Using Virtual Reality Simulation Environments to Assess Competence for Emergency Medicine Learners

A virtual patient authoring tool for transcatheter aortic valve replacement

PURPOSE

Computer-based medical training scenarios, derived from patient's records, often lack variability, modifiability, and availability. Furthermore, generating image datasets and creating scenarios is resource-intensive. Therefore, patient authoring tools for rapid dataset-independent creation of virtual patients (VPs) is a pressing need.

METHODS

An authoring tool and a virtual catheterization laboratory environment were developed. The tool allows customised VP generation through a real-time morphable heart model and Euroscore parameters. The generated VP can be examined inside the vCathLab using a fluoroscopy and monitoring device, both on desktop and immersive virtual reality. Seven board-certified experts evaluated the proposed method from three aspects, i.e. System Usability Scale, qualitative feedback, and its performance in VR.

RESULTS

All participants agreed that this method could provide the necessary information and is anatomically correct within an educational context. Its modifiability, variability, and simplicity were well recognised. The prototype achieved excellent usability score and considerable performance results.

CONCLUSION

We present a highly variable VP authoring tool that enhances variability in medical training scenarios. Although this work does not aim to explore didactic aspects, the potential of using this approach in an educational context has been confirmed in our study. Accordingly, these aspects can benefit from a thorough investigation in the future. In addition, our tool can be improved to provide more realistic parameter ranges for procedure-specific cases.

Effects of virtual reality training on clinical skill performance in nursing students: A systematic review, meta-analysis and meta-regression

AIMS

This review examined the impact of virtual reality (VR) training on nursing students' clinical skill performance and identified essential features of VR training.

BACKGROUND

VR provides immersive content, simulating real-life scenarios and preventing errors in clinical settings.

DESIGN

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.

DATA SOURCES

Studies were obtained from Ovid-EMBASE, MEDLINE, CINAHL and PubMed.

REVIEW METHODS

Studies related to VR training published from 1 January 2000 to 8 May 2024 were included. Comprehensive Meta-Analysis 4.0 software was used for meta-analysis and random effects meta-regression. The overall effect was assessed with Hedges' g and Z-statistics (p < 0.05). Heterogeneity was measured using I-squared (I2) statistics.

RESULTS

Among the 31 476 studies, 11 randomized controlled trial studies were included. Meta-analysis demonstrated a significant improvement in clinical skill performance, with a medium to large effect (g = 0.61) in the VR group (Z = 3.80, p < 0.001). Subgroup analyses highlighted higher nursing skills in the VR training topic. Meta-regression revealed that the VR training topic (β = 1.23, p < 0.001) and method of VR training (β = -0.53, p = 0.05) were significant covariates influencing clinical skill performance.

CONCLUSION

VR training improves nursing students' clinical skill performance, addressing shortcomings in the clinical practicum.

Evaluation of high-fidelity and virtual reality simulation platforms for assessing fourth-year medical students' encounters with patients in need of urgent or emergent care

BACKGROUND

Medical students in the U.S. must demonstrate urgent and emergent care competence before graduation. Urgent and emergent care competence involves recognizing, evaluating and initiating management of an unstable patient. High-fidelity (HF) simulation can improve urgent and emergent care skills, but because it is resource intense, alternative methods are needed.

STUDY OBJECTIVE

Our primary purpose was to use program evaluations to compare medical student experiences with HF and virtual reality (VR) simulations as assessment platforms for urgent and emergent care skills.

METHODS

During their emergency medicine clerkship, students at The Ohio State University College of Medicine must demonstrate on HF manikins, competence in recognizing and initiating care of a patient requiring urgent or emergent care. Students evaluated these simulations on a five-point quality scale and answered open-ended questions about simulation strengths and weaknesses. Faculty provided feedback on student competence in delivering urgent or emergent care. In 2022, we introduced VR as an alternative assessment platform. We used Wilcoxon Signed Ranks and Boxplots to compare ratings of HF to VR and McNemar Test to compare competence ratings. Comments were analyzed with summative content analysis or thematic coding.

RESULTS

We received at least one evaluation survey from 160 of 216 (74.1%) emergency medicine clerkship students. We were able to match 125 of 216 (57.9%) evaluation surveys for students who completed both. Average ratings of HF simulations were 4.6 of 5, while ratings of VR simulations were slightly lower at 4.4. Comments suggested that feedback from both simulation platforms was valued. Students described VR as novel, immersive, and good preparation for clinical practice. Constructive criticism identified the need for additional practice in the VR environment. Student performance between platforms was significantly different with 91.7% of students achieving competence in HF, but only 65.5% in VR (p≤.001, odds-ratio = 5.75).

CONCLUSION

VR simulation functions similarly to HF for formative assessment of urgent and emergent care competence. However, using VR simulation for summative assessment of urgent and emergent care competence must be considered with caution because students require considerable practice and acclimation to the virtual environment.

Virtual Obstetric Emergency Simulations: Enhancing Knowledge, Skills, and Confidence of Emergency Medicine and Obstetric Professionals

OBJECTIVE

 Between 2008 and 2016, 23% of pregnancy-related deaths in Ohio occurred in an emergency department (ED) or outpatient setting. Prior research showed that 98% of Ohio's delivery hospitals conduct obstetric (OB) emergency simulations, whereas only 30% include ED staff. The goal of the grant was to increase the knowledge, skill, and self-efficacy of emergency medicine (EM) professionals in managing OB emergencies. In addition to EM professionals, there was high interest by obstetrics and gynecology (OB/GYN) and other professionals in the course. Therefore, the goal of the project was to increase these elements for all professionals including EM and non-EM professionals in managing OB emergencies.

STUDY DESIGN

 Twelve virtual training courses using simulated patient encounters and video-based skills training were conducted across Ohio on the management of OB emergencies. Scenarios focused on common causes of pregnancy-related death using data from the Ohio Pregnancy-Associated Mortality Review Committee. Pre- and posttests assessed training effectiveness.

RESULTS

 Between August 1, 2020, and June 30, 2023, 258 learners completed the course. Most were female (76.76%), White (90.61%), and under 45 years old (69.40%). Most (66.49%) were from EM, followed by OB/GYN (18.09%), and other specialties (15.43%) including family medicine and pediatric EM. Most worked in hospital settings (89.19%). Learners reported a median 10.00 (interquartile range [IQR]: 15.00) years in clinical practice. Overall, mean knowledge scores increased by 0.81 (95% confidence interval [CI]: 0.62, 1.01), after the course (p < 0.001). Mean knowledge scores increased by 0.90 (95% CI: 0.64, 1.16; p < 0.001), 0.67 (95% CI: 0.24, 1.09; p = 0.003), and 0.60 (95% CI: 0.16, 1.04; p = 0.01) for those from EM, OB/GYN, and other specialties, respectively. Median scores for reported self-efficacy increased by 24.00 (IQR: 22.33) and self-reported skills increased by 30.42 (IQR: 22.83) points (p < 0.001).

CONCLUSION

 Virtual simulations can be effective in improving EM, OB, and other professionals' knowledge, self-efficacy, and self-reported skills in managing OB emergencies.

KEY POINTS

· Obstetric knowledge and skills can be taught effectively in a virtual environment.. · Educational interventions can use pregnancy-associated mortality data to target local patterns.. · Simulation can teach management of high-acuity, low-frequency obstetric emergencies to learners..

A Serious Game for Enhancing Rescue Reasoning Skills in Tactical Combat Casualty Care: Development and Deployment Study

BACKGROUND

Serious games (SGs) have emerged as engaging and instructional digital simulation tools that are increasingly being used for military medical training. SGs are often compared with traditional media in terms of learning outcomes, but it remains unclear which of the 2 options is more efficient and better accepted in the process of knowledge acquisition.

OBJECTIVE

This study aimed to create and test a scenario-based system suitable for enhancing rescue reasoning skills in tactical combat casualty care.

