Development and Considerations for Virtual Reality Simulations for Resuscitation Training and Stress Inoculation

Examining the applicability of virtual battle space for stress management training in military personnel-A validation study

Military personnel are often exposed to high levels of both physical and psychological challenges in their work environment and therefore it is important to be trained on how to handle stressful situations. The primary aim of this study was to examine whether military-specific virtual battle space (VBS) scenarios could elicit a physiological and subjective stress response in healthy military personnel, as compared to that of a virtual reality height exposure (VR-HE) stress task that has shown to reliably increase stress levels. Twenty participants engaged in two VBS scenarios and the VR-HE during separate sessions, while measurements of heart rate (HR), heart rate variability (HRV), respiration rate, and subjective stress levels were collected. Contrary to our initial expectations, analysis revealed that neither of the VBS scenarios induced a significant stress response, as indicated by stable HR, HRV, and low subjective stress levels. However, the VR-HE task did elicit a significant physiological stress response, evidenced by increased HR and HRV changes, aligning with previous research findings. Moreover, no discernible alterations were detected in cognitive performance subsequent to these stressors. These results suggest that the current VBS scenarios, despite their potential, may not be effective for stress-related training activities within military settings. The absence of a significant stress response in the VBS conditions points to the need for more immersive and engaging scenarios. By integrating interactive and demanding elements, as well as physical feedback systems and real-time communication, VBS training might better mimic real-world stressors and improve stress resilience in military personnel. The findings of this study have broader implications for stress research and training, suggesting the need for scenario design improvements in virtual training environments to effectively induce stress and improve stress management across various high-stress professions.

Virtual reality for assessing emergency medical competencies in junior doctors - a pilot study

BACKGROUND

The teaching and assessment of clinical-practical skills in medical education face challenges in adequately preparing students for professional practice, especially in handling emergency situations. This study aimed to evaluate the emergency medical competencies of junior doctors using Virtual Reality (VR)-based scenarios to determine their preparedness for real-world clinical situations.

METHODS

Junior doctors with 0-6 months of professional experience participated in one of three VR-based emergency scenarios. These scenarios were designed to test competencies in emergency medical care. Performance was automatically assessed through a scenario-specific checklist, and participants also completed self-assessments and a clinical reasoning ability test using the Post-Encounter Form.

RESULTS

Twenty-one junior doctors participated in the study. Results showed that while general stabilization tasks were performed well, there were notable deficiencies in disease-specific diagnostic and therapeutic actions. On average, 65.6% of the required actions were performed correctly, with no significant variance between different scenarios. Participants achieved an average score of 80.5% in the Post-Encounter-Form, indicating a robust ability to handle diagnostic decisions. Self-assessments did not correlate significantly with objective measures of competency, highlighting the subjective nature of self-evaluation.

CONCLUSION

VR-based simulations can provide a detailed picture of EMC, covering both diagnostic and therapeutic aspects. The findings of this pilot study suggest that while participants are generally well-prepared for routine tasks, more focus is needed on complex case management. VR assessments could be a promising tool for evaluating the readiness of new medical professionals for clinical practice.

Virtual Reality for Pediatric Trauma Education - A Preliminary Face and Content Validation Study

PURPOSE

Pediatric trauma education remains expensive and available only to a few providers worldwide. Innovative educational technologies like virtual reality (VR) can be key to decentralizing trauma education. This preliminary validation study evaluates the face and content validity of a VR software designed to enhance pediatric trauma skills.

METHODS

Physicians were invited to test a VR software simulating a child with blunt head and truncal trauma. After the simulation, they filled out surveys assessing the face and content validity of the scenario, including the software's realism, interaction, ease of use, and educational content. Additionally, they completed a cybersickness questionnaire. A descriptive statistical analysis was performed.

RESULTS

Eleven physicians from eight different countries tested the VR software. Most found it valuable, and realistic and would prefer using it over high-fidelity mannequins for training. The software received more favorable evaluations for non-technical skills training than for technical skills. Regarding cybersickness most participants reported discomfort during the simulation.

