Learning with Immersive Virtual Reality: An Exploratory Study of Chinese College Nursing Students

Abstract

As an emerging technology, virtual reality (VR) is now being used in education, particularly with STEM-related learning. However, as with all pedagogical innovation, there is a lack of empirical research on the application of VR in situations where students are using it with their second language (L2) and existing studies generally rely on the use of non-immersive VR tools. This paper is one step in a process of understanding the affordances and constraints of a fully immersive VR system in facilitating language learning for English as a foreign language (EFL) nurses. The results of a small-scale study suggested that learners appreciated the different features of VR, which enhanced the integration of virtuality, reality, and mentality. In addition, mediating factors of this VR learning experience were discussed based on the data set. Informed by the current findings, the paper puts forward suggestions for designing VR-supported language learning, which hopefully sheds some light on the complex nature of the effective use of VR in learning.

Keywords

Virtual reality English for specific purposes nursing education immersive technology simulated learning

Introduction

Virtual reality (VR), one extended form of mobile learning, places users in an immersive, virtual environment through simulations and 360° videos (Wang et al., 2018). Differing from augmented reality (AR) that superimposes virtual content onto the physical world, VR replaces the user's actual surroundings by immersing the user in a three-dimensional (3D) virtual world.

With the rapid advancement of affordable educational VR systems (e.g., ClassVR), the Horizon Report of 2019 expects VR, among other advanced technologies, to become widely adopted in education by 2022 (Alexander et al., 2019). VR has showcased its educational potential with its ability to provide an experiential process of learning. It allows users to place themselves in a simulated environment that may not be feasible for them in traditional classrooms. Through immersion and simulation, learning is able to take place with an increased range of learning tasks and activities. For example, in order to support history learning, a VR learning system was employed by Villena Taranilla et al. (2019) to re-create an ancient Spanish historical site. Their students were reported to have enjoyed an immersive, interactive, and exciting experience with the aid of the system that greatly extended their learning capacity.

Benefits of using a simulated 3D world to gain first-hand experience of the learning environment are beginning to be reported. For example, studies have suggested that students’ learning motivation and engagement can be promoted (Shadiev et al., 2020) and users’ attention and enthusiasm to learn are improved and sustained (Vazquez et al., 2018). In addition to these factors, VR technology protects users from unsafe and dangerous environments (e.g., training firefighters in a VR fire scene). This feature may also meet the special learning needs of medical and nursing students in high-risk clinical settings (e.g., Birt et al., 2017; Moro et al., 2017), especially in the COVID-19 era when it may be riskier to place them in hospital surroundings. This unique characteristic of VR is exemplified in the present study when a group of EFL nursing students undertook medical procedures in a simulated operating room.

In spite of the educational benefits, VR, as an emerging technology, has its own constraints. Due to sensory mismatch, students in Moro et al.’s (2017) study reported some adverse health issues when using VR devices, including a sense of disorientation, headache, blurred vision, and sore eyes. It seems that this new technology is still in a development stage and there is much we need to discover about its advantages and limitations, especially in language learning contexts.

With limited understanding of the use of fully immersive VR in education, this study is a preparatory investigation which aims to explore the educational affordances and constraints of VR in a limited English for specific purposes (ESP) learning context. As an exploratory study, we are interested in how one group of students from a nursing college perceive the use of VR in enhancing their general subject learning and specific English vocabulary learning. This research aims to address the following questions:

What are the affordances of VR learning in an ESP nursing course?

What are the constraints of VR learning in an ESP nursing course?

VR-Assisted Language Learning

Compared with science, technology, engineering, and mathematics (STEM) education, language educators have not yet begun to exploit VR-assisted language learning (see an overview of VR in education by Kavanagh et al., 2017). In many classroom situations, students’ attention is firmly on the teacher and the textbook. This is what happens in ESP nursing courses in China (Zhang et al., 2020), and few if any language teachers are exploring the use of VR with their students. According to Lin and Lan (2015), in spite of an increasing interest in VR-assisted language studies, only a limited number of research papers (29 among 811 papers) were located in the four representative language learning with technology journals from 2004 to 2013. To date, language educators are facing a wide range of challenges of adopting VR in their teaching, including insufficient infrastructure support, the lack of technological training, and the absence of useful theoretical foundation and pedagogical frameworks for language teachers to design effective, innovative, and interactive learning activities (Lan, 2020).

