Evaluating an Education Program That Incorporated Virtual Reality for Teaching Aggression Management: A Pre‐Post Pilot Study With Nursing Students

ABSTRACT

Aim

This paper presents a pilot study evaluating the acceptability, feasibility and effectiveness of an education program incorporating virtual reality for teaching aggression management among final‐year undergraduate nursing students at one university in Western Australia.

Background

Virtual reality can be useful for simulating high‐risk clinical situations without exposing nursing students to the potential consequences of encountering the event in the real world. As such, virtual reality is useful when incorporated into education on the prevention and management of aggression, preparing students to be industry‐ready. However, there is a gap in the literature regarding the use of virtual reality in teaching in this area of the curriculum.

Design

This is a pilot study that used a quantitative pre‐ and post‐education survey design.

Methods

Nursing students completed pre‐education surveys, participated in an educational program that incorporated virtual reality (VR) to teach aggression management and then completed post‐education surveys.

Results

The participants (n = 11) completed both the pre‐ and post‐education surveys, as well as provided qualitative responses. The findings showed that the education program was effective in increasing nursing students' confidence in managing aggression (p > 0.022). Participants also reported that the use of virtual reality was realistic to simulate the aggressive clinical scenario (M = 6.18, SD = 0.75), to stimulate experiential learning to manage aggressive persons (M = 6.18, SD = 0.60) and that the debrief helped them to reflect and consolidate their learning (M = 6.36, SD = 0.67). They also reported that the Virtual Reality Aggression Management education program was more effective than traditional didactic methods of teaching this subject area (M = 6.45, SD = 0.52).

Conclusions

The findings of this pilot study will be further explored and developed based on the findings of this pilot work. Further research will be conducted with a larger scale of nursing and other healthcare students.

1. Introduction

Aggression in the clinical setting is a serious problem that can significantly erode the safety of both staff and patients (Hills et al. 2018; Lantta et al. 2016). Aggression is viewed as behaviours such as verbal abuse or physical assaults that have the potential to hurt others or cause damage to objects (Lim et al. 2017). Aggression in the healthcare setting can significantly increase health expenditure due to medical and legal costs, the need for higher staff ratios or the use of security guards to maintain safety (Grossi et al. 2015; Heckemann et al. 2019; Morphet et al. 2014; Tattoli et al. 2019). To limit the impact of aggression, many health services have adopted a proactive risk prevention and management approach towards any individual who displays disruptive behaviours (Slemon et al. 2017).

Internationally, it is estimated that 75% to 100% of nurses will encounter aggression at some point in their work life (Chambers et al. 2015; Iozzino et al. 2015; Olupona et al. 2017). It is well documented that nurses who experience aggression may display symptoms of acute or post‐traumatic stress (Ashton et al. 2018; Jalil et al. 2017; Lantta et al. 2020; Olsson et al. 2015). Some may experience feelings of guilt, self‐doubt and professional incompetence if they blame themselves for failing to recognise or de‐escalate a situation before the aggressive incident occurred (Edward et al. 2014; Jalil et al. 2017; Llor‐Esteban et al. 2017; Searby et al. 2019). These negative experiences can negatively impact the individual nurse's work performance, job satisfaction, and, ultimately, their career choices (Dickens et al. 2013; Edward et al. 2014; Itzhaki et al. 2015; Llor‐Esteban et al. 2017). Those who develop a fear for their safety can become focused on performing clinical tasks and distance themselves by spending less time interacting with and caring for patients (Lim et al. 2017).

Nurses must routinely complete mandatory education to prepare them with the knowledge and skills to de‐escalate, prevent and manage aggression in clinical settings (Morphet et al. 2018). This education is generally delivered using didactic presentations and hands‐on teaching techniques including role plays, practical skill training, lectures and workshops (Baby et al. 2018; de la Fuente et al. 2019), to equip nurses with a range of breakaway techniques and de‐escalation strategies (Duxbury et al. 2019; Heckemann et al. 2015; Morphet et al. 2018; Wilson et al. 2017). These regular training sessions are critical to maintaining nurses' confidence to work with persons at risk for aggression and to minimise harm if aggression does eventuate (Kuivalainen et al. 2017; Maguire et al. 2017).

