Developing a Framework for the Design and Deployment of Virtual Reality (VR) in Clinical Education.

The emerging cost-effective and powerful standalone VR hardware is an increasingly viable supplement to traditional clinical educational modalities. These traditional approaches are effective but can be limited by the cost of simulation infrastructure, the requirement to attend at fixed times and locations and instructor availability present challenges in meeting the needs of clinicians. One barrier facing educators looking to develop bespoke VR-based solutions is the lack of guidelines around their design, development, deployment, and evaluation. Our team has produced and deployed a number of VR-based educational applications. Through reflecting on findings from surveys, interviews, observation, we summarise a range of insights into the complexity and nuances of the clinical VR design and deployment in a framework that can inform and guide educators, clinicians and developers looking to create their own VR applications for use in healthcare.

Designing Virtual Reality-Based Conversational Agents to Train Clinicians in Verbal De-escalation Skills: Exploratory Usability Study.

BACKGROUND: Violence and aggression are significant workplace challenges faced by clinicians worldwide. Traditional methods of training consist of "on-the-job learning" and role-play simulations. Although both approaches can result in improved skill levels, they are not without limitation. Interactive simulations using virtual reality (VR) can complement traditional training processes as a cost-effective, engaging, easily accessible, and flexible training tool. OBJECTIVE: In this exploratory study, we aimed to determine the feasibility of and barriers to verbal engagement with a virtual agent in the context of the Code Black VR application. Code Black VR is a new interactive VR-based verbal de-escalation trainer that we developed based on the Clinical Training Through VR Design Framework. METHODS: In total, 28 participants with varying clinical expertise from 4 local hospitals enrolled in the Western Sydney Local Health District Clinical Initiative Nurse program and Transition to Emergency Nursing Programs and participated in 1 of 5 workshops. They completed multiple playthroughs of the Code Black VR verbal de-escalation trainer application and verbally interacted with a virtual agent. We documented observations and poststudy reflection notes. After the playthroughs, the users completed the System Usability Scale and provided written comments on their experience. A thematic analysis was conducted on the results. Data were also obtained through the application itself, which also recorded the total interactions and successfully completed interactions. RESULTS: The Code Black VR verbal de-escalation training application was well received. The findings reinforced the factors in the existing design framework and identified 3 new factors-motion sickness, perceived value, and privacy-to be considered for future application development. CONCLUSIONS: Verbal interaction with a virtual agent is feasible for training staff in verbal de-escalation skills. It is an effective medium to supplement clinician training in verbal de-escalation skills. We provide broader design considerations to guide further developments in this area.

Experiences of Patients Undergoing Chemotherapy With Virtual Reality: Mixed Methods Feasibility Study.

BACKGROUND: Current research into virtual reality (VR) use during chemotherapy shows that it can be an effective distraction intervention. However, there is limited research in adult patients and to investigate how VR can be sustainably implemented in health care organizations. OBJECTIVE: The aim of this study was to explore the feasibility and acceptability of using VR for adult patients undergoing chemotherapy, and to identify the factors that would enable the sustained use of VR during chemotherapy in health care organizations. METHODS: Patients undergoing chemotherapy were recruited to participate in a VR intervention during chemotherapy infusion. Participants were observed during the session and completed a postintervention survey. Each participant was invited to participate in a semistructured interview about their experience. RESULTS: A total of 18 patients participated in the study, 5 of whom participated in semistructured interviews. Findings indicated that the use of VR was acceptable for patients undergoing chemotherapy and the intervention was also feasible. Some participants felt that the VR was an effective distraction during chemotherapy infusion, although most still seemed to be aware of how long their treatment was taking. Although VR was acceptable and feasible to patients, interviews identified several barriers to sustained implementation, including access to a reliable app library and impact on staff workloads. CONCLUSIONS: VR was acceptable to patients with a diagnosis of cancer undergoing chemotherapy treatment. Patients found VR beneficial for breaking up the monotony of treatment, to provide an additional choice of activity in addition to other recreation, and in some instances as a distraction from the treatment itself. However, there are challenges to address if VR is to be implemented in practice for this patient group.

A Video Self-Modeling Intervention Using Virtual Reality Plus Physical Practice for Freezing of Gait in Parkinson Disease: Feasibility and Acceptability Study.