In a recent assessment, Parmaxi (2020) reviewed 26 research papers about the theme of VR-supported language learning from 17 high-impact journals learning with technology from 2015 to 2018. Results suggested that current studies mostly used desktop computer-based non-immersive VR systems, via which the user explores the virtual world through a mouse, a keyboard, and the computer screen. The educational potential of fully immersive VR with head-mounted equipment is yet to be understood. In addition, VR papers tended to explore speaking skills only, while other language skills are neglected (Parmaxi, 2020).

With the high cost of VR devices (Lan, 2020), language educators may find it particularly difficult to afford to conduct VR-assisted language studies. One way to address this issue is to borrow and repurpose tools and software that are being used by STEM departments, as they tend to own more advanced technological software than humanities departments.

In this paper, we report on an exploratory case study of an English language teacher who designed immersive vocabulary learning activities for her ESP nursing students based on a VR operating room software developed originally for surgery training by the Department of Nursing.

One key language area of research has been the acquisition of vocabulary and the role VR plays in this. With reference to Webb and Nation (2017), the use of VR may help learners comprehend and make use of specialized vocabulary which may otherwise be more difficult to learn from text-based sources only. Webb and Nation mention that there are two key factors which underpin learning conditions for vocabulary: repetition and quality. The more often a learner sees a new word in use, the more opportunity there is to learn it. Furthermore, the deeper the quality of learning, e.g., by seeing the word in context or in memorable circumstances, the more likely learning will occur. Both of these aspects are realized within a VR learning situation, and we will return to them later on.

In a recent example of the benefits to vocabulary learning via VR, Alfadil (2020), using a quasi-experimental research design, explored Saudi Arabian students’ use of vocabulary in a VR gaming context. The study reported that students who participated in the VR experiment group achieved higher marks in a vocabulary post-test than those with a traditional method of vocabulary acquisition. Reasons include the interactive nature of gaming with other participants who repeatedly use similar vocabulary. This results in a higher level of attentiveness, motivation, engagement, and confidence during the learning process: i.e., the quality of learning is increased. As discussed above, VR affords learners a unique opportunity to interact with people and objects, through which their perceptions of the world are extended beyond the traditional brick-and-mortar classroom. Diverse senses are activated to augment the learning experience and contribute to learners’ understanding of the target words (Tseng et al., 2013). As such, language learners may gain unique benefits in immersive learning since they are “learning it [a word] by living it” (Alfadil, 2020: 9, emphasis in original).

Methodology

Participants

Ten Year-2 nursing students and their ESP teacher, Sylvia (pseudonyms are used in the present study), from a nursing college in Guangdong Province, China, volunteered and consented to participate in this exploratory study, which was part of a larger research project. All the students were from Sylvia's class and were female, aged 19–20, with Mandarin as their native language. It is worth noting that nursing colleges in China generally have low admission requirements of English and most of the courses are instructed via Chinese. However, due to the increasing need of English in international hospitals, this nursing college required every student to take a one-year compulsory English course. Based on Sylvia's in-class observations, the student participants were pre-intermediate English learners (around IELTS 4.0) who did not have high motivation or autonomy for English learning. Moreover, the students and teacher participants had no prior experience of using VR for language learning/teaching.

Before they attended the VR lesson, students had attended traditional classroom lessons where they learned via textbooks the basic theories related to surgeries, such as the general steps of an operation and dos and don'ts during medical treatment. However, none of them had had the chance to practice their clinical knowledge in clinical settings.

Though the teacher had five-year ESP teaching experience, she had never incorporated VR into her teaching practice, but was curious as to what it might offer and was a keen volunteer for the project. Furthermore, she had no exposure to this technology in her personal life.

