more than 53% of nursing students have mild to moderate anxiety during their clinical experience (Bayoumi, Elba-suny, Mohamed mofereh, Mohamed assiri, & Al fesal, 2012). Another study indicated nursing students' anxiety levels were significantly higher than other college students and highlighted how nursing students who are beginning clinical nursing courses experienced the highest level of anxiety during this learning period (Wedgeworth, 2016). In a cross-sectional descriptive exploratory study of 437 undergraduate nursing students, Chernomas and Shapiro (2013) found that lack of knowledge of the physical environment was one stressor associated with the anxiety experienced by nursing students who were entering the clinical setting.

The stimuli of entering a new environment can induce and increase physiological and psychological anxiety response symptoms during the new learning experience in a clinical environment. Research has related how the clinical environment and psychological factors have a significant effect on nursing students' learning outcomes and professional development (Jun & Lee, 2017; Liao & Liu, 2016).Thus, as students focus on the anxiety stimuli and how to cope or relieve the symptoms of anxiety, the elevated anxiety levels have a negative effect on safe patient care outcomes and students' learning success (Cheung & Au, 2011; Kameg, Szpak, Cline, & McDermott, 2014; Khalaila, 2014; Rossignol, 2017).

Preparing prelicensure students to transition to the clinical environment has been the responsibility of nursing clinical faculty (Ganzer & Zauderer, 2013). However, the academic nursing field has found the need to adapt their teaching methodology to accommodate varying circumstances, including the shortage of nursing faculty, a decrease in clinical site availability leading to reduced clinical experiences, and the new generation of learners (Nardi & Gyurko, 2013; Rosseter, 2015; Skiba, 2014). The Institute of Medicine (2011) has published patient safety recommendations focusing on how nurse educators need to develop and evaluate new approaches for teaching clinical education that allow prelicensure nurses to gain knowledge of real-world context. Through the practical, cost-effective use of technology and application tools such as AR, educators can implement teaching strategies that capture learners in a multitude of settings (Blattner & Lomicka, 2012; Ferguson, Davidson, Scott, Jackson, & Hickman, 2015; Garrett, Jackson, & Wilson, 2015). These settings include on-campus, off-campus, and clinical settings.

Augmented Reality

AR in its simplest form is combining reality with virtual experiences through technology. This allows individuals real-time connectivity to a panoramic atmosphere. As individuals view the virtual computer-generated superimposed objects, they are able to interact in the 3D real-world environment (Azuma, 1997; Chandler & Munday, 2016; Lyon, 2017; Riva, Banos, Botella, Mantovani, & Gaggioli, 2016). AR applications are effective educational tools because learners can virtually experiment within an environment (Yilmaz & Batdi, 2016). The immersive nature of AR allows an increased realism of the experience, which transforms the individual's external experience and in turn brings an individual awareness to the new environment (Riva et al., 2016; Vaughn, Lister, & Shaw, 2016). When learners have the immersive experience, there is a sense of presence and emotional engagement in the environment, which permits a more authentic learning experience (Riva et al., 2016; Vaughn et al., 2016). With the experience, learners can self-reflect, which assists in developing knowledge, decreasing apprehension and anxiety, and building confidence and self-efficacy in reaching the learning outcome (Quail, Brundage, Spitalnick, Allen, & Beilby, 2016; Riva et al., 2016; Yilmaz & Batdi, 2016).

One type of AR application is the 360° photosphere that is produced with a 360° camera and allows embedded images to be introduced into the 3D environment (Andert & Alexakis, 2015; Wong, 2016). The AR 360° photosphere has the benefit of allowing users to visually view distant environments, such as a clinical environment, and receive specific general information about this environment without leaving their current location, allowing a fully immersed and interactive experience (Giard & Guitton, 2016; Wong, 2016). After the use of AR in a skills laboratory setting, Garrett et al. (2015) suggested the development of an AR application for a clinical site environment potentially could be an efficient method to orientate prelicensure nursing students to a clinical site before their first clinical experience. In the current study, an AR 360° photosphere of the maternal-child clinical area (Figure 1) was built through a collaborative effort among the clinical site's organizational research committee, the hospital's nursing executives, a midwestern university's college of nursing, and a research and development technical team in 2016. This photosphere was placed on a secured platform that required an individual specific password for access to the web-site link to view the clinical environment.