CONCLUSION

Participants agreed that a VR platform for pediatric trauma is realistic and immersive, and they endorsed it for enhancing performance, particularly in non-technical skills. Most participants, however, faced some discomfort with the technology, and efforts to minimize cybersickness should be made in future implementation, feasibility, and effectiveness studies.

LEVEL OF EVIDENCE

IV.

Creation of a Virtual Reality Telesimulation Program in Response to Mandatory COVID-19 Social Distancing During the Pandemic: A Primer for Those considering VR Simulation and Application to a Group of Physicians Naive to Virtual Reality

The COVID-19 pandemic necessitated the closure of traditional simulation centers, prompting innovative solutions for medical education. Drawing from prior studies, which advocated for telesimulation and virtual reality (VR) as alternatives, this article explores the development and implementation of VR simulation in medical training. Leveraging the Acadicus® VR platform, a VR simulation solution was created, enabling interactive scenarios simulating pediatric critical care situations. Thirty-one diverse scenarios were designed and executed over an 8-month period, involving pediatric and emergency medicine residents and fellows. The development process involved creating lifelike mannequins and dynamic cardiac waveforms, enhancing realism and spontaneity. Using VR headsets and streaming technology, participants engaged in immersive scenarios remotely. Performance evaluation used a modified version of the Tool for Resuscitation Assessment Using Computer Simulation, revealing comparable outcomes across different training levels and specialties. Participant feedback underscored the immersive nature of VR simulation, offering enhanced realism and in-depth debriefing opportunities compared with traditional mannequin-based simulation. However, limitations such as the lack of haptic feedback and the need for better integration with existing simulation center infrastructure were noted. Cost-effectiveness emerged as a significant advantage of VR simulation, with lower upfront costs compared with traditional simulation centers. VR simulation also demonstrated versatility in staging training across various hospital settings, offering a more comprehensive learning experience. Although acknowledging the need for further research to measure skill acquisition and retention, this study highlights the potential of VR simulation as an adjunctive modality in medical education.

Virtual Reality for Cardiopulmonary Resuscitation Healthcare Professionals Training: A Systematic Review

INTRODUCTION

Virtual reality (VR) is becoming increasingly popular to train health-care professionals (HCPs) to acquire and/or maintain cardiopulmonary resuscitation (CPR) basic or advanced skills.

AIM

To understand whether VR in CPR training or retraining courses can have benefits for patients (neonatal, pediatric, and adult), HCPs and health-care organizations as compared to traditional CPR training.

METHODS

A systematic review (PROSPERO: CRD42023431768) following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. In June 2023, the PubMed, Cochrane Library, Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched and included studies evaluated in their methodological quality with Joanna Briggs Institute checklists. Data were narratively summarized.

RESULTS

Fifteen studies published between 2013 and 2023 with overall fair quality were included. No studies investigated patients' outcomes. At the HCP level, the virtual learning environment was perceived to be engaging, realistic and facilitated the memorization of the procedures; however, limited decision-making, team building, psychological pressure and frenetic environment were underlined as disadvantages. Moreover, a general improvement in performance was reported in the use of the defibrillator and carrying out the chest compressions. At the organizational level, one study performed a cost/benefit evaluation in favor of VR as compared to traditional CPR training.

CONCLUSIONS

The use of VR for CPR training and retraining is in an early stage of development. Some benefits at the HCP level are promising. However, more research is needed with standardized approaches to ensure a progressive accumulation of the evidence and inform decisions regarding the best training methodology in this field.

SIMPEDVR: using VR in teaching pediatric emergencies to undergraduate students-a pilot study

