virtual reality in healthcare research paper

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Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings

Marileen m. t. e. kouijzer.

1 Centre for eHealth and Wellbeing Research; Department of Technology, Human & Institutional Behaviour, University of Twente, Enschede, Netherlands

Hanneke Kip

2 Department of Research, Transfore, Deventer, Netherlands

Yvonne H. A. Bouman

Saskia m. kelders, associated data.

All dataset(s) supporting the conclusions of this article are available in the included primary studies.

Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space. Despite the potential added value of virtual reality technology in healthcare, its uptake in clinical practice is still in its infancy and challenges arise in the implementation of VR. Effective implementation could improve the adoption, uptake, and impact of VR. However, these implementation procedures still seem to be understudied in practice. This scoping review aimed to examine the current state of affairs in the implementation of VR technology in healthcare settings and to provide an overview of factors related to the implementation of VR.

To give an overview of relevant literature, a scoping review was undertaken of articles published up until February 2022, guided by the methodological framework of Arksey and O’Malley (2005). The databases Scopus, PsycINFO, and Web of Science were systematically searched to identify records that highlighted the current state of affairs regarding the implementation of VR in healthcare settings. Information about each study was extracted using a structured data extraction form.

Of the 5523 records identified, 29 were included in this study. Most studies focused on barriers and facilitators to implementation, highlighting similar factors related to the behavior of adopters of VR and the practical resources the organization should arrange for. However, few studies focus on systematic implementation and on using a theoretical framework to guide implementation. Despite the recommendation of using a structured, multi-level implementation intervention to support the needs of all involved stakeholders, there was no link between the identified barriers and facilitators, and specific implementation objectives or suitable strategies to overcome these barriers in the included articles.

To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., healthcare provider-related barriers, as is common in current literature. Based on the results of this study, we recommend that the implementation of VR entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies. This implementation process could be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice.

Contributions to the literature

• Virtual reality is an innovative technology that is increasingly applied within different healthcare settings. Despite its potential to improve treatment, the adoption and uptake of VR are generally lacking.
• In this scoping review, we identified factors related to the implementation of VR that are important for successful adoption and effective use in practice. However, most often these factors are not sufficiently translated from research outcomes to healthcare practice.
• The findings of this scoping review contribute to the recognized gaps in the literature, stating recommendations for practice and future research on the systematic implementation of VR in healthcare.

Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space [ 1 , 2 ]. VR offers a broad range of possibilities in which the user can interact with a virtual environment or with virtual characters. Virtual characters, also known as avatars, can provide the user with a greater sense of reality and facilitate meaningful interaction [ 1 ]. VR interventions have been piloted in various healthcare settings, for example in treating chronic pain [ 3 ], improving balance in patients post-stroke [ 4 ], managing symptoms of depression [ 5 ], improving symptom burden in terminal cancer patients [ 6 ], and applied within treatment for forensic psychiatric patients [ 7 ]. These studies highlight the opportunities for VR as an innovative technology that could be of added value for healthcare. While there is a need for more research on the efficacy of VR in healthcare, experimental studies have shown that VR use is effective in improving the treatment of, among others, anxiety disorders [ 8 ], psychosis [ 9 ], or eating disorders [ 10 ]. However, the added value of VR is often not observed in practice due to the lack of usage of this technology.

Regarding uptake in clinical practice, VR is still in its infancy [ 11 , 12 ]. Various barriers are identified as limiting the uptake, such as a lack of time and expertise on how to use VR in treatment, a lack of personalization of some VR applications to patient needs and treatment goals, or the gap in knowledge on the added value of VR in a specific setting [ 11 , 13 ].

Not only VR uptake is challenging, but also other eHealth technologies experience similar difficulties in implementation [ 14 ]. eHealth is known as “the use of technology to improve health, well-being, and healthcare” [ 14 ]. For years, implementation has been out of scope for many eHealth research initiatives and healthcare practices, resulting in technologies that have not surpassed the level of development [ 15 ]. For these technologies to succeed and be used as effectively as intended, they must be well integrated into current healthcare practices and connected to the needs of patients and healthcare practitioners [ 13 ]. As a result, a focus on the implementation is of added value. It has the potential to improve the adoption, uptake, and impact of technology [ 16 ]. However, implementation procedures for VR technology still seem to be understudied in both research and practice [ 12 , 17 ].

One of the reasons for the lacking uptake of (eHealth) technology is the complexity of the implementation process [ 18 , 19 ]. The phase between the organizational decision to adopt an eHealth technology and the healthcare providers actually using the technology in their routine is complex and multifaceted [ 18 , 19 ]. This highlights the importance of a systematic and structured implementation approach that fits identified barriers. The use of implementation strategies, known as the “concrete activities taken to make patients and healthcare providers start and maintain use of new evidence within the clinical setting,” can help this process by tackling the implementation barriers [ 20 ]. These strategies can be used as standalone, multifaceted, or as a combination [ 21 ]. Often, they are part of an implementation intervention, which describes what will be implemented, to whom, how, and when, with the strategies as a how-to description in the intervention [ 17 ]. In addition, according to Proctor et al. [ 22 ], it is important to conceptualize and evaluate implementation outcomes. Implementation outcomes, such as acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability, can be used to set specific and measurable implementation objectives. Furthermore, assessing implementation outcomes will increase the understanding of the success of the implementation process and form a starting point for studies focusing on the effectiveness of VR in healthcare [ 22 ].

While implementation interventions could help the systematic implementation of VR, they are rarely used in practice. A way to stimulate systematic implementation and help develop an implementation intervention is by using an implementation model to guide this process. While a broad range of implementation models have been developed, there is still limited use of these models to structure the implementation of VR in healthcare [ 23 ]. One framework that could be used to identify important aspects of implementation is the NASSS framework, which investigates the n on-adoption, a bandonment, and challenges to s cale up, s pread, and s ustainability of technology-supported change efforts in health and social healthcare [ 24 ]. The NASSS framework does not only focus on the technology itself, but includes the condition of the target group, the value proposition, the adopter system (staff, patients, and healthcare providers), the healthcare organization(s), the wider system, and the embedding and adoption of technology over time [ 24 ]. The framework is used to understand the complexity of the adoption of new technologies within organizations [ 25 ]. However, it remains unclear if and what factors of the NASSS framework, or any other implementation framework, can be found in the implementation of VR in various healthcare settings.

In summary, virtual reality interventions have the potential to improve the quality of care, but only if implemented thoroughly. As VR use becomes more prevalent, studies should expand the focus to identify factors specifically related to the implementation of this new technology [ 19 ]. It is advised to perform a needs assessment, understand potential barriers to implementation early, set implementation objectives, and identify fitting implementation strategies before testing VR interventions in practice [ 26 ]. Therefore, this scoping review aims to examine the current state of affairs in the implementation of VR technology in healthcare settings and provide an overview of factors related to the implementation of VR. Within this research, the following sub-questions are formulated: (1) Which barriers play a role in the implementation of VR in healthcare? (2) Which facilitators play a role in the implementation of VR in healthcare? (3) What implementation strategies are used to implement VR in healthcare? (4) To what extent are specific implementation objectives and outcomes being formulated and achieved? (5) What are the recommendations for the implementation of VR in healthcare?

To address the study aims, a scoping review was undertaken on the current state of affairs regarding the implementation of virtual reality in healthcare settings. Due to the broad scope of the research questions, a scoping review is most suitable to examine the breadth, depth, or comprehensiveness of evidence in a given field [ 23 ]. As a result, scoping reviews represent an appropriate methodology for reviewing literature in a field of interest that has not previously been comprehensively reviewed [ 24 ]. This scoping review is based on the methodological framework of Arksey and O’Malley [ 27 ] including the following steps: (1) identifying the research questions, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing and reporting the results. A protocol was developed and specified the research questions, study design, data collection procedures, and analysis plan. To the authors’ knowledge, no similar review had been published or was in development. This was confirmed by searching academic databases and the online platforms of organizations that register review protocols. The protocol was registered at OSF (Open Science Framework) under registration https://doi.org/10.17605/OSF.IO/5Z3MN . OSF is an online platform that enables researchers to plan, collect, analyze, and share their work to promote the integrity of research. This scoping review adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 26 ].

A comprehensive, systematic electronic literature search was undertaken using three databases: Scopus, PsycINFO, and Web of Science. In each database, the same search strategy was used. Search terms were identified and included in the search strategy for three main categories relevant to the research questions: implementation, virtual reality, and healthcare. The search terms within a category were combined using the Boolean term “OR” and the term “AND”was used between the different categories. The search strategy was piloted to check if keywords and databases were adequate and adjustments were made whenever necessary. The full electronic search strategy can be found in Appendix 1 .

Study inclusion and exclusion criteria

All identified records published up until February 2022, that were peer-reviewed, and written in English, Dutch, or German, were included in the initial results. All references and citation details from different electronic databases were imported into the online review management system Covidence and duplicate records were removed automatically. A three-step screening approach, consisting of a title, abstract, and full-text screening, was used to select eligible studies.

Records were included if the titles indicated that the article focused on VR within a healthcare setting and that VR was used as a tool for prevention or treatment of patients. Because of the possibility of implementation not being mentioned in the title, broad criteria were used to prevent the unjust exclusion of relevant studies. In addition, records were included if they outline (parts of) the implementation process of VR technology (e.g., needs assessment, planning, execution, or lessons learned). Furthermore, the primary target group of the VR technology had to be patients with mental or physical disorders. If the studies focused solely on augmented reality (AR) or mixed reality (MR) and/or described a VR technology that was utilized to train healthcare professionals, they were excluded. Additionally, studies were excluded if full texts could not be obtained or if the study design resulted in no primary data collection, such as meta-analyses, viewpoint papers, or book chapters.

In the first step, two authors (MK & HK) screened all titles for assessment against the inclusion and exclusion criteria for the scoping review. Titles were included based on consensus between both authors. In the event of doubt or disagreement, the title was discussed by both authors. After screening the titles, both authors screened and assessed the abstracts using the inclusion and exclusion criteria. Abstracts were included or excluded based on consensus. In the final step, one author screened the full-text articles (MK). Reasons for excluding and any reservations about including were discussed with the other authors. The results of the search are reported in full and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram [ 28 ] (Fig.  1 ).

Search strategy and results

Data extraction strategy

The data extraction of this scoping review is mostly based on the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions [ 29 ]. A systematic assessment of study quality was not performed because this review focused on giving a broad overview of all factors related to the implementation of VR. This resulted in a heterogeneous sample of included study topics and designs: ranging from explorative qualitative studies to reflective quantitative studies. The data extraction process started with the creation of a detailed data extraction form based on the research questions in Microsoft Excel. This form was generated to capture the most relevant information from all obtained studies and standardize the reporting of relevant information. The extracted data included the fields as presented in Table ​ Table1. 1 . One author (MK) filled out the data extraction forms; in case of uncertainties, a second author was consulted (HK). Secondly, for each category, relevant text fragments from each study were copied from the articles into the data extraction forms.

Information extracted from included articles

Data synthesis and presentation

To answer the first and second research questions, the fragments from the data extraction forms were coded inductively. To answer the third and fourth research questions, fragments were first coded deductively, based on the main categories of the NASSS framework: technology, adopters, organization(s), wider system or embedding, and adaptation over time [ 24 ]. Second, within these categories, the specific barriers and facilitators were coded inductively to identify recurrent themes. The implementation recommendations were coded inductively to answer the fifth and last research question. The first author executed the coding process, which included multiple iterations and constant adaptations until data saturation was reached. During this iterative process, multiple versions of the coding scheme were discussed with all authors and adapted accordingly.

Search results

The search strategy, the number of included records, and the reasons for full-text exclusion are provided in Fig.  1 . The main reason for excluding full-text articles was that studies focused on the usability or effectiveness of VR, rather than on the needs assessment, planning, execution, or lessons learned from the implementation process of VR.

Study and technology characteristics

An overview of the characteristics of the 29 included records and the used VR technology is provided in Appendix 2 . The following study designs were identified: qualitative ( n  = 13), quantitative cross-sectional ( n  = 10), and studies that used qualitative as well as quantitative methods ( n  = 6).