METHODS

To evaluate the effectiveness of the SGs, a randomized, observational, comparative trial was conducted. A total of 148 members from mobile medical logistics teams were recruited for training. Pre- and posttraining assessments were conducted using 2 different formats: a video-based online course (n=78) and a game simulation (n=70). We designed 3 evaluation instruments based on the first 2 levels of the Kirkpatrick model (reaction and learning) to measure trainees' satisfaction, knowledge proficiency, and self-confidence.

RESULTS

There were 4 elements that made up the learning path for the SGs: microcourses (video-based online courses), self-test, game simulation, and record query. The knowledge test scores in both groups were significantly higher after the intervention (t154=-6.010 and t138=-7.867, respectively; P<.001). For 5 simulation cases, the average operation time was 13.6 (SD 3.3) minutes, and the average case score was 279.0 (SD 57.6) points (from a possible total of 500 points), with a score rate of only 44% (222/500 points) to 67% (336/500 points). The results indicated no significant difference in trainees' satisfaction between the 2 training methods (P=.04). However, the game simulation method outperformed the video-based online course in terms of learning proficiency (t146=-2.324, P=.02) and self-perception (t146=-5.492, P<.001).

CONCLUSIONS

Despite the high satisfaction reported by trainees for both training methods, the game simulation approach demonstrated superior efficiency and acceptance in terms of knowledge acquisition, self-perception, and overall performance. The developed SG holds significant potential as an essential assessment tool for evaluating frontline rescue skills and rescue reasoning in mobile medical logistics teams.

A virtual simulation-based clinical skills course

BACKGROUND

Advancements in technology continue to transform the landscape of medical education. Virtual reality (VR) and remote simulation represent unique approaches to teaching students clinical skills through experiential learning.

APPROACH

We developed, implemented and evaluated a virtual simulation-based course modelled on Kolb's Learning Cycle. A 5-day, 15-h virtual clerkship clinical skills curriculum designed to help students recognise a patient requiring urgent or emergent care was piloted in May 2020. VR and remote simulations facilitated concrete experiences, reflective observation, concept formation, and active experimentation. Curricular evaluation included analysis of usage, performance, self-assessment, and perceptions of educational value.

EVALUATION

One hundred and fifty-six students completed 436 VR sessions (median 3 per student). Students repeated virtual cases, on average, 75% of the time, demonstrating improvement in average performance scores from 59% (attempt 1) to 72% (attempt 2). Post-course evaluations, completed by 109 (69.9%) students, demonstrated significant improvements in mean scores in all domains of a self-assessment based on emergent care skills.

IMPLICATIONS

We developed and implemented a virtual clinical skills course that allowed students to progress through all four stages of Kolb's Learning Cycle. VR and remote simulations represent an opportunity for educators to reimagine and expand opportunities for experiential learning. The number of students accommodated, total virtual simulations completed, and positive student feedback suggests that this may be a feasible, acceptable, and scalable method for increasing opportunities for progression through Kolb's Learning Cycle. Further investigation into impact on educational outcomes is needed.

Reviewing the current state of virtual reality integration in medical education - a scoping review

BACKGROUND

In medical education, new technologies like Virtual Reality (VR) are increasingly integrated to enhance digital learning. Originally used to train surgical procedures, now use cases also cover emergency scenarios and non-technical skills like clinical decision-making. This scoping review aims to provide an overview of VR in medical education, including requirements, advantages, disadvantages, as well as evaluation methods and respective study results to establish a foundation for future VR integration into medical curricula.

METHODS

This review follows the updated JBI methodology for scoping reviews and adheres to the respective PRISMA extension. We included reviews in English or German language from 2012 to March 2022 that examine the use of VR in education for medical and nursing students, registered nurses, and qualified physicians. Data extraction focused on medical specialties, subjects, curricula, technical/didactic requirements, evaluation methods and study outcomes as well as advantages and disadvantages of VR.

RESULTS

A total of 763 records were identified. After eligibility assessment, 69 studies were included. Nearly half of them were published between 2021 and 2022, predominantly from high-income countries. Most reviews focused on surgical training in laparoscopic and minimally invasive procedures (43.5%) and included studies with qualified physicians as participants (43.5%). Technical, didactic and organisational requirements were highlighted and evaluations covering performance time and quality, skills acquisition and validity, often showed positive outcomes. Accessibility, repeatability, cost-effectiveness, and improved skill development were reported as advantages, while financial challenges, technical limitations, lack of scientific evidence, and potential user discomfort were cited as disadvantages.

DISCUSSION

Despite a high potential of VR in medical education, there are mandatory requirements for its integration into medical curricula addressing challenges related to finances, technical limitations, and didactic aspects. The reported lack of standardised and validated guidelines for evaluating VR training must be overcome to enable high-quality evidence for VR usage in medical education. Interdisciplinary teams of software developers, AI experts, designers, medical didactics experts and end users are required to design useful VR courses. Technical issues and compromised realism can be mitigated by further technological advancements.

Comparing virtual reality and simulation to teach the assessment and management of acute surgical scenarios: A pilot study

Background and Aims

Traditional apprenticeship-based surgical training presents with challenges, especially in acute scenarios. Simulation provides the current standard of facilitating surgical training in a low-risk environment but is restricted by limited accessibility and high costs. Virtual reality (VR) offers immersive three-dimensional computer-generated training scenarios and can connect users from various locations. We aimed to compare the performance of junior doctors to manage an acute surgical scenario using VR and mannequin-based simulation. We hypothesised that VR would be as effective as mannequin-based simulation in performance outcomes.

Methods

This multicentre, randomised controlled pilot study was conducted with eighteen junior doctor volunteers (Foundation and Core Trainee Year 1). Ten were randomly allocated to VR and eight to mannequin-based simulation. Participants completed questionnaires and a 15-min pneumothorax scenario. Quantitative metrics included overall score, time-to-critical decisions, and academic buoyancy scores (ABS). Qualitative metrics included participants' likes and dislikes of their allocated simulation modality.

Results

VR participants scored significantly higher than mannequin-based simulation participants in overall scores (74.30% (SD ± 5.08%) vs. 59.75% (SD ± 10.14) (p = 0.04)), and technical skills aspects (77.20% (SD ± 8.01%) vs. 65.00% (SD ± 8.21%) (p = 0.01)). Mannequin-based simulation participants initiated critical decisions faster and demonstrated a trend towards a faster mean time-to-completion (p = 0.06). ABS scores increased for both study groups, though was only significant for VR participants (p ≤ 0.01). VR participants liked how VR fostered independent learning but disliked the formulaic content and impaired communication-learning compared to mannequin-based simulation.

Conclusion

Both VR and mannequin-based simulation training are effective in training junior doctors in acute surgical scenarios but present different educational benefits. Future research should recruit a larger sample size for a full comparative randomised controlled trial.

Educational Strategies in Pediatric Trauma Resuscitation Across Disciplines: A Scoping Review

INTRODUCTION

Trauma is the leading cause of death and disability in children. Differences in mechanism, injury pattern, severity, and physiology in this population distinguish pediatric trauma patients from adults. Educational techniques including simulation and didactics may improve pediatric readiness in this setting. We summarize the literature across disciplines, highlighting the curricular approaches, target provider population, educational content, content delivery method, and Kirkpatrick level for pediatric trauma resuscitation education.

METHODS

The MEDLINE (via Ovid), Embase (via Elsevier), Cumulative Index to Nursing & Allied Health Literature Complete (via EBSCO), Education Database (via ProQuest), and Web of Science Social Science Citation Index and Science Citation Index (via Clarivate) were searched. We reviewed 90 manuscripts describing pediatric trauma resuscitation education programs. When available, target provider population, curricular content, delivery method, and Kirkpatrick level were obtained.

RESULTS

Nurses (50%), residents (45%), and attending physicians (43%) were the most common participants. Airway management (25%), shock (25%), and general trauma (25%) were the most frequently taught concepts, and delivery of content was more frequently via simulation (65%) or didactics (52%). Most studies (39%) were Kirkpatrick Level 1.