Technological Tool

In this study, we employed a VR teaching program, Modern Operation Room (MOR), developed by the Department of Nursing at the college where Sylvia works. MOR is a recently developed VR teaching software tool that aims to provide nursing students with opportunities to experience a simulated operating room and conduct surgical training before they can become qualified nurses. Due to its experimental stage, MOR has so far not been used extensively with the nursing students. That is, students in this nursing college still rely heavily on textbook learning in traditional classrooms. As discussed earlier, due to the lack of financial and technological support, language teachers tend not to own advanced technological tools. Under these circumstances, the present study repurposed the MOR to cater to the students’ ESP learning needs.

MOR is designed based on the university hospital affiliated to this nursing college. It provides the participant with virtual hospital scenes. In one scene, the participant needs to take part in an appendectomy to assist in removing the patient's appendix. Before the operation, the participant uses the handset controller to change into a medical operation gown and shoes, wear a medical mask, hat, and gloves, and wash hands before surgery. During the operation, the participant plays the role of an instrument nurse who assists a non-player character (NPC) doctor in different ways (e.g., Figures 1 and 2). The system prompts the participant if he or she makes any mistakes during the surgery. In such a case, the participant must perform the action again as the surgery will not continue unless the participant follows the instructions correctly. Therefore, there can be a lot of repetitive use of specialized vocabulary terms as students repeat the procedures.

Figure 1.

Handling a scalpel to the doctor in the MOR.

Figure 2.

Assisting the doctor in performing surgery in the MOR.

To participate in the lesson, both the teacher and students took a 20-minute training session on how to wear a VR headset and deal with the handset controllers before the teaching session. Approval was obtained from the college to utilize the software and the figures shown in this paper.

Pedagogical Design

The teacher and student participants were immersed in the fully virtual operation room with the use of VR headsets and handset controllers for 80 minutes. The main pedagogical objective was to help students to experience a simulated medical context where English was used in the operating room and also to enhance the students’ medical vocabulary (e.g., scalpel, pickup, lamp). A case study of an appendicitis surgery was chosen as the student participants would be more familiar with such an operation.

The 80-minute session was designed by the English teacher with three stages to further support vocabulary learning – Input, Use, and Output – throughout which the participants kept their headsets on.

Input: Students were introduced to the hospital scene and instructed to finish the pre-surgery procedures, such as washing hands and wearing a mask correctly. Before the surgery started, the teacher, Sylvia, made use of MOR to introduce various types of surgical equipment in English and offered students chances to pick up and observe different instruments. By doing so, learners were expected to develop their spatial awareness of the surgical instruments by seeing and touching them and to associate them with their corresponding English names in the context of an operating room.

Use: To use the specific vocabulary, students were instructed by the teacher who played the role of a nurse supervisor (e.g. “pass the scalpel”) to cooperate with the NPC doctor to successfully finish the simulated surgery. As mentioned above, students would not be allowed to proceed with the task until they performed the right action. Thus, Sylvia monitored students’ performances and provided guidance and support regarding the names of the instruments and the steps of the surgery.

Output: Differing from the passive recipient role of instructions in the second stage, students in this stage worked in pairs and took turns to take on the role of a nurse supervisor. They restarted the VR system and used the newly learned English expressions to issue orders to their partners in the surgery (e.g., “stitch up the wound”). In this way, students were expected to actively practice the knowledge acquired in the session, improve their surgical skills and knowledge, and develop a better and deeper understanding of relevant ESP vocabulary related to nursing.

Data Collection and Analysis

At the end of the 80-minute session, the participating students completed a six-point (1 = Strongly disagree, 6 = Strongly agree) Likert-scale questionnaire. The questionnaire was adapted from McGill and Hobbs (2008) and was intended to understand the students’ perceptions and attitudes regarding their VR-supported learning experience. Items covered surgical content learning, ESP vocabulary learning, and teacher support during the lesson. The adapted questionnaire was piloted and discussed with a senior researcher specialized in immersive learning. Due to the exploratory nature of the present study, a descriptive analysis was applied to the questionnaire data in order to depict the overall picture of students’ participatory experiences.

In addition to the attitudinal questionnaire, semi-structured interviews were conducted to further understand students’ VR learning experience. Similar to the questionnaire, the interviews were conducted in Mandarin to ensure better comprehension and to elicit more thoughts from the interviewees. The interviews were transcribed and the interview transcripts were later reviewed and confirmed by the interviewees for accuracy. A thematic analysis was applied to this data set based on Braun and Clarke’s (2006) suggested steps (Table 1): several readings of the data; data coding; searching for themes; revisions; naming themes. Following this method, the first author coded the data set while the second author reviewed and commented on the initial coding results until agreed-upon themes were created.