Of the 29 included records, 11 focused on VR use in rehabilitation clinics. Additional settings in which VR was applied are general health clinics, mental health clinics, or clinics for specific disorders, e.g., eating disorder clinics or burn clinics. The goal of VR technology was often to be of added value as a treatment tool. It was used to improve movement in rehabilitation patients ( n  = 11) or decrease anxiety in patients with a stress-related disorder ( n  = 2). In addition, it was applied to offer distraction or relaxation during medical procedures ( n  = 4). In addition to the variety in settings and applications of VR, the type of technology that was applied differed as well: from interactive VR ( n  = 26), in which patients can be immersed in a virtual environment, such as a shopping street or a restaurant, via a VR headset and interact with this environment, to (360°) videos ( n  = 4) in which patients are immersed in a virtual environment shown on a (computer) screen, with limited to no possibility for interaction.

Implementation characteristics

An overview of the 29 included studies and the implementation characteristics, such as the use of an implementation model or the stage of implementation research are presented in Appendix 2 . In this review, 8 of the 29 studies used a theoretical framework to structure implementation or data analysis. The Consolidated Framework for Implementation Research (CFIR) [ 30 ] was used in 3 studies and the Decomposed Theory of Planned Behavior (DTPB) [ 31 ] was also used in 3 studies. In addition, the Unified Theory of Acceptance and Use of Technology (UTAUT2) [ 32 ] was used in a single study, and the Innovation Diffusion Theory [ 33 ] was applied in one study as well.

Of the 29 included studies, the data collection of 12 studies took place before actual implementation and focused on factors, expected by stakeholders, that could influence future implementation. The data collection of the other 17 studies took place after actual implementation and reflected on existing factors related to implementation. Thus, most identified barriers, facilitators, and recommendations stated in this review were observed in studies that evaluated an existing implementation process.

Barriers to implementation

Barriers to the implementation of VR were identified based on relevant fragments from the articles. In 26 records, a total of 69 different barriers were identified and divided into categories of the NASSS framework. All barriers are provided in Table ​ Table2. 2 . The barriers are explained in the accompanying text below.

Barriers to implementation and the number of publications they were mentioned in ( n )

A broad range of barriers was relevant to the implementation of VR in healthcare. Most identified barriers were related to the organization category of the NASSS framework. These were mainly focused on the lack of practical resources for healthcare providers to use VR. For example, the organization does not schedule sufficient time for healthcare providers to learn how to use VR and how to integrate VR into practice. In addition to a lack of time, not enough technical support, treatment rooms for VR, and VR equipment to treat patients were mentioned as organizational barriers.

Frequently mentioned barriers related to the adopters were factors that negatively influence healthcare providers’ opinions of VR. First, a lack of research and evidence on the added value of VR was mentioned as a barrier. Second, a perceived lack of experience in working with VR was said to cause a lack of confidence and self-efficacy in healthcare providers to work with VR during treatment. The perceived lack of time and limited opportunities to learn how to use VR contributed to this feeling.

Furthermore, technical barriers were identified to hinder VR implementation. Functional issues, such as technical malfunctioning of VR hardware or software, or a lack of client safety while wearing a VR headset in the limited space of the treatment room that limits freedom of movement were most frequently mentioned as barriers. Related to the VR headset, a lack of physical comfort for the patient when wearing the VR headset and the feeling of isolation while wearing the headset were frequently mentioned as barriers.

Lastly, barriers related to the condition, value proposition, wider system, and embedding and adoption over time categories of the NASSS framework were less frequently identified. The conditions and physical limitations of patients that could negatively influence VR use, such as several cognitive limitations, distress, or cybersickness during VR, were mentioned as barriers. Related to the value proposition, barriers such as high costs to purchase VR equipment or the lack of time for maintaining the VR hardware were mentioned. In addition, the lack of personalization to patients’ needs and treatment goals was mentioned as a barrier. The barriers related to the wider system and adoption over time, such as organizations not being innovation-minded or the lack of insurance reimbursement to compensate for costs of VR use, were mentioned less frequently.

Facilitators to implementation

Besides barriers, a total of 53 different facilitators to the implementation of VR in healthcare were identified in 26 records. Facilitators were identified based on relevant fragments from the articles and are divided into categories of the NASSS framework. They are mentioned and explained in Table ​ Table3 3 and the accompanying text below.

Facilitators to implementation and the number of publications they were mentioned in ( n )

In comparison to the barriers, facilitators to implementation were identified less frequently in the included studies. Similar to the barriers, most facilitators were related to the organization category of the NASSS framework. As an organization, providing support, time, room, and technical system support to healthcare providers to learn and use VR were mentioned most frequently as facilitators.

In multiple studies, it was mentioned that adopters of VR technology need training and education on how to use and integrate VR into treatment. Healthcare providers want to increase their knowledge, skills, and experience with VR to feel confident and increase self-efficacy in using VR in treatment with patients. Besides, as a facilitator in the adopter’s category, it is mentioned that having access to evidence on the added value of VR for treatment is a major facilitator in VR implementation because healthcare providers feel the use of VR is validated within the treatment.

Lastly, facilitators in the condition, technology, value proposition, wider system, and embedding and adoption over time category of the NASSS framework were identified less frequently. For example, when looking at the sociodemographic factors of patients, the young age of patients was identified as a facilitator since these people tend to be more open to new technology and treatments and feel more comfortable using VR. Related to technology, ensuring client safety was mentioned as a facilitator, that is creating a physically safe space in the treatment room for patients to use VR. This safe and controlled environment was also identified in the value proposition category. Meaning that healthcare providers can create a safe space for patients to practice challenging behavior. Lastly, being innovation-minded as an organization and VR becoming more and more commonplace and affordable to scale up were both mentioned as facilitators in the wider system category and the adoption over time category of the NASSS framework.

Implementation strategies, objectives, and outcomes

An overview was created of the implementation strategies, objectives, and outcomes that were extracted from the included studies (see Appendix 2 ). In two studies, a clear implementation objective was mentioned [ 13 , 43 ]. These objectives both focused on designing an implementation intervention, the knowledge translation (KT) intervention, to translate knowledge about the use of VR to the healthcare provider. In addition, they aimed to identify factors that influenced VR adoption and healthcare providers’ support needs.

Of the 29 included records, 8 studies described actual implementation strategies [ 13 , 34 , 35 , 43 , 44 , 48 , 53 , 60 ]. Most were mentioned in studies that collected data after implementation and reflect on existing implementation processes. In the included studies that described expected implementation factors, implementation strategies were most often not described. These studies focused on identifying potential barriers and/or facilitators in preparation for the implementation phase and did not evaluate the used strategies.

A summary of the described implementation strategies mentioned in the included records is displayed below in Table ​ Table4. 4 . Examples of strategies focused on practical resources were VR equipment to be used in treatment, treatment rooms in which the VR technology can be set up and used, and time for healthcare providers to learn about VR use. In addition, training and education on VR use were mentioned as important strategies. Hands-on interactive training, e-learning modules, mentorship for support and troubleshooting, and matching protocols and guidelines on how to use VR were mentioned. To set up VR treatment, an identified implementation strategy is to give support to healthcare providers in selecting appropriate content in VR that fits the patient’s needs and give information on how to instruct the patient about VR treatment. Lastly, implementation strategies that help to increase the motivation of healthcare providers to use VR were addressed. For example, having sufficient time to discuss the potential and added value of VR or having support from champions or mentors, experienced healthcare providers who share their experience with VR, to motivate others to integrate VR into their treatment practice were used during implementation.

Summary of implementation strategies mentioned in included records

The explicit conceptualization of implementation outcomes and the use of these outcomes to formulate implementation objectives or design implementation strategies was not described as such in the included records. The concepts of acceptability, adoption, uptake, or feasibility were mentioned in 12 records (see Appendix 2 ); however, they were not integrated as outcomes into a systematic implementation process.

Recommendations for implementation

In Table ​ Table5, 5 , an overview of the 51 different recommendations for the implementation of VR in healthcare that were mentioned in 20 records is provided. These recommendations were inductively coded and divided into seven categories: (1) Increase understanding of patient suitability, (2) Improve knowledge and skills on VR use, (3) Improve healthcare providers’ engagement with VR, (4) Have support staff available, (5) Points of attention for developing VR treatment, (6) Support functionality of VR hardware and software, and (7) Design and development of implementation.

Recommendations on implementation and the number of publications they were mentioned in ( n )

The first recommendation was to increase the understanding of patient suitability. In other words, it should be clear for healthcare providers how they can determine for which patients VR treatment is a fitting option. One way to determine patient suitability is to take into account the functional limitations of patients, such as their level of mobility or communication skills, before referring patients to VR treatment. Next to functional limitations, one should take into account cognitive limitations and any sensitivity to cybersickness. Patient suitability can be dependent on the goal of VR treatment, as some functional or cognitive limitations are not always a barrier to VR use.

The second recommendation was to improve the knowledge and skills of healthcare providers on VR use. Training programs and other educational resources, such as training days, online meetings, or instruction videos, that should be developed and disseminated to healthcare providers were mentioned as key elements to improving knowledge and skills.

The third recommendation was to improve healthcare providers’ engagement with VR. To accomplish this, the benefits of VR use and its possible contributions to treatment should be communicated to healthcare providers and patients. The use of successful example cases and disseminating supportive evidence of the added value of VR were mentioned as options to increase the engagement of healthcare providers with VR.

The fourth recommendation was to have sufficient support staff available to support VR use during treatment and maintain VR equipment. In addition, champions or mentors, healthcare providers experienced in VR treatment, were mentioned to promote uptake and increase the self-efficacy of other healthcare providers in VR use.

The fifth recommendation was related to developing VR treatment. The included studies gave some inconsistent suggestions on the frequency of use, from daily to once a week. Important aspects of developing a VR treatment are to set clear treatment goals, let the patient become familiar and comfortable with the VR equipment and software, and increase the treatment difficulty step by step.

The sixth recommendation was to support the functionality of VR hardware and software and ensure that it fits the user. Software should be appropriate for the patient’s needs, and age, and should fit the treatment setting. For example, VR software for forensic mental healthcare patients with aggression regulation problems should be able to let patients practice self-regulation strategies in virtual environments in which their undesired behavior is triggered. This could be a bar or supermarket with strangers for one patient, or a more intimate setting with a partner at home for another. The hardware needs to be adaptable for the limited mobility of patients, for example, patients that are wheelchair-bound. In addition, the VR hardware should still give the possibility for healthcare providers and patients to interact during the use of VR. The patient needs to be able to hear the voice of the healthcare provider.

The seventh and last recommendation was related to the design and development of the implementation of VR in practice. In multiple studies, it was advised that healthcare organizations use a structured, multi-model implementation intervention to support the needs of stakeholders and address barriers to VR use. The key stakeholders should be engaged during the development process of implementation interventions. It was recommended to use a theoretical framework, such as the Consolidated Framework for Implementation Research (CFIR) [ 46 ] or the Decomposed Theory of Planned Behavior (DTPB) [ 47 ] to guide the development of relevant implementation strategies to enhance the uptake of VR in healthcare practice.

Principal findings

This scoping review was conducted to provide insight into the current state of affairs regarding the implementation process of virtual reality in healthcare and to identify recommendations to improve implementation research and practice in this area. This review has resulted in an overview of current implementation practices. A broad range of study designs was identified: from qualitative studies that described expected factors of implementation, to quantitative methods that summarized observed factors. From the included studies, it can be concluded that the main focus of the implementation of VR is on practical barriers and facilitators, and less attention is paid to creating a systematic implementation plan, including concrete implementation objectives, developing suitable implementation strategies to overcome these barriers, and linking these barriers or facilitators to clear implementation outcomes. Only two studies described objectives for implementation and the practical strategies that were used to reach these objectives. Most implementation strategies that were described were related to practical resources and organizational support to create time and room for healthcare providers to learn about VR and use it in treatment. Despite differences in the type of VR technology, healthcare settings, and study designs, many studies identified the same type of barriers and facilitators. Most identified barriers and facilitators focused on the adopter system and organization categories of the NASSS framework [ 24 ], e.g., the needs of healthcare providers related to VR use and the organizational support during the implementation of VR. The most frequently mentioned barriers were a lack of practical resources, a lack of validated evidence on the added value of VR, and a perceived lack of experience in working with VR. This review showed that facilitators were studied less than barriers. Most of the included studies only described the implementation barriers. However, in the studies that did mention facilitators, similar themes were found between identified barriers and facilitators, mostly related to practical resources, organizational support, and providing evidence of the added value of VR were found. The content of the recommendations for the implementation of VR fits with the foregoing.