CONCLUSIONS

This review suggests that diverse strategies exist to promote pediatric readiness. Most training programs are interdisciplinary and use a variety of educational techniques. However, studies infrequently report examining the impact of educational interventions on patient-centered outcomes and lack detail in describing their curriculum. Future educational efforts would benefit from heightened attention to such outcome measures and a rigorous description of their curricula to allow for reproducibility.

Collaborative virtual reality environment in disaster medicine: moving from single player to multiple learners

BACKGROUND

The use of virtual reality (VR) in healthcare education is on the increase. In disaster medicine, it could be a solution to the cost and logistic constraints for a "full-scale" scenarios. However, VR is mainly designed for single players, which is not appropriate for the objectives pursued in disaster medicine. We decided to evaluate the educational value of using individual VR simulation in disaster medicine on a group of learners.

METHODS

The VR scenario used was a reproduction of a major train crash, with 21 victims and whose objectives were START triage and first aid techniques. The sessions were carried out in multi-participant groups with different roles (active and immersed with headset, paper triage without headset, and active for communications not immersed in the headset). Their perceived self-efficacy was assessed before (T0), after (T1) and 2 months (T2) after the training. Satisfaction and confidence in learning were also measured.

RESULTS

The median levels of satisfaction and confidence in learning were of 21/25 and 32/40 respectively. Their perceived self-efficacy increased significantly between T0 and T1 (p < 0.001), and remained stable until T2. The different roles of participant showed no difference in terms of satisfaction, confidence in learning or changes in perceived self-efficacy. One third of the participants agreed that the number of participants had interfered with their learning. A significant negative correlation (rS = -0.51, p = 0.002) was found between satisfaction and the fact of having been hindered by the number of participants. Around 90% of participants found the activity entertaining and found the new technologies appropriate for learning technical skills.

CONCLUSIONS

This first experience of VR in a group setting is satisfactory and shows its positive effects. The limitations highlighted here will enable areas of improvement to be identified for the use of VR in disaster medicine, pending the development of multi-player tools. It would now be appropriate to analyse the impact of this type of simulation on learning and its retention over time.

Perceptions and needs for a community nursing virtual simulation system for Chinese nursing students during the COVID-19 pandemic: A qualitative study

Background

Virtual simulation systems are being increasingly used in the field of nursing education. However, these systems are mostly designed based on the perspective of developers, and the needs of the end users are often neglected. The purpose of this study was to explore the perceptions and needs of Chinese undergraduate nursing students for the development of a community nursing virtual simulation system.

Methods

This was a descriptive qualitative study enrolling 12 undergraduate nursing students at a University in China. Data were collected through semi-structured interviews. The content analysis method was used for data analysis.

Result

Three themes and 15 sub-themes were extracted from this study: (1) Positive perceptions regarding virtual systems: a) Provides space for trials and errors, b) Not limited by time and space, c) Provides auxiliary tools; (2) Design and use requirements: a) Performance needs, b) Contents design needs, c) Appearance design needs, d) Support Needs; (3) Competency enhancement needs: a) Community nursing practice ability, b) Critical thinking ability, c) Independent thinking ability, d) Ability to deal with emergencies, e)Teamwork skills, f) Self-efficacy, g) Resilience, h)Interpersonal communication skills.

Conclusion

Designers and engineers should consider students' needs, aim to improve students' abilities, improve the diversity, the scientific and rigor of content, and enhance user immersion and interest. The system should be programmed to provide real-time feedback, timely technical and professional support, in order to optimize use experience of nursing students.

Multiuser immersive virtual reality simulation for interprofessional sepsis recognition and management

INTRODUCTION

Sepsis is a leading cause of pediatric mortality. While there has been significant effort toward improving adherence to evidence-based care, gaps remain. Immersive multiuser virtual reality (MUVR) simulation may be an approach to enhance provider clinical competency and situation awareness for sepsis.

METHODS

A prospective, observational pilot of an interprofessional MUVR simulation assessing a decompensating patient from sepsis was conducted from January to June 2021. The study objective was to establish validity and acceptability evidence for the platform by assessing differences in sepsis recognition between experienced and novice participants. Interprofessional teams assessed and managed a patient together in the same VR experience with the primary outcome of time to recognition of sepsis utilizing the Situation Awareness Global Assessment Technique analyzed using a logistic regression model. Secondary outcomes were perceived clinical accuracy, relevancy to practice, and side effects experienced.

RESULTS

Seventy-two simulations included 144 participants. The cumulative odds ratio of recognizing sepsis at 2 min into the simulation in comparison to later time points by experienced versus novice providers were significantly higher with a cumulative odds ratio of 3.70 (95% confidence interval: 1.15-9.07, p = .004). Participants agreed that the simulation was clinically accurate (98.6%) and will impact their practice (81.1%), with a high degree of immersion (95.7%-99.3%), and the majority of side effects were perceived as mild (70.4%-81.4%).

CONCLUSIONS

Our novel MUVR simulation demonstrated significant differences in sepsis recognition between experienced and novice participants. This validity evidence along with the data on the simulation's acceptability supports expanded use in training and assessment.

Virtual, Augmented, and Mixed Reality Applications for Surgical Rehearsal, Operative Execution, and Patient Education in Spine Surgery: A Scoping Review

Background and Objectives: Advances in virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies have resulted in their increased application across many medical specialties. VR's main application has been for teaching and preparatory roles, while AR has been mostly used as a surgical adjunct. The objective of this study is to discuss the various applications and prospects for VR, AR, and MR specifically as they relate to spine surgery. Materials and Methods: A systematic review was conducted to examine the current applications of VR, AR, and MR with a focus on spine surgery. A literature search of two electronic databases (PubMed and Scopus) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The study quality was assessed using the MERSQI score for educational research studies, QUACS for cadaveric studies, and the JBI critical appraisal tools for clinical studies. Results: A total of 228 articles were identified in the primary literature review. Following title/abstract screening and full-text review, 46 articles were included in the review. These articles comprised nine studies performed in artificial models, nine cadaveric studies, four clinical case studies, nineteen clinical case series, one clinical case-control study, and four clinical parallel control studies. Teaching applications utilizing holographic overlays are the most intensively studied aspect of AR/VR; the most simulated surgical procedure is pedicle screw placement. Conclusions: VR provides a reproducible and robust medium for surgical training through surgical simulations and for patient education through various platforms. Existing AR/MR platforms enhance the accuracy and precision of spine surgeries and show promise as a surgical adjunct.

Health Care Simulation in Person and at a Distance: A Systematic Review

ABSTRACT

Distance simulation is a method of health care training in which the learners and facilitators are in different physical locations. Although methods of distance simulation have existed in health care for decades, this approach to education became much more prevalent during the COVID-19 pandemic. This systematic review studies a subset of distance simulation that includes combined in-person and distance simulation elements, identified here as "mixed- distance simulation." A review of the distance simulation literature identified 10,929 articles. Screened by inclusion and exclusion criteria, 34 articles were ultimately included in this review. The findings of this review present positive and negative aspects of mixed-distance simulation formats, a description of the most frequent configurations related to delivery, terminology challenges, as well as future directions including the need for faculty development, methodological rigor, and reporting details.

Integrating Battlefield Documentation into Virtual Reality Medical Simulation Training: Virtual Battlefield Assisted Trauma Distributed Observation Kit (BATDOK)

INTRODUCTION

Clinical documentation is an essential component of the provision of medical care, enabling continuity of information across provider and site handoffs. This is particularly important in the combat casualty care setting when a single casualty may be treated by four or more or five completely disparate teams across the roles of care. The Battlefield Assisted Trauma Distributed Observation Kit (BATDOK) is a digital battlefield clinical documentation system developed by the Air Force Research Laboratory to address this need. To support the deployment of this tool, we integrated BATDOK into a commercially available virtual reality (VR) medical simulation platform used by the U.S. Air Force and Defense Health Agency personnel in order to provide an immersive simulation training experience which included battlefield documentation.