Table 1.

Examples of data coding.

Interview data	Sub-category	Sub-theme	Theme
(1) You can feel more engaged through actions such as handing a scalpel to the NPC doctor, which reinforced the memorization and understanding of the situation.	Interactions with NPC	Interactive learning	Affordances of VR-supported language learning
(2) I not only saw the surgical tools but also assisted the doctor in this system.	Interactions with NPC
(3) When working in pairs, we practiced the linguistic expressions and applied our surgical knowledge within the simulated operating room.	Interactions with student peers
(1) A bit dizzy and bad for eyes.	Dizziness and eye sore	Physical discomfort	Constraints of VR-supported language learning
(2) I felt tired when I had worn the VR glasses for a long period of time.	Tiredness
(3) After some time, I felt dizzy and would like to have a rest.	Dizziness and tiredness

Findings

Based on the two research questions, this section reports on the major findings based on our dataset. Although the students’ English language proficiency levels were quite low, they were motivated to become registered nurses and fulfill the requirements of their nursing program. Therefore, the issues of content and language learning became somewhat conflated in the data. The main objective of the lesson was on learning specific vocabulary, and we attempted to examine this separately; however, other context-related findings are valuable in explaining the overall unique affordances and constraints in using VR in this learning process. It should, though, be noted that the current findings are exploratory and as such should be treated with caution due to the short-term nature of the study.

Research question 1: What are the affordances of VR learning in an ESP nursing course?

The six-point Likert-scale survey conducted at the end of the teaching session suggested the students’ overall attitudes toward this VR-supported learning session. Compared with the nursing subject learning (M = 4.40, SD = 0.52), students believed that the use of MOR improved their learning motivation (M = 4.60, SD = 0.52) and learning effectiveness (M = 4.60, SD = 0.52). The student participants held a more positive attitude towards the use of VR in enhancing their ESP vocabulary learning (M = 4.70, SD = 0.67).

To account for these results, four main themes emerged from the responses from the semi-structured interviews, as follows. Students’ representative comments are reported to illustrate the findings in this VR lesson.

Immersive and Multimodal Learning with Body Movements

Most student participants remarked that the immersive operating room afforded them a unique chance to acquire the specialized nursing vocabulary in a multimodal fashion. Chloe, for example, explained that:

The VR software visualizes the English words we discussed. I could see very clearly how a scalpel looks like…Sometimes, I forgot I was learning a word, but I was acquiring the word in the VR world.

This excerpt highlights the affordance of visualization with our VR system. Contrary to the 2D pictures in the traditional textbook, students in the present study were enabled to perceive the surgical equipment in a 3D manner. Apart from visualizing the surgical equipment used in an operating room, this student also talked about acquiring words from the contextualized learning. Learning seemed to take place subconsciously without a particular emphasis on the word but on its context.

Other students talked about how the VR system supported their learning through body movements in an immersive manner. Polly said:

The system immerses us into an authentic operating room where I could see and feel the different equipment in that specific context. The simulated world enhances our understanding of the words taught in this lesson. That is much more engaging than the traditional learning in class.

Due to the fully immersive nature of our VR system, the student participants maintained that the coordination of the eyes, hands, and brain works effectively when acquiring English nursing vocabulary. Similarly, Lorraine mentioned that:

The use of hands and eyes in the virtual world facilitates the understanding and memorization of words. It leaves a deeper impression on the users, which may help sustain our memory.

With such a physical experience of vocabulary learning within context, some participants felt that the cognitive process, especially the retention of words, was augmented.

Interactive Learning with Objects, Non-Player Characters, and People

The various kinds of interactions in the MOR facilitated the nursing students’ understanding of the surgical equipment and steps. Jane commented:

With the headset, I interacted with the objects and the doctor. I could explore and get familiar with the operating room and the procedures of the surgery.