Comparison with prior work

Despite the importance of concrete strategies to successfully implement VR [ 20 ] and the conceptualization of implementation outcomes to understand the process and impact of implementation [ 22 ], there is a lack of research on this systematic implementation approach. In this review, only a few studies used a theoretical framework to structure implementation or data analysis. Frameworks that were mentioned most often were the Consolidated Framework for Implementation Research (CFIR) [ 30 ], and the Decomposed Theory of Planned Behavior (DTPB) [ 31 ]. However, none of the studies that mentioned the use of these models described an explicit link between the separate strategies, barriers, or facilitators and the integrated systematic implementation process. This illustrates the gap in research between identifying factors that influence implementation and linking them to practical strategies and implementation outcomes to form a coherent implementation intervention. The development of a coherent implementation intervention was only mentioned in two studies that were included in this review. To illustrate, one study set up an implementation intervention that promotes clinician behavior change to support implementation and improves patient care [ 63 ]. A coherent intervention could be an option to structure the implementation process and bridge the gap between knowledge of the use of VR to actual uptake in practice [ 63 ]. However, from implementation frameworks, such as the NASSS framework [ 24 ] or the CFIR [ 30 ], it is clear that the focus should lie on a coherent multilevel implementation intervention that focuses on all involved stakeholders and end-users, not only on one stakeholder.

The importance of focusing on the behavior change of all involved stakeholders, such as healthcare providers, patients, support staff, and managers, is reflected in the results of this review. Most barriers, facilitators, strategies, and recommendations are related to stakeholders within the healthcare organization that need to change their behavior in order to support implementation. For example, healthcare providers are expected to learn new skills to use VR and organizational management needs to make time and room available to support healthcare providers in their new learning needs and actual VR use during treatment. This highlights the importance of focusing on strategies that target concrete behavior of stakeholders for successful implementation. Identifying concrete behavior that is targeted in an implementation intervention can help describe who needs to do what differently, identify modifiable barriers and facilitators, develop specific strategies, and ultimately provide an indicator of what to measure to evaluate an intervention’s effect on behavior change [ 64 ]. The focus on behavior in implementation is not new, it is an important point of attention in the implementation of other eHealth technology [ 14 ]. However, based on the results of this scoping review, this focus is lacking in research on VR implementation.

To design implementation interventions that focus on the behavior change of stakeholders, existing intervention development frameworks can be used. An example is Intervention Mapping (IM). Intervention Mapping is a protocol that guides the design of multi-level health promotion interventions and implementation strategies [ 65 , 66 ]. It uses a participatory development process to create an implementation intervention that fits with the implementation needs of all involved stakeholders [ 65 ]. Eldredge et al. [ 65 ] and Donaldson et al. [ 67 ] IM can provide guidance on overcoming barriers by applying implementation strategies based on behavioral determinants and suitable behavior change techniques [ 65 ]. For example, when reflecting on the implementation strategies described in this review, providing feedback as a behavior change method can be used during the education or training on VR use to support the learning needs of healthcare providers. In addition, providing opportunities for social support could be seen as the behavior change technique behind the need for support and discussion of VR use during intervision groups with other healthcare providers.

Implications for practice and future research

The results from this review provide various points of departure for future implementation research and implications for practice. An important implication for both is the need for a systematic approach to the implementation process. Most studies identified in this review focused only on barriers or facilitators to implementation, not paying attention to the systematic process of developing an implementation intervention that specifies implementation objectives, describes suitable strategies that fit with these barriers and facilitators, and conceptualizes implementation outcomes to evaluate the effectiveness of these strategies. The development of an implementation intervention should preferably be supported by theoretical implementation frameworks such as the Consolidated Framework of Implementation Research [ 30 ], or the NASSS framework [ 24 ]. In this review, all implementation factors could be coded with and analyzed within the categories of the NASSS framework. Indicating its usefulness in structuring implementation research. Future research could focus on applying and evaluating such implementation frameworks to the implementation of VR in healthcare, specifying factors related to the implementation of VR and focusing on all phases and levels of implementation.

In addition, it could be valuable to focus on existing intervention development frameworks, such as Intervention Mapping, to guide the design of a complete implementation intervention. Future research could apply these existing frameworks in an implementation context, reflect on the similarity in working mechanisms and evaluate their influence on the implementation process and the behavior change of the involved stakeholders. This way, a first step in identifying the added value of systematic implementation intervention development can be made.

Furthermore, as being aware and convinced of the added value of VR within the treatment of patients is seen as an important facilitator of implementation for healthcare providers and organizations, it would be valuable for future research to focus on the evaluation of the efficacy of VR within healthcare practice. However, this raises an interesting paradox. Healthcare organizations and healthcare providers would like to have evidence of the added value of VR before investing in the technology for its implementation, but the efficacy of VR in practice can only be determined in an ecologically valid way when it is already thoroughly implemented in healthcare practice.

Strengths and limitations

This review set out to give an overview of factors that are related to the implementation practice of VR in healthcare. A strength of this study is that it used the NASSS framework to structure the analysis and review process. The use of an implementation framework contributed to systematic data collection and analysis, which can increase the credibility of the findings [ 68 ]. However, the use of the NASSS framework also revealed some drawbacks. Although all implementation factors were categorized within the categories of the NASSS framework, this coding was limited by the description of these categories and the overlap between some categories. For example, most barriers and facilitators that were categorized under organization, adopters, or technology were relevant for sustainable embedding and thus could fit in the category “embedding and adaptation over time” as well. In addition, the description of the category “condition,” the illness of the patient, and possible comorbidities, which are often influenced by biomedical and epidemiological factors [ 24 ], is too limited to describe all factors related to patient suitability for VR. The condition of a patient within mental healthcare is often related to other aspects, such as sociodemographic factors like age, technical skills, and feeling comfortable using new technology. All these factors could influence patient suitability for VR. Besides, in most included studies, the barriers or facilitators were not described in great detail, which made the coding process within the NASSS categories more difficult.

Furthermore, when titles of screened records did not focus on the implementation process of VR, e.g., studies that only focused on usability or effectiveness, they were excluded. Since usability studies could still partly focus on implementation, this may have caused us to miss publications that could provide interesting insights on implementation but whose main focus was other than that. We tried to overcome this limitation by selecting detailed inclusion and exclusion criteria for the literature search and abstract screening. The study was excluded only when there was no indication of a link between usability and implementation.

In addition, the full-text screening and data-extraction process were executed by one researcher. This could have caused us to miss information related to the topic. However, since the researcher used inclusion criteria that were thoroughly discussed during the title and abstract screening, and used a detailed data-extraction form, the chances of missing information are considered to be low. Furthermore, the first and second authors both extracted data from a few full-text articles, and in case of doubt, full-text were discussed with both authors.

Furthermore, because this scoping review aimed to provide an overview of the current state of affairs related to the implementation of VR in healthcare, all available studies were included, regardless of their quality and type of results. This is in line with the general aim of scoping reviews, which is to present a broad overview of the evidence on a topic. Since a quality assessment was not conducted, not all results of included studies might be valid or reliable. In addition, most of the barriers, facilitators, and recommendations stated in this review are observed in studies that took place after actual implementation. However, some of these factors were mentioned as potential factors related to implementation in studies that collected data before actual implementation. These factors were described as expected factors by involved stakeholders, but not observed. Therefore, these findings should be interpreted with care.

This scoping review has resulted in an initial overview of the current state of affairs regarding the implementation of VR in healthcare. It can be concluded that in the included publications, a clear focus on practical barriers and facilitators to the implementation of VR has been identified. In only a few studies implementation frameworks, specified strategies, objectives, or outcomes were addressed. To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., therapist-related barriers, but that it entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies, clear implementation objectives and predefined outcomes. This implementation process should be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice.

Acknowledgements

Not applicable.

Appendix 1. Full electronic search strategy

Search terms, search string.

TS = (implement* OR adopt* OR disseminat* OR introduc* OR “uptake”) AND TS = (“virtual reality” OR VR OR “virtual technolog*” OR “virtual environment”) AND TS = (health* OR “care” OR treat*)

Appendix 2. Study, technology, and implementation characteristics per study

Table 6 Study characteristics, characteristics of VR technology, and implementation characteristics per study

Authors’ contributions

MK, HK, and SK designed the study and wrote the protocol. MK conducted literature searches. MK and HK screened the titles and abstracts. MK analyzed the data and wrote the first draft of the manuscript. HK, SK, and YB contributed to the final manuscript and the authors have read and approved the final manuscript.

Funding for this study was provided by Stichting Vrienden van Oldenkotte. They had no role in the study design; collection, analysis, or interpretation of the data; writing the manuscript; or decision to submit the paper for publication.

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Open access
• Published: 11 September 2023

Virtual and augmented reality in intensive care medicine: a systematic review

• Dominika Kanschik 1 ,
• Raphael Romano Bruno 1 ,
• Georg Wolff 1 ,
• Malte Kelm 1 , 2 &
• Christian Jung   ORCID: orcid.org/0000-0001-8325-250X 1 , 2  

Annals of Intensive Care volume  13 , Article number:  81 ( 2023 ) Cite this article

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Virtual reality (VR) and augmented reality (AR) are rapidly developing technologies that offer a wide range of applications and enable users to experience digitally rendered content in both physical and virtual space. Although the number of studies about the different use of VR and AR increases year by year, a systematic overview of the applications of these innovative technologies in intensive care medicine is lacking. The aim of this systematic review was to provide a detailed summary of how VR and AR are currently being used in various areas of intensive care medicine.

We systematically searched PubMed until 1st March 2023 to identify the currently existing evidence for different applications of VR and AR for both health care providers in the intensive care unit and children or adults, who were in an intensive care unit because of a critical illness.

After screening the literature, a total of 59 studies were included. Of note, a substantial number of publications consists of case reports, study plans or are lacking a control group. Furthermore, study designs are seldom comparable. However, there have been a variety of use cases for VR and AR that researchers have explored. They can help intensive care unit (ICU) personnel train, plan, and perform difficult procedures such as cardiopulmonary resuscitation, vascular punctures, endotracheal intubation or percutaneous dilatational tracheostomy. Patients might benefit from VR during invasive interventions and ICU stay by alleviating stress or pain. Furthermore, it enables contact with relatives and can also assist patients in their rehabilitation programs.

Both, VR and AR, offer multiple possibilities to improve current care, both from the perspective of the healthcare professional and the patient. It can be assumed that VR and AR will develop further and their application in health care will increase.

Graphic Abstract

Virtual reality (VR) and augmented reality (AR) are emerging technologies that allow various applications, ranging from immersive entertainment or educational experiences to medical care. VR is defined as the user’s complete immersion into a virtual three-dimensional environment, while AR retains the connection to the real world but supplements it with virtual elements to increase information [ 1 ]. Both VR and AR necessitate special VR/AR glasses for the user. Medical applications are growing and there are already areas that have been intensively researched, such as cardiovascular care [ 2 ] or neurosurgery [ 3 ]. The technologies are also increasingly being used in intensive care medicine and might positively influence this area of medicine from the perspectives of both medical staff and patients [ 4 ]. In a safe environment, VR can help health care providers in acquiring and practice complex intensive care procedures [ 5 ]. Augmented reality can also support the user both before and during procedures by integrating various additional information into reality [ 6 ]. From the patient´s point of view, VR can help to reduce stress during the stay in the intensive care unit through different means, such as distraction from pain, for both adults [ 7 ] and children [ 8 ]. In addition, by combining virtual reality and gaming, it is possible to improve cognitive and motor skills [ 9 ]. Thus, VR and AR could potentially be used at different time points by several users and for different purposes.

The present systematic review presents the current status of the application of VR and AR in critical care medicine. Based on a literature review, we summarized the current state-of-the-art.

Literature search

We systematically searched PubMed databases for publications up until 1st March 2023, applying the following keywords: “VR” and “ICU”, “virtual reality” and “ICU”, "virtual reality" and "critical care", “virtual reality” and “intensive care unit”, "augmented reality" and "ICU, “augmented reality" and "critical care", "augmented reality" and "intensive care", “mixed reality” and “ICU”, "mixed reality" and "critical care", “mixed reality” and “intensive care unit” (Appendix 1) to identify all published studies reporting on the application of virtual or augmented reality in the intensive care unit.