The objective of this work was to provide pilot data on feasibility of using virtual reality (VR) to train undergraduate students in pediatric emergency scenarios. We staged VR sessions for a total of 45 medical and nursing students; in every session, each student managed two pediatric emergency virtual scenarios. At the end of the sessions, students completed a Technology Assessment Questionnaire to evaluate the perceived usefulness and perceived ease-of-use of their VR training experience and rated their perceived level of competence in managing the two clinical scenarios. The median perceived usefulness was 91.7/100 (interquartile range (IQR) 80.6-100), while the median perceived ease-of-use was 77.8/100 (IQR 63.9-88.9). The perceived level of competence increased from 2 (IQR 1-3) to 4 (IQR 3-4) on a 5-point Likert scale, for both scenarios (p < 0.001, Wilcoxon test for paired samples).       Conclusions: The staged VR sessions had a good perceived usefulness and resulted in an increase in the perceived level of competence. The results on the ease-of-use, however, show that an assumption that millennials and younger students can navigate with confidence VR hardware in a healthcare training setting should not be made; further work is required to ease the integration of VR into curricula. What is Known: • Virtual reality (VR) is a rising simulation training methodology in Pediatric Emergency Medicine (PEM), however little experience is reported about its use for undergraduate students What is New: • VR PEM trainiing was found useful by undergraduate students and its use increased their perceived level of competence, although ease-of-use received lower ratings. • Despite the young age, an assumption that millennials and younger students can navigate with confidence VR hardware in a healthcare training setting should not be made.

Virtual reality in simulation-based emergency skills training: A systematic review with a narrative synthesis

Objective

An important role is predicted for virtual reality (VR) in the future of medical education. We performed a systematic review of the literature with a narrative synthesis, to examine the current evidence for VR in simulation-based emergency skills training. We broadly define emergency skills as any clinical skill used in the emergency care of patients across all clinical settings.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The data sources accessed during this study included: PubMed, CINAHL, EMBASE, AMED, EMCARE, HMIC, BNI, PsychINFO, Medline, CENTRAL, SCOPUS, Web of Science, BIOSIS Citation Index, ERIC, ACM Digital Library, IEEE Xplore, and ProQuest Dissertations and Thesis Global. Cochrane's Rob 2 and ROBVIS tools were used during study quality assessment. No ethical review was required for this work.

Results

Thirty-four articles published between 14th March 1998 and 1st March 2022 were included in this review. Studies were predominantly conducted in the USA and Europe and focussed on a variety of healthcare disciplines including medical, nursing, and allied health. VR education was delivered using head-mounted displays, Cave Automatic Virtual Environment systems, and bespoke setups. These systems delivered education in a variety of areas (emergency medicine, equipment training, obstetrics, and basic/advanced life support). Subjective potential advantages of this technology included realism, replayability, and time-effectiveness. Reports of adverse events were low in frequency across the included studies. Whilst clear educational benefit was generally noted, this was not reflected in changes to patient-based outcomes.

Conclusion

There may be educational benefit to using VR in the context of simulation-based emergency skills training including knowledge gain and retention, skill performance, acceptability, usability, and validity. Currently, there is insufficient evidence to demonstrate clear cost-effectiveness, or direct improvement of patient or institutional outcomes, at this stage.

Frequently Used Conceptual Frameworks and Design Principles for Extended Reality in Health Professions Education

Health professions education (HPE) has witnessed a dramatic increase in the use of extended reality (XR), but there is limited evidence that conceptual frameworks are being effectively employed in the design and implementation of XR. This paper introduces commonly utilized conceptual frameworks that can support the integration of XR into the learning process and design principles that can be helpful for the development and evaluation of XR educational applications. Each framework and design principle is summarized briefly, followed by a description of its applicability to XR for HPE and an example of such application.

Some Things Change, Some Things Stay the Same: Trends in Canadian Education in Paediatric Cardiology and the Cardiac Sciences

Education in paediatric cardiology has evolved along with clinical care. The availability and application of new technologies in education, in particular, have had a significant impact. Artificial intelligence; virtual, augmented, and mixed reality learning tools; and gamification of learning have all resulted in new opportunities for today's trainees compared with those of the past. A new training model is also being used. Though currently focused on residency education, competency-based medical education is also being applied to undergraduate education in some Canadian medical schools. Competency-based medical education offers a more transparent relationship between education and physicians' social contract with society. It provides greater accountability for programmes and learners to teach and learn the skills required to function as competent specialists. However, it has not come without challenges. Coincident with the application of this model for learners, there has been increased educational accountability for physicians in practice and for the institutions training them. Despite these changes, some things have remained the same. On the positive side, the importance of good clinical teachers to effective learning remains constant. Unfortunately, the mistreatment of learners within our education system also remains and is perhaps the most important challenge facing medical education in Canada today. Learning to be better teachers and learner advocates is an important goal for all of those involved in educating Canadian medical learners.

Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial)

BACKGROUND

Neonatal mortality accounts for approximately 46% of global under-5 child mortality. The widespread access to mobile devices in low- and middle-income countries has enabled innovations, such as mobile virtual reality (VR), to be leveraged in simulation education for health care workers.

OBJECTIVE

This study explores the feasibility and educational efficacy of using mobile VR for the precourse preparation of health care professionals in neonatal resuscitation training.

METHODS

Health care professionals in obstetrics and newborn care units at 20 secondary and tertiary health care facilities in Lagos, Nigeria, and Busia, Western Kenya, who had not received training in Helping Babies Breathe (HBB) within the past 1 year were randomized to access the electronic HBB VR simulation and digitized HBB Provider's Guide (VR group) or the digitized HBB Provider's Guide only (control group). A sample size of 91 participants per group was calculated based on the main study protocol that was previously published. Participants were directed to use the electronic HBB VR simulation and digitized HBB Provider's Guide or the digitized HBB Provider's Guide alone for a minimum of 20 minutes. HBB knowledge and skills assessments were then conducted, which were immediately followed by a standard, in-person HBB training course that was led by study staff and used standard HBB evaluation tools and the Neonatalie Live manikin (Laerdal Medical).

RESULTS

A total of 179 nurses and midwives participated (VR group: n=91; control group: n=88). The overall performance scores on the knowledge check (P=.29), bag and mask ventilation skills check (P=.34), and Objective Structured Clinical Examination A checklist (P=.43) were similar between groups, with low overall pass rates (6/178, 3.4% of participants). During the Objective Structured Clinical Examination A test, participants in the VR group performed better on the critical step of positioning the head and clearing the airway (VR group: 77/90, 86%; control group: 57/88, 65%; P=.002). The median percentage of ventilations that were performed via head tilt, as recorded by the Neonatalie Live manikin, was also numerically higher in the VR group (75%, IQR 9%-98%) than in the control group (62%, IQR 13%-97%), though not statistically significantly different (P=.35). Participants in the control group performed better on the identifying a helper and reviewing the emergency plan step (VR group: 7/90, 8%; control group: 16/88, 18%; P=.045) and the washing hands step (VR group: 20/90, 22%; control group: 32/88, 36%; P=.048).

CONCLUSIONS

The use of digital interventions, such as mobile VR simulations, may be a viable approach to precourse preparation in neonatal resuscitation training for health care professionals in low- and middle-income countries.

Treatment of status epilepticus in pediatrics: curriculum learning combined with in-situ simulations

BACKGROUND

Appropriate and timely treatment of status epilepticus (SE) reduces morbidity and mortality. Therefore, skill-based identification and management are critical for emergency physicians.

PURPOSE

To assess whether the ability of training physicians, residents, nurses, and others to respond to SE as a team could be improved by using curriculum learning [Strategies and Tools to Enhance Performance and Patient Safety of Team (TeamSTEPPS) course training] combined with in-situ simulations of emergency department (ED) staff.

APPROACH

A pre-training-post-training design was used on SE skills and teamwork skills. Emergency training, residents, and N1 and N2 nurses completed the SE skill and teamwork assessments (pre-training) through in-situ simulation. Next, the participating physicians and nurses attended the SE course [Strategies and Tools to Enhance Performance and Patient Safety of Team (TeamSTEPPS) course training], followed by conscious skill practice, including in-situ simulation drills every 20 days (eight times total) and deliberate practice in the simulator. The participants completed the SE skill and teamwork assessments (post-training) again in an in-situ simulation. Pre-training-post-training simulated SE skills and teamwork performance were assessed. The simulation training evaluation showed that the training process was reasonable, and the training medical staff had different degrees of benefit in increasing subject interest, improving operational skills, theoretical knowledge, and work self-confidence.

FINDINGS

Sixty doctors and nurses participated in the intervention. When comparing the SE skills of 10 regular training physicians pre-training and post-training, their performance improved from 40% (interquartile range (IQR): 0-1) before training to 100% (IQR: 80.00-100) after training (p < 0.001). The teamwork ability of the 10 teams improved from 2.43 ± 0.09 before training to 3.16 ± 0.08 after training (p < 0.001).