BACKGROUND: Despite optimal medical and surgical intervention, freezing of gait commonly occurs in people with Parkinson disease. Action observation via video self-modeling, combined with physical practice, has potential as a noninvasive intervention to reduce freezing of gait. OBJECTIVE: The aim of this study is to determine the feasibility and acceptability of a home-based, personalized video self-modeling intervention delivered via a virtual reality head-mounted display (HMD) to reduce freezing of gait in people with Parkinson disease. The secondary aim is to investigate the potential effect of this intervention on freezing of gait, mobility, and anxiety. METHODS: The study was a single-group pre-post mixed methods pilot trial for which 10 participants with Parkinson disease and freezing of gait were recruited. A physiotherapist assessed the participants in their homes to identify person-specific triggers of freezing and developed individualized movement strategies to overcome freezing of gait. 180° videos of the participants successfully performing their movement strategies were created. Participants watched their videos using a virtual reality HMD, followed by physical practice of their strategies in their own homes over a 6-week intervention period. The primary outcome measures included the feasibility and acceptability of the intervention. Secondary outcome measures included freezing of gait physical tests and questionnaires, including the Timed Up and Go Test, 10-meter walk test, Goal Attainment Scale, and Parkinson Anxiety Scale. RESULTS: The recruitment rate was 24% (10/42), and the retention rate was 90% (9/10). Adherence to the intervention was high, with participants completing a mean of 84% (SD 49%) for the prescribed video viewing and a mean of 100% (SD 56%) for the prescribed physical practice. One participant used the virtual reality HMD for 1 week and completed the rest of the intervention using a flat-screen device because of a gradual worsening of his motion sickness. No other adverse events occurred during the intervention or assessment. Most of the participants found using the HMD to view their videos interesting and enjoyable and would choose to use this intervention to manage their freezing of gait in the future. Five themes were constructed from the interview data: reflections when seeing myself, my experience of using the virtual reality system, the role of the virtual reality system in supporting my learning, developing a deeper understanding of how to manage my freezing of gait, and the impact of the intervention on my daily activities. Overall, there were minimal changes to the freezing of gait, mobility, or anxiety measures from baseline to postintervention, although there was substantial variability between participants. The intervention showed potential in reducing anxiety in participants with high levels of anxiety. CONCLUSIONS: Video self-modeling using an immersive virtual reality HMD plus physical practice of personalized movement strategies is a feasible and acceptable method of addressing freezing of gait in people with Parkinson disease.

A comparison design study of feedback modalities to support deep breathing whilst performing work tasks.

BACKGROUND: Deep breathing exercises are known to help decrease stress. Wearable and ambient computing can help initiate and support deep breathing exercises. Most studies have focused on a single sensory modality for providing feedback on the quality of breathing and other physiological data. OBJECTIVE: Our research compares different feedback modalities on an individual's experience and ability to perform breath-based techniques at work. METHODS: We designed three different interactive prototypes that used light, vibration and sound feedback modalities. We tested each prototype with 19 participants whilst they were performing typical work tasks in a naturalistic setting, followed by semi-structured interviews. RESULTS: We found that sound was the most successful feedback for the majority of participants, followed by vibration and ambient light. We developed an analytic tool, the Extended Cycle of Awareness, to facilitate understanding of the patterns of awareness and the flow of experience generated by participant interaction with prototype systems that provide feedback on the quality of breathing. Participants followed one of three different types of patterns: (1) ignoring the feedback; (2) not understanding the feedback and being overwhelmed by it; (3) successfully using the feedback to initiate deep breathing and reflect on the change in the quality of breathing. CONCLUSIONS: We offer a set of design recommendations for crafting interactive systems to support deep breathing at work, including personalization, designing for the cyclical process of attention and awareness, and designing for reflective practice.

Exploring User Needs in the Development of a Virtual Reality-Based Advanced Life Support Training Platform: Exploratory Usability Study.