Eligibility and selection criteria

Eligible articles were: randomized controlled trials, nonrandomized trials, observational studies (cases and controls, cohort, and cross-sectional studies), proof-of-concept studies, study protocols, and case reports or series. All studies that met the following criteria were included: (1) type of participants: subjects were either health care providers in the intensive care unit or children or adults, who were in an intensive care unit because of a critical illness. (2) Type of interventions: VR or AR (3) Language: studies published in English or German, both in full text or abstract-only formats.

Data abstraction

Three independent reviewers screened all articles using the above-mentioned inclusion criteria. An independent fourth investigator was involved in the case of discrepancies in the extraction and assessment of the data. The following data were abstracted: author’s name, year of publication, study type, sample size, inclusion criteria, patient characteristics (age, medical background, and treatment), use of AR/VR, frequency of application, and outcomes.

Data synthesis

The key characteristics and results of included studies were summarized and synthesized using tables and complemented by a qualitative summary. This study was conducted and reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for reporting systematic reviews [ 10 ].

The initial search strategy identified 786 articles (Fig.  1 ). After the screening on predefined criteria and removal of duplicates, 59 studies were included.

Study flowchart

There were 48 studies about the application of VR: 12 randomized control trials, 2 nonrandomized trials, 26 observational studies, 2 proof-of-concept studies, 4 study protocols and 2 case reports, and 11 studies about the use of AR: 3 randomized control trial, 7 observational studies, and 1 case series.

Table 1 and Table 2 summarize all studies about the use of VR (Table 1 ) and AR (Table 2 ) in intensive care medicine that were included in the search strategy. So all relevant studies are described and commented on in a systematic review. Part 1 focuses on VR and Part 2 on AR. For each perspective, we discuss different applications, both in the adult and pediatric intensive care unit.

VR as a tool for health care providers to improve clinical practice

Adult intensive care medicine.

VR might assist in educating and training healthcare professionals [ 2 ] (Fig.  2 ) as intensive care treatment strategies are often complex and require not only theoretical knowledge but also practical preparation. In a randomized controlled trial of 381 participants, Nas et al. evaluated the value of VR for learning cardiopulmonary resuscitation (CPR). They reported comparable chest compression rates but an inferior compression depth compared with face-to-face training [ 11 ]. The research on VR/AR in this field is generally very heterogeneous [ 12 ]. Wolff et al. developed a VR training environment to improve the traditional training for extracorporeal membrane oxygenation (ECMO) [ 5 ]. Bronchoscopy is another important tool for diagnostic and therapeutic purposes in ICU patients and performing this procedure can be challenging. Colt et al. created a virtual reality bronchoscopy simulation. Through the acquired skills after VR training, five novice physicians were comparable to four experienced physicians regarding dexterity, speed, and accuracy in the model [ 13 ]. In a prospective randomized study with 60 healthcare providers, Chiang et al. evaluated 15-min VR-based learning on tracheostomy care. The use of VR materials increased significantly participants' self-efficacy (increased familiarity, more self-confidence, and less anxiety) and the positive impact persisted until 3 to 4 weeks later [ 14 ].

VR application for the training of health care providers

Pediatric intensive care unit

Caring for patients in the neonatal and pediatric intensive care units (PICU) can be particularly challenging [ 15 ], and aspects such as performance, knowledge, self-efficacy, and learner satisfaction are of great importance. In terms of these endpoints, Yu et al. evaluated the effects of a VR simulation program on nursing students. In three scenarios, the interventional group ( n  = 25) experienced a 40-min VR simulation and routine practice, and the control group ( n  = 25) only did routine practice. The use of VR resulted in a significant increase in high-risk neonatal infection control performance, self-efficacy, and learner satisfaction [ 16 ]. Yang et al. investigated in a non-randomized controlled study the impact of VR neonatal resuscitation program among others on knowledge, problem-solving, or degree of anxiety [ 17 ]. The VR group ( n  = 29) participated in a neonatal resuscitation gamification program, while the simulation group ( n  = 28) participated in high-fidelity simulations of neonatal resuscitation and online lectures. The control group ( n  = 26) had only online lectures on neonatal resuscitation. VR and simulation groups achieved significantly higher levels of neonatal resuscitation knowledge and learning motivation than the control group. Furthermore, VR application was found to be effective in increasing problem-solving ability and self-confidence compared to the others groups. However, anxiety was lowest in the simulation group. Ralston et al. investigated VR-based simulation of two scenarios: ectopic junctional tachycardia and low cardiac output syndrome in the early postoperative period and acute respiratory failure in a patient with suspected coronavirus disease [ 15 ]. All six pediatric cardiac critical care physicians successfully navigated the VR environment and met the critical endpoints such as connect the patient to the pacemaker and correctly overdrive pace or intubate the patient and connect to the ventilator. Farra et al. compared the success of VR training versus web-based clinical updates for emergency evacuation in a newborn ICU. Although there was no significant difference in terms of cognitive assessments and self-efficacy, the VR group performed statistically and clinically better in the live exercise [ 18 ]. Agasthya et al. evaluated a VR tutorial for endotracheal intubation. Participants of the interventional group completed a 19-min immersive guiding and the control group listed the steps from memory. Both groups demonstrated their skills with traditional manikins and were scored on a 24-point checklist. There was no significant difference between the groups [ 19 ].

VR as a tool for healthcare providers to reduce stress

Stress is a common phenomenon in the intensive care unit for both patients and health care providers. In a study with 66 ICU nurses investigated Nijland et al. the effect of VR on perceived stress levels. Sixty-two percent of the ICU nurses, who used VR-Relaxation during their breaktime reported VR to be helpful to reduce stress [ 20 ]. Bodet-Contentin et al. also showed in a study of 88 intensive unit caregivers that the use of VR could improve the efficiency of the breaks [ 21 ].

Patient experiences with VR during and after ICU-stay

Adult intensive care.

From the patients' perspective, intensive care treatment is associated with a number several symptoms such as pain [ 1 ]. If one now modulates attention, environmental conditions, and mood with VR, this can reduce the attention devoted to pain [ 22 ] (Fig.  3 ). Mosso-Vázquez et al. used VR to present different immersive environments such as Cliff or Dream Castle to 67 patients after cardiac surgery [ 23 ]. The results were evaluated with a Likert scale and almost 90% of the patients reported a decreased level of pain experienced post-therapy with VR. Esumi et al. evaluated VR in a patient whose pain after a fasciotomy for acute compartment syndrome could not be adequately controlled and opioid-related side effects, such as respiratory depression, have occurred. The use of VR led to a 25–75% dose reduction in fentanyl administration and the concomitant alleviation of respiratory depression [ 24 ]. In a randomized, prospective study of 200 cardiac surgery patients, Laghlam et al. demonstrated that VR application was equivalent to conventional treatment with oxygen and nitrous oxide in terms of reported pain scores during removal of chest tube [ 25 ]. Markus et al. focused on the technical and procedural feasibility of VR in daily routine and showed that the VR application takes almost an hour for setup, instruction, VR therapy, and cleaning. Especially in smaller centers such programs would be difficult to implement due to lack of staff and resources [ 26 ]. Hoffman et al. demonstrated in their study with 11 burn-injured patients the positive effects of 3-min VR application during wound care on pain relief and a positive correlation between the immersive strength of VR and its pain-relieving effect [ 27 ]. However, Faber et al. showed that the effect would be less after three consecutive days [ 28 ].

VR application during ICU treatment to distract the patients

Due to discomforts such as aggressive noises, lights, and a lack of information, the intensive care units are often associated with negative feelings such as anxiety or stress for patients [ 7 ]. Merliot‑Gailhoustet et al. investigated in a randomized trial E‑CHOISIR (Electronic‑CHOIce of a System for Intensive care Relaxation) the effects of different electronic relaxation devices on the reduction of overall discomfort, pain, anxiety, dyspnea, thirst, lack of rest feeling and stress in sixty ICU-patients. The patients received four relaxation sessions (standard relaxation with TV or radio, music therapy, and two VR systems with real or synthetic motion pictures). In the group with synthetic motion pictures the overall discomfort, pain, and stress could be significant decrease, while the real motion pictures were associated with a reduction in lack of rest. Both VR-Systems led to a significant decrease in anxiety. Three adverse events might occur: claustrophobia, dyspnea, and agitation. However, in general cybersickness (occurrence of symptoms such as headaches or nausea during VR use) rarely occurred [ 29 ].

Haley et al. evaluated in a pilot study 5-min VR sessions in 10 mechanically ventilated patients. VR therapy proved to be a potential means of managing anxiety in this patient group without the occurrence of predefined safety events or cybersickness [ 30 ]. The quality of sleep could also be positively influenced by the use of VR. In a study with 100 patients, it was shown that due to the VR application, the sleep quality was significantly better but the total sleep time and light sleep time did not differ between the groups [ 31 ].

Hypnosis has been used in the management of acute and chronic pain for a long time [ 32 ]. Rousseaux et al. tested a “virtual reality hypnosis” in patients undergoing cardiac surgery comparing VR to control patients, hypnosis without VR, and VR without hypnosis. All four techniques were used one day before and one day after surgery [ 33 , 34 ]. However, in their randomized-controlled study with 100 patients, there were no significant differences regarding the outcome measures (anxiety, pain, fatigue, relaxation, physiological parameters, and opioid use) between the groups [ 35 ].

To evaluate the usefulness of VR for reducing sensory overload and deprivation in the ICU Jawed et al. put VR goggles on 15 ICU patients for 15 min and exposed them to relaxing beach videos with nature sound effects. Most patients tolerated the headsets well and reported the positive effects of VR therapy on anxiety and stress [ 36 ]. Naef et al. investigated how long visual and auditory stimuli should be provided to intensive care unit patients. In their study, visual stimuli should not exceed 10 – 15 min, while auditory stimuli should not exceed one hour to prevent negative side effects [ 37 ].

Suvajdzic et al. used a combined approach to prevent delirium in ICU patients—The DREAMS system (Digital Rehabilitation Environment-Altering Medical System) [ 38 ], which combined an immersive digital reality acquisition system with a measurement system. The VR environment consisted of a commercially available VR headset. The measurement was sophisticated: it includes physiologic sensors 3-axis wearable accelerometers, a video camera, and environmental sensors for light and noise exposures for measurement of movement, physiologic and emotional responses to assess the movement, physiologic and emotional responses. In addition, an electroencephalogram sensor measures the sleep quality and response to therapy [ 39 ]. The DREAMS system has so far only been used in a small feasibility study with 59 non-intubated ICU patients and was well-received but there was no significant effect on physiologic measures, pain, or sleep [ 40 ].

Family support also plays a big role for the patients in the ICU [ 41 ]. Therefore, He et al. used the fifth generation plus virtual reality (5G + VR) equipment to establish visitation channels for patients and their families during the COVID-19 pandemic. They showed in a cohort study with 141 ICU patients that after 5G + VR visitations, the Hospital Anxiety Depression Scale (HADS) decreased significantly, along with a significant reduction in the proportion of delirium [ 42 ].

ICU patients often experience not only delirium but also other neurocognitive impairments [ 43 ]. In this context, Turon et al. examined in a pilot study the benefits of VR-assisted early neurocognitive stimulation in 20 critically ill adult patients [ 44 ]. The simulation includes a virtual avatar that accompanies patients, helped them orient to time, delivered instructions, motivated them to complete exercises, and encouraged them to relax. This application was found to be feasible, safe, and reliable, and stimulated cognitive functions. Navarra-Ventura et al. evaluated also a VR-based neurocognitive intervention during ICU stay in 34 critically ill patients. A 1-month follow-up that these patients had better working memory scores and showed up to 50% less non-specific anxiety and depression compared to the control group [ 45 ].

Early mobilization of ICU patients improves patient outcomes and reduced hospital stay length [ 46 ]. Gomes et al. used Nintendo Wii™ in 60 adult ICU patients to increase their physical activity [ 47 ]. Activity levels were light to moderate on a modified Borg scale and a majority of patients expressed a desire to play the videogame during their upcoming physical therapy sessions. The study from Parke et al. utilized a similar approach: Xbox Kinect Jintronix software targeting arm, leg, and trunk strength, range of motion, and endurance in 20 adult ICU patients [ 48 ]. Most patients found the activity enjoyable, and easy to understand, as well as motivating to continue participating.