CONCLUSION

SE curriculum learning combined with in-situ simulation training provides the learners with SE identification and management knowledge in children and teamwork skills.

Comparison of extended reality and conventional methods of basic life support training: protocol for a multinational, pragmatic, noninferiority, randomised clinical trial (XR BLS trial)

Background

Conventional cardiopulmonary resuscitation (CPR) training for the general public involves the use of a manikin and a training video, which has limitations related to a lack of realism and immersion. To overcome these limitations, virtual reality and extended reality technologies are being used in the field of medical education. The aim of this study is to explore the efficacy and safety of extended reality (XR)-based basic life support (BLS) training.

Methods

This study is a prospective, multinational, multicentre, randomised controlled study. Four institutions in 4 countries will participate in the study. A total of 154 participants will be randomly assigned to either the XR group or the conventional group stratified by institution and sex (1:1 ratio). Each participant who is allocated to either group will be sent to a separate room to receive training with an XR BLS module or conventional CPR training video. All participants will perform a test on a CPR manikin after the training. The primary outcome will be mean compression depth. The secondary outcome will be overall BLS performance, including compression rate, correct hand position, compression, and full release and hands-off time.

Discussion

Using virtual reality (VR) to establish a virtual educational environment can give trainees a sense of realism. In the XR environment, which combines the virtual world with the real world, trainees can more effectively learn various skills. This trial will provide evidence of the usefulness of XR in CPR education.

Trial registration

ClinicalTrials.gov NCT04736888. Registered on 29 January 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05908-z.

Virtual, Augmented, and Alternate Reality in Medical Education: Socially Distanced but Fully Immersed

BACKGROUND

Advancements in technology continue to transform the landscape of medical education. The need for technology-enhanced distance learning has been further accelerated by the coronavirus disease (COVID-19) pandemic. The relatively recent emergence of virtual reality (VR), augmented reality (AR), and alternate reality has expanded the possible applications of simulation-based education (SBE) outside of the traditional simulation laboratory, making SBE accessible asynchronously and in geographically diverse locations.

OBJECTIVE

In this review, we will explore the evidence base for use of emerging technologies in SBE as well as the strengths and limitations of each modality in a variety of settings.

METHODS

PubMed was searched for peer-reviewed articles published between 1995 and 2021 that focused on VR in medical education. The search terms included medical education, VR, simulation, AR, and alternate reality. We also searched reference lists from selected articles to identify additional relevant studies.

RESULTS

VR simulations have been used successfully in resuscitation, communication, and bronchoscopy training. In contrast, AR has demonstrated utility in teaching anatomical correlates with the use of diagnostic imaging, such as point-of-care ultrasound. Alternate reality has been used as a tool for developing clinical reasoning skills, longitudinal patient panel management, and crisis resource management via multiplayer platforms.

CONCLUSION

Although each of these modalities has a variety of educational applications in health profession education, there are benefits and limitations to each that are important to recognize prior to the design and implementation of educational content, including differences in equipment requirements, cost, and scalability.

Use of Virtual Reality for Pediatric Cardiac Critical Care Simulation

Simulation is a key component of training in the pediatric cardiac intensive care unit (CICU), a complex environment that lends itself to virtual reality (VR)-based simulations. However, VR has not been previously described for this purpose. Two simulations were developed to test the use of VR in simulating pediatric CICU clinical scenarios, one simulating junctional ectopic tachycardia and low cardiac output syndrome, and the other simulating acute respiratory failure in a patient with suspected coronavirus disease 2019. Six attending pediatric cardiac critical care physicians were recruited to participate in the simulations as a pilot test of VR’s feasibility for educational and practice improvement efforts in this highly specialized clinical environment. All participants successfully navigated the VR environment and met the critical endpoints of the two clinical scenarios. Qualitative feedback was overall positive with some specific critiques regarding limited realism in some mechanical aspects of the simulation. This is the first described use of VR in pediatric cardiac critical care simulation.