METHODS

A multidisciplinary team consisting of medical educators, VR simulation engineers, emergency physicians and pararescuemen, and BATDOK developers first developed a specification for a virtual BATDOK capability, including a detailed listing of learning objectives, critical interfaces and task plans, and sensor integrations. These specifications were then implemented into the commercially available Virtual Advancement of Learning for Operational Readiness VR Medical Simulation System and underwent developmental testing and evaluation during pararescueman training exercises at the Air Force Special Operations Command Special Operations Center for Medical Integration and Development.

RESULTS AND CONCLUSIONS

The BATDOK capability was successfully implemented within the VR Medical Simulation System. The capability consisted of a virtual tablet with replicated interfaces and capabilities based on the developed specifications. These capabilities included integrated point-of-care ultrasound capability, multi-patient management, vitals sign monitoring with sensor pairing and continuous monitoring, mechanism of injury documentation (including injury pattern documentation), intervention logging (including tourniquets, dressing, airways, lines, tubes and drains, splints, fluids, and medications), and event logging. The capability was found to be operational and in alignment with learning objectives and user acceptance goals.

Comparing the Outcomes of Virtual Reality-Based Serious Gaming and Lecture-Based Training for Advanced Life Support Training: Randomized Controlled Trial

BACKGROUND

Simulation-based Advanced Cardiac Life Support (ACLS) or Advanced Life Support (ALS) training for health care professionals is important worldwide for saving lives. Virtual reality (VR)-based serious gaming can be an alternative modality to be used as a part of simulation-based ALS training.

OBJECTIVE

The aim of this study is to investigate whether a VR-based ALS serious game module can replace classroom-based ALS lectures, the latter being part of existing conventional ALS training protocols in addition to skills training.

METHODS

Participants were students from Acibadem Mehmet Ali Aydinlar University's Vocational School for Anesthesiology (N=29) randomly divided into 2 groups with 15 (conventional training group) and 14 (VR-based training group) participants each. Participants in the conventional training group had to complete the pretest consisting of multiple-choice questions at the beginning of the study. Afterward, they took part in an interactive classroom-based ALS lecture. The next step involved skills training with task trainers to teach them compression skills. Following this, the conventional training group was divided into Code Blue teams, each consisting of 5 participants for the simulation session. Two independent instructors evaluated video recordings in terms of technical and nontechnical skills. The score acquired from the manikin-based simulation session was considered the main performance indicator in this study to measure the learning outcome. A similar workflow was used for the VR-based training group, but this group was trained with the VR-based ALS serious game module instead of the theoretical lecture. The final stage of the study involved completing the posttest consisting of multiple-choice questions. A preference survey was conducted among the study participants. Mann-Whitney U and Wilcoxon signed-rank tests were used to analyze the 2 groups' performances in this study.

RESULTS

The improvement in posttest results compared with pretest results was significant in the conventional training group (P=.002). Hands-on technical scores of the conventional training group were higher than those of the VR-based training group during manikin-based simulation, but total scores, including those for technical and crisis resource management skills, acquired from the manikin-based simulation session did not reveal any significant difference between the 2 groups. The results of the VR preference survey revealed that the majority of the participants prefer VR-based serious game-based training instead of classroom lectures.

CONCLUSIONS

Although hands-on technical scores of the conventional training group during the manikin-based simulation session were higher than those of the VR-based training group, both groups' total performance scores, including those for technical and crisis resource management skills, did not differ significantly. The preference survey reveals that the majority of the participants would prefer a VR-based ALS serious gaming module instead of lecture-based training. Further studies are required to reveal the learning outcome of VR-based ALS serious gaming.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05798910; https://clinicaltrials.gov/study/NCT05798910.

Developing a virtual reality (VR) application for practicing the ABCDE approach for systematic clinical observation

BACKGROUND

The Airways, Breathing, Circulation, Disability, Exposure (ABCDE) approach is an international approach for systematic clinical observation. It is an essential clinical skill for medical and healthcare professionals and should be practiced repeatedly. One way to do so is by using virtual reality (VR). The aim was therefore to develop a VR application to be used by inexperienced health students and professionals for self-instructed practice of systematic clinical observation using the ABCDE approach.

METHODS

An iterative human-centred approach done in three overlapping phases; deciding on the ABCDE approach, specifying the requirements, and developing the application.

RESULTS

A total of 138 persons were involved. Eight clinical observations were included in the ABCDE approach. The requirements included making it possible for inexperienced users to do self-instructed practice, a high level of immersion, and a sense of presence including mirroring the physical activities needed to do the ABCDE approach, allowing for both single and multiplayer, and automatic feedback with encouragement to repeat the training. In addition to many refinements, the testing led to the development of some new solutions. Prominent among them was to get players to understand how to use the VR hand controllers and start to interact with the VR environment and more instructions like showing videos on how to do observations. The solutions in the developed version were categorised into 15 core features like onboarding, instructions, quiz, and feedback.

CONCLUSION

A virtual reality application for self-instructed practice of systematic clinical observation using the ABCDE approach can be developed with sufficient testing by inexperienced health students and professionals.

Perceptions of Doctors in Saudi Arabia Toward Virtual Reality and Augmented Reality Applications in Healthcare

Background Several studies suggested that artificial intelligence (AI), including virtual reality (VR) and augmented reality (AR), may help improve visualization, diagnostic, and therapeutic abilities and reduce medical and surgical errors. These technologies have been revolutionary in Saudi Arabia. We aimed to elucidate physicians' perceptions toward these technologies. Methodology We carried out a cross-sectional electronic questionnaire-based study in November 2021. The study targeted doctors of different medical and surgical specialties in the western region of Saudi Arabia. Results In our study, 53.2% of the participants were 25-30 years old. Most participants were residents (53.6%) with career experiences <5 years. Only 32.3% had a good familiarity with AR and VR technologies. However, 64.5% agreed that AR and VR technologies had practical applications in the medical field. Moreover, 35% agreed that the diagnostic and therapeutic ability was superior to the clinical experience of a human doctor. About 41.4% agreed they would always use AR and VR technologies for future medical decisions. Conclusion Doctors are open to using AR and VR technologies in healthcare. Although most people are unfamiliar with these technologies, most agree that they positively impact healthcare.

[Emergencies-Infinite worlds? : Extended reality as a medium in the education, continuing and advanced training in emergency medicine]

BACKGROUND

Simulation training is indispensable in emergency medicine, especially for enhancing patient safety. Methods and technologies used include a wide spectrum ranging from simple skill trainers to complex full-scale simulated environments integrating standardized patient actors. Limitations include the simulation of dynamic changes of clinical symptoms, the depiction of emotions and patient movements as well as complex environments, such as lively traffic. Extended reality (XR) holds the potential to overcome these limitations.

METHODS/AIMS

Starting with the technological basis and the didactic considerations in the field of XR, the paper reflects the potentials and limitations of this new technology in the domain of medical simulation training. Further focus is put on the integration of XR into existing training curricula.

RESULTS

The XR covers various technologies, ranging from PC-based applications that are similar to conventional computer games, over virtual realities enabling spatially freely navigable 3‑dimensional simulation (using closed 3D glasses: head mounted displays, HMD), to mixed-reality applications that combine virtual elements and real physical objects; however, technology alone does not stimulate learning. As with other simulation methods, it is crucial with XR to implement learning objectives, methods and technologies in a suitable teaching-learning arrangement and to familiarize teachers and students with the new technology. Evidence in the literature with respect to learning success is limited by the heterogeneity of technologies, target groups, teaching-learning arrangements and learning outcomes. Overall, significant increases can be shown for the intrinsic motivation of learners, and for high emotional participation (measured as perceived presence in the virtual environment).

DISCUSSION

Technological developments and the increasing use of digital media in emergency medical education and training favor the leap from XR-based pure demonstration projects to educational practice. Decisive for the educational success are the clear orientation towards concrete learning goals and a thorough familiarization with the new technology.