ICU stay constitutes a considerable psychological burden for patients. In several studies, Valke et al. investigated the effects of ICU-specific virtual reality on mental health [ 49 , 50 , 51 , 52 ]. In one of them with 104 patients the group evaluated three and six months after ICU treatment, repetition of 14-min VR modules about ICU treatment improves subjective well-being and quality of life. VR resulted in a reduction of post-traumatic stress disorder, and depression scores, and the effect was still present six months after exposure. Although the mental health was also initially better this effect was no longer observed after six months.

The stay in the pediatric intensive care unit (PICU) can be an emotional and stressful experience for both children and parents [ 53 ]. In a pilot study with 32 critically ill children, Badke et al. investigated the feasibility and satisfaction of virtual reality in the PICU. All participants enjoyed using the technology, and 84% expressed interest in using it for a longer period. The positive effects were also observed among the parents, with 100% reporting satisfaction while watching their children use virtual reality. Moreover, parents reported that their children were calmed by VR [ 54 ]. In another study by this group with 115 critically ill children, the positive influence of VR on engagement and physiologic effects such as heart rate variability was confirmed [ 55 ].

Kucher et al. [ 56 ] and Hoffmann et al. [ 8 ] evaluated VR for better pain management and both were able to show positive effects. Abdulsatar et al. investigated the feasibility and safety of using Nintendo Wii™ in a pilot-trials with 12 critically ill children [ 57 ]. The application improved upper limb activity but grip strength did not change significantly from baseline. Lai et al. used VR on two adolescents suffering from Covid-19. The patients could choose from various active games such as boxing and non-active games such as racing. The authors conclude that VR gaming improved participants’ affect and alertness, motivating them to engage more in early mobilization therapy [ 58 ].

The hospital-induced separation between the child and the family is difficult for both sides. Therefore, Tallent et al. also established a VR-based virtual visit and the staff surveys showed that the application did not lead to an increased duration of the visit. Endpoints on parental perception are not reported, but VR appeared to be very well accepted by the treatment team in this study [ 59 ].

AR as a tool to assist ICU procedures

Adult intensive care unit.

AR can also help health care providers in the implementation of procedures in the ICU. Huang et al. evaluated the AR application during central venous line placement. The AR intervention consisted of a 5- to 10-min hands-on instructional course to allow familiarity with the AR equipment and—during central line placement in a manikin—a video that repeated essential steps. There was no difference between the groups regarding the meantime for placement or procedure time, but a significantly higher adherence level to the checklist between the two groups favoring the AR group was observed [ 60 ]. Fumagalli et al. evaluated the value of AR for venous puncture in 103 ICU patients. The use of AR reduced the incidence of hematomas and anxiety levels but did not reduce the duration of the procedure or the number of attempts [ 61 ]. Morillas Perez et al. also confirmed the positive influence of AR on vascular puncture in a study with 6 operators, who performed a total of 76 punctures. AR application resulted in higher accuracy and better quality of the images and eliminated variability between operators and sonographers. Furthermore, it provided more comfort as the hands are free and the view remains focused on the work area [ 62 ]. In a controlled trial with 32 ICU trainees, Alismail et al. investigated the use of AR during the endotracheal intubation of a manikin. The use of AR, where the essential steps were repeated, resulted in a longer need of time to intubate and ventilate but demonstrated higher compliance with the checklist [ 63 ]. Heo et al. randomized 30 nurses without experience in mechanical ventilation into 2 training groups: with or without AR. Compared to the control group, the AR group requested less assistance and showed higher self-confidence [ 64 ]. Gan et al. evaluated in 6 cases the AR for percutaneous dilatational tracheostomy and again it was confirmed that this new technology allowed the procedure to be carried out successfully [ 65 ]. A pilot study by Zackoff et al. evaluated AR in two critical situations. AR not only improved the ability to assess many factors such as the mental or respiratory status of the patient, but also had a positive impact on the recognition of critical situations such as shock, apnea, and hypoxemia. However, the detection of cardiac arrest was not significantly better [ 66 ]. To improve the training of future perfusionists in the field of extracorporeal circulation (ECC) Yamada et al. developed an AR program for smartphones or tablets [ 67 ]. The AR training might be beneficial for future perfusionists, but currently there has not yet been a clinical study examining the use of the app.

Pediatric intensive

Dias et al. also evaluated AR to improve performing endotracheal intubation. Forty-five participants were randomly divided into three groups and used for intubation on a manikin either direct laryngoscopy or indirect video laryngoscopy or AR-assisted video laryngoscopy. AR-assisted video laryngoscopy was comparable to indirect video laryngoscopy but resulted in increased safety compared with direct laryngoscopy [ 68 ]. The dosage of the drugs used during critical situations in the ICU is often based on weight. Therefore, Scquizzato et al. developed a smartphone app that estimates child weight using the smartphone camera and augmented reality (AR). So far, it has not been evaluated in clinical trials [ 69 ].

Limitations

Although the number of studies about the use of VR or AR significantly increases year by year, attempts at systematic synthesis of evidence such as the present study are limited by scarcely comparable methods, devices, and protocols [ 70 ]. A limited number of prospective randomized controlled trials are currently available in this field and the data are generally very heterogeneous. Thus, quantitative synthesis by meta-analysis and the use of methods to assess the risk of bias in the included studies is hardly possible. Several sources of bias could affect the validity and reliability of studies investigating the use of VR and AR in the ICU. The sample size of the studies is often small and not representative of the overall population of ICU patients, what increases the selection bias. Moreover, the inclusion of older adults may be limited by the fact that they are less familiar with new technologies such as VR/AR and may be hesitant or resistant to trying these innovation methods. It is important that VR/AR interfaces can accommodate age-related changes, such as visual impairments, hearing impairments, and decreased dexterity, to facilitate use the technologies. The performance bias can be high because most studies are not blinded and this can influence the behavior of participants. Furthermore, the outcomes are in most studies subjective and dependent on observation. Establishment of objective evaluation criteria is necessary to improve these aspects. However, there are some subjects such as post-traumatic disorders that are inherently complex and multifaceted, making it difficult to develop such criteria that capture all relevant factors. In addition, a common challenge is the diversity of applied VR and AR systems. This can affect not only the complexity of the application but also the tolerance of the users. VR/AR tools can provide varying levels of user comfort, performance, and immersion. This can make it difficult to reproduce the data, which can reduce the reliability and comparability of the research results. Furthermore, only a few studies describe exactly how time-intensive the application of the technologies can be. This, combined with differences in cost and accessibility, may impact the widespread application of VR/AR.

The present systematic review found the same difficulties for intensive and critical care medicine. In upcoming studies, the protocols should be harmonized as far as possible to expand significant clinical knowledge. The development of a core outcome set plays an important role for future systematic research about VR and AR. This would allow better comparability of studies, improve the quality and relevance of results, and facilitate evidence synthesis and meta-analyses. By providing this information, it would be even more possible to generalize the results and to understand the benefits and limitations of VR in the clinical setting.

This review showed that VR and AR offer new possibilities for many aspects of daily intensive care medicine. There are several approaches to supporting traditional clinical training and taking medical education to the next level. They provide a safe environment to practice procedures such as bronchoscopy [ 13 ], without risking harm to patients. In the ICU, the health care providers often have to make quick decisions, and by simulating different scenarios using VR such as low cardiac output syndrome [ 15 ], the critical decision-making skills can be improved. In addition, the technologies can positively influence aspects such as knowledge or self-efficacy [ 14 , 16 ], and the stress level of hospital staff [ 20 ]. However, the studies also have shown that VR/AR applications do not lead to a significant improvement in the performance of invasive procedures such as central line placement [ 60 ]. Furthermore, VR-based CPR training compared with traditional training provided inferior results [ 71 ].

Although there is currently limited data on clinically relevant outcomes, combining traditional training with VR/AR applications may be the way to achieve the best results in daily clinical practice.

Several studies confirmed that VR also might be an effective tool for pain management. VR allows us to generate a virtual environment to distract patients from their pain for example after surgery [ 23 ] or during wound care [ 8 , 27 ]. As a result, VR therapy can reduce the need for pain medication and thus prevent the occurrence of undesirable side effects of traditional therapy [ 24 ]. Furthermore, the use of VR can lower the stress level and reduce anxiety during the stay in the ICU [ 36 , 72 ]. This can have a positive impact on sleep quality [ 31 ], development of delirium [ 42 ], and cognitive impairment [ 45 ]. Six studies have also shown that VR can help during rehabilitation [ 47 , 48 , 57 , 58 , 73 , 74 ]. The application led to an increase in activity and was well tolerated by the patient without the occurrence of adverse events such as falls.

It is necessary to pay attention to the duration of the application of these technologies because overstimulation can negatively affect the outcome of patients [ 37 ]. Furthermore, cybersickness may occur during the application [ 29 ]. Lastly, the implementation of these technologies into clinical practice requires a significant investment of time by ICU staff [ 26 ], which also may reduce readiness to use them.

Overall, while VR is not a substitute for established therapy, it can be a useful tool in combination with other treatments to improve the patient's stay in an intensive care unit.

Augmented reality (AR) and virtual reality (VR) are no longer the domains of the science fiction world. We are on the verge of making virtual and augmented reality mainstream in the field of medicine and critical care has the potential to be at the forefront of this evolution. However, we cannot forget that VR and AR are not intended to distract us from the patient. They are provided to complement and optimize, but not replace the relationship between a health care provider and a patient. Furthermore, these are still in the research and development phase. Our involvement in this process is important to ensure that these technological developments are made in the best interest of our patients. This makes it possible to provide the best care and to improve the quality of the hospital stay in the ICU.

Availability of data and materials

The anonymized data can be requested from the authors if required.

Abbreviations

Three dimensional

Fifth generation

• Augmented reality

Cardiopulmonary resuscitation

Extracorporeal circulation

Extracorporeal membrane oxygenation

Hospital Anxiety Depression Scale

Head-mounted display

Intensive care unit

Interpupillary distance

Post-intensive care syndrome-family

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Transcatheter aortic valve replacement

• Virtual reality

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Open Access funding enabled and organized by Projekt DEAL. This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich-Heine-University Düsseldorf No. 2020-21 to RRB for a Clinician Scientist Track. Furthermore, institutional support has been received by the German Research Council (SFB 1116, B06) as well as the State of North Rhine Westphalia (Giga for Health: 5GMedizincampus. NRW, Project number 005-2008-0055 and PROFILNRW-2020-107-A, TP4). No (industry) sponsorship has been received.

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Kanschik, D., Bruno, R.R., Wolff, G. et al. Virtual and augmented reality in intensive care medicine: a systematic review. Ann. Intensive Care 13 , 81 (2023). https://doi.org/10.1186/s13613-023-01176-z

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• Mixed reality
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Virtual and augmented reality in critical care medicine: the patient’s, clinician’s, and researcher’s perspective

• Raphael Romano Bruno 1 ,
• Georg Wolff 1 ,
• Bernhard Wernly 2 , 3 ,
• Maryna Masyuk 1 ,
• Kerstin Piayda 4 ,
• Susannah Leaver 5 ,
• Ralf Erkens 1 ,
• Daniel Oehler 1 ,
• Shazia Afzal 1 ,
• Houtan Heidari 1 ,
• Malte Kelm 1 , 6 &
• Christian Jung 1  

Critical Care volume  26 , Article number:  326 ( 2022 ) Cite this article

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Virtual reality (VR) and augmented reality (AR) are aspiring, new technologies with increasing use in critical care medicine. While VR fully immerses the user into a virtual three-dimensional space, AR adds overlaid virtual elements into a real-world environment. VR and AR offer great potential to improve critical care medicine for patients, relatives and health care providers. VR may help to ameliorate anxiety, stress, fear, and pain for the patient. It may assist patients in mobilisation and rehabilitation and can improve communication between all those involved in the patient’s care. AR can be an effective tool to support continuous education of intensive care medicine providers, and may complement traditional learning methods to acquire key practical competences such as central venous line placement, cardiopulmonary resuscitation, extracorporeal membrane oxygenation device management or endotracheal intubation. Currently, technical, human, and ethical challenges remain. The adaptation and integration of VR/AR modalities into useful clinical applications that can be used routinely on the ICU is challenging. Users may experience unwanted side effects (so-called “cybersickness”) during VR/AR sessions, which may limit its applicability. Furthermore, critically ill patients are one of the most vulnerable patient groups and warrant special ethical considerations if new technologies are to be introduced into their daily care. To date, most studies involving AR/VR in critical care medicine provide only a low level of evidence due to their research design. Here we summarise background information, current developments, and key considerations that should be taken into account for future scientific investigations in this field.