BACKGROUND: Traditional methods of delivering Advanced Life Support (ALS) training and reaccreditation are resource-intensive and costly. Interactive simulations and gameplay using virtual reality (VR) technology can complement traditional training processes as a cost-effective, engaging, and flexible training tool. OBJECTIVE: This exploratory study aimed to determine the specific user needs of clinicians engaging with a new interactive VR ALS simulation (ALS-SimVR) application to inform the ongoing development of such training platforms. METHODS: Semistructured interviews were conducted with experienced clinicians (n=10, median age=40.9 years) following a single playthrough of the application. All clinicians have been directly involved in the delivery of ALS training in both clinical and educational settings (median years of ALS experience=12.4; all had minimal or no VR experience). Interviews were supplemented with an assessment of usability (using heuristic evaluation) and presence. RESULTS: The ALS-SimVR training app was well received. Thematic analysis of the interviews revealed five main areas of user needs that can inform future design efforts for creating engaging VR training apps: affordances, agency, diverse input modalities, mental models, and advanced roles. CONCLUSIONS: This study was conducted to identify the needs of clinicians engaging with ALS-SimVR. However, our findings revealed broader design considerations that will be crucial in guiding future work in this area. Although aligning the training scenarios with accepted teaching algorithms is important, our findings reveal that improving user experience and engagement requires careful attention to technology-specific issues such as input modalities.

Synthesizing Multiple Stakeholder Perspectives on Using Virtual Reality to Improve the Periprocedural Experience in Children and Adolescents: Survey Study.

BACKGROUND: Virtual reality (VR) technology is a powerful tool for augmenting patient experience in pediatric settings. Incorporating the needs and values of stakeholders in the design of VR apps in health care can contribute to better outcomes and meaningful experiences for patients. OBJECTIVE: We used a multiperspective approach to investigate how VR apps can be designed to improve the periprocedural experiences of children and adolescents, particularly those with severe anxiety. METHODS: This study included a focus group (n=4) and a survey (n=56) of clinicians. Semistructured interviews were conducted with children and adolescents in an immunization clinic (n=3) and perioperative setting (n=65) and with parents and carers in an immunization clinic (n=3) and perioperative setting (n=35). RESULTS: Qualitative data were examined to determine the experience and psychological needs and intervention and design strategies that may contribute to better experiences for children in three age groups (4-7, 8-11, and 12-17 years). Quantitative data were used to identify areas of priority for future VR interventions. CONCLUSIONS: We propose a set of ten design considerations for the creation of future VR experiences for pediatric patients. Enhancing patient experience may be achieved by combining multiple VR solutions through a holistic approach considering the roles of clinicians and carers and the temporality of the patient's experience. These situations require personalized solutions to fulfill the needs of pediatric patients before and during the medical procedure. In particular, communication should be placed at the center of preprocedure solutions, while emotional goals can be embedded into a procedure-focused VR app to help patients shift their focus in a meaningful way to build skills to manage their anxiety.

Design Strategies for Virtual Reality Interventions for Managing Pain and Anxiety in Children and Adolescents: Scoping Review.

BACKGROUND: Virtual reality (VR) technology has been explored in the health sector as a novel tool for supporting treatment side effects, including managing pain and anxiety. VR has recently become more available with the launch of low-cost devices and apps. OBJECTIVE: This study aimed to provide an updated review of the research into VR use for pain and anxiety in pediatric patients undergoing medical procedures. Specifically, we wanted to gain an understanding of the techniques and goals used in selecting or designing VR apps in this context. METHODS: We performed a scoping review. To identify relevant studies, we searched three electronic databases. Two authors screened the titles and abstracts for relevance and eligibility criteria. RESULTS: Overall, 1386 articles published between 2013 and 2018 were identified. In total 18 articles were included in the review, with 7 reporting significant reduction in pediatric pain or anxiety, 3 testing but finding no significant impact of the VR apps employed, and the rest not conducting any test of significance. We identified 9 articles that were based on VR apps specifically designed and tailored for pediatric patients. The findings were analyzed to develop a holistic model and describe the product, experience, and intervention aspects that need to be considered in designing such medical VR apps. CONCLUSIONS: VR has been demonstrated to be a viable choice for managing pain and anxiety in a range of medical treatments. However, commercial products lack diversity and meaningful design strategies are limited beyond distraction techniques. We propose future VR interventions to explore skill-building goals in apps characterized by dynamic feedback to the patient and experiential and product qualities that enable them to be an active participant in managing their own care. To achieve this, design must be part of the development.

An Immersive Virtual Reality Platform for Assessing Spatial Navigation Memory in Predementia Screening: Feasibility and Usability Study.