Example of a view of the interactive AR 360° photosphere (A). The student actively navigates the room, and when labeled items are clicked on, the area will open. In the photograph, when cabinet C is opened, the monitoring equipment needed in the clinical area is found (B). When cabinet I behind the bed is opened, the student is able to view respiratory equipment (C).

Figure 1.

Example of a view of the interactive AR 360° photosphere (A). The student actively navigates the room, and when labeled items are clicked on, the area will open. In the photograph, when cabinet C is opened, the monitoring equipment needed in the clinical area is found (B). When cabinet I behind the bed is opened, the student is able to view respiratory equipment (C).

Driven by the recommendations of the Institute of Medicine, the need for nurse educators to have innovative strategies is evident. The purpose of this study was to determine the effect of the AR 360° photosphere on prelicensure nursing students' anxiety levels as they entered a new clinical environment compared with prelicensure nursing students' anxiety levels who did not experience AR 360° photosphere orientation.

Method

Design and Setting

This quantitative study used a two-group, pretest/posttest, quasiexperimental research method with a convenience sample of prelicensure junior-level nursing students entering their first maternal-child rotation from three Midwestern colleges of nursing. Each college of nursing had a bachelor of nursing program and at least one clinical group at the maternal-child setting where the AR 360° photosphere could be used as the orientation method. Random assignment to the control and comparison groups was not possible because all of the students had an existing clinical group assignment. Each nursing program had at least 2 clinical groups; one group from each of the colleges had traditional faculty-led orientation (control) and one group participated in the AR 360° photosphere (comparison) group. Institutional review board approval was obtained before initiation of the study. Randomization of the clinical groups was not possible as the prelicensure nursing students were preassigned to clinical groups by each college at the beginning of the semester.

Anxiety levels of the sample were measured with the State-Trait Anxiety Inventory (STAI) (Spielberger, Gorusch, Lushene, Vagg, & Jacobs, 2015). This instrument includes 40 questions that are scored using a 4-point ordinal Likert scale. The STAI has been used in multiple diverse studies, establishing the validity and reliability of the results (American Psychological Association, 2017; Julian, 2011). The STAI instrument has two forms. The Y-1 form consists of the first 20 questions, which relate only to the individual's stated acute conscious awareness of anxiety. The Y-2 form contains the second 20 questions, which focus on an individual's chronic trait anxiety. The Y-2 form was used to control the students' trait anxiety to decrease the potential error of statistical analysis while measuring state anxiety. The higher an individual's chronic trait anxiety, the more difficult it is for one to functionally cope with an acute threat, which influences performance outcomes and increases one's stated acute anxiety (Horsley & Wambach, 2015; Villada, Hidalgo, Almela, & Salvador, 2016).

Copyright permission for the online survey license was obtained, and the license and software were placed on a secured third-party online survey platform where data were completely deidentified to ensure confidentiality and anonymity. Directions on how to complete the survey, along with demographic questions, were included. Inclusion criteria for this study were junior-level prelicensure nursing students who were enrolled at one of three schools of nursing, were scheduled for their maternal-child clinical rotation, and had not previously worked in or been exposed to the maternal-child clinical site environment.

Recruitment occurred 1 week prior to the prelicensure nursing students' first clinical experience to the maternal-child environment. Potential participants were asked to attend scheduled informational sessions on the study prior or immediately after their theory course. Students who volunteered to participate were asked to complete the presurvey, which included consent to participate, demographic information, and the STAI tool prior to their clinical orientation with a deidentified code included on the information handout. Completing the consent and presurvey the week before their first clinical setting allowed students who used the AR 360° photosphere orientation enough time to complete the interactive orientation and discover the maternal-child clinical environment.

To access the AR 360° photosphere orientation, those in the intervention AR 360° photosphere group used their deidentified code to access the secure database platform. The control group received the routine one-time, faculty-led orientation and had no interaction with the AR 360° photosphere as they were at different clinical sites where no AR 360° photosphere was available. The postsurvey STAI was administered in an online format to both groups through a link sent by the third-party platform after the participants had completed orientation and immediately before students entered their first clinical experience.