Graphical abstract

Both, virtual reality (VR) and augmented reality (AR) are technological breakthroughs which facilitate entertainment and communication worldwide [ 1 ]. VR immerses its user completely into a three-dimensional, virtual world, while AR maintains the connection to the “real world” and fuses virtual elements with reality [ 2 ]. VR/AR applications have also gained momentum in critical care medicine. Only recently, Critical Care published E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation), the first cross-over randomised controlled trial that clearly shows the benefits of VR on stress, discomfort, and pain in critically ill patients [ 3 ]. In addition, VR may help providers learn and improve their practical skills in a protected setting [ 4 ], whilst AR offers procedural assistance and continuous surveillance during daily ICU procedures. From a patient’s perspective, VR can alleviate stress, pain [ 5 ], and anxiety [ 6 ] during critical care, and may also promote coordination, mobilisation, physical, and mental rehabilitation. VR has the potential to improve communication between all stakeholder, including relatives, and thus enable coordinated care and understanding. There are numerous potential opportunities for digital VR/AR applications in critical care medicine (see Figs.  1 and 2 , Table 1 ). However, current VR/AR applications have several drawbacks that need refinement. To date there is limited evidence of benefit in this new emerging field of research.

Overview about different users, applications, and the time-course of VR in critical care medicine

Existing studies where VR/AR applications were used for performing procedures (left panel) and training procedures (right panel)

Virtual reality from the patient’s perspective

Alleviating stress and anxiety.

Patients often experience the ICU as a “hostile” environment due to a number of factors including: excessive noise, loss of self-autonomy and a lack of information [ 5 ]. This is augmented by stress and anxiety, both of which are considered to be significant risk factors for the development of delirium. Delirium occurs in 35% to 80% of non-ventilated/ventilated ICU patients and is associated with an increased length of stay and mortality [ 7 ]. Since pharmacological interventions often have unwanted, and severe side effects, non-pharmacologic options are of utmost importance to treat, and potentially prevent delirium [ 8 ]. ICU stress can be reduced significantly by a calm environment and relaxation techniques. This is an area where VR has been tested. (Fig.  3 ).

VR with hypnosis used to calm patients during their ICU stay. With permission of Healthy Mind®, France

Rousseaux et al. randomised 100 cardiac surgery patients into four arms (control, hypnosis, VR, and VR combined with hypnosis). Every patient underwent one of the techniques for 20 min the day before and the day after surgery. [ 9 , 10 ]. However, there were no significant differences in the pre-defined outcome measures (anxiety, pain, fatigue, relaxation, physiological parameters, and opioid use) [ 11 ]. Further studies are required to investigate potential beneficial effects, and cost-effectiveness. A relative advantage of VR over hypnosis is that VR does not require additional human resources and does not increase the workload of employed ICU staff. By contrast, the previously mentioned E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation) trial found VR to have a positive effect. Sixty alert, and non-delirious ICU patients were randomised into four relaxation sessions (standard relaxation with television/radio, music therapy, and two virtual reality systems with real motion pictures or synthetic motion pictures). There was a significant decrease in overall discomfort and stress response in the synthetic motion pictures group. Both VR systems led to a reduction in anxiety, but only the synthetic motion pictures group reported lower subjective levels of pain. Three incidents (claustrophobia/dyspnoea/agitation) occurred during the VR sessions, but cybersickness was rare [ 3 ]. Gerber et al. achieved similar results. The investigators used VR with immersive nature scenes in 33 critically ill patients after cardiac surgery. VR acceptance was high, and most patients reported positive effects on stress. These results were supported by a decrease in respiratory rate during VR sessions [ 12 , 13 ]. VR has also been found to have a positive effect on sleep quality: in a randomised-controlled trial of 48 ICU patients, VR use resulted in significantly better sleep quality, although the total sleep time and light sleep time did not differ between the groups [ 14 ].

In the subgroup of paediatric critically ill patients, VR applications have been shown to have a positive effect on stress, anxiety, and delirium. Badke et al. conducted a cross-sectional, single-arm pilot study with 32 paediatric ICU patients who were provided with simple VR headsets and smartphone videos from a widely available multimedia source for distraction [ 15 ]. In this exploratory setting, 82% of parents observed that VR had a calming effect on their child. The same group subsequently recruited 115 critically ill paediatric patients into a comparable study.[ 16 ]. During the VR interaction (median duration: 10 min) the majority of patients and their relatives observed a calming effect. However, children returned to their pre-intervention state once the VR application was stopped.

In conclusion, many studies suggest a positive effect of VR on stress, anxiety, and delirium in critically ill patients. To date, the largest, prospective, randomised-controlled trials in this area have shown neutral [ 11 ] or positive [ 3 ] results.

Virtual reality for pain management

Along with anxiety and stress, pain is one of the most common, and burdensome symptoms in critical care patients. The concept of using VR to distract patients during painful procedures emerged in the late nineteen nineties (Fig.  4 ): There is good evidence for the benefit of VR for the management of chronic [ 17 ] and post-operative pain. Mosso-Vázquez et al. enrolled 67 patients after cardiac surgery. Their VR intervention consisted of different immersive environments [ 18 ]. After VR sessions, 59 patients (88%) reported a decreased level of pain on a Likert Scale. Furthermore, a systematic review and meta-analysis by Ding et al. including eight randomised-controlled trials [ 19 ] found that patients who underwent a VR intervention had lower postoperative pain scores than those receiving standard care. However, there was no significant postoperative pain relief when VR was applied during the pre-operative period. Laghlam et al. evaluated whether VR use in cardiac surgery patients was non-inferior to a combination of nitrous oxide and oxygen. This randomised prospective, non-inferiority, open-label study in 200 patients specifically assessed the degree of pain associated with chest tube removal. VR was inferior to an additionally used inhaled analgetic with regards to the reported level of pain [ 20 ]. Hoffmann et al. tested a VR game in 48 burns victims, age between 6 and 17 years old, while their wounds were cleaned. Compared with the control group, the self-reported pain was significantly reduced [ 21 ]. However, Faber et al. found that the effect of repeated VR interventions might become less effective after three successive days [ 22 ]. According to a study by Hoffman et al. in 11 burn victims, there is a correlation between the “immersive strength” (degree of immersion) of VR and its analgesic effects [ 23 ]. Other research groups additionally focused on the feasibility of VR applications in daily clinical practice. Markus et al. required 59 min for VR setup, instruction, therapy, and cleaning [ 24 ]. In summary, there is convincing evidence for the positive effects of VR on pain management, especially in burn victims and children.

VR for distraction during critical care treatment

Virtual reality for rehabilitation during the intensive care unit stay

“Intensive care unit acquired weakness” during an extended ICU stay is a common phenomenon and has a negative impact on short- and long-term outcomes [ 25 ]. VR applications can support rehabilitation programs on the ICU. Gomes et al. integrated a commercially available gaming platform (Nintendo Wii™) into physical therapy sessions in 60 adult ICU patients, with no mobility restrictions, to enhance their physical activity [ 26 ]. Activity levels were classified as light to moderate on a modified Borg scale. After 100 sessions, 86% of patients stated that they would like to play the videogame in future physical therapy sessions. The same gaming platform (Nintendo Wii™) was evaluated by Abdulsatar et al. in a pilot-trial with 12 critically ill children [ 27 ]. Upper limb activity during Wii™ sessions increased significantly; although grip strength did not change when compared to baseline findings. There were no adverse events attributed to the VR intervention. Although most VR platforms are primarily used in the entertainment industry, specific VR solutions have been designed for health care use. A study conducted by Parke et al. looked to enhance early ICU mobilisation with VR support: 20 adult ICU patients engaged in therapy sessions with the Jintronix virtual therapy system targeting arm, leg, and trunk strength, as well as range of motion, and/or endurance exercises [ 28 ]. The primary objective of this investigation, which was achieved, was safety and feasibility. However, almost all participants reported that the VR activity was enjoyable, improved body strength and range of motion, and would motivate them to continue exercising. ImmersiveRehab® is a commercially available VR environment that uses different tasks to enhance rehabilitation after critical illnesses such as stroke (Fig.  5 ). Additionally, Wang et al. developed a VR application for early mobilisation of critically-ill patients, which has not yet been evaluated in patients or volunteers [ 29 ]. In summary, commercially available VR entertainment applications are safe, feasible and well accepted in critically ill patients and might be beneficial in the physical rehabilitation process on the ICU, although randomised-controlled studies are currently lacking.

VR with virtual gaming for rehabilitation. With permission from Immersive Rehab Ltd., United Kingdom

Virtual reality for early neurocognitive stimulation

Up to 60% of ICU survivors suffer from significant long-term neurocognitive impairment [ 30 ]. Turon et al. conducted a pilot study on the value of VR-assisted early neurocognitive stimulation in 20 critically ill adult patients undergoing and/or having undergone mechanical ventilation for ≥ 24 h. In brief, the simulation included a virtual avatar that accompanies patients, helps them to orient in time, delivers instructions, motivates them to complete exercises, and encourages them to relax. This VR-assisted neurocognitive intervention was found to be feasible, safe, tolerable, and effectively stimulated cognitive function. However, there was no control group, and no follow-up data were available [ 31 ]. To date, there is no evidence from randomised-controlled trials to support the role of VR in reducing neurocognitive impairment, although promising pilot studies exist.

Virtual reality after intensive care

Following ICU treatment, many patients suffer from Post Intensive Care Syndrome (PICS), which consists of mental health issues, cognitive dysfunction, and problems with mobility [ 32 ]. It was therefore hypothesised that more information on ICU therapy and subsequent medical procedures might be beneficial. Indeed, many ICU patients would like to enhance their knowledge about critical care [ 33 ]. Conventional methods, such as written brochures, are either not well accepted or not utilised [ 33 ]. A randomised-controlled trial by Vlake et al. aimed to determine whether the repetitive application of VR modules explaining ICU treatment improved subjective well-being and quality of life three and six months after ICU treatment. These modules lasted about 14 min and explained different aspects of ICU treatment that were felt to be the most frightening [ 34 , 35 ]. In total, 57 ICU patients were randomised to VR, and 47 patients served as a control group. VR resulted in a reduction of post-traumatic stress disorder and lower depression scores. Mental health was better from two days until one month after initial VR exposure. Interestingly, this effect was still present for post-traumatic stress disorder and depression, but not mental quality of life six months after exposure. Regarding safety, cybersickness scores were low, and no changes in vital signs were observed [ 34 , 35 ]. Recently, the same working group conducted a multicentre randomised-controlled trial including 89 COVID-19 ICU survivors [ 36 ]. The VR strategy consisted of a 14-min informational video with different scenes explaining the ICU environment and treatment. The VR intervention was performed during the COVID-19 post-ICU follow-up clinic appointment, three months after hospital discharge. VR did not reduce the psychological distress or quality of life as compared to the control group. However, VR significantly improved subjective satisfaction scores and the overall rating of ICU aftercare. Most VR patients stated that they would recommend ICU-VR to other ICU survivors. In summary, the use of VR after ICU does not improve clinically relevant endpoints, but has a high acceptance rate among patients.

Virtual reality from the patient relative’s perspective

Situational understanding: virtual intensive care unit rounds.

Admission to a paediatric intensive care unit poses significant stress and uncertainty on relatives—especially the parents. During the COVID-19 pandemic, parents had limited ability to participate in clinical rounds. As a countermeasure, Tallent et al. developed a VR-based virtual visit to the ICU. The VR-visit did not increase the duration of the ward. [ 37 ]. In this study the VR-ICU ward rounds potentially helped to maintain close communication between patients, their relatives, and the health care providers. However, to date, not a single study exists which investigates patient or patient-relative related outcomes in this context.

Virtual reality from the health care provider’s perspective

Virtual reality for education and training.

VR can be used as a tool to train staff how to manage different clinical scenarios and perform clinical skills. [ 2 , 4 ]. VR has some theoretical advantages compared to “real-life training”: complex activities can be repeated as often as desired, no patients or volunteers are required, no company representative is required for instruction, training can be performed at any given time, and no consumable goods are necessary, which might be associated with significant expenditure. For example, when practicing the priming of extracorporeal membrane oxygenation or other cardiac assist devices, considerable material costs can arise per training session.