MOR extended our traditional pedagogical approach by allowing the user to interact with virtual objects and characters in a simulated learning environment. Students had the opportunity to interact with the surgical instruments and the NPC doctor via their headsets and controllers. These virtual elements increased the authenticity of learning, which enhanced the learning experience.

Moreover, peer interactions facilitated the language learning experience. In the final stage of the 80-minute learning session, students were encouraged to work collaboratively to apply what they had learned. They took turns playing the role of the nurse supervisor and communicated instructions with their partners. Cathay mentioned:

When working in pairs, we practiced the linguistic expressions and applied our surgical knowledge within the simulated operating room. That was quite beneficial and we learned from each other.

As suggested by Cathay, this VR-assisted learning session catered to language learners’ needs of collaborative learning and facilitated nursing students’ use of linguistic and surgical knowledge.

Authentic Learning with an Increase in Learning Motivation and Effectiveness

Students in the post-learning interviews appreciated the surgical learning opportunities afforded in the MOR. First, the authenticity of the VR learning system was again discussed, which was believed to improve the effectiveness in learning and prepared these nursing students for the real medical environments they would eventually encounter. Angela, for example, remarked:

Videos are not authentic enough. On the contrary, MOR provided a chance for me to immerse myself in the operating room. That was quite conducive to not only vocabulary learning, but also medical learning.

Comparing MOR with video-based learning, Angela maintained that immersion was a key to effective nursing learning. Videos are only visual and could not afford learners an authentic way of learning, while the MOR created the medical world for users to explore.

Second, the simulation was deemed fun and professional according to the interviews. Compared with traditional classroom learning, our participants felt that they were more motivated and willing to engage in their learning. Ann talked about rote learning and the current VR learning experience:

Differing from traditional classroom learning, this VR-supported lesson was more engaging and professional. I felt more motivated to learn the new words by exploring the VR system, which was totally different from the boring rote learning method.

Interestingly, Ann used the word “professional” to describe the MOR learning experience, which indicated that the authenticity of the simulated operating room was appreciated as a unique affordance and the MOR brought ESP learning to completely new levels. Moreover, Cathay remarked: “This learning experience was quite novel and useful and it would definitely help us in applying for jobs at international hospitals in China.” The use of MOR surprisingly improved Cathay's career expectations.

Gamification with Reduced Feelings of Anxiety and Embarrassment

Contrary to the internship in hospitals, the MOR had the unique feature of alleviating students’ levels of anxiety in the context of surgery through gamification. The VR system allowed the user to participate in and perform different actions in surgery, during which operational mistakes were identified by the system. Ada in the interview talked about her attitudes:

I was not qualified and would not dare to assist a doctor in real surgeries. I might make lots of mistakes and even accidentally kill the patient! But MOR felt like a game and I would not worry too much about making mistakes. It gave me another chance to correct my mistakes, which was not possible in real-life surgeries.

With personalized feedback from the VR system, students were enabled to learn from mistakes without being overly concerned about the negative consequences. Meanwhile, the participants in the present study believed that it was less embarrassing to make mistakes in the virtual world. Jane commented:

It would be humiliating to make language and medical mistakes in front of the classmates in the real operating room. However, in this virtual room, I know that we are allowed to learn from our mistakes.

It is worth noting that our participants were from a Confucian cultural background, which is known for its face-saving ethos (Xu and Carless, 2017). Based on the excerpt, face was a sensitive and important topic for Jane, which influenced her psychological state of learning. It seemed the virtual learning environment installed more confidence in Jane.

Similarly, Polly raised an interesting point of confidence during her interview:

Honestly, I am not very confident about my English proficiency as I am from a vocational college. But I believed that my familiarity with the nursing knowledge required in the VR activities gave me more confidence in learning and using the English language.

Polly talked about how the application of her nursing knowledge in the VR system improved her confidence in learning English. Instead of having to deal with language and medical knowledge simultaneously, students in this study appreciated the chance to apply what they had learned and move forward their understanding with the aid of VR. It seemed that this affordance in turn helped Polly improve her self-confidence in language learning as she could spend more time in acquiring the linguistic knowledge in a nursing environment, of which she had had previous knowledge.

Research question 2: What are the constraints of VR learning in an ESP nursing course?