CONCLUSION

Simulation training based on XR expands the spectrum of existing simulation methods to integrate new dimensions of learning objectives. Further research on the effectiveness of this method is needed.

Virtual Reality for Emergency Medicine Training in Medical School: Prospective, Large-Cohort Implementation Study

BACKGROUND

Virtual reality (VR)-based simulation is being increasingly used to train medical students in emergency medicine. However, because the usefulness of VR may depend on various factors, the best practices for implementing this technology in the medical school curriculum are yet to be determined.

OBJECTIVE

The overall objective of our study was to assess the perceptions of a large cohort of students toward VR-based training and to identify the associations between these attitudes and individual factors, such as gender and age.

METHODS

The authors implemented a voluntary, VR-based teaching session in the emergency medicine course at the Medical Faculty in Tübingen, Germany. Fourth-year medical students were invited to participate on a voluntary basis. Afterward, we asked the students about their perceptions, collected data on individual factors, and assessed the test scores achieved by them in the VR-based assessment scenarios. We used ordinal regression analysis and linear mixed-effects analysis to detect the impact of individual factors on the questionnaire answers.

RESULTS

A total of 129 students participated in our study (mean age 24.7, SD 2.9 years; n=51, 39.8% male; n=77, 60.2% female). No student had previously used VR for learning, and only 4.7% (n=6) of the students had prior experience with VR. Most of the students agreed that VR can convey complex issues quickly (n=117, 91%), that VR is a useful addition to mannequin-based courses (n=114, 88%) or could even replace them (n=93, 72%), and that VR simulations should also be used for examinations (n=103, 80%). However, female students showed significantly less agreement with these statements. Most students perceived the VR scenario as realistic (n=69, 53%) and intuitive (n=62, 48%), with a relatively lower agreement for the latter among female respondents. We found high agreement among all participants (n=88, 69%) for immersion but strong disagreement (n=69, 54%) for empathy with the virtual patient. Only 3% (n=4) of the students felt confident regarding the medical content. Responses for the linguistic aspects of the scenario were largely mixed; however, most of the students were confident with the English language (not native) scenarios and disagreed that the scenario should be offered in their native language (female students agreed more strongly than male students). Most of the students would not have felt confident with the scenarios in a real-world context (n=69, 53%). Although physical symptoms during VR sessions were reported by 16% (n=21) of the respondents, this did not lead to the termination of the simulation. The regression analysis revealed that the final test scores were not influenced by gender, age, or prior experience in emergency medicine or with virtual reality.

CONCLUSIONS

In this study, we observed a strong positive attitude in medical students toward VR-based teaching and assessment. However, this positivity was comparatively lower among female students, potentially indicating that gender differences need to be addressed when VR is implemented in the curriculum. Interestingly, gender, age, or prior experience did not influence the final test scores. Furthermore, confidence regarding the medical content was low, which suggests that the students may need further training in emergency medicine.

A scoping review of metaverse in emergency medicine

BACKGROUND

Interest in the metaverse has been growing worldwide as the virtual environment provides opportunities for highly immersive and interactive experiences. Metaverse has gradually gained acceptance in the medical field with the advancement of technologies such as big data, the Internet of Things, and 5 G mobile networks. The demand for and development of metaverse are different in diverse subspecialties owing to patients with varying degrees of clinical disease. Hence, we aim to explore the application of metaverse in acute medicine by reviewing published studies and the clinical management of patients.

METHOD

Our review examined the published articles about the concept of metaverse roadmap, and four additional domains were extracted: education, prehospital and disaster medicine, diagnosis and treatment application, and administrative affairs.

RESULTS

Augmented reality (AR) and virtual reality (VR) integration have broad applications in education and clinical training. VR-related studies surpassed AR-related studies in the emergency medicine field. The metaverse roadmap revealed that lifelogging and mirror world are still developing fields of the metaverse.

CONCLUSION

Our findings provide insight into the features, application, development, and potential of a metaverse in emergency medicine. This study will enable emergency care systems to be better equipped to face future challenges.

Metaverse applied to musculoskeletal pathology: Orthoverse and Rehabverse

The Metaverse is 'an integrated network of 3D virtual worlds.' It incorporates digitally created realities into the real world, involves virtual copies of existing places and changes the physical reality by superimposing digital aspects, allowing its users to interact with these elements in an immersive, real-time experience. The applications of the Metaverse are numerous, with an increasing number of experiences in the field of musculoskeletal disease management. In the field of medical training, the Metaverse can help facilitate the learning experience and help develop complex clinical skills. In clinical care, the Metaverse can help clinicians perform orthopedic surgery more accurately and safely and can improve pain management, the performance of rehabilitation techniques and the promotion of healthy lifestyles. Virtualization can also optimize aspects of healthcare information and management, increasing the effectiveness of procedures and the functioning of organizations. This optimization can be especially relevant in departments that are under significant care provider pressure. However, we must not lose sight of the fundamental challenges that still need to be solved, such as ensuring patient privacy and fairness. Several studies are underway to assess the feasibility and safety of the Metaverse.

Curricular Integration of Virtual Reality in Nursing Education

AIM

The purpose of this article was to evaluate the ability of an interactive virtual reality (VR) platform guided by standards of best practice to provide an effective immersive learning environment. We specifically evaluated usability of the platform and learners' perceptions of the experience.

BACKGROUND

A variety of strategies are needed to train a highly competent nursing workforce.

METHODS

We conducted a quantitative cross-sectional study to evaluate the VR experience using the System Usability Scale (SUS)^® and the Simulation Effectiveness Tool-Modified (SET-M).

RESULTS

Post-simulation evaluations were completed by 127 prelicensure and 28 advanced practice students. On the SUS scale, students found the overall VR system easy to navigate, and on the SET-M, they rated the VR experience positively.

CONCLUSION

Immersive technology such as VR with a defined curriculum and facilitated debriefing can be valuable for student learning and may ultimately effect patient care. [J Nurs Educ. 2023;62(X):XXX-XXX.].

Efficiency of virtual reality for cardiopulmonary resuscitation training of adult laypersons: A systematic review

BACKGROUND

Virtual reality (VR) is an interesting and promising way to teach cardiopulmonary resuscitation (CPR) to adult laypersons as its high immersive characteristics could improve the level of skills and acquired knowledge in learning basic life support (BLS).

METHODS

This systematic review assesses current literature about BLS training with VR and its possible effect on CPR-quality parameters, self-efficacy, perceived learning, and learners' satisfaction and short and long-term patients' outcome. We screened the Cochrane Library, PubMed, CINAHL, MEDLINE Ovid, Web of Science, and Scopus databases and included only clinical trials and quasi-experimental studies published from inception to October 1, 2021, which analyzed adult laypersons' BLS training with the use of VR. Primary outcomes were CPR parameters (chest compression rate and depth, Automated External Defibrillator use). Secondary outcomes were self-efficacy, perceived learning and learners satisfaction, and patients' outcomes (survival and good neurologic status). The risk of bias of included study was assessed using the Cochrane Handbook for Systematic Reviews of Interventions tool to evaluate randomized control trials and the transparent reporting of evaluations with nonrandomized designs checklist for nonrandomized studies.

RESULTS

After full article screening, 6 studies were included in the systematic review (731 participants) published between 2017 and 2021. Because of the heterogeneity of the studies, we focused on describing the studies rather than meta-analysis. The assessment of the quality of evidence revealed overall a very low quality. Training with VR significantly improved the rate and depth of chest compressions in 4 out of 6 articles. VR was described as an efficient teaching method, exerting a positive effect on self-efficacy, perception of confidence, and competence in 2 articles.

CONCLUSION

VR in BLS training improves manual skills and self-efficacy of adult laypersons and may be a good teaching method in a blended learning CPR training strategy. VR may add another way to divide complex parts of resuscitation training into easier individual skills. However, the conclusion of this review suggests that VR may improve the quality of the chest compressions as compared to instructor-led face-to-face BLS training.