Data Analysis

The demographic and STAI data were exported from the third-party platform to SPSS® version 25. Data were analyzed with a paired t test to compare the mean difference within each group. An independent t test was used to examine the mean difference of state anxiety between each group. An individual's immediate acute situation and stated anxiety may be related to his or her chronic trait of anxiety and could influence an immediate response to a situation or the individual's stated anxiety level. By separating the two different concepts of acute state and chronic trait anxiety, a one-way analysis of covariance (ANCOVA) was used to control for the chronic trait anxiety to determine statistically whether there was a potential influence or effect that chronic trait anxiety has on the dependent outcome variable of state anxiety.

Results

Pre- and postsurvey data were collected with the STAI instrument for a total of four clinical rotations among the three colleges of nursing during the spring of 2018. A total of 146 prelicensure nursing students who were entering their junior level maternal-child clinical rotation were eligible to participate in the study. Of these, 113 completed the presurvey, with 67 students using the AR 360° photosphere orientation method and 46 students using the faculty-led orientation method. Thirty-one participants did not meet inclusion criteria and were excluded from the study because they answered “yes” to having previous exposure to the maternal-child environment questions. Thus, of those who completed the presurvey, 50 of the AR students and 32 of the faculty-led orientation students qualified for the study; these students were sent a postsurvey to complete after their orientation to their first clinical experience on the maternal-child floor. The completion of both the pre- and postsurvey was required for students to be included in the study. Thirty postsurveys were completed for the AR group and 17 postsurveys were completed for the faculty-led orientation; the results were analyzed with this sample.

The average age of the students as reported by the three colleges was 25 years. Based on credit hours, all but one of the participants were classified as a junior; one student was at a senior semester classification level but in junior-level nursing curriculum courses.

Documentation of previous clinical experience ranged from four participants having no previous experience, with the maternal-child setting being their first clinical experience. Slightly more than 21.3% of the participants were unsure of the number of clinical hours they had completed but had at least one previous rotation. The remaining participants had a varied amount of clinical experience. Descriptive characteristics for both groups are listed in Table 1.

Prelicensure Curriculum Characteristics of Participants (N = 47)

Table 1:

Prelicensure Curriculum Characteristics of Participants (N = 47)

A paired-sample t test showed statistical significance (t[46] = 2.464, p = .018) in stated anxiety levels decreasing after the sample group of prelicensure nursing students underwent orientation to the clinical environment (M = 4.383, SD = 12.19). An independent t test compared the mean difference score from the pre- and postsurvey of the dependent variable of state anxiety between the two groups. The null hypothesis was retained as there was no statistically significant mean difference (t[21.87] = 1.07, p = .30) in the effect that AR 360° photosphere orientation (M = −2.73, SD = 9.12) had on prelicensure nursing students' stated anxiety compared with the faculty-led orientation method (M = 7.29, SD = 16.20). The 95% confidence interval for the difference in means ranged from −4.29 to 13.42. To verify no statistical difference between the two orientation methods, Cohen's d also was calculated and revealed a small effect size at 0.457. Figure 2 compares the results for the two groups.

Results of the independent sample t test with SD for the two samples' stated anxiety levels. Error bars display the mean difference (black solid line) of pre- and poststate anxiety results between the two orientation methods, with the SD represented above and below the mean by the surrounding shaded box.

Figure 2.

Results of the independent sample t test with SD for the two samples' stated anxiety levels. Error bars display the mean difference (black solid line) of pre- and poststate anxiety results between the two orientation methods, with the SD represented above and below the mean by the surrounding shaded box.

A second research question also was examined: When controlling for chronic trait anxiety, what is the effect of the augmented reality 360° photosphere on the anxiety level of preli-censure nursing students as they enter a clinical environment compared with the anxiety level of prelicensure nursing students who do not experience the augmented reality 360° photosphere? Assumptions underlying ANCOVA were met. The result of the ANCOVA was not statistically significant (F [1,44] = 1.13, MSE = 64.86, p = .29). Thus, controlling for trait anxiety had no statistically significant effect on the orientation method, and the null hypothesis was retained.

Discussion

Although there was a decrease in the anxiety levels of prelicensure nursing students who had AR 360° orientation, there was no statistically significant difference between AR 360° photosphere technology and faculty-led orientation on prelicensure nursing students' anxiety levels as they entered a new clinical environment. Previous studies that compared preparatory clinical orientation course methods also found no significant effects. Baksi, Gumus, and Zengin (2017) compared anxiety levels in a group of nursing students who did not receive a preparatory clinical orientation course and anxiety levels of a group who received a 2-week preparatory clinical orientation course. There was no statistically significant difference in anxiety levels between the two groups.