The participants were asked to reflect on any challenges they encountered in their VR learning experience. In response, some students pointed out that they experienced a few health effects, including disorientation, dizziness, fatigue, neck pain, and eyestrain. Eva, Ann, and Polly said that in addition to the VR headset they needed to wear their own eyeglasses. In other words, they had to wear two sets of glasses during the class, which posed challenges to their physical comfort. Ann, for example, explained:

The headset was very heavy and it was not easy for shortsighted people like me to wear two glasses. Without my own glasses, I could not see clearly.

Meanwhile, students like Ada, Milly, and Jane talked about the loss of direction. As they were required to move around the operating room to accomplish learning activities, students sometimes felt disoriented and dizzy. Ada said:

I walked around the VR room to participate in the learning activities. With the headset on I had no idea where I was in the room. I felt a bit dizzy and tired.

It seemed that, in this case, the technology was not sophisticated enough to provide a comfortable user experience. In a similar vein, the participants suggested that the technology was not mature as it occasionally malfunctioned. Eva commented: “The controller was sometimes not responding to my movement.” As a new technology, the interviews suggested a need for designers to consider the physical comfort of the user. However, it was worth noting that one student, Cathay, disagreed with the other students as she did not find MOR uncomfortable or harmful to her health in any way.

In addition, the extent to which teachers should offer help seemed to become a debatable issue. In the present study, the ESP teacher monitored the student learning and provided support when students encountered learning and technical problems. Chloe said:

The teacher was responsible and the lesson was well designed. I could tell she had spent a lot of time designing this session…During the session, she also helped us to address learning issues.

Yet, some participants believed that teacher support was not sufficient during the learning. Ann reflected:

However, I think she could have provided more technical support for us. But, after all, she was a language teacher, not a technician. I could tell she had tried her best to help us.

Ann's response was interesting as she raised the issue of who should be responsible for providing technical support in VR-supported language learning. Ann, on the one hand, relied on the language teacher for support, but on the other hand, she pitied her teacher for her dual identity as a teacher and technician.

Discussion

Focusing on the student participants’ perceptions, this study aimed to explore the effect of a fully immersive VR system – MOR in an ESP nursing course. Overall, the questionnaire findings suggested that the students held positive attitudes towards the use of MOR in improving their medical content knowledge and also enhancing their English vocabulary knowledge. At the same time, students believed that compared with traditional classroom teaching, their learning motivation and the effectiveness of the pedagogy were augmented with the aid of VR. Reasons were further provided in the post-project interviews, including the features of immersion, multimodality, interactivity, authenticity, and gamification. These findings are in line with Wu and Miller (2021), in that students were consciously and unconsciously building learning patterns and acquiring contextualized linguistic and content knowledge based on their previous knowledge and experience; they internalized and constructed knowledge through action via a dynamic, discovery process; and the virtual environment created a “real” environment in which to experience the learning of vocabulary multimodally (this is usually referred to as a constructivist approach to learning). In addition to the affordances of VR in learning, the study also pointed to the constraints of it, covering aspects of physical comfort and health, technological issues, and the lack of technical support.

Based on the two research questions, we suggest several factors that have come out of this investigative study. First, the simulated VR world is closely intertwined with the real world. Though VR creates a virtual, immersive world, the use of VR in language learning is by no means independent from reality. Findings suggest that our VR system enabled the nursing students to participate in learning through visual, auditory, and kinesthetic manners of learning. With the 3D spatial immersion, MOR provided a first-person, multimodal, and multisensory learning experience for our participants (Wang et al., 2020). The participants appreciated the unique chance to learn about the surgical instruments by seeing, touching, and handling them. In accordance with other researchers such as Villena Taranilla et al. (2019) and Lan (2020), our study points out that an important affordance of 3D virtual learning is the stimulation of different senses, which creates better conditions for learning, specifically for learning vocabulary. Students can learn vocabulary both deliberately and incidentally in an elaborated context (Webb and Nation, 2017). Deliberate learning occurs when they focus on the task and are aided by such things as pictures or key words (as happens with VR). Incidental learning happens when specialized vocabulary is used within phrases or sentences during instructions or commands: “scrub up before we begin”; “pass the scalpel” (combined with visuals). Webb and Nation (2017) refer to this as instantiation learning whereby the quality of learning is based on authenticity of context and is memorable to the learner. When this is combined with repeated exposure to the new words, as often happens during an authentic surgery, we see how the two key factors of vocabulary learning – repetition and quality – are met with a VR lesson.