BACKGROUND: Traditional methods for assessing memory are expensive and have high administrative costs. Memory assessment is important for establishing cognitive impairment in cases such as detecting dementia in older adults. Virtual reality (VR) technology can assist in establishing better quality outcome in such crucial screening by supporting the well-being of individuals and offering them an engaging, cognitively challenging task that is not stressful. However, unmet user needs can compromise the validity of the outcome. Therefore, screening technology for older adults must address their specific design and usability requirements. OBJECTIVE: This study aimed to design and evaluate the feasibility of an immersive VR platform to assess spatial navigation memory in older adults and establish its compatibility by comparing the outcome to a standard screening platform on a personal computer (PC). METHODS: VR-CogAssess is a platform integrating an Oculus Rift head-mounted display and immersive photorealistic imagery. In a pilot study with healthy older adults (N=42; mean age 73.22 years, SD 9.26), a landmark recall test was conducted, and assessment on the VR-CogAssess was compared against a standard PC (SPC) setup. RESULTS: Results showed that participants in VR were significantly more engaged (P=.003), achieved higher landmark recall scores (P=.004), made less navigational mistakes (P=.04), and reported a higher level of presence (P=.002) than those in SPC setup. In addition, participants in VR indicated no significantly higher stress than SPC setup (P=.87). CONCLUSIONS: The study findings suggest immersive VR is feasible and compatible with SPC counterpart for spatial navigation memory assessment. The study provides a set of design guidelines for creating similar platforms in the future.

Virtual Reality interventions for acute and chronic pain management.

Virtual Reality (VR) is now consumer ready and nearing ubiquity. In terms of clinical applications, several studies suggest that VR can be effective as a complementary adjunct or alternative non-pharmacologic analgesic in a range of pain-inducing procedures and in management of chronic pain. The increasing affordability and quality of portable VR headsets and the ongoing utility of pain therapy signals an exciting future for the use of VR for analgesia. However, further research is needed to establish its long-term benefits if VR is to be adopted into mainstream protocols for analgesia management. This research requires a range of study designs with collection of patient self-report and clinical data together to develop bespoke interventions for different cohorts.

Aircraft passenger comfort experience: underlying factors and differentiation from discomfort.

Previous studies defined passengers' comfort based on their concerns during the flight and a set of eight experiential factors such as 'peace of mind', 'physical wellbeing', 'pleasure', etc. One Objective of this paper was to determine whether the factors underlying the passengers' experience of comfort differ from those of discomfort. Another objective was to cross-validate those factors. In the first study, respondents provided written reports of flight comfort and discomfort experiences separately and gave ratings on the impact of the eight factors on each experience. Follow up interviews were also conducted. Significant difference was found between comfort and discomfort ratings for two factors of 'pleasure', denoted by one's concern for stimulation, ambience and exceeded expectations, and 'physical wellbeing' characterized in terms of bodily support and energy. However, there were no significant differences between the comfort and discomfort ratings on the other six factors. The evidence does not support the proposition that passenger comfort and discomfort are underline by different sets of factors. It is therefore suggested that the evaluation of overall passenger comfort experience, as a whole, employ one spectrum ranging from extreme comfort to discomfort. In study two, a pool of comfort descriptors was collected. Those that were less relevant to passenger comfort were eliminated in a number of steps. Factor analysis was used to classify the remaining descriptors, using respondents' ratings on their potential impact on passenger comfort. Seven factors corresponded to the pre-determined passenger comfort factors from previous research, validating those with an exception of 'proxemics' (concerning one's privacy and control over their situation) but it was argued that this is due to the nature of the factor itself, which is context dependent and generally perceived unconsciously.

The thematic structure of passenger comfort experience and its relationship to the context features in the aircraft cabin.

This paper describes passenger comfort as an experience generated by the cabin interior features. The findings of previous studies are affirmed regarding a set of 22 context features. Passengers experience a certain level of comfort when these features impact their body and elicit subjective perceptions. New findings characterise these perceptions in the form of eight themes and outline their particular eliciting features. Comfort is depicted as a complex construct derived by passengers' perceptions beyond the psychological (i.e. peace of mind) and physical (i.e. physical well-being) aspects, and includes perceptual (e.g. proxemics) and semantic (e.g. association) aspects. The seat was shown to have a focal role in eliciting seven of those themes and impacting comfort through its diverse characteristics. In a subsequent study, a group of aircraft cabin interior designers highlighted the possibility of employing the eight themes and their eliciting features as a framework for design and evaluation of new aircraft interiors.