1.1. Applicability of Virtual Reality Technology for Aggression Management

Using novel technologies such as virtual reality (VR) has the potential to improve or change aggression management education as it allows nurses' exposure to simulated challenging and confronting behaviours in a safe environment (Liaw, Wu, et al. 2020; Mendez et al. 2020; Rim and Shin 2021; Rourke 2020). VR is already used in many areas of health, such as completing surgical procedures (Bracq et al. 2019), interprofessional competencies (Liaw, Ooi, et al. 2020; Williams et al. 2020), intravenous catheter insertion (İsmailoğlu et al. 2020) and gastrointestinal endoscopy (Bhushan et al. 2018), to name a few.

VR can also be used to simulate high‐risk clinical situations without exposing individuals to the potential consequences of encountering such events in the real world (İsmailoğlu et al. 2020; Rourke 2020). For example, Zikas et al. (2021) utilised VR to train nurses in the techniques of performing nasopharyngeal swabs and donning and doffing Personal Protective Equipment (PPE) during the COVID‐19 pandemic. Their preliminary study results showed a statistically significant improvement in sensorimotor performance of VR trainees (approximately 16% higher) compared to training using traditional methods (Zikas et al. 2021). In the field of mental health, VR was used to help health professionals learn about people with dementia (Wijma et al. 2018), psychosis and schizophrenia (Banks et al. 2004; Lee, Kim, and Eom 2020; Yellowlees and Cook 2006), and perform a mental state assessment (Kidd et al. 2012). Currently, there is a gap in the literature regarding the use of VR to teach nurses how to manage high‐risk, aggressive clinical situations. A pilot study in this area was developed and conducted by the team.

1.2. Purpose of This Pilot Study

The purpose of this pilot study was to evaluate the feasibility, acceptability and effectiveness of an education program incorporating VR for teaching aggression management. The aim was to test the education program with nursing students before testing it with nurses working in hospitals. The research questions guiding this study were:

1. Are there pre‐ and post‐education differences in nursing students' attitudes and confidence in managing aggression?

2. Are there pre‐ and post‐education differences in nursing students' empathy, knowledge and attitudes towards persons with a mental illness?

3. What is the experience of nursing students regarding the use of VR in the education program for teaching aggression management?

2. Methods

2.1. Design

The pilot study used a quantitative pre‐ and post‐education survey design. Nursing students completed the pre‐education surveys, participated in an educational session that incorporated virtual reality (VR) to teach aggression management, and then completed the post‐education surveys. The following data questionnaires were used to answer the research questions.

2.2. Education Intervention

Virtual Reality Aggression Management (VRAM) is an educational program designed to teach aggression management, utilising virtual reality technology. The (Anonymised A) developed and shared the education program with (Anonymised B) through a research collaboration agreement. VRAM consists of a 50‐min didactic lecture, a 30‐min pre‐practical discussion of the scenario and the use of a VR head‐mounted device and a 50‐min practical session, which includes a post‐practical group debrief. Table 1 provides more details of the components in VRAM.

TABLE 1.

Structure and components of VRAM.

Components	Duration	Content
Didactic lecture	50 min	Define aggression in clinical settings. Discuss the five stages of the assault cycle (Kaplan and Wheeler 1983). Discuss the possible triggers and risks for aggression. Describe the management of an aggressive person.
Pre‐practical discussion	30 min	Provide a handover of the person in the VR scenario. Provide instructions on how to operate the head‐mounted device and controllers such as how to navigate and teleport in the simulated VR environment.
Practical session	50 min	Immerse participants into a virtual ward environment. Conduct a post‐practice group debrief.

2.3. Participants

This study was conducted with a class of 14 final‐year nursing students enrolled in the undergraduate pre‐registration comprehensive nursing course at (Anonymised B). As there is no standard for pilot study sample size, a sample size as small as 10–40 has been recommended (Hertzog 2008; Saab et al. 2018). These participants chose a Mental Health Wellbeing unit as their elective unit, which was delivered in Semester 1, 2024. This unit is delivered in four workshops (defined as practical hands‐on interactive sessions) over a four‐week period. Each workshop is three hours' duration.