Multiple studies have been conducted to test the ability of VR to support learning and training of health care providers. In an ICU setting, Chiang et al. evaluated the success of VR-based learning on tracheostomy care in a prospective, controlled, 2:1 randomised pre–post-study. The interventional group ( n  = 30) received a VR simulation for 15 min, and the control group regular text-based training. VR increased self-efficacy, including familiarity and confidence, and reduced anxiety about tracheostomy-related knowledge and skills compared to the control group. This effect persisted until three to four weeks after the intervention [ 38 ]. Yu et al. evaluated the impact of a VR simulation program on Korean nursing students’ knowledge, performance self-efficacy, and learner satisfaction in neonatal critical care [ 39 ]. The VR group showed greater improvements in high-risk neonatal infection control performance, self-efficacy and learner satisfaction compared to the control group [ 39 ]. Ralston et al. evaluated a VR environment to test the use of VR in simulating paediatric critically ill clinical scenarios. One scenario simulated an ectopic junctional tachycardia and low cardiac output syndrome; the other simulated an acute respiratory failure in a patient with suspected Covid-19 infection [ 40 ]. Although there was no control group, all six paediatric cardiac critical care physicians successfully navigated the VR environment.

Agasthya et al. evaluated the value of a 19-min immersive tutorial (interventional group) on intubating an infant manikin, in a controlled trial. The primary endpoint (the performance accuracy measured by a checklist) did not differ between groups [ 41 ]. Over 20 years ago, Colt et al. established a VR bronchoscopy simulation for critical care medicine. After VR-training, five novice physicians had comparable skills, in terms of dexterity, speed, and accuracy, to four experienced physicians [ 42 ]. Farra et al. compared the success of VR emergency evacuation training versus web-based clinical updates in a neonatal critical care unit. Both approaches did not statistically differ in their perceived self-efficacy, although the VR group performed statistically better in the live exercise [ 43 ]. Recently, Wolff et al. developed a VR environment consisting of different steps in ECMO-priming (Fig.  6 ) [ 4 ]. In summary, VR or AR might be a complementary, but not a substitution, for training health care providers in basic and advanced life support. In this context, currently available data show heterogeneous results [ 44 ].

VR for health care providers to train in complex procedures. With permission from Weltenmacher®, Germany

Virtual reality for stress relief

Stress affects ICU health care providers, potentially resulting in burnout and decreased productivity [ 45 ]. Nijland et al. evaluated the impact of VR on the self-perceived stress level of 66 ICU nurses during their breaks. Sixty-two percent of those stated that VR was helpful in reducing stress [ 46 ]. Gerber et al. evaluated the stress relieving effect of VR in 45 healthy subjects: dynamic, virtual, natural, and urban environments were presented inside the head-mounted display and a neutral video on an ICU television screen. The natural environment had the highest positive and restorative impact on the subject’s physiological and psychological state [ 47 ]. Furthermore, ICU caregivers enjoyed pleasant artificial VR environments during their breaks [ 48 ].

Augmented reality for training

AR can assist health care providers in critical care procedures, such as intubation or central line placement. Alismail et al. conducted a controlled trial with 32 ICU trainees. The AR group (15 participants) used head-mounted AR glasses during endotracheal intubation of a training doll. The AR display repeated the essential, practical steps. The interventional group needed more time to intubate and ventilate, but had a higher adherence to evidence-based intubation practice [ 49 ]. Airway management is of pivotal importance in neonatal ICUs [ 50 ]. Dias et al. compared three learning strategies for endotracheal intubation in ICU nurses: direct laryngoscopy, indirect video laryngoscopy and AR-assisted video laryngoscopy with a magnified video of the airway alongside normal vision. AR-assisted video laryngoscopy was not inferior to normal indirect video laryngoscopy and safer than direct laryngoscopy. Huang et al. used a similar AR-based approach for the training of central venous line placement. Although, there was no difference in procedure time, there was a higher adherence to the procedure check list in the AR group ( p  = 0.003) [ 51 ]. Heo et al. conducted a prospective, controlled pilot study, randomising nurses with no prior experience in mechanical ventilation to conventional training or AR-assisted training. In the AR-group, the nurses were guided by AR-based instructions and could request assistance using the head-mounted display. AR resulted in a lower need for assistance compared to the manual group and a higher level of confidence after training [ 52 ].

AR can also be used to assess the mental and physical status of patients more accurately and may improve the recognition of deteriorating vital signs. In a trial by Zackoff et al., ICU teams completed two critical care scenarios: first, traditional training using a manikin, then AR-enhanced training using a manikin. AR improved the ability to assess the patient's mental status, respiratory status, and perfusion status, as well as recognition of hypoxemia, shock, apnoea and decompensation, but not the recognition of cardiac arrest.

Augmented reality in performing invasive procedures

Central line placement and endotracheal intubation are standard ICU procedures but can be associated with severe complications. Percutaneous dilatational tracheostomy is a frequently performed intervention on the ICU. In this context, Gan et al. used AR in six patients undergoing the aforementioned procedure with “good success and excellent user feedback” [ 53 ]. The use of an AR-assisted near-infrared electromagnetic radiation device in older ICU patients undergoing venous puncture lowered the incidence of hematomas in venous puncture but did not decrease procedure length or the number of attempts [ 54 ]. Yamada et al. developed an AR interface for smartphones and tablets that can be used by ECMO-perfusionists [ 55 ]. However, to date there are no studies evaluating its effectiveness compared to traditional learning methods. Similarly, Scquizzato et al. proposed an AR based smartphone application for estimating the weight of critically ill paediatric patients, but it has not been evaluated in a clinical setting.[ 56 ]. In conclusion, there is currently no convincing evidence for or against the use of AR-supported invasive procedures in critical care medicine.

AR/VR from a clinician’s perspective

There are a number of promising indications for AR/VR use in critical care medicine, which could be integrated into daily practice. VR could be part of a multimodal strategy, used to reduce analgesic requirements. Likewise, VR may help to support cognitive stimulation and physical activity. However, AR/VR applications are not designed to, and will not be able to, replace personal communication. Patients and their relatives welcome VR-assisted information about ICU procedures [ 57 ]. A similar conclusion applies to VR-based training for health care providers: there are promising approaches to support, but not to replace, traditional learning techniques. To date, there is no convincing evidence for the role of AR-supported practical procedures, such as endotracheal intubation or central venous line placement in critical care medicine outside of clinical trials.

The “vergence accommodation conflict”, cybersickness and possible solutions

VR can cause side effects such as headache, nausea and vomiting—so-called “cybersickness”—which can be related to motion sickness [ 58 ]. Cybersickness is not yet a defined health condition. Motion sickness occurs due to a difference between actual and expected motion. However, this pathophysiological mechanism may not be 100% transferrable to cybersickness. The “vergence accommodation conflict” during VR sessions also plays a role. This phenomenon arises because wearing the VR glasses leads to a disparity between the physical surface of the screen (“accommodation”) and the focal point of the virtual simulated world the user gazes at (“vergence”). This disparity can lead to nausea, headache, and discomfort. At the moment, several possible solutions to the “vergence accommodation conflict” are under evaluation [ 59 ], which potentially challenges the broad application of VR in medical training [ 60 ]. However, cybersickness might be stronger in AR than VR: in one study, 15.3% of participant reported headache and 17 other symptoms, including nausea, after using AR-based training for gross anatomy dissection (HoloAnatomy®) [ 61 ]. By contrast, Bruno et al. found no increased signs of cybersickness during their pilot study, which used VR to distract patients during transcatheter aortic valve implantation [ 6 ]. AR/VR related side-effects seem to vary among different age and gender groups [ 62 ]; an effect which is not yet fully understood and needs further investigation. Thus, the cornerstone of VR-based application might be careful patient selection and prompt assistance should side effects occur.

VR/AR from an ethical perspective

In vulnerable patient groups, such as critically ill patients, there are some ethical concerns regarding the use of VR/AR. For this purpose, Kellermeyer et al. established three core principles [ 63 ]:

If there is a choice, a human-to-human interaction should be preferred (“therapeutic alternativism”) over human-to-machine interaction (no “technological solutionism”).

VR technology should centre around “critical human values,” including dignity and autonomy (“human-oriented value alignment”).

VR systems should be patient centred, not focusing on the need of professional customers (“patient-centered design”).

From our point of view, these principles are of pivotal importance. VR/AR should always enhance the real-world provider—patient-relationship and should not be a tool to replace it. Some researchers proposed the creation of a new medical specialty, the “virtualist”, who undergoes extensive technical and medical training, but also has a deep understanding of the ethical implications of VR/AR technologies [ 64 ]. We believe that critical care physicians and patient representatives should actively participate in the development and continuous improvement of all virtual and digital technologies to ensure they are user-friendly and patient-centred.

VR/AR from a researcher’s perspective

There are a number of difficulties surrounding clinical studies using VR/AR applications. Namely, due to the extensive range of VR/AR glasses (hardware) and software it is extremely difficult to make a direct comparison. In fact, both components are often tested simultaneously in one trial, which may lead to interaction and a lack of clarity in the interpretation of results. [ 65 ]. In future studies, protocols and endpoint definitions should be harmonised as much as possible. The software used differs considerably. Some studies simply use commercially available devices and software (e.g. Nintendo Wii [ 27 ]) while others—such as physicians and researchers—customise the software from existing VR environments to specific patient/educational needs [ 6 ]. Additionally, some manufacturers specifically produce the exact software to create the environment required for the clinical purpose (ImmersiveRehab Ltd or Healthy Mind®). Most studies are "proof-of-principle" approaches focusing on the feasibility and safety of a specific VR/AR application.

Another problem is that VR hardware is rapidly evolving: head-mounted displays are generating ever-higher graphics resolution, easier interactivity, and, thus, greater immersion. Therefore, studies using the latest VR hardware demonstrate greater utility than older devices.

Unfortunately, the degree of immersion and occurrence of cybersickness are rarely measured or reported, although the effect of VR crucially depends on it [ 66 ]. Complex scores have been developed and validated for this purpose. The Simulator Sickness Questionnaire (SSQ), for example, uses 16 questions with four levels of severity to examine "nausea, oculomotor problems and disorientation" [ 67 ].

Currently, there is a lack of prospectively randomised controlled trials in this area of research. In addition, none of the studies were blinded. Theoretically, the intervention group could be compared with a control group, in which “sham VR applications” are used. “Sham VR applications” could consist of using VR glasses with no specific digital content. It is often difficult to distinguish between the relative benefits of immersive VR compared with established non-pharmacological distraction methods such as relaxation techniques or music therapy. At a minimum, investigators should be blinded to reduce bias.

In summary, future studies should consider the following aspects:

Methodical separation of software and hardware.

A detailed statement of the software development and validation process.

Prospective trial design with a randomised-controlled recruitment.

If possible, double blinding, but at least single blinding should be ensured.

Degree of immersion measurement.

Structured recording of "cybersickness" using validated scores.

Descriptive measures of “usual care” in the control group.

Conclusion and future directions

With the ongoing COVID-19 pandemic, innovative VR and AR applications offer new solutions for many aspects of daily critical care medicine. With advancing data transfer speeds; additional applications are emerging, such as remote distance treatment and care. Currently, remote treatments using robotic devices are under development [ 68 ]. This might enable independent, high-quality care in remote locations where expertise is unavailable. We believe that VR and AR will soon become mainstream reality in ICUs all over the globe. To create evidence-based knowledge, particular attention should be paid to consistent research design in further (clinical) trials.

Availability of data and materials

We did not use and individual participant or patient data.

Abbreviations

Three dimensional

• Augmented reality

Cardiopulmonary resuscitation

Computed tomography scan

Extracorporeal membrane oxygenation

Intensive care unit

Transcatheter aortic valve replacement

Post-traumatic stress disorder

• Virtual reality

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Acknowledgements

We thank Filiz Demirtas, Jonas Diepers, Torge Zense and Lisa Jäger for their assistance.

Open Access funding enabled and organized by Projekt DEAL. This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich-Heine-University Düsseldorf, No. 2018-32 to GW and No. 2020-21 to RRB for a Clinician Scientist Track. No specific funding was received for this work. Furthermore, institutional support has been received by the German Research Council (SFB 1116, B06) as well as the State of North Rhine Westphalia (Giga for Health: 5GMedizincampus. NRW, Project number 005-2008-0055 and PROFILNRW-2020-107-A, TP4).