Turner and McCarthy (2017) also had inconclusive results on methods to elevate stress after reviewing 26 studies that focused on identifying the unique stressors and exacerbation of anxiety that occur when undergraduate nursing students have their first clinical rotation or are introduced to the clinical setting for the first time. However, the authors recommended the development of an effective method that could be used both immediately and long-term to reduce anxiety that would benefit students, faculty, health care employers, and patients (Turner & McCarthy, 2017).

The discussion of anxiety-reducing methods for both short-and long-term benefits also was reflected in a phenomenological study by Sun et al. (2016) on undergraduate nursing students' lived experiences of anxiety during their first clinical practicum. The findings showed nursing students' anxiety levels increased with uncertainties related to the clinical area before the first clinical experience and were exacerbated during the clinical setting until near the end of the rotation when the students became accustomed to the clinical setting. Having an orientation to a clinical environment that focuses on multiple methods over time may be the most beneficial for students during the initial and long-term clinical learning experience (Baksi et al., 2017; Cowen, Hubbard, & Hancock, 2016; Turner & McCarthy, 2017). With no immediate significant statistical difference found in the current study between the AR 360° photo-sphere orientation and the faculty-led orientation, it is evident that the autonomous AR 360° photosphere orientation method offers the benefit of being able to be used multiple times both immediately as well as in the long term.

Additional findings from this study also were noted with the potential benefit to the standardization that the AR 360° photosphere orientation methodology offers. In the STAI score interpretation (Spielberger et al., 2015), there are specific psychometric properties to full-time college students. The full-time college student state anxiety level has a psychometric average range from 36.47 to 38.76 (males versus females) with an SD of 10.02 and 11.95, respectively, and alpha reliabilities of 0.91 and 0.93, respectively (Spielberger et al., 2015).

However, results in the current study differed from the psychometric properties norms of Spielberger et al. (2015), with the pre- to postscore differences in SD. The difference of state anxiety in the prelicensure nursing students in the faculty-led orientation method was M = −7.29 (SD, 16.20) compared with M = −2.73 (SD, 9.12) for the prelicensure nursing students in the AR 360° photosphere orientation. The 95% confidence interval for the difference in means ranged from −4.29 to 13.42. The faculty-led orientation method had a large SD that was higher than the norm reported by Spielberger et al. (2015) for full-time college students (10.02 or 11.95, dependent on sexual orientation). The AR 360° photosphere orientation method SD was lower than the norm reported by Spielberger et al. (2015). Conversely, the results of this study aligned with the work of Wedgeworth (2016), who compared prelicensure nursing student scores with normal non-nursing college students and found early nursing state anxiety levels at 51.16 with an SD of 9.29.

The large difference in SD for the prelicensure nursing students' anxiety levels within the faculty-led orientation could reflect the variance of the orientation method. For instance, Killam and Heerschap (2013) reported inconsistencies with clinical orientation between clinical educators and the preferences of clinical units regardless of the expectation set by the educating institution. Dunker, Manning, and Knowles (2017) acknowledged that novice and seasoned clinical nurse instructors are overwhelmed in giving a thorough student clinical orientation on the first day entering the clinical environment. A thorough orientation can be difficult and overwhelming as variances include not only the faculty inconsistency of the orientation but also the availability of the clinical environment to allow the orientation to occur at the fullest potential. Despite the difficulty in giving thorough orientations, Cowen et al. (2016) recommended an in-depth orientation to the clinical setting to decrease anxiety. Lea, Andrews, Stronach, Marlow, and Robinson (2017) also studied the importance of a strategic constructed orientation that would support nursing students.

The results of this study showed no statistical difference in anxiety levels between the two orientation methods. Previous researchers such as Baksi et al. (2017), Cowen et al. (2016), and Turner and McCarthy (2017) suggested the potential benefit of an orientation method that offers both short- and long-term benefits to students as it highlights the opportunity that self-directed learning, AR, has in becoming the standardized orientation method to a new clinical environment. The technology of the AR 360° photosphere ensures prelicensure nursing students receive the same information and the ability to discover their new clinical environment. The discovery of learning can occur before the first clinical experience and during the entire clinical rotation, allowing prelicensure nursing students to continue to discover or reinforce their awareness to previous encounters within the clinical environment. With each encounter in the clinical setting, one becomes more comfortable in the environment, and there is the potential to decrease the anxiety experienced when entering the clinical setting.

