Investigation of the Effect of Virtual Reality Software on Nurses' Clinical Practice, Problem Solving and Clinical Decision Making Skills and Anxiety in the Care Management of Intensive Care Patients.

The importance of qualified nurses in providing intensive care services and ensuring comfort cannot be denied. In this context, intensive care nurses are seen as the most important member and backbone of the interdisciplinary team. The realization of nurses' roles and responsibilities in the care management of patients in line with the nursing process, in line with evidence-based practices and guidelines, reduces the possible complications that may develop due to hospitalization in the intensive care unit . The prerequisite for providing quality and safe care in intensive care is that 75% of intensive care unit staff should be composed of specially trained nurses . During the training of nurses working in intensive care units, which is a specialized field, today's changing technology should be kept up with. The most effective and efficient way to do this is to develop continuous education opportunities. However, in addition to the problems experienced in accessing continuing education opportunities due to reasons such as responsibilities related to work and family life, unsuitability of working hours and places, and workload, the fact that learning methods continue mostly with traditional methods can make the situation difficult.

Increasing knowledge in line with technological developments reveals the necessity of "learner-centered methods" beyond traditional teaching methods. Especially in recent years, there has been an increasing interest in simulation applications to improve patient safety and patient care in the education of health care providers/nurses. Simulation applications give students the opportunity to realize complex learning objectives, demonstrate their competencies and be objectively evaluated in a realistic clinical environment without harming the patient. At the same time, many factors such as the inadequacy of clinical practice areas and the number of learners require the inclusion of simulation applications in nursing education. It is emphasized that virtual reality applications, which are one of the simulation applications for the continuous and professional development of learners / nurses, who are called digital natives today, are taking their place in these programs and will increase gradually in the future. It is stated that health technologies will contribute to healthcare professionals making fewer mistakes, accelerating the healing process of patients, increasing the quality and efficiency of health services, and that virtual reality technology will have an important place among the important technologies and trends that will affect the field of health until 2025. It is defined virtual reality as a virtual environment consisting of different sensory stimuli by combining computer software and hardware, while virtual reality used in healthcare is defined as a treatment, care and education tool with interactive, fun and three-dimensional visual feedback. The area of use of virtual reality application, which first started to be applied with video games, is gradually expanding. Since the most important feature that distinguishes virtual reality from other learning methods is that it gives a real feeling in practice, it acts as a bridge between theory and practice in nursing education. Virtual reality, which is not expensive to implement and use in education, does not cause side effects, is non-invasive, and has an effective role in physical, psychological, social, emotional and spiritual recovery, is not a choice but a necessity in current and future nursing practices and education.

In the light of all this information, it is important that intensive care nursing is a specialized field / branch, post-graduate education should be certified, critical thinking skills should be developed, critical patients' care needs should be met, and continuous training should be supported in order to adapt to changing and developing technology, care and treatment methods. The World Federation of Intensive Care Nurses Associations and the European Federation of Intensive Care Nurses Associations recommend that the care of the intensive care patient should be carried out by nurses specialized in intensive care nursing with postgraduate programs. It is known that a qualified intensive care nurse should receive at least 1200 hours of training after graduation and is trained in an average of five years. The intensive care nursing certificate program standards prepared in line with the Ministry of Health's Regulation on Certified Education aim to "train intensive care nurses who ensure the physical, psychological and social empowerment of the individual with preventive, developmental / rehabilitative interventions, establish therapeutic communication with patients and their families, adapt to developments in health science and technology, new treatment and care methods, have competence to meet emergency, critical and complex patient care needs, and have advanced problem-solving skills". In the training program, it is listed that learning methods such as oral lecture, video teaching, small group work, demonstration, active discussion with question-answer, simulation and clinical practice can be used.

Orientation programs have an important place in the adaptation process of newly graduated nurses to their professional roles. Orientation training consists of a comprehensive and intensive program that is based on the learning needs of newly graduated nurses, meets their expectations from the institution/profession, facilitates their adaptation to the profession/unit, provides competence to novices, and increases institutional commitment and job satisfaction. In orientation training, the scope, content and duration of which vary from institution to institution and according to the unit worked in, it is stated that the orientation period varies between 6 weeks and 12 months; in specialized units such as emergency, intensive care, etc., this period can increase from 12 weeks to 18 months.

Intensive care nurses have the opportunity to improve their competencies in basic knowledge and practice skills with clinical orientation training, competencies in advanced knowledge and practice skills with in-service training, and professionalism with certificates and courses. It is seen that most of the studies conducted abroad on the education of intensive care nurses are related to the implementation and evaluation of orientation programs. Studies show that special orientation models focusing on critical thinking skills, patient care management and the development of self-esteem are utilized in the orientation training of intensive care nurses. In researches' country, research on continuing education activities for the training and development of intensive care nurses is limited. In these limited studies, although participation in trainings, especially in-service trainings, is considered partially sufficient, it is also noteworthy that they cannot participate in trainings due to workload and lack of staff. In addition to these findings, the fact that the majority of the training method is lecture with slides is an indication that today's education system is based on traditional knowledge and this is reflected in continuing education activities such as orientation training and in-service training.

Studies show that the stress levels of newly graduated nurses whose first working experience is in specialized units such as intensive care, emergency, etc. are higher. However, when the literature is examined, it is seen that a significant portion of newly graduated nurses are directly assigned to specialized units. In the a study, 11% of newly graduated nurses worked in intensive care and 16% in emergency services; in the an other study, 16% worked in intensive care and 9% in emergency services; and in the other study, it was reported that 77% of newly graduated nurses were first assigned to specialized units such as intensive care, emergency, oncology, etc. Considering that newly graduated nurses start their professional practice with basic level professional knowledge and skills, specialized units such as intensive care, emergency service and oncology put more pressure on new graduates. This situation causes newly graduated nurses to feel professionally inadequate, experience intense stress and leave the profession/institution in the future. In researches' country, as in the international arena, it is seen that newly graduated nurses mostly start working in specialized units such as intensive care, emergency, etc. . In another study, it was determined that the area where new graduate nurses felt least competent was intensive care units and that they needed training specific to this area.

In the literature, there are studies in which virtual reality method is used in nursing education, and it is seen that these studies are mainly aimed at nurse students.

Virtual reality applications enable participants to learn interactively and analyze problems by increasing the learning outcomes for all learning areas (cognitive, affective, psychomotor) in educational institutions, increasing the permanence of learning. As seen in other studies, it is thought that the use of virtual reality in trainings organized for intensive care nurses in health institutions can increase the quality of care, increase patient comfort, reduce the error rate, reduce the stress level of learners and provide psychomotor skills. In addition, virtual reality applications can be used as a unique and useful alternative teaching method for intensive care nurses to gain more advanced and abstract skills such as collaboration, problem solving, critical thinking or communication skills and to evaluate these skills.