2.4. Procedures

VRAM was delivered in the third workshop. Students were informed that their attendance and participation in the workshop were mandatory to support them in learning how to manage aggression, but their participation in the study was voluntary. All participants were given a copy of the Participant Information Form to inform them of the nature and purpose of this study. They were also informed that their responses to the pre‐ and post‐education surveys would be non‐identifiable and that only basic demographic information would be collected.

During the workshop, the corresponding author (an experienced lecturer and mental health nurse) delivered the didactic lecture and pre‐practical discussion. Participants were then divided into groups of 3 to 5 to attempt the immersive VR scenario. The third author supported each new group of participants in starting the VR scenario. Finally, the corresponding author conducted the debrief with participants once each group had completed the VR scenarios.

During the practical session, participants were presented with three consecutive scenarios. The first scenario requires them to manage an angry person who was upset with the quality of care provided to his mother, and the second and third scenarios require them to manage a woman who is experiencing paranoid delusions and was angry to be admitted to the hospital (see Figure 1; permission to use the pictures was obtained from SYSG and CSHH of the research team). The first scenario allows the participant to identify ways to de‐escalate the angry person; the second scenario focuses on the participant's ability to interact therapeutically with a person with paranoid delusions; and the third scenario tests the participant's ability to diffuse an angry person. During their interactions with the VR character, a time‐forced (8‐s) multiple‐choice question appeared on the screen when a clinical decision was needed. The participant is required to choose an answer in the given time frame. There are a total of 16 multiple‐choice questions in the VR scenario, and the answer chosen by the participant determines the outcome of their VR scenario.

FIGURE 1.

Screenshot of (a) an angry person who was upset with the quality of care provided to his mother in scenario 1 and (b) a woman with paranoid delusions who was angry to be admitted to the hospital in scenarios 2 and 3.

2.5. Ethical Considerations

This pilot study was conducted at (Anonymised B) in February 2024. Approval of the study was obtained from (Anonymised B) Human Research Ethics Committee (Approval number: HRE2022‐0491).

2.6. Outcomes

2.6.1. Demographic Data

Demographic variables, including age, gender, highest qualification and nationality, were collected through a self‐report questionnaire prior to the education session.

2.6.2. Confidence in Coping With Patient Aggression Instrument (CCPA)

The CCPA (Thackrey 1987) was used to collect measures on nursing students' confidence in coping with an aggressive person. The CCPA (Cronbach's α = 0.81) consists of 10 items that utilise an 11‐point Likert scale, ranging from 1 (low confidence) to 11 (high confidence). Higher scores indicate greater confidence, while lower scores suggest a need for further training or support in managing aggressive situations.

2.6.3. Jefferson Scale of Empathy Health Professions Student Version (JSE‐HPS)

The JSE‐HPS (Hojat et al. 2018) was used to collect measures of nursing students' empathy towards an aggressive person. JSE‐HPS (Cronbach's α = 0.81) consists of 20 items, each using a 7‐point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicate higher levels of empathy, while lower scores suggest lower levels of empathy.

2.6.4. Management of Aggression and Violence Attitude Scale (MAVAS)

The MAVAS (Duxbury 2003) was used to collect measures on nursing students' attitudes towards managing aggression. MAVAS (Cronbach's α = 0.74) consists of 13 statements communicating causes of aggression and violence (internal, external and situational/interactional) and 14 statements communicating different approaches to aggression management on a visual analogue scale (VAS) representing the extent to which they agree or disagree with the statement (Duxbury et al. 2008; Lepiešová and Tomagová 2014). Examples of internal factors are the person's illness, personality traits and substance abuse; examples of external factors are aspects of the ward environment, such as overcrowding or loud noises; and examples of situational/interactional factors are interpersonal conflict, relationship or communication breakdown (Duxbury 2015). Higher scores may indicate more positive attitudes towards managing aggression and violence in healthcare, while lower scores may indicate less positive attitudes.

2.6.5. Mental Health Literacy Scale (MHLS)

The MHLS (O'Connor and Casey 2015) was used to collect measures on nursing students' knowledge and attitudes regarding mental health. MHLS (Cronbach's α = 0.87) consists of 35 items. The first 15 items are scored on a 4‐point Likert scale ranging from 1 (very unlikely) to 4 (very likely). Items 16–35 are scored on a 5–5‐point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate greater knowledge and more positive attitudes towards mental health.

