Integrating Virtual Reality Approaches to Simulations in Interprofessional Education: A Case Study

International Journal on Cybernetics & Informatics (IJCI) Vol.14, No.4, August 2025
Bibhu Dash et al: EDU, IOTCB, MLDA - 2025
pp. 01-12, 2025. IJCI – 2025 DOI:10.5121/ijci.2025.140401
INTEGRATING VIRTUAL REALITY
APPROACHES TO SIMULATIONS
IN INTERPROFESSIONAL
EDUCATION: A CASE STUDY
Susan Toth-Cohen 1
and Sara Stainthorpe 2
1 College of Rehabilitation Sciences, Department of Occupational Therapy,
Thomas Jefferson University, Philadelphia, USA
2
College of Nursing, Thomas Jefferson University, Philadelphia, USA
ABSTRACT
This paper presents a case study on developing and implementing metaverse-based VR
simulations for training interprofessional health and human service students to work with
vulnerable populations. Key challenges and strategies are discussed and include the need
and justification for the simulation programs, the challenge of changing technology and
educational trends over time and plans for enhancing existing programs and creating new
programs and cases.
KEYWORDS
Virtual Worlds, Healthcare, Educational Technology, Interprofessional Education
1. INTRODUCTION
The use of virtual reality (VR) has increased exponentially in health education and many other
professional fields [1]. From an educational perspective, VR can be viewed as a form of
computer technology that enables realistic simulated environments in which people can interact
to accomplish learning goals. VR can be conceptualized broadly under the term extended reality
(XR), which encompasses specific forms including augmented reality and immersive reality [2].
Within this overall categorization, some authors classify VR as consisting of different subtypes.
For example, Bracq et al. [3] classify VR into the three categories of screen-based systems,
virtual worlds (VW) accessed through laptops or desktops, and immersive VR. However, the
lines between these different categories increasingly overlap as enhanced VR options and
technologies have become more multi-faceted.
Building on these developments in VR, the concept of the metaverse has emerged as a more
expansive and immersive application of XR technologies. The metaverse is an immersive virtual
3-dimensional (3D) environment which uses both augmented and immersive realities [4].
Metaverse-learning allows multiple people to have interactive role play experiences in a virtual
environment that mimics a real-life environment [5]. Several advantages of metaverse learning
have been identified in the literature. Metaverse platforms provide an infinite potential for
creativity and sharing, a safe place to collaborate with others while practicing a variety of skills
without the risk of harm, and cost-effectiveness due to the ability to produce simulations that
would otherwise be expensive to reproduce and repeat [4,5,6].

2
The two metaverse-based programs discussed in this article are the Persons experiencing
homelessness Interprofessional Virtual Outreach Training (PIVOT, formerly called Enhancing
Services for Homeless Populations) and the Alzheimer’s Virtual Interprofessional Training
program (AVIT), both using a case-based learning format described by Okun [7] and further
elaborated by Smith [8]. The two programs are implemented in a large academic health center in
a densely populated area on the East Coast of the U.S. within a University Center for
Interprofessional Education. PIVOT trains interprofessional students in health and human service
professions to use strategies and resources for working with people experiencing homelessness
(PEH) while AVIT focuses on training these future professionals to work with people who have
Alzheimer’s disease and related dementias (ADRD) and their caregivers. More detailed
descriptions of both programs’ delivery methods and outcomes have been published in scholarly
work elsewhere [9, 10].
In both AVIT and PIVOT, students from various health and human services professions are
invited to participate in the simulations, including students from Advanced Practice Nursing,
Medicine, Pharmacy, Public Health, Occupational Therapy, and Physical Therapy programs
within the University. All participants are added to an online course consisting of pre-work
including the learning objectives of the simulation, educational materials, articles, and videos, an
overview of each case scenario, and a detailed description of each role and the corresponding
schedule for each student within their respective roles. Students are placed in interprofessional
teams and assigned to a virtual world designed and created for each case and program. Students
rotate between the roles of various health care providers, patients, family members, and
observers, allowing them to take on different perspectives in each case. After each simulation, a
debriefing is led by trained facilitators.
1.1. Rationale for Using VR and the Metaverse for Interprofessional Simulations
Jeremy Bailensen [11], a researcher at Stanford University created a framework for justifying VR
using the DICE acronym that illustrates the fit-for-purpose of PIVOT and AVIT. In this
framework, use of VR is justified when a training experience is too Dangerous, Impossible,
Counterproductive, and/or too Expensive to enact in real life. In both the AVIT and PIVOT
simulations, students practice techniques with each other as they enact the roles of provider and
patient. These situations could be dangerous to enact in real life, due to student errors or poor
judgement when providing care—such as mistakes in medication management with a person who
has ADRD (AVIT) or inadequate recommendations when advising a PEH with diabetes and
alcohol addiction on how they can enact harm reduction strategies such as caring for a foot ulcer
to avoid infection or amputation (PIVOT).
In the impossible category, a 22-year-old White male student would be unable to become a 77-
year-old Black woman experiencing ADRD or a 35-year-old mother of three children aged 2
months through 13 years. And, if enacting a situation in real-life settings that involves mobile
outreach (e.g. going to where PEH are living), additional personnel would be required to
participate, along with physical transportation, making a real-life experience counterproductive
(not worth the additional resources considering students themselves could enact these roles).
Additionally, VR simulations can reduce costs when students enact the roles of provider and
patient, since the simulation would not require paid standardized patients.

