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Mixed Reality


Mixed reality is defined in the Healthcare Simulation Dictionary as “a category that encompasses the hybrid combination of virtual reality environments and reality (e.g., real environment, standardized patient, normal manikin simulator). Often encompasses the definition of Augmented Reality (AR), but has more virtual features than typical AR.” (Lioce et al., 2020, p. 30)


In 2017/2018, nursing faculty were introduced to mixed reality simulations that were being used by the School of Education in partnership with California State University Northridge (CSUN). Faculty was interested in exploring the possibility of the use of mixed reality in nursing education to improve opportunities for practical experience related to communication in health care situations. Often times, clinical experiences may allow for students to observe patient/family/staff interactions and conversations, but typically are not led by the student nurse. Therefore, many times nursing experience to practice and prepare for difficult situations occurs upon graduation during the first years in practice. In an effort to improve student preparation and communication skills necessary for the nursing role, mixed reality has been integrated into nursing education courses.


In partnership with CSUN’s SIMpact program (previously known as TeachLive), mixed reality simulations provide the ability for nursing students to engage in difficult conversations with highly realistic real-time virtual avatars. Prior to the simulated experience, following INACSL (2021) guidelines, students are provided information about the planned mixed reality simulation session (i.e. date, time, connection/arrival information, scenario overview, resources). At the start of the session, students are pre-briefed about the scenario again and oriented to the simulator, roles, and timeline for the session. In small groups, students take on the role of either the “action seat” or the “brain” to determine the direction of the conversation and how to tackle the situation. The students are in small groups (typically 8-15) either live in a classroom with a large monitor, or connected online via Zoom. The avatar engages in real time on screen, acknowledging the body language and communication of the individual in the action seat who is representing the nursing role. Using the “pause feature” the student in the action seat can pause at anytime for guidance from the “brain” or student team to take next steps. The

One scenario focused on social work was initially modified and used in pilot phases within the nursing program. Claire, a newly diagnosed diabetic patient, connects with a nurse (student role) to obtain more information and healthcare education. Since initial piloting, three scenarios are currently used aligned to student level and curriculum content: Claire, needing diabetic education; Vivian and Jack, meeting to discuss end of life care decisions for their mother; and Corrine, an experienced nurse who is meeting with the nurse manager about issues related to leadership and civility on the nursing unit. A fourth scenario is under construction.

Faculty facilitate discussion and direction of the scenario to guide students and prompt reflective thinking. The faculty facilitator can also “pause” if needed to support student navigation of the simulated experience. During the scenario coordination with the SIMpact interactor and time tracking of the scenario and role rotation into the action seat is best managed with a tech or other faculty assisting. The mixed reality simulation sessions are booked in advance with SIMpact, based on a variety of options for securing contract hours during any given academic year. Typically one student session is run over 2 hours. Connection to wifi, a monitor, and Zoom are the technical requirements with additional consideration to space if you are running live in-person sessions.

Example(s) and Student Feedback

It was such a raw experience, which I loved. It felt so real and really made me think about an important conversation such as this one. I would not have known how to handle it in the actual clinical setting had we not done this.

CI Nursing Student, Class of 2018
CI Nursing Students in Medical-Surgical course participating in Mixed Reality.

I found it to be a very heavy and emotional situation. I remember having to breathe out heavily when it was done. I really liked it though because I feel it presented us with a good learning situation in a safe environment.

CI Nursing Student, Class of 2018
CI Nursing Students in Leadership Course engaging in Mixed Reality.

I loved seeing the wide range of realistic responses from the patient. It was also I think very low-stress and engaging to be able to “pause” and speak to the rest of the group when you feel like you’ve said the wrong thing. Being able to essentially “phone a friend” takes a lot of the pressure off, and really allowed students to engage in total learning.

CI Nursing Student, Class of 2019

The video example below provides an example of clips from both the School of Education students and Nursing students “in action” using SIMpact (previously known as TeachLive). This provides an example of how the sessions can run in a face to face setting. In the online transition in 2020, faculty also have successfully facilitated mixed reality simulations using Zoom to connect remotely with a faculty facilitator and small groups of 8 to 15 students.



Claire Student Guide

End of Life Student Guide

Civility Student Guide

For additional resources, questions, or faculty/instructor guides, please email jaime.hannans@csuci.edu