Leading Transformation in Medical Education Through Extended Reality

Extended reality (XR) has exponentially developed over the past decades to incorporate technology whereby users can visualise, explore, and interact with 3-dimensional-generated computer environments, and superimpose virtual reality (VR) onto real-world environments, thus displaying information and data on various levels of the reality-virtuality continuum. In the context of medicine, VR tools allow for anatomical assessment and diagnosis, surgical training through lifelike procedural simulations, planning of surgeries and biopsies, intraprocedural guidance, and medical education. The following chapter aims to provide an overview of the currently available evidence and perspectives on the application of XR within medical education. It will focus on undergraduate and postgraduate teaching, medical education within Low-Middle Income Countries, key practical steps in implementing a successful XR programme, and the limitations and future of extended reality within medical education.

Extended reality as a training method for medical first responders in mass casualty incidents: A protocol for a systematic review

INTRODUCTION/BACKGROUND

Mass-casualty incidents (MCIs) and disasters require an organised and effective response from medical first responders (MFRs). As such, novel training methods have emerged to prepare and adequately train MFRs for these challenging situations. Particular focus should be placed on extended reality (XR), which encompasses virtual, augmented and mixed reality (VR, AR, and MR, respectively), and allows participants to develop high-quality skills in realistic and immersive environments. Given the rapid evolution of high-fidelity simulation technology and its advantages, XR simulation has become a promising tool for emergency medicine. Accordingly, this systematic review aims to: 1) evaluate the effectiveness of XR training methods and 2) explore the experience of MFRs undergoing such training.

METHODS

A comprehensive search strategy will encompass four distinct themes: MFRs, disasters/MCIs, education and simulation, and XR. Four databases (MEDLINE, EMBASE, CINAHL and LILACs) will be searched along with an in-depth examination of the grey literature and reference lists of relevant articles. MetaQAT will be used as a study quality assessment tool and integrated into Covidence as part of the data extraction form. Given the predicted high heterogeneity between studies, it may not be possible to standardise data for quantitative comparison and meta-analysis. Thus, data will be synthesised in a narrative, semi-quantitative manner.

DISCUSSION

This review will examine the existing literature on the effectiveness of XR simulation as a tool to train MFRs for MCIs, which could ultimately improve preparedness and response to disasters.

TRIAL REGISTRATION

Protocol registration: PROSPERO CRD42021275692.

A Novel Scenario-Based, Mixed-Reality Platform for Training Nontechnical Skills of Battlefield First Aid: Prospective Interventional Study

BACKGROUND

Although battlefield first aid (BFA) training shares many common features with civilian training, such as the need to address technical skills and nontechnical skills (NTSs), it is more highly scenario-dependent. Studies into extended reality show clear benefits in medical training; however, the training effects of extended reality on NTSs, including teamwork and decision-making in BFA, have not been fully proven.

OBJECTIVE

The current study aimed to create and test a scenario-based, mixed-reality platform suitable for training NTSs in BFA.

METHODS

First, using next-generation modeling technology and an animation synchronization system, a 10-person offensive battle drill was established. Decision-making training software addressing basic principles of tactical combat casualty care was constructed and integrated into the scenarios with Unreal Engine 4 (Epic Games). Large-space teamwork and virtual interaction systems that made sense in the proposed platform were developed. Unreal Engine 4 and software engineering technology were used to combine modules to establish a mixed-reality BFA training platform. A total of 20 Grade 4 medical students were recruited to accept BFA training with the platform. Pretraining and posttraining tests were carried out in 2 forms to evaluate the training effectiveness: one was knowledge acquisition regarding the NTS and the other was a real-world, scenario-based test. In addition, the students were asked to rate their agreement with a series of survey items on a 5-point Likert scale.

RESULTS

A battlefield geographic environment, tactical scenarios, scenario-based decision software, large-space teamwork, and virtual interaction system modules were successfully developed and combined to establish the mixed-reality training platform for BFA. The posttraining score of the students' knowledge acquisition was significantly higher than that of pretraining (t=-12.114; P≤.001). Furthermore, the NTS score and the total score that the students obtained in the real-world test were significantly higher than those before training (t=-17.756 and t=-21.354, respectively; P≤.001). However, there was no significant difference between the scores of technical skills that the students obtained before and after training. A posttraining survey revealed that the students found the platform helpful in improving NTSs for BFA, and they were confident in applying BFA skills after training. However, most trainees thought that the platform was not helpful for improving the technical skills of BFA, and 45% (9/20) of the trainees were not satisfied with the simulation effect.

CONCLUSIONS

A scenario-based, mixed-reality platform was constructed in this study. In this platform, interaction of the movement of multiple players in a large space and the interaction of decision-making by the trainees between the real world and the virtual world were accomplished. The platform could improve the NTSs of BFA. Future works, including improvement of the simulation effects and development of a training platform that could effectively improve both the technical skills and NTSs of BFA, will be carried out.

Investigating science teachers' intention to adopt virtual reality through the integration of diffusion of innovation theory and theory of planned behaviour: the moderating role of perceived skills readiness

This study contributes to the extant literature on instructional technology by investigating the relationships between the social and personal factors and behavioral intention to use virtual reality. Moreover, the current study examined the links between perceived characteristics of virtual reality and attitude and the moderating role that can be played by perceived skills readiness between those links. Inspired by the Theory of Planned Behaviour and Diffusion of Innovation Theory, a set of hypotheses was formed to test the proposed relationships using structural equation modeling partial least square to a sample of 171 science teachers in Oman. The results showed that attitude, social norms and perceived behavioral control can predict behavioral Intention to use virtual reality with attitude as the strongest predictor. Furthermore, the results indicated that relative advantage could predict attitude towards using virtual reality while compatibility and observability cannot. Finally, perceived skills readiness can strengthen the relationship between the perceived characteristics of virtual reality applications (relative advantage, compatibility and observability) and attitude towards using the virtual reality in the science classroom. Thus, this study highlights the importance of focussing on science teachers' skills readiness to use virtual reality so that they can use it confidently. Implications and future research studies are discussed.

Application of problem-based learning combined with a virtual simulation training platform in clinical biochemistry teaching during the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a great impact on the traditional teaching mode (Lecture-based Learning, LBL) and laboratory teaching. To address this challenge, the researchers conducted online Problem-based learning (PBL) teaching and virtual simulation laboratory teaching through DingTalk, and evaluated the effectiveness of this method in teaching clinical biochemistry.

METHODS

With the method of cluster sampling, the researchers randomly selected 60 students from two classes of the Class 2019 as the experimental group for this prospective experimental study. The theory class was taught online PBL through DingTalk, and experimental lectures were given by virtual simulation. After the experimental teaching, students were assessed for theory and operation. Self-administered questionnaires were administered through DingTalk. 65 students from our 2018 medical laboratory class were randomly selected as the control group, and offline LBL and traditional experimental teaching methods were used. Examination results were obtained through teaching portfolios.

RESULTS

The experimental group had significantly better examination scores in theoretical knowledge and experimental operational skills than the control group (87.45 ± 5.91 vs. 83.52 ± 9.94, P = 0.0095; 87.08 ± 12.42 vs. 80.18 ± 14.04, P = 0.0044). The results of the questionnaire survey revealed that the experimental group was more receptive to the DingTalk-PBL teaching method and virtual simulation laboratory teaching. Moreover, this hybrid teaching method was more effective in promoting basic knowledge understanding (95.0%, 57/60), facilitating the mastery of operational skills (93.3, 56/60), cultivating interest in learning (96.7%, 58/60), training clinical thinking (95.0%, 57/60), improving communication skills (95.0%, 57/60), and enhancing self-learning ability (91.7%, 55/60) and was more satisfying than traditional teaching method (all P < 0.05).

CONCLUSION

The DingTalk-based PBL method combined with virtual simulation experiments was an effective and acceptable teaching strategy during the pandemic compared with the traditional teaching method.