3
1.2. Changes in VR Technologies
PIVOT launched in 2017 using Second LifeTM
an early foundation of the metaverse [12]. AVIT
was implemented using the same overall structure in 2018. The Second LifeTM
platform offered
several advantages for implementing metaverse-based interprofessional training, including
remote student participation and access to many free or low-cost, high-quality resources for
creating realistic virtual environments. These benefits were especially evident when AVIT
andPIVOT trainings continued without interruption. We also noted disadvantages of the Second
LifeTM
program. For example, in each cohort of students participating from AVIT or PIVOT,
some students had difficulty running the program because 1) their computers lacked the ability to
handle its complex graphics 2) not all students could use the voice option, making it necessary to
use a separate program (Zoom) for the audio 3) they had to download the program to their
personal computers to participate in the program and 4) there was a steep learning curve for
doing tasks they expected to be easy such as navigating the simulated world and sitting on a
chair. This made it necessary to hold extensive orientations and multiple “check your tech”
sessions to accommodate different student schedules. While helpful for orienting and increasing
students’ comfort with the technology, sessions were time-consuming and complex for faculty
and staff to schedule, implement, and track.
We found that typically, students with more experience in using VR worlds or playing computer
games found it easier to manage the demands of downloading the Second LifeTM
program and
navigating the virtual world. However, there were always some with limited or no experience.
Level of interest for engaging in VR also varied. While some students viewed the simulations as
opportunities to practice safe “hands on” clinical skills, others expressed feeling limited by the
inability to read non-verbal cues or make eye contact--despite our emphasis on “suspension of
disbelief” [13] as key to feeling engaged and immersed in the simulations. At the same time these
challenges for students and the faculty were occurring, the first author began taking classes to
learn virtual reality development, gaining exposure to newer metaverse formats that could be
used in VR simulations, such as Spatial and VR Chat. This led to consideration of Spatial as an
alternate platform for PIVOT and AVIT.
2. METHODOLOGY
We conducted a series of pilot case studies [14] framed within a continuous quality improvement
(CQI) process using the Plan-Do-Study-Act cycle [15]. The purpose of these exploratory pilot
case studies was to examine the feasibility of using the alternate metaverse platform, Spatial, for
delivering PIVOT and AVIT simulations. The specific focus was to assess the Spatial platform’s
usability, level of student immersion, and perceived value in supporting student learning related
to working with vulnerable populations. This was accomplished throughorientations, simulations
and debriefings within Spatial that formed the structure for obtaining feedback from two
stakeholder groups: administrative staff of the University Center for Interprofessional Practice
and Education and students/alumni.
Key guiding questions for this CQI process included:
1. How effectively can staff set up and use Spatial to support students during simulations?
2. How easily can students navigate Spatial and complete simulation tasks?
3. To what extent do students experience a sense of immersion in the simulation
environment?
4. How well does the metaverse-based simulation format support student learning about
working with vulnerable populations in an interprofessional, team-based contex?