Limitations and Recommendations

This study was completely voluntary, with no compensation for participation reflecting a significant attrition rate from those eligible, to initial consent, and to final completion of the postsurvey, leading to a small sample size. The generaliz-ability of the study may be limited due to the small sample, which was a convenience sample, and nonrandomization of bachelor of science nursing programs in a midwestern metropolitan area. Due to the small sample size that could allow minorities to be identified, minimal demographic information was obtained.

There also was no verification of the consistency level of the faculty-led orientation method. An orientation checklist was supposed to be followed, but potential variation may have occurred with the faculty-led orientation based on the different experience levels of the faculty and their familiarity with the specific clinical site. There was also the potential variation due to the availability of the clinical environment as there were no guarantees at the time of the faculty-led orientation that the specific area to be included in the orientation, such as a patient room, would be available for use. Another potential limitation was having participants complete the postsurvey only once right after their orientation did not allow understanding of the long-term benefit of each orientation.

Future recommendations would be to compensate participants upon completion of the postsurvey and to have participants complete an additional postsurvey at the end of the clinical rotation. In addition, adding a qualitative method should be considered in future research studies. By using only a quantitative quasiexperimental method, it was difficult to understand whether there were any other variables affecting the participant's state-anxiety level during the study period, which would be understood with a qualitative component.

Conclusion

This study sought to determine the effect that the use of AR 360° photosphere technology had on prelicensure nursing students' level of anxiety as they entered a new clinical environment compared with prelicensure nursing students' level of anxiety who did not experience AR 360° photosphere orientation. Although there was no statistical difference in anxiety levels between the AR and faculty-led orientation groups, value was brought forth in the form of standardization of information delivered and in reduced faculty and student time commitments, which has a direct impact on faculty productivity. By using AR 360° photosphere as a standardized, autonomous, and active orientation method, nursing academia can adopt a new standardized clinical orientation approach that initially occurs prior to students' first clinical experience and that can be referenced on-demand as needed throughout the clinical rotation, giving nursing students the opportunity to maximize their clinical experience to achieve learning outcomes.

Future research could focus on other variables such as illness, relationships, or academic stressors (e.g., examinations) that could affect nursing students' state-anxiety level, along with adding a postsurvey at the end of the clinical rotation. The increased focus on achieving learning outcomes realized by the implementation of AR has a direct impact on the safety and quality of care being provided to patients and the achievement of desired outcomes that lead to safe and quality patient care.

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Prelicensure Curriculum Characteristics of Participants (N = 47)

CharacteristicAll Participants, n (% of Total)AR, n (%)Faculty-Led, n (%)
Current semester level
  Junior 1st12 (25.5)12 (25.5)0
  Junior 2nd20 (42.8)9 (19.1)11 (23.4)
  Junior 3rd14 (29.8)8 (17)6 (12.8)
  Senior 1st1 (2.1)1 (2.1)0
Previous clinical hour experience
  0 to 35 hours7 (14.9)6 (12.8)1 (2.1)
  36 to 72 hours7 (14.9)7 (14.6)0
  72 to 108 hours8 (17)4 (8.5)4 (8.5)
  >108 hours15 (31.9)9 (19.1)6 (12.8)
  Not sure10 (21.3)4 (8.5)6 (12.8)
Previous clinical experiences
  Long-term care6 (12.8)6 (12.8)0
  Medical-surgical27 (57.4)13 (27.7)14 (29.8)
  Pediatrics3 (6.4)3 (6.4)0
  Psychiatric7 (14.9)4 (8.5)3 (6.4)
  None4 (8.5)4 (8.5)0
Authors

Dr. Ball is Assistant Professor, Creighton University College of Nursing, Omaha, Nebraska; and Dr. Hussey is Academic Program Coordinator, School of Nursing, College of Health Sciences, Walden University, Minneapolis, Minnesota.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Sarah Ball, PhD, RN, RNC-OB, C-EFM, 16603 Ehlers Street, Omaha, NE 68135; e-mail: sarahkoza@yahoo.com.

Received: April 06, 2019
Accepted: November 25, 2019

10.3928/01484834-20200220-04

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