The study of virtual reality influence on the process of professional training of miners

Virtual reality technologies are actively applied for the organization of professional training in various industries, as well as in distance learning. However, numerous studies show the presence of a large number of negative factors that limit the effectiveness of using these technologies (united by the concept of "cybersickness"). The study, identification and reduction in the influence of these negative factors will increase the immersiveness and quality of the professional training process. Within the framework of this study, several hypotheses have been put forward regarding the negative and positive impact of VR technologies on the process of professional training, the coal and mining industry has been chosen as the subject area. Thus, the problem of effective training of miners for activities in regular and emergency situations is considered, in the latter case, VR technologies would allow forming the necessary set of skills and knowledge about actions in emergency situations. To confirm the declared hypotheses, an experimental group of 30 people was formed, corresponding to the trained miners by age characteristics. Based on the analysis, a list of quantitative and qualitative metrics for evaluating interaction with virtual reality was formed, the software of virtual scenes for two tasks (moving simple objects and a set of exercises in a virtual mine) was developed. The experimental group repeatedly performed these exercises, which allowed us to analyze the dynamics of changes in the average values of quantitative and qualitative metrics. The data obtained were processed by statistical tests (Shapiro-Wilk, Kruskal-Wallis, Mann-Whitney), which allowed us to assess the impact of the selected configurations (with and without VR) and the number of attempts on the selected metrics. The obtained results partially or completely confirmed the declared hypotheses and allowed us to form a list of recommendations for the organization of high-quality professional training using virtual reality technologies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-022-00687-7.

Digital body preservation: Technique and applications

High-fidelity anatomical models can be produced with three-dimensional (3D) scanning techniques and as such be digitally preserved, archived, and subsequently rendered through various media. Here, a novel methodology-digital body preservation-is presented for combining and matching scan geometry with radiographic imaging. The technique encompasses joining layers of 3D surface scans in an anatomical correct spatial relationship. To do so, a computed tomography (CT) volume is used as template to join and merge different surface scan geometries by means of nonrigid registration into a single environment. In addition, the use and applicability of the generated 3D models in digital learning modalities is presented. Finally, as computational expense is usually the main bottleneck in extended 3D applications, the influence of mesh simplification in combination with texture mapping on the quality of 3D models was investigated. The physical fidelity of the simplified meshes was evaluated in relation to their resolution and with respect to key anatomical features. Large- and medium-scale features were well preserved despite extensive 3D mesh simplification. Subtle fine-scale features, particular in curved areas demonstrated the major limitation to extensive mesh size reduction. Depending on the local topography, workable mesh sizes ranging from 10% to 3% of the original size could be obtained, making them usable in various learning applications and environments.

Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students during COVID-19 pandemic: a randomised controlled trial

BACKGROUND

Virtual reality (VR) is a computer-generated simulation technique which yields plenty of benefits and its application in medical education is growing. This study explored the effectiveness of a VR Basic Life Support (BLS) training compared to a web-based training during the COVID-19 pandemic, in which face-to-face trainings were disrupted or reduced.

METHODS

This randomised, double-blinded, controlled study, enrolled 1^st year medical students. The control group took part in web-based BLS training, the intervention group received an additional individual VR BLS training. The primary endpoint was the no-flow time-an indicator for the quality of BLS-, assessed during a structural clinical examination, in which also the overall quality of BLS (secondary outcome) was rated. The tertiary outcome was the learning gain of the undergraduates, assessed with a comparative self-assessment (CSA).

RESULTS

Data from 88 undergraduates (n = 46 intervention- and n = 42 control group) were analysed. The intervention group had a significant lower no-flow time (p = .009) with a difference between the two groups of 28% (95%-CI [8%;43%]). The overall BLS performance of the intervention group was also significantly better than the control group with a mean difference of 15.44 points (95%-CI [21.049.83]), p < .001. In the CSA the undergraduates of the intervention group reported a significant higher learning gain.

CONCLUSION

VR proved to be effective in enhancing process quality of BLS, therefore, the integration of VR into resuscitation trainings should be considered. Further research needs to explore which combination of instructional designs leads to deliberate practice and mastery learning of BLS.

Developing the Virtual Resus Room: Fidelity, Usability, Acceptability, and Applicability of a Virtual Simulation for Teaching and Learning

PROBLEM

Physical distancing restrictions during the COVID-19 pandemic led to the transition from in-person to online teaching for many medical educators. This report describes the Virtual Resus Room (VRR)-a free, novel, open-access resource for running collaborative online simulations.

APPROACH

The lead author created the VRR in May 2020 to give learners the opportunity to rehearse their crisis resource management skills by working as a team to complete virtual tasks. The VRR uses Google Slides to link participants to the virtual environment and Zoom to link participants to each other. Students and facilitators in the emergency medicine clerkship at McMaster University used the VRR to run 2 cases between June and August 2020. Students and facilitators completed a postsession survey to assess usability and acceptability, applicability for learning or teaching, and fidelity. In addition, students took a knowledge test pre- and postsession.

OUTCOMES

Forty-six students and 11 facilitators completed the postsession surveys. Facilitators and students rated the VRR's usability and acceptability, applicability for learning and teaching, and fidelity highly. Students showed a significant improvement in their postsession (mean = 89.06, standard deviation [SD] = 9.56) compared with their presession knowledge scores (mean = 71.17, SD = 15.77; t(34) = 7.28, P < .001, with a large effect size Cohen's d = 1.23). Two perceived learning outcomes were identified: content learning and communication skills development. The total time spent (in minutes) facilitating VRR simulations (mean = 119, SD = 36) was significantly lower than time spent leading in-person simulations (mean = 181, SD = 58; U = 20.50, P < .008).

NEXT STEPS

Next steps will include expanding the evaluation of the VRR to include participants from additional learner levels, from varying sites, and from other health professions.

Using Immersive Virtual Reality Simulation to Ensure Competence in Contrast-Enhanced Ultrasound

Contrast-enhanced ultrasound (CEUS) is used in various medical specialties as a diagnostic imaging tool and for procedural guidance. Experience in the procedure is currently attained via supervised clinical practice that is challenged by patient availability and risks. Prior simulation-based training and subsequent assessment could improve and ensure competence before performance on patients, but no simulator currently exists. Immersive virtual reality (IVR) is a new promising simulation tool that can replicate complex interactions and environments that are unfeasible to achieve by traditional simulators. This study was aimed at developing an IVR simulation-based test for core CEUS competencies and gathering validity evidence for the test in accordance with Messick's framework. The test was developed by IVR software specialists and clinical experts in CEUS and medical education and imitated a CEUS examination of a patient with a focal liver lesion with emphasis on the pre-contrast preparations. Twenty-five medical doctors with varying CEUS experience were recruited as test participants, and their results were used to analyze test quality and to establish a pass/fail standard. The final test of 23 test items had good internal reliability (Cronbach's α = 0.85) and discriminatory abilities. The risks of false positives and negatives (9.1% and 23.6%, respectively) were acceptable for the test to be used as a certification tool prior to supervised clinical training in CEUS.

Virtual Simulation in Undergraduate Medical Education: A Scoping Review of Recent Practice

Virtual simulation (VS) as an emerging interactive pedagogical strategy has been paid more and more attentions in the undergraduate medical education. Because of the fast development of modern computer simulation technologies, more and more advanced and emerging VS-based instructional practices are constantly increasing to promote medical education in diverse forms. In order to describe an overview of the current trends in VS-based medical teaching and learning, this scoping review presented a worldwide analysis of 92 recently published articles of VS in the undergraduate medical teaching and learning. The results indicated that 98% of included articles were from Europe, North America, and Asia, suggesting a possible inequity in digital medical education. Half (52%) studies reported the immersive virtual reality (VR) application. Evidence for educational effectiveness of VS in medical students’ knowledge or skills was sufficient as per Kirkpatrick’s model of outcome evaluation. Recently, VS has been widely integrated in surgical procedural training, emergency and pediatric emergency medicine training, teaching of basic medical sciences, medical radiation and imaging, puncture or catheterization training, interprofessional medical education, and other case-based learning experiences. Some challenges, such as accessibility of VS instructional resources, lack of infrastructure, “decoupling” users from reality, as well as how to increase students’ motivation and engagement, should be addressed.