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Raphael Romano Bruno, Georg Wolff, Maryna Masyuk, Ralf Erkens, Daniel Oehler, Shazia Afzal, Houtan Heidari, Malte Kelm & Christian Jung

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Bruno, R.R., Wolff, G., Wernly, B. et al. Virtual and augmented reality in critical care medicine: the patient’s, clinician’s, and researcher’s perspective. Crit Care 26 , 326 (2022). https://doi.org/10.1186/s13054-022-04202-x

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Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings

• Marileen M. T. E. Kouijzer   ORCID: orcid.org/0000-0001-9857-9337 1 ,
• Hanneke Kip 1 , 2 ,
• Yvonne H. A. Bouman 2 &
• Saskia M. Kelders 1  

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Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space. Despite the potential added value of virtual reality technology in healthcare, its uptake in clinical practice is still in its infancy and challenges arise in the implementation of VR. Effective implementation could improve the adoption, uptake, and impact of VR. However, these implementation procedures still seem to be understudied in practice. This scoping review aimed to examine the current state of affairs in the implementation of VR technology in healthcare settings and to provide an overview of factors related to the implementation of VR.

To give an overview of relevant literature, a scoping review was undertaken of articles published up until February 2022, guided by the methodological framework of Arksey and O’Malley (2005). The databases Scopus, PsycINFO, and Web of Science were systematically searched to identify records that highlighted the current state of affairs regarding the implementation of VR in healthcare settings. Information about each study was extracted using a structured data extraction form.

Of the 5523 records identified, 29 were included in this study. Most studies focused on barriers and facilitators to implementation, highlighting similar factors related to the behavior of adopters of VR and the practical resources the organization should arrange for. However, few studies focus on systematic implementation and on using a theoretical framework to guide implementation. Despite the recommendation of using a structured, multi-level implementation intervention to support the needs of all involved stakeholders, there was no link between the identified barriers and facilitators, and specific implementation objectives or suitable strategies to overcome these barriers in the included articles.

To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., healthcare provider-related barriers, as is common in current literature. Based on the results of this study, we recommend that the implementation of VR entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies. This implementation process could be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice.

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Contributions to the literature

Virtual reality is an innovative technology that is increasingly applied within different healthcare settings. Despite its potential to improve treatment, the adoption and uptake of VR are generally lacking.

In this scoping review, we identified factors related to the implementation of VR that are important for successful adoption and effective use in practice. However, most often these factors are not sufficiently translated from research outcomes to healthcare practice.

The findings of this scoping review contribute to the recognized gaps in the literature, stating recommendations for practice and future research on the systematic implementation of VR in healthcare.

Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space [ 1 , 2 ]. VR offers a broad range of possibilities in which the user can interact with a virtual environment or with virtual characters. Virtual characters, also known as avatars, can provide the user with a greater sense of reality and facilitate meaningful interaction [ 1 ]. VR interventions have been piloted in various healthcare settings, for example in treating chronic pain [ 3 ], improving balance in patients post-stroke [ 4 ], managing symptoms of depression [ 5 ], improving symptom burden in terminal cancer patients [ 6 ], and applied within treatment for forensic psychiatric patients [ 7 ]. These studies highlight the opportunities for VR as an innovative technology that could be of added value for healthcare. While there is a need for more research on the efficacy of VR in healthcare, experimental studies have shown that VR use is effective in improving the treatment of, among others, anxiety disorders [ 8 ], psychosis [ 9 ], or eating disorders [ 10 ]. However, the added value of VR is often not observed in practice due to the lack of usage of this technology.

Regarding uptake in clinical practice, VR is still in its infancy [ 11 , 12 ]. Various barriers are identified as limiting the uptake, such as a lack of time and expertise on how to use VR in treatment, a lack of personalization of some VR applications to patient needs and treatment goals, or the gap in knowledge on the added value of VR in a specific setting [ 11 , 13 ].

Not only VR uptake is challenging, but also other eHealth technologies experience similar difficulties in implementation [ 14 ]. eHealth is known as “the use of technology to improve health, well-being, and healthcare” [ 14 ]. For years, implementation has been out of scope for many eHealth research initiatives and healthcare practices, resulting in technologies that have not surpassed the level of development [ 15 ]. For these technologies to succeed and be used as effectively as intended, they must be well integrated into current healthcare practices and connected to the needs of patients and healthcare practitioners [ 13 ]. As a result, a focus on the implementation is of added value. It has the potential to improve the adoption, uptake, and impact of technology [ 16 ]. However, implementation procedures for VR technology still seem to be understudied in both research and practice [ 12 , 17 ].

One of the reasons for the lacking uptake of (eHealth) technology is the complexity of the implementation process [ 18 , 19 ]. The phase between the organizational decision to adopt an eHealth technology and the healthcare providers actually using the technology in their routine is complex and multifaceted [ 18 , 19 ]. This highlights the importance of a systematic and structured implementation approach that fits identified barriers. The use of implementation strategies, known as the “concrete activities taken to make patients and healthcare providers start and maintain use of new evidence within the clinical setting,” can help this process by tackling the implementation barriers [ 20 ]. These strategies can be used as standalone, multifaceted, or as a combination [ 21 ]. Often, they are part of an implementation intervention, which describes what will be implemented, to whom, how, and when, with the strategies as a how-to description in the intervention [ 17 ]. In addition, according to Proctor et al. [ 22 ], it is important to conceptualize and evaluate implementation outcomes. Implementation outcomes, such as acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability, can be used to set specific and measurable implementation objectives. Furthermore, assessing implementation outcomes will increase the understanding of the success of the implementation process and form a starting point for studies focusing on the effectiveness of VR in healthcare [ 22 ].

While implementation interventions could help the systematic implementation of VR, they are rarely used in practice. A way to stimulate systematic implementation and help develop an implementation intervention is by using an implementation model to guide this process. While a broad range of implementation models have been developed, there is still limited use of these models to structure the implementation of VR in healthcare [ 23 ]. One framework that could be used to identify important aspects of implementation is the NASSS framework, which investigates the n on-adoption, a bandonment, and challenges to s cale up, s pread, and s ustainability of technology-supported change efforts in health and social healthcare [ 24 ]. The NASSS framework does not only focus on the technology itself, but includes the condition of the target group, the value proposition, the adopter system (staff, patients, and healthcare providers), the healthcare organization(s), the wider system, and the embedding and adoption of technology over time [ 24 ]. The framework is used to understand the complexity of the adoption of new technologies within organizations [ 25 ]. However, it remains unclear if and what factors of the NASSS framework, or any other implementation framework, can be found in the implementation of VR in various healthcare settings.

In summary, virtual reality interventions have the potential to improve the quality of care, but only if implemented thoroughly. As VR use becomes more prevalent, studies should expand the focus to identify factors specifically related to the implementation of this new technology [ 19 ]. It is advised to perform a needs assessment, understand potential barriers to implementation early, set implementation objectives, and identify fitting implementation strategies before testing VR interventions in practice [ 26 ]. Therefore, this scoping review aims to examine the current state of affairs in the implementation of VR technology in healthcare settings and provide an overview of factors related to the implementation of VR. Within this research, the following sub-questions are formulated: (1) Which barriers play a role in the implementation of VR in healthcare? (2) Which facilitators play a role in the implementation of VR in healthcare? (3) What implementation strategies are used to implement VR in healthcare? (4) To what extent are specific implementation objectives and outcomes being formulated and achieved? (5) What are the recommendations for the implementation of VR in healthcare?

To address the study aims, a scoping review was undertaken on the current state of affairs regarding the implementation of virtual reality in healthcare settings. Due to the broad scope of the research questions, a scoping review is most suitable to examine the breadth, depth, or comprehensiveness of evidence in a given field [ 23 ]. As a result, scoping reviews represent an appropriate methodology for reviewing literature in a field of interest that has not previously been comprehensively reviewed [ 24 ]. This scoping review is based on the methodological framework of Arksey and O’Malley [ 27 ] including the following steps: (1) identifying the research questions, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing and reporting the results. A protocol was developed and specified the research questions, study design, data collection procedures, and analysis plan. To the authors’ knowledge, no similar review had been published or was in development. This was confirmed by searching academic databases and the online platforms of organizations that register review protocols. The protocol was registered at OSF (Open Science Framework) under registration https://doi.org/10.17605/OSF.IO/5Z3MN . OSF is an online platform that enables researchers to plan, collect, analyze, and share their work to promote the integrity of research. This scoping review adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 26 ].

A comprehensive, systematic electronic literature search was undertaken using three databases: Scopus, PsycINFO, and Web of Science. In each database, the same search strategy was used. Search terms were identified and included in the search strategy for three main categories relevant to the research questions: implementation, virtual reality, and healthcare. The search terms within a category were combined using the Boolean term “OR” and the term “AND”was used between the different categories. The search strategy was piloted to check if keywords and databases were adequate and adjustments were made whenever necessary. The full electronic search strategy can be found in Appendix 1 .

Study inclusion and exclusion criteria

All identified records published up until February 2022, that were peer-reviewed, and written in English, Dutch, or German, were included in the initial results. All references and citation details from different electronic databases were imported into the online review management system Covidence and duplicate records were removed automatically. A three-step screening approach, consisting of a title, abstract, and full-text screening, was used to select eligible studies.

Records were included if the titles indicated that the article focused on VR within a healthcare setting and that VR was used as a tool for prevention or treatment of patients. Because of the possibility of implementation not being mentioned in the title, broad criteria were used to prevent the unjust exclusion of relevant studies. In addition, records were included if they outline (parts of) the implementation process of VR technology (e.g., needs assessment, planning, execution, or lessons learned). Furthermore, the primary target group of the VR technology had to be patients with mental or physical disorders. If the studies focused solely on augmented reality (AR) or mixed reality (MR) and/or described a VR technology that was utilized to train healthcare professionals, they were excluded. Additionally, studies were excluded if full texts could not be obtained or if the study design resulted in no primary data collection, such as meta-analyses, viewpoint papers, or book chapters.

In the first step, two authors (MK & HK) screened all titles for assessment against the inclusion and exclusion criteria for the scoping review. Titles were included based on consensus between both authors. In the event of doubt or disagreement, the title was discussed by both authors. After screening the titles, both authors screened and assessed the abstracts using the inclusion and exclusion criteria. Abstracts were included or excluded based on consensus. In the final step, one author screened the full-text articles (MK). Reasons for excluding and any reservations about including were discussed with the other authors. The results of the search are reported in full and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram [ 28 ] (Fig.  1 ).

Search strategy and results

Data extraction strategy

The data extraction of this scoping review is mostly based on the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions [ 29 ]. A systematic assessment of study quality was not performed because this review focused on giving a broad overview of all factors related to the implementation of VR. This resulted in a heterogeneous sample of included study topics and designs: ranging from explorative qualitative studies to reflective quantitative studies. The data extraction process started with the creation of a detailed data extraction form based on the research questions in Microsoft Excel. This form was generated to capture the most relevant information from all obtained studies and standardize the reporting of relevant information. The extracted data included the fields as presented in Table 1 . One author (MK) filled out the data extraction forms; in case of uncertainties, a second author was consulted (HK). Secondly, for each category, relevant text fragments from each study were copied from the articles into the data extraction forms.

Data synthesis and presentation

To answer the first and second research questions, the fragments from the data extraction forms were coded inductively. To answer the third and fourth research questions, fragments were first coded deductively, based on the main categories of the NASSS framework: technology, adopters, organization(s), wider system or embedding, and adaptation over time [ 24 ]. Second, within these categories, the specific barriers and facilitators were coded inductively to identify recurrent themes. The implementation recommendations were coded inductively to answer the fifth and last research question. The first author executed the coding process, which included multiple iterations and constant adaptations until data saturation was reached. During this iterative process, multiple versions of the coding scheme were discussed with all authors and adapted accordingly.

Search results

The search strategy, the number of included records, and the reasons for full-text exclusion are provided in Fig.  1 . The main reason for excluding full-text articles was that studies focused on the usability or effectiveness of VR, rather than on the needs assessment, planning, execution, or lessons learned from the implementation process of VR.

Study and technology characteristics

An overview of the characteristics of the 29 included records and the used VR technology is provided in Appendix 2 . The following study designs were identified: qualitative ( n  = 13), quantitative cross-sectional ( n  = 10), and studies that used qualitative as well as quantitative methods ( n  = 6).

Of the 29 included records, 11 focused on VR use in rehabilitation clinics. Additional