2.6.6. Opening Minds Scale for Healthcare Providers (OMS‐HC)

The OMS‐HC (Kassam et al. 2012) was used to collect measures on nursing students' degree of stigma towards people with mental disorders. OMS‐HC (Cronbach's α = 0.82) consists of 15 items that use a 5‐point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores may indicate more positive attitudes, greater empathy and better understanding of mental health issues.

2.6.7. Virtual Reality Neuroscience Questionnaire (VRNQ)

The VRNQ (Kourtesis et al. 2019) was used to collect measures of nursing students' experiences with immersive VR for neuropsychological assessments following the education session. The VRNQ (Cronbach's α = 0.82) consists of 20 items on a 7‐point Likert scale, ranging from 1 (extremely low) to 7 (extremely high).

2.7. Session Evaluation Questionnaire

The session evaluation questionnaire was developed by the SYSG and CSHH research teams to collect post‐education variables related to the nursing students' learning experiences. In this unvalidated questionnaire, nursing students were able to provide qualitative written comments or feedback on their learning experiences.

2.8. Data Collection

Participants who volunteered to participate in this pilot study were provided with a hardcopy booklet that contained Part 1—demographic data questionnaire and pre‐education questionnaires (CCPA, JSE‐HPS, MAVAS, MHLS and OMS‐HC), and Part 2—session evaluation questionnaire and post‐education questionnaires (CCPA, JSE‐HPS, MAVAS, MHLS, OMS‐HC and VRNQ). They were informed to complete Part 1 before attending VRAM and then Part 2 after attending VRAM on the same day at their convenience. Students who volunteered were asked to drop the booklet into a sealed box outside the first author's office, and their informed consent was inferred if they returned the completed booklet to the research team. Students who did not wish to participate in the study did not complete the pre‐ and post‐data collection procedures.

2.9. Data Analysis

The collected pre‐ and post‐education measures were analysed using SPSS, and the selected statistical significance level for testing the hypotheses was p < 0.05. Due to the small sample size and non‐normal distribution of scores, the Wilcoxon signed‐rank test was used to evaluate the median difference between the collected pre‐ and post‐education measures, with an alpha level of 0.05. When data are not normally distributed, comparing medians instead of means reflects the difference between two time points better. Lastly, the education demographic variables of the participants, VRNQ and the session evaluation questionnaire were analysed using descriptive statistics.

3. Results

All 14 nursing students took a copy of the hardcopy booklet. However, two of the nursing students were absent during Workshop 3, and one did not return the booklet to the research team. Thus, only 11 nursing students participated and were included in the data collection. Most participants identified as female (n = 9) and were aged between 20 and 29 (n = 9). Table 2 provides additional information on the demographic characteristics of the participants.

TABLE 2.

Demographic data of the participants.

Demographic data (n = 11)	Frequency (%)
Age
20 to 29	9 (82)
30 to 39	1 (9)
(Missing)	1 (9)
Gender
Male	1 (9)
Female	9 (82)
(Missing)	1 (9)
Highest attained education level
High school	5 (46)
Diploma	1 (9)
Undergraduate	3 (27)
(Missing)	2 (18)

4. Findings

Table 3 provides an overview of all the comparisons between pre‐ and post‐education scores. The data analysis found a statistical difference in median total scores of MAVAS factors external and situational/interactional and CCPA scale. The median total score of the external factor was 11.00 (IQR = 4), while it decreased to 10.00 (IQR = 3) after the VR scenario. A Wilcoxon matched‐pairs signed‐rank test revealed a statistically significant decrease after the VR scenario, with a large effect size, p < 0.041. The median total score of the situational/interactional factor was 16.00 (IQR = 3), while it decreased to 13.00 (IQR = 1) after the VR scenario. A Wilcoxon matched‐pairs signed‐rank test revealed that the decrease after the VR scenario was both large and statistically significant (p < 0.024). Finally, the median total score of the CCPA was 28.00 (IQR = 16), while it increased to 32.00 (IQR = 7) after the VR scenario. A Wilcoxon matched‐pairs signed‐rank test revealed that the increase after the VR scenario was both large and statistically significant (p < 0.022). Lastly, there were no significant differences between the other pre‐ and post‐education JSE‐HPS, MHLS and OMS‐HC measures.