Recognizing Personality Traits Using Consumer Behavior Patterns in a Virtual Retail Store

Virtual reality (VR) is a useful tool to study consumer behavior while they are immersed in a realistic scenario. Among several other factors, personality traits have been shown to have a substantial influence on purchasing behavior. The primary objective of this study was to classify consumers based on the Big Five personality domains using their behavior while performing different tasks in a virtual shop. The personality recognition was ascertained using behavioral measures received from VR hardware, including eye-tracking, navigation, posture and interaction. Responses from 60 participants were collected while performing free and directed search tasks in a virtual hypermarket. A set of behavioral features was processed, and the personality domains were recognized using a statistical supervised machine learning classifier algorithm via a support vector machine. The results suggest that the open-mindedness personality type can be classified using eye gaze patterns, while extraversion is related to posture and interactions. However, a combination of signals must be exhibited to detect conscientiousness and negative emotionality. The combination of all measures and tasks provides better classification accuracy for all personality domains. The study indicates that a consumer's personality can be recognized using the behavioral sensors included in commercial VR devices during a purchase in a virtual retail store.

Learner attitudes towards a virtual microbiology simulation for pharmacy student education

INTRODUCTION

Simulation for education has become popular, but much literature on this modality fails to critically examine the learner's experience, focusing instead on learning outcomes. Learner attitudes should be scrutinised and monitored to appraise a technology-enhanced learning experience as student perceived educational benefits of technology-enhanced learning is reported to be more important than the intrinsic characteristics of any particular medium or tool. This study sought to evaluate pharmacy students' attitudes toward a virtual microbiology simulation.

METHODS

The virtual microbiology simulation (VUMIE) was compared with a traditional wet laboratory (lab) in a second-year integrated pharmacotherapeutics course for bachelor of pharmacy students. Data were collected using surveys deployed at baseline (pre-intervention), post-intervention (VUMIE or wet lab), and endpoint (post-interventions). Statistical and qualitative thematic analyses were performed.

RESULTS

Learners found the simulation valuable, and outcomes suggest that it is possible for technology-enhanced learning activities to replace face-to-face instruction to some extent, which may be useful given the current challenges with in-person education resulting from COVID-19. More students reported a specific preference for the wet lab rather than VUMIE_. CONCLUSIONS: Although technology-enhanced simulation can produce a similar learning experience to a traditional wet lab, this evidence is not sufficient to completely replace the traditional lab experience for clinical courses of study. Technology-enhanced simulation could be considered for just-in-time training before exposure to traditional lab activities, for specific skill acquisition using deliberate practice, and perhaps for standardised assessment for clinical microbiology education.

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.

Rapid Cycle Deliberate Practice in Virtual Reality: Teaching Transvenous Pacemaker Insertion to Emergency Medicine Residents

Introduction

Transvenous pacemaker insertion is a critical life-saving procedure that is infrequently performed. Traditional mannequin-based training paradigms are resource intensive and sometimes inadequate due to time constraints. Rapid Cycle Deliberate Practice (RCDP) is an effective teaching modality for highly scripted procedures. We propose using a simulation-based technique of RCDP in virtual reality (VR) to teach this procedure.

Methods

Sixteen emergency medicine residents were recruited. A pre-survey was administered at the start of the session, followed by a baseline task trainer checklist-based assessment. This checklist was created based on expert consensus. Participants then underwent the RCDP VR intervention with a subsequent repeat checklist-based assessment as well as a post-survey. 

Results

Post-test scores were found to be significantly higher than pre-test scores after residents completed VR deliberate practice simulation (19.5±3.5 vs 24.1±2.0; p<0.001). Subanalysis did not reveal any significant difference based on post-graduate year, previous performance of procedure on a live patient, or previous VR experience. The experience increased participant feelings of preparedness and comfort in performing the procedure (2-disagree vs 4-agree) based on a 5-point Likert scale. 

Conclusions

Virtual reality using RCDP to teach transvenous pacemaker insertion demonstrated an improvement in task trainer performance. Further investigation into whether this translates into better patient outcomes or can be generalized to other procedures needs to be considered.

Virtual Reality vs. High-Fidelity Mannequin-Based Simulation: A Pilot Randomized Trial Evaluating Learner Performance

Background Virtual Reality (VR) simulation has been found to be useful in learning technical and non-technical skills. However, empirical data about its efficacy in clinical education are limited. This pilot study compares the efficacy of VR to mannequin-based simulation for learners managing status epilepticus (SE). Methods Pediatric and emergency medicine interns at an academic tertiary care referral center were randomized to either VR (intervention, using an Oculus Rift^Ⓡ (Occulus from Facebook, Facebook Inc., USA)) or mannequin-based (control) simulation for the same SE scenario. The control group participated in two mannequin-based simulation sessions while the intervention group had a VR session followed by a mannequin-based session. Sessions were one-one with an instructor and held three months apart. Performance was assessed by measuring the time-to-critical actions during the second session. Results Of 42 interns, 22 were in the intervention group and 20 in the control group. There was no statistical difference in time-to-critical actions for VR vs. standard groups; for example, VR times (in seconds) compared to standard times were 18.1 (SD 10.5) and 18.9 (SD 15.8) (p=.90) for oral suction, and 61.6 (SD 24.8) and 62.8 (SD 26.9) (p=.82) for IV lorazepam completion. Conclusion This pilot trial suggests that VR is feasible for clinical simulation. We did not find a significant difference between the two groups in learner performance. Larger studies are needed to corroborate our findings, investigate the best applications of VR in clinical training, and determine if it could lead to more rapid learning at a lower cost.

An Overview of Ontologies in Virtual Reality-Based Training for Healthcare Domain

Virtual reality (VR) is one of the state-of-the-art technological applications in the healthcare domain. One major aspect of VR applications in this domain includes virtual reality-based training (VRT), which simplifies the complicated visualization process of diagnosis, treatment, disease analysis, and prevention. However, not much is known on how well the domain knowledge is shared and considered in the development of VRT applications. A pertinent mechanism, known as ontology, has acted as an enabler toward making the domain knowledge more explicit. Hence, this paper presents an overview to reveal the basic concepts and explores the extent to which ontologies are used in VRT development for medical education and training in the healthcare domain. From this overview, a base of knowledge for VRT development is proposed to initiate a comprehensive strategy in creating an effective ontology design for VRT applications in the healthcare domain.

Brain Activity-Based Metrics for Assessing Learning States in VR under Stress among Firefighters: An Explorative Machine Learning Approach in Neuroergonomics

The nature of firefighters` duties requires them to work for long periods under unfavorable conditions. To perform their jobs effectively, they are required to endure long hours of extensive, stressful training. Creating such training environments is very expensive and it is difficult to guarantee trainees' safety. In this study, firefighters are trained in a virtual environment that includes virtual perturbations such as fires, alarms, and smoke. The objective of this paper is to use machine learning methods to discern encoding and retrieval states in firefighters during a visuospatial episodic memory task and explore which regions of the brain provide suitable signals to solve this classification problem. Our results show that the Random Forest algorithm could be used to distinguish between information encoding and retrieval using features extracted from fNIRS data. Our algorithm achieved an F-1 score of 0.844 and an accuracy of 79.10% if the training and testing data are obtained at similar environmental conditions. However, the algorithm's performance dropped to an F-1 score of 0.723 and accuracy of 60.61% when evaluated on data collected under different environmental conditions than the training data. We also found that if the training and evaluation data were recorded under the same environmental conditions, the RPM, LDLPFC, RDLPFC were the most relevant brain regions under non-stressful, stressful, and a mix of stressful and non-stressful conditions, respectively.