Knoo Lee - Faculty Exchange Report 2025

University of Missouri South African Education Program (UMSAEP) Progress Report – Year 2024–2025

Principal Investigator: Knoo Lee, PhD, RN

Collaborators: University of Missouri (MU) & University of the Western Cape (UWC)

1. Introduction and Background

   Nursing education requires learners to practice in environments that simulate critical, often unpredictable, clinical situations. Traditional simulation-based training, while valuable, is resource-intensive, dependent on specialized equipment, and constrained by faculty-to-student ratios. More critically, such simulations often cannot fully replicate high-stakes emergency scenarios like cardiac arrest.

   Commercial VR platforms exist, but they are costly, proprietary, and often lack interoperability. This creates barriers for institutions with limited resources and restricts the sharing of educational innovations. To address these limitations, our project is developing an open-access VR simulation platform designed to:

   • Provide low-cost, scalable access to advanced simulation training.
   • Adapt to local clinical and cultural contexts.

   • Foster equitable global collaboration in nursing education.

     In 2023–2024 (Year 1), the UMSAEP-funded pilot demonstrated the feasibility of VR training by creating and testing a cardiac arrest scenario at MU and UWC. Based on positive results, the program approved an extension for 2024–2025 (Year 2). This year’s work focused on refinement, cultural customization, and larger-scale evaluation.

2. Project Aims (2024–2025)

   The Year 2 extension outlined four guiding aims:

   1. Customization & Localization – Refine the VR simulation to align with South African cultural and clinical practices.
   2. Expansion & Validation – Increase the number of participants and employ robust quantitative analysis to establish statistical significance.
   3. Strengthened Collaboration – Facilitate faculty and student exchange between MU and UWC.
   4. Publication & Dissemination – Produce scholarly outputs and secure external funding to scale the project.

3. Activities and Achievements
   

   1. Customization & Localization
      
      • Stakeholder input from UWC faculty and students informed clinical and cultural modifications.
      • Adjustments to NPC roles, emergency cart placement, and code blue button positioning were implemented.
      • Usability improvements addressed controller sensitivity and space limitations.
   2. Expansion & Validation
      
      • In 2024, 11 nursing students at UWC participated in the VR simulation.
      • Overall confidence scores rose by 4.11 points and anxiety dropped by 2.56 points, though neither was statistically significant (low sample size of 11 students). At the item level, confidence in applying personal knowledge increased by 0.50 (p = 0.046), anxiety decreased by 0.44 (p = 0.016) for the same item, and anxiety about decision-making in new settings dropped by 0.65 (p = 0.016). These findings show item-specific improvements despite no overall statistical significance.
      • For the 2025 cycle, a total of 75 nursing students at UWC were recruited to test the revised and customized VR simulation, expanding the dataset for robust analysis.
      • Pre- and post-surveys (NASC-CDM, GUESS-18, NASA-TLX) were conducted.
      • Preliminary findings show gains in readiness to practice and confidence.
   3. Collaboration & Exchange
      
      • MU faculty visited UWC, facilitating workshops, lectures, and demonstrations.
      • Students served as research assistants, enhancing training and mentorship.

   4. Dissemination Conference Presentations:

      Lee, K., Murrell, S., Fiebelkorn, L., Lewis, S., Nalmas, A., Pfingsten, B., Sturn, M., & Wang, F. (July 31, 2024). Leveraging Translation by Design in Nursing-Oriented Virtual Reality of Equitable Access. Panel: Translation by Design: Sustainable Research Approaches to Enhance Digital Health Equity. Presented at the International Medical Informatics Association – Nursing Informatics 2024, Manchester, UK. (International)

      Lee, K., Murrell, S., Fiebelkorn, L., Lewis, S., Nalmas, A., Pfingsten, B., Sturn, M., & Wang, F. (July 30, 2024). NOVA: Nursing-Driven Virtual Reality of Equitable Access. Presented at the International Medical Informatics Association – Nursing Informatics 2024, Manchester, UK. (International)

      Lee, K., Murrell, S., Hoffman, J., Peterson, M., Fiebelkorn, L., Lewis, S., Nalmas, A., Wang, F., & Chipps, J.-A. (April 24, 2025). Pilot Study: Open-Access Virtual Reality Simulations for Enhancing Clinical Readiness in Nursing. Accepted for presentation at the DisruptxRN Conference 2025, Columbus, OH. (National)

   5. Publications in Progress:
      
      1. Lee, K., Nalmas, A., Fiebelkorn, L., White, C., Murrell, S., Lane, K., Ulbrich, S., Lewis, S., Oscarson, M., Koboldt, T., & Wang, F. (2025). A feasibility study of open- access virtual reality simulation for nursing readiness. Manuscript submitted for publication.
      2. Paper 1 – 2024 Study (MU + UWC): Combined quantitative and qualitative results. MU’s quantitative analysis is complete, while UWC’s qualitative analysis is in progress. The manuscript will be submitted once both sets of results are finalized.
      3. Paper 2 – 2025 Study (MU + UWC): Quantitative data sorting from the 2025 expanded UWC cohort (75 students) is complete and a separate manuscript is being prepared for submission.

   6. Media Coverage:

      “UWC Incorporates Virtual Reality in Nursing Curriculum in Collaboration With University of Missouri.” University of the Western Cape – News & Announcements, 30 August 2024

   7. Grant (Submitted)

      Building on this collaboration, the following grant has been submitted:

      Project Title: Open-Access AI-Driven VR Simulations for Nursing Ethics Education Funding Agency: American Associations of Colleges of Nursing

      Funding Mechanism/Grant Number: AACN Faculty Scholars Grant Role: PI

      Principal Investigator: Knoo Lee

      Co-Investigators: John Robert Bautista, Fang Wang, Jennifer-Anne Chipps Dates of Project Period: 12/2025-11/2026

      Total Costs: $24,999

4. Future Plans

   Complete MU vs. UWC data analysis by Q3–Q4 2025.

   Develop new scenarios (syncope, hepatic encephalopathy, obstetric emergencies) and begin piloting by Q1-Q2 2026.

   Submit at least two peer-reviewed manuscripts by Q4 2025.

   Pursue NIH and ANA Innovation grants for scale-up during Q1–Q4 2026. Expand student mentorship in VR and nursing research throughout 2026. Share the open-source framework internationally by Q4 2026.

5. Conclusion
   

   The 2024–25 project year achieved key milestones in simulation customization, validation, and collaboration. Preliminary results confirm VR’s effectiveness in improving readiness and confidence. The project demonstrates the promise of open-access VR platforms for nursing education worldwide and sets the stage for future expansion and dissemination.