4
2.1. Participants and Focus of Pilot Cases
Table 1 illustrates the specific pilot cases that were conducted for PIVOT and AVIT. We started
with a 10-participant staff pilot primarily addressing technical issues with the Second Life
platform, then ran a small-scale student/alumni pilot. Finally, we conducted a larger AVIT pilot.
We ran the pilots three months apart, over a 7-month period.
Table 1. Simulation Timeline and Data Collection
Stakeholder
Group
Program Participants Activity Focus Date(s) Data Collection
Method
Staff N/A
(applied to both)
8 Set up account
and avatar
8-22-24 Discussion (inperson
and Zoom)
PIVOT 8 Simulation 8-29-24 Post-simulation
Survey
Students PIVOT 3 Simulation and
debriefing
12-10-24 Focus Group
Students/
alumna
AVIT 36 Simulation and
Debriefing
3-04-25 Post-simulation
Survey (response
rate 55.6% - n= 20)
3. RESULTS
3.1. Staff Pilot
The staff pilot consisted of two components: a general test of our initial plan to set up Spatial for
both PIVOT and AVIT (focused on orientation and basic features of how to implement the
simulation) and a simulation of two of the three PIVOT cases. The staff pilot (n=8) focused on
ease of use and technology issues, with data collected using a survey.
Survey data collection categories were derived from usability challenges previously reported by
staff with the Second LifeTM
program. Main subcategories were related to initial setup and task-
specific issues during simulation-based case enactment (see Table 2).

5
Table 2. Staff Pilot Survey Results
Ease or Difficulty of Spatial Compared to Second Life Platform
Task
Type
Initial
Set-up
Tasks Required to Fully Engage in Simulation
Down-
load or
update
software,
connect
to
Internet
Change
avatar
outfit for
specific
role
Interact
with
objects
Use
keyboard
shortcuts
to zoom
in and out
Move
around
using
keyboard
arrows
Locate
tools
required
to
engage
in sim
Find
other
location
within
sim
TP
quickly
to other
location
Partic. Rating
1 4 3 2 2 2 3 3 4
2 4 4 2 2 2 4 4 3
3 4 3 3 4 4
4 3 4 4 2 3
5 3 4 3 3 3 4 4
6 4 2 2 2 3 4 3
7 4 3 2 2 1 1
8 3 4 3 2 3 4 4
Mean 3.6 3.3 2.6 2.3 2.5 3.0 3.4 3.5
Key
4 Significantly easier
3 Easier
2 Same
1 More difficult
0 Significantly more difficult
The survey also included open-ended items asking staff to identify specific issues and reflect on
their experiences with the existing Second LifeTM platform and the Spatial program under
consideration for adoption. Most frequent comments about greater ease using Spatial were related
to the procedures necessary to set up the program for use and to navigate through the simulation:
• …each time I logged into SL, I had to wait for the system to set up or there was some
downtime message.... I first set up on a laptop using Spatial on [network names]and 2nd
time on a desktop, no problem either time.
• [in Spatial] I found it easier to interact with objects in the environment. As soon as I get
close to an object, the "F" shortcut popped up, allowing me to interact. [And] it was more
intuitive to stand using my laptop arrow keys than to utilize a separate command.”
• “…It is vastly easier to navigate to different locations within a simulation utilizing Spatial.
The use of teleportation in SecondLife had always been a struggle for staff and students
alike.”