Due to the inclusive learning environment, potential learning distractions may be reduced and learners are more likely to concentrate on the learning process. With the alignment of body and mind, MOR has the benefit of catering to different individual learning styles (Hafner and Miller, 2011). Moreover, our participants referred to other language learning approaches (e.g., textbook learning and video watching) as less authentic compared with the MOR learning. In the pandemic era, it may be difficult to place students in the hospital environment. Yet, solely relying on the traditional learning methods including textbook learning may not be enough for our learners’ needs, as nursing communication relies heavily on verbal and physical interactions (Chandler et al., 2015). The MOR system in this study enabled the participants to interact with each other both verbally and physically. Therefore, students may not only have the chance to explore an operating room safely, but also engage in deep learning where information and experiences are connected.

Second, learners’ mental and emotional state is associated with the successful application of VR in language learning. This study is significant as it moves along our current understanding of VR in language learning. Previous studies have primarily focused on the alliance between virtuality and reality, whereas the psychological and affective dimensions of VR in learning have not been discussed intensively.

Minor mistakes in real-world operating rooms can be fatal ones, which without doubt would increase the emotional burden for nursing students. Moreover, when making mistakes in front of others, Confucian-heritage learners may experience a high chance of losing face, which jeopardizes their confidence and interest in learning (Xu and Carless, 2017). However, the present study showcased that with a proper design of learning activities, VR has the advantages of improving students’ learning motivation and reducing feelings of anxiety and embarrassment. Students felt more motivated to engage in learning rather than feel discouraged from making mistakes.

Third, more needs to be taken into account when designing the technology. The equipment needs to be comfortable and teachers need to be able to deal with on-the-spot technical issues. Perhaps a “Quick Help” feature can be added to provide timely support for teachers and students. Similar to other VR learning studies (e.g., Alfadil, 2020; Moro et al., 2017), learners in the present study reported some concerns related to health problems when using MOR, including the loss of direction, sore eyes, and neck pains. When such issues exist, both the teacher and students may be reluctant to make extensive use of VR for language learning purposes.

As an emerging technology, the design of VR systems apparently needs more careful consideration around their usefulness (Tang and Hew, 2019), consisting of utility (the functions needed to participate in learning activities) and usability (user-friendliness of utilizing the technology). To accomplish this, Zhang et al. (2020) lately proposed a framework for designing new technology-enhanced language learning based on their theoretical review. They suggested that designers should work collaboratively with language instructors and learners to understand learning needs, identify technical requirements, and therefore provide customized technical support.

Fourth, differing from the traditional teacher role, instructors play a different role in VR-supported language learning. The present study suggests that instructors should try to provide a conducive learning environment where there is an ecological interplay of reality, virtuality, and mentality in such a way that the language barrier is removed and the focus of attention is placed on the application of language in real-life contexts. However, technical issues may still prevent students from fully engaging in the learning environment. Our student participants said that more teacher support would have been useful in using the technology. Interestingly, they also raised the question of who should be responsible for providing technical guidance. In a recent study by Liu et al. (2020), their science teacher received three-month professional training on the use of VR before applying it to his classroom teaching. Apparently, more discussions of teacher training are needed in relation to the integration of VR in different disciplinary education and language learning.

Meanwhile, our participants appreciated the appropriate learning design and effective pedagogical support provided by the language teacher during their learning. There is often a misconception that technology per se is a pedagogical approach to improving student learning (Traxler and Kukulska-Hulme, 2016). Yet, more educators have realized that technological, pedagogical, and content knowledge jointly plays a crucial role in the success of teachers’ design and implementation of technology-supported language learning (see TPACK, Mishra and Koehler, 2006). As such, training aiming for the improvement of teachers' TPACK knowledge is urgent.