TABLE 3.

Pre‐test and post‐test comparisons of the scores.

	Pre‐test median (IQR)	Post‐test median (IQR)	p
MAVAS	58 (12)	51 (14)	0.126
Internal	15 (3)	14 (3)	0.964
External	11 (4)	10 (3)	0.041*
Situational/interactional	16 (6)	13 (1)	0.024*
Management	14 (3)	13 (4)	0.672
CCPA	28 (16)	32 (7)	0.022*
JSE‐HPS	115 (20)	119 (19)	0.091
MHLS	138 (21)	143 (26)	0.197
OMS‐HC	25 (6)	26 (15)	0.759

Abbreviations: CCPA, Confidence in Coping with Patient Aggression Scale; JSE‐HPS, Jefferson Scale of Empathy for Health Profession Scale; MAVAS, The Management of Aggression and Violence Attitude Scale; MHLS, The Mental Health Literacy Scale, OMS‐HC, Opening Minds Stigma Scale for Health Care Providers.

^* p < 0.05.

Table 4 shows the descriptive statistics of the VRNQ scores of the 11 participants who completed the VRAM. The overall mean VRNQ score was 4.91 (SD = 0.60). As shown in Table 5, the mean scores that participants provided for Questions 1 to 15 revealed that they were largely positive about their experience of using VR in education for aggression management. Most participants reported that they enjoyed the VR scenario (M = 6.09, SD = 0.83). They also expressed positive opinions about the quality of sound (6.45, SD = 0.688), game instructions (M = 6.18, SD = 0.98), game prompts (M = 6.09, SD = 0.83) and overall quality of the VR technology (M = 6.09, SD = 0.70). Furthermore, the mean scores that participants provided to Questions 16 to 20 indicated that most of the participants did not experience adverse reactions to the use of VR.

TABLE 4.

Virtual Reality Neuroscience Questionnaire (VRNQ) scores.

Questions	N	Min.	Max.	Mean	SD
1. What is the level of immersion you experienced?	11	4	7	5.82	1.079
2. What was your level of enjoyment of the VR experience?	11	5	7	6.09	0.831
3. How was the quality of the graphics?	11	4	7	5.64	1.120
4. How was the quality of sound?	11	5	7	6.45	0.688
5. How was the quality of the VR technology overall?	11	5	7	6.09	0.701
6. How easy was it to use the navigation system in the virtual environment?	11	3	7	5.36	1.206
7. How easy was it of physically move in the virtual environment?	11	4	7	5.55	0.934
8. How easy was it to pick up/or place items in the virtual environment?	11	4	7	5.55	0.820
9. How easy was it to use items in the virtual environment?	11	4	7	5.64	0.924
10. How easy was the two‐handed interactions?	11	3	7	5.09	1.375
11. How easy was it to complete the tutorial?	11	3	7	5.91	1.300
12. How helpful was/were the tutorial?	11	5	7	6.36	0.809
13. How did you feel about the duration of the tutorial?	11	3	7	5.82	1.168
14. How helpful were the in‐game instructions for the task you needed to perform?	11	4	7	6.18	0.982
15. How helpful were the in‐game prompts?	11	5	7	6.09	0.831
16. Did you experience nausea?	11	1	5	1.91	1.375
17. Did you experience disorientation?	11	1	5	3.09	1.640
18. Did you experience dizziness?	11	1	6	2.27	1.489
19. Did you experience fatigue?	11	1	3	1.45	0.820
20. Did you experience instability?	11	1	4	1.73	1.191

TABLE 5.

Session Evaluation Questionnaire Scores.