6
Comments noting instances in which some participants mentioned that Spatial was less easy to
use than Second Life focused on greater difficulty identifying other participants through their
name tags:
• …in Spatial not all users had their names consistently above their avatars, whereas in
SecondLife, they were,”
• I found it challenging to determine who was who. Only a few people (the same ones
throughout) came up with name labels even when I approached them.”
Participants had noted difficulty with audio:
• Bad sound using a laptop. Breaks up.
• The audio could be choppy within Spatial, though I never lost comprehension.
Others had difficulty but thought they might be able to solve the issues with more careful set-up.
• I did not fully explore the audio settings to ensure whether a different setting would
alleviate the choppiness.
Even with these challenges, participants generally expressed that use of built-in audio vs. using
the metaverse program along with Zoom as we had done previously with Second Life helped
make the simulation more engaging:
• The use of audio…made the simulation extremely more immersive. The avatars seem a lot
more dimensional and life-like.”
3.2. Student/Alumni PIVOT Pilot
The student and alumnus focus group consisted of two current students and one alumnus who had
participated in the PIVOT program as a student (N=3). Their professional disciplines were
Nursing, Occupational Therapy, and User Experience and Interface Design. We introduced the
focus group by asking students to discuss their experiences with previous simulations and to
describe what they liked and disliked. All described commercially available simulations for
science or healthcare used on a computing device or a physical mannikin.
Participants discussed customization as a primary advantage regardless of the medium used. For
example, the nursing student reported that “with the simulated mannequin practice I used in
nursing school, a person can change their vitals and symptoms, even religious aspects to learn
respect on spiritual beliefs.”The main disadvantage of the commercial products was also related
to customization: “Everything was pre-scripted, there was not much variation, [it] was interactive
but had restrictions, if you did something outside of the box you were not listened to.” Similarly,
lack of customizability was also in relation to the product’s inability to produce spontaneous
responses.
• fully scripted simulations [are] not as beneficial because you do not have to come up
with you want to say, there are many ways the guided conversations can go, you get to decide
what way you take it.
• more spontaneous responses are more helpful because in real world situations you really
do not know what people are going to say. This teaches you how to respond to people. How
someone says something depends on who is playing the part and changes how you need to
respond to them.”

7
After the initial warm-up question, participants were asked to share what they liked and disliked
about Spatial. They discussed technical aspects along with general comments and suggestions:
Table 3. Student and Alumni Comments
Beneficial to Learning Less Beneficial to Learning
Really easy to play around with Spatial and grasp as
a platform.
It was difficult to switch avatars, I premade both
avatars but could not find the new custom one
while I was in the simulation.
The PIVOT simulation has real people [peers]
unlike other [commercial] simulations where it is
more individualized [has computer generated
patients]
Makes computers choppy and would freeze,
takes up a lot of memory on a computer. I do not
remember if this was the same situation as
second life or not.
Instructions were easy to follow when creating the
avatar and setting everything up.
Audio issues, was not clear that the avatar needs
to be close to the other avatars to hear other
people.
General Comments
Would be beneficial if the city looked more like Philadelphia, [the Spatial sim] looked less urban than
the second life world.
If people got used to the spatial site at first, maybe by playing some of the other games spatial offers,
this could make people feel more comfortable and be more “fluid” in using it.
3.3. AVIT Pilot
The AVIT pilot consisted of three cases with two separate student groups (n=36). The three cases
had been used for previous AVIT programs. See Figure 1 for an illustration of the first case, in
which a 78-year-old woman is diagnosed with ADRD by her primary care provider (left), who
conducts a cognitive screening test. The patient (right center), is accompanied by her caregiver
(left center). During the encounter the primary care provider collaborates with an in-office
pharmacist (right) who performs a medication review.

8
Figure 1. AVIT Pilot Showing Doctor’s Office Simulation
Data reported for this paper consist of survey responses to questions about student satisfaction
indictors: perceived usefulness, ease of use, and engagement. Other data including knowledge of
ADRD and confidence with specific tasks learned in the simulation (including technical and non-
technical skills) will be reported in a separate scholarly work currently in progress, along with
student satisfaction indicators.
Table 3. AVIT Student Pilot Survey Results (n=20)
Strongly
Disagree
Disagree Neither
Agree
Nor
Disagree
Agree Strongly
Agree
Overall, my experience in the AVIT
program was positive.
0 0 1 14 5
I was fully able to immerse myself
into the client or provider role in the
simulation.
0 1 4 10 5
The case based virtual learning
format was a good way to learn
about the needs of persons with
dementia.
1 1 2 11 5
It was easy to navigate the virtual
world.
3 0 3 11 3
Students were also asked, “what were your main takeaways from this experience,” in which they
identified some of the aspects they felt contributed to the educational value of the Spatial
simulation. Sample comments included:
• Patience and compassion go a long way when working with fellow healthcare providers
and the caregivers in giving the best treatment.