Conclusion

Though VR can by no means replace the real surgical experience, the present study illustrates some of the benefits VR has in training nursing students in an immersive English learning environment. This study reports the experiences of one group of ESP college nursing students and their perceptions of language learning regarding immersive virtual reality in the simulated medical context. The study is of particular importance as it showcases how a language teacher repurposed and customized the VR technology into her use in a language course. The findings demonstrate that affordances and challenges coexist, which can inform the development of VR technology and VR-supported language teaching. With the proliferation of new technologies in various domains of learning, we suggest that future research should continue investigating the effectiveness of learning in fully immersive contexts. In addition, the lack of strong theoretical support calls for more discussions of theory-driven learning frameworks for using VR in language learning.

Yet, this study is not flawless. First, as an exploratory study, this paper focused on the participants’ perceptions and attitudes in relation to their novel learning experience. Together with the short-term nature of this exploratory study, the current findings should be carefully interpreted in terms of the generalizability. Future research may employ a longitudinal research design with alternative research methods. Second, large-scale VR studies, different from the current limited number of participants, will be more informative to obtain a comprehensive understanding for educators in different contexts. Third, teacher training in VR-assisted language education is an underexplored but key issue if we aim to completely understand, creatively utilize, and critically evaluate VR in English language education. As students had different expectations of teacher support in the present study, an in-depth discussion from the teacher's perspective seems critical.

Although some learning and technological challenges were reported in this study, students appreciated the invaluable learning opportunities afforded by the emerging technology. In accordance with Hockly and Dudeney (2018), in the not-too-distant future VR for language learning may not be considered as a fringe technology, but be used in mainstream language classrooms.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Junjie Gavin Wu

Lindsay Miller

Qing Huang

Junjie Gavin Wu is an Assistant Professor in the School of Foreign Languages, Shenzhen Technology University. He has won several international awards and scholarships over the past years. He serves on the committee of PacCALL International Association and organizes GLoCALL International Conferences. His latest publications can be found in Computer Assisted Language Learning, Language in Society, Australasian Journal of Educational Technology, Journal of Education for Teaching, and RELC Journal. His edited book Language Learning with Technology: Perspectives from Asia has just been published by Springer in 2021. His research interests are technology and learning, language education, and teacher education. ORCID ID: 0000-0003-4937-4401

Lindsay Miller is an Associate Professor in the Department of English at City University of Hong Kong. He teaches courses at BA and MA level and is the PhD coordinator. His main research interests are in the areas of learner autonomy, listening, and ESP. He has published widely in these areas and has co-authored, Second Language Listening: Theory and Practice, 2005 (with J. Flowerdew), CUP; Managing Self-Access Language Learning, 2014 (with D. Gardner), CityU Press; and English in the Disciplines: A Multidimensional Model for ESP Course Design, 2019 (with C.A. Hafner), Routledge Press.

Qing Huang, Sunny is an ESP (English for Specific Purposes) teacher in Huizhou Health Sciences Polytechnic in Guangdong, China. She teaches College English, Nursing English and Medical English. She is pursuing her PhD in the fields of ESP, language education and Health Communication in the Department of English of City University of Hong Kong. Her email: qinghuang6-c@my.cityu.edu.hk, ORCID ID: 0000-0002-2008-9888

Minjuan Wang is Professor of Learning Design and Technology at San Diego State University (SDSU), and an executive board member of the Immersive Learning Research Network (iLRN). She also worked as a project manager for the Chancellor's Office of California State University. Her research specialties are multidisciplinary, focusing on X-Reality and Immersive Learning, sociocultural aspects of online learning, mobile learning, augmented reality, and intelligent environments. She served as the Chief Editor for the EAI Transactions on E-Learning, and was a guest editor to two premiere journals, Virtual Reality and Interactive Learning Environments. In addition, she serves on editorial boards for four other education technology journals. As a winner of several research awards and international grants, Minjuan is recognized as one of the high-impact authors in blended and mobile learning. She has more than 100 peer-reviewed articles published in indexed journals and conference proceedings, including Educational Technology Research and Development, IEEE Transactions on Education, and British Journal of Educational Technology. She was a keynote and invited speaker to nearly 30 international conferences and also participated in the organization of numerous conferences.

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