Questions	N	Min.	Max.	Mean	SD
The VR software helped me to understand symptoms faced by a person with mental health conditions in a realistic manner.	11	5	7	6.18	0.874
The scenario depicted are realistic and have learning values.	11	5	7	6.18	0.751
The VR software provided an immersive experience.	11	5	7	6.27	0.786
I would like to recommend other people to go through this experience because I find it helpful.	11	5	7	6.45	0.688
The session was conducted in an engaging manner.	11	5	7	6.45	0.820
The debriefing session was useful for consolidating my learning.	11	5	7	6.36	0.674
I would like to use the VR software again.	11	5	7	6.45	0.688
I now have a better understanding of how to manage agitated person.	11	5	7	6.18	0.603
The VR software allowed me to learn how to manage agitated person and person with a mental illness more effectively than just attending didactic lectures and tutorials.	11	6	7	6.45	0.522

Table 5 shows the descriptive statistics of the session evaluation scores of the 11 nursing students who completed VRAM. The overall mean score of the session evaluation was 6.33 (SD = 0.57).

As shown in Table 5, most participants reported that the sessions in the education on aggression management were conducted in an engaging manner (M = 6.45, SD = 0.82) and that the debrief session was helpful in consolidating my learning (M = 6.36, SD = 0.67). The findings were supported by the participants' written comments that the education was “interesting, easy to understand” (P3) and that “everything was good” (P5). Additionally, most participants also indicated that the use of VR allowed them to learn how to manage an agitated person and a person with a mental illness more effectively than just attending didactic lectures and tutorials (M = 6.45, SD = 0.52). Hence, they would like to use the VR software again (M = 6.45, SD = 0.69) would recommend other people to go through this experience (M = 6.45, SD = 0.688). Again, the findings were supported by the participants' written comments, which included “the graphics and sound are good” (P3), “creative, fun, great source of learning” (P5), and that the use of VR was “engaging, good visual learning” (P10).

Lastly, the participants highlighted some elements of VRAM that they felt could be improved. While immersed in the VR scenario, some participants reported that it was “difficult to teleport on a specific location” (P3) and that “the words can be hard to read [so] the game instructions should pause until the player toggles continue in case of readers” (P5). Other participants recommended that it “may be good to have more head‐mounted devices as [they] have to wait for a while to get a turn to use the VR googles” (P6) and that “the screen of the could be shown on the big screen so that other students could see. This could be much more interactive for the rest of the class” (P10). One of the participants who gave feedback positively stated that she “would like to see some higher level of [challenging behaviours], for example, someone who is… threatening to deliberate self‐harm or harm others” (P9) in a future education program for teaching aggression management that incorporates VR.

5. Discussion

This paper reports a pilot study with nursing students to test the acceptability, feasibility and effectiveness of VRAM. This education program incorporated the use of VR to teach aggression management. We found that first, VRAM was effective in improving nursing students' confidence in coping with an aggressive person; second, VR was realistic in simulating the aggressive clinical scenarios; third, the VR stimulated experience was informative for practical management of aggressive persons; fourth, the debrief helped them to reflect and consolidate their learning; and finally, VRAM was more effective than didactic methods in teaching nursing students about aggression management.

The findings highlighted that VRAM was well accepted by the participants as an engaging and interactive way of learning aggression management. They found the practical session to be novel, fun, realistic and practical, as it allowed them to experience an aggressive situation in a clinical setting. The participants' experiences in this study were similar to those in other nursing education studies that incorporated the use of VR (Breitkreuz et al. 2021; Saab, Hegarty, et al. 2021; Saab, Landers, et al. 2022; Thompson et al. 2020).

The participants found the debrief helpful for consolidating their learning. Debriefing is considered the most critical feature of an education program that incorporates the use of VR, as it facilitates the process of reflection after the learning experience (Verkuyl et al. 2018). This pilot study found that the debriefing fostered participants' performance and supported them in consolidating their learning to manage future aggressive situations in clinical settings (Lee, Lee, et al. 2020). However, some participants suggested that it would be more beneficial for them to observe how their peers managed aggression, for example, on a seminar room's presentation screen, so that they could reflect on and learn from each other's experiences.

The findings showed that VRAM has the potential to improve nursing students' confidence in managing a challenging clinical situation, such as de‐escalating a person with aggression or a person with paranoid delusion. Although nursing students were generally excluded from caring for persons at risk of aggression during their clinical placement, they are still frontline healthcare providers in the clinical settings. As such, they are still at risk of encountering an aggressive person due to the amount of time that they spend in the clinical environment. Previous studies identified nursing students as a high‐risk sub‐group to encounter aggression at some point in their clinical practice (Beech 2008; Parkin 2010). Yet, nursing students are generally not well prepared to manage an aggressive clinical situation (Beech 2008). If an education program such as VRAM is incorporated into the nursing curriculum, nursing students may be better prepared to handle aggressive situations clinically. This may reduce the negative psychological impacts of experiencing an aggressive incident. Nursing students who are better prepared to manage an aggressive situation are also more likely to make clinical decisions confidently to contain or de‐escalate the person's level of aggression risk.