9
• That dementia can be a frustrating disease state for everyone involved and it takes a team
of [skilled] health care workers …to provide the best level of care.
• Utilizing a collaborative team approach to effectively treat individuals diagnosed with
Alzheimer’s disease represents one of the most advantageous strategies for delivering
high-quality care, not only for the patients themselves but also for their family members.
• I learned how important it is to work collaboratively with a variety of professionals to
ensure the patient's needs are met on all fronts. Also, how important it is to support the
caregivers in these scenarios as their role is quite difficult and comes with a lot of
conflicting thoughts and emotions.
• Knowing patient perspective and role-playing helps to look at the real life
scenario/situation
Student recommendations for improving the AVIT program using Spatial focused primarily on
the need to become more familiar with the metaverse world prior to participating in the
simulation.
• It may be a good idea to have a "virtual playground" available a day before for
participants to familiarize themselves with the virtual space, supervised or unsupervised.
• I had trouble navigating the Avatar world, but I'm not verse (sic) in the world of video
games, which would have been very helpful to me. Overall, I enjoyed the experience.
• I think it would have been helpful to have a space in Spatial where we could practice
moving around a bit while doing our pre-work. I think getting the hang of using the
platform was my biggest challenge.
4. DISCUSSION
The pilot implementation of the Spatial platform for both PIVOT and AVIT simulations yielded
promising results, highlighting both the potential and the challenges of transitioning from Second
Life™ to a more modern metaverse environment. Across staff, student, and alumni participants,
the findings suggest that Spatial offers several usability and engagement advantages, while also
presenting areas for improvement that warrant further development and support.
4.1. Usability and Technical Considerations
Staff participants generally found Spatial easier to set up and navigate compared to Second
Life™, particularly appreciating the intuitive interaction with objects and simplified movement
controls. These findings align with prior literature emphasizing the importance of ease of use in
virtual learning environments. However, some technical issues persisted, especially in regard to
audio quality and avatar identification. The inconsistent display of name tags in Spatial was a
noteworthy disadvantage compared to Second Life™, which consistently labeled avatars. Audio
issues, while not universally disruptive, were frequently mentioned and suggest a need for clearer
guidance on audio settings and troubleshooting.
Participants in the small student and alumni pilot also discussed some of the same points. While
they found Spatial relatively easy to learn and appreciated the realism and interactivity of peer
based simulations, technical challenges such as avatar switching, memory usage, and audio
clarity were noted. These issues may be especially relevant for users less familiar with gaming or
virtual environments, underscoring the need to prepare students for participation using orientation
sessions or “virtual playgrounds” to build confidence and ease of enacting the simulation.

10
4.2. Engagement and Learning Value
Participants across all groups reported that Spatial enhanced the immersive quality of the
simulations. They expressed that the integration of built-in audio, rather than relying on external
platforms like Zoom made the experience more engaging. This immersive quality seemed to be
especially valued in the AVIT pilot, where students reported high levels of engagement and
perceived usefulness for learning about dementia care.
The student and alumni focus group also emphasized the value of customization and spontaneity
in simulations. Unlike commercial products that rely on scripted interactions, they valued the
PIVOT simulation’s flexibility and the presence of real human participants, which allowed for
more authentic, unscripted interactions. This aligns with experiential learning theory, which
emphasizes the value of learner-driven, context-rich environments in developing critical thinking
and communication skills.
The ability to engage in spontaneous dialogue and adapt to dynamic scenarios was seen as
facilitating more dynamic and responsive communication, which participants felt better mirrored
real-world scenarios. This aligns with educational approaches that emphasize the importance of
authentic, learner-driven experiences in developing critical thinking and collaboration skills.
4.3. Limitations
This pilot study was limited by small sample sizes, especially in the student and alumni focus
group (n=3). And, while the response rate to the AVIT post-program survey was more than 50%,
a higher response rate may have provided more diverse views about the Spatial simulation. One
possibility is that students who perceived the simulation more favorably responded to the survey
at a higher rate than those who did not find the experience worthwhile. Additionally, while this
CQI focus provided actionable findings to improve usability and engagement, future scholarly
work could utilize quantitative and qualitative research approaches to explore learning outcomes
more systematically, including knowledge gains, skill development, and long-term application to
actual clinical settings.
5. ENHANCEMENTS AND FUTURE PLANNING
In addition to implementing key recommendations discussed by the stakeholder groups, such
focusing on improving or solving audio and avatar identification issues, we are planning several
other enhancements. Our main focus will be to continue testing and building upon ways to make
the simulations more engaging and interactive. Through our experience with the pilots and a grant
that enabled us to hire a VR consultant, we have learned how to add scripts to the existing Spatial
interface to complement its Quest development feature. We plan to incorporate a game format to
enable students to self-orient by using a quest game in which they follow clues to learn specific
tasks and do quizzes to gain a greater command of the knowledge base needed to work with
people PEH and patients and caregivers experiencing ADRD. Additional strategies for fostering
interactivity are to use a quest-type game format for specific steps in the simulation— such as
identifying home environmental hazards in AVIT. The home hazards will include obstacles
making it difficult for an older person to move around optimally within her home and specific
tripping hazards that make the home unsafe (e.g., throw rugs and electrical extension cords).

11
6. CONCLUSION
This CQI initiative, implemented through multiple pilot case studies discussed how a University
Center for Interprofessional Education designed and implemented two metaverse-based
simulation programs—PIVOT and AVIT—to support interprofessional student learning in
working with people experiencing homelessness (PEH) and individuals with Alzheimer’s disease
and related dementias (ADRD), along with their caregivers. The development process was guided
by Bailensen’s [7] DICE framework and included a platform transition from Second Life™ to
Spatial to enhance usability and immersion.
Looking ahead, planned improvements will focus on expanding the range of cases and programs
offered in addition to incorporating greater interactivity. These enhancements aim to provide
students with more opportunities to practice interprofessional collaboration and develop skills for
working with vulnerable populations. As with previous iterations, we will apply the Plan-
DoStudy-Act (PDSA) cycle to guide and evaluate these changes, focusing our attention on
perceived usefulness, ease of use, and learner engagement.
Through this ongoing CQI process, we remain committed to strengthening our training programs
and better preparing health and human services students to meet the complex needs of PEH,
individuals with ADRD, and other underserved populations.
ACKNOWLEDGEMENTS
The authors would like to thank the Jefferson Center for Interprofessional Education and Practice
at Thomas Jefferson University, for its substantial contributions and support in developing,
implementing, evaluating, and sustaining this work. We also thank the peer reviewers who
provided thoughtful, in-depth comments which contributed to enhancing this paper.
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AUTHORS
Susan Toth-Cohen, PhD, OTR/L is Professor of Occupational Therapy at the
Jefferson College of Rehabilitation Sciences and Co-Lead of the Alzheimer’s Virtual
Interprofessional Training (AVIT) program and Lead of the People experiencing
homelessness Interprofessional Virtual Outreach Training (PIVOT) program at the
Jefferson Center for Interprofessional Practice and Education at Thomas Jefferson
University in Philadelphia, USA
Sara Stainthorpe, DNP, CRNP, AGPCNP-BC, is Program Director of the Adult-
Gerontology Primary Care Nurse Practitioner Program at Jefferson College of Nursing
and Co-Lead of the Alzheimer’s Virtual Interprofessional Training program (AVIT) at
the Jefferson Center for Interprofessional Practice and Education, Thomas Jefferson
University in Philadelphia, USA

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