The findings showed that VR was effective in simulating aggressive clinical situations to engage nursing students in experiential learning. Previous studies found that the use of VR when used in clinical situations that are complex to demonstrate yielded the most positive learner experiences (Botha et al. 2021; Jeong et al. 2022). This is because participants are immersed in a three‐dimensional virtual environment, and the combination of audio‐visual effects can enhance the realism of experiencing the scenario (Botha et al. 2021; Hannans et al. 2021; Lange et al. 2020).

Finally, the participants reported that they were more likely to focus on the internal factors of aggression caused after being immersed in the VR scenario. This could be due to the focus of the VR scenario on creating realistic interpersonal aggression for testing the participants' abilities to de‐escalate the person. However, studies have found that health professionals are more likely to use reactive practices and an over‐reliance on coercion if they do not perceive external factors or situational/interactional factors as the cause of their aggression (Duxbury 2015). This is particularly so if the other contributory factors are not recognised or addressed as part of a preventative strategy (Duxbury 2015). As such, more work is needed to ensure that the use of VR in education on aggression management can support participants in learning to recognise and de‐escalate the multifactorial factors for aggression in clinical settings (Bowers et al. 2015; Kuivalainen et al. 2017; Maguire et al. 2017; Price and Baker 2012).

6. Limitations

This pilot study is limited by the small sample size, which may hinder the generation of generalizable findings. However, the findings can inform novel insights into the effects of using VR in education on aggression management for nursing students. The high retention rate of participants who attended VRAM (91.6%) can be attributed to the attractiveness of education on aggression management, the use of VR in education, or both, in preparing nursing students for real‐life challenges during their clinical placements. Secondly, there was a lack of a control group to compare the changes in outcomes resulting from VRAM. As such, a crossover experimental study involving nursing students may be considered in future research to compare the use of traditional methods, clinical simulation methods and virtual reality (VR) in delivering education on aggression management. Thirdly, the researchers were limited by the cost of acquiring head‐mounted devices and developing additional VR scenarios to test the use of VR in teaching health professionals to manage aggression in clinical settings. Lastly, the Session Evaluation Questionnaire used in this study was not validated.

7. Implications of Findings

VR in nursing education is potentially beneficial in preparing nursing students for real‐life clinical challenges and should be further explored to develop evidence‐based practice. While the initial cost of acquiring the head‐mounted device and developing more VR scenarios may appear unattractive for academic and healthcare organisations, the use of VR is, in fact, more cost‐effective. Moreover, it standardises the content exposure across different students attending different clinical sites. This means it installs consistency in organising education across complex healthcare situations for many participants at different times and locations. For example, nursing students in this pilot study experienced the same level of aggression. They enabled the first author to debrief the participants simultaneously and achieve a more standardised, controlled, positive learning experience.

8. Conclusion

To the authors' knowledge, this paper is one of the first few studies to evaluate the use of an education program incorporating VR to teach nursing students how to manage aggression in clinical settings. As such, the findings are valuable for informing future research on the use of VR to teach health professionals how to manage aggression. Further research will be conducted with a larger number of nursing students and other health professionals to generate more empirical findings and develop evidence‐based education.

Funding

This work was supported by the Curtin School of Nursing Strategic Fund 2023 and the Curtin University Faculty of Health Science 2023 Mark Liveris Seminar and Research Day Pitch Your Project seed grant‐ EMCR.

Conflicts of Interest

The authors declare no conflicts of interest.

Goh, S. Y. S. , Ho C. S. H., Sezer B., et al. 2026. “Evaluating an Education Program That Incorporated Virtual Reality for Teaching Aggression Management: A Pre‐Post Pilot Study With Nursing Students.” Nursing Open 13, no. 1: e70393. 10.1002/nop2.70393.

Data Availability Statement

Data available on request due to privacy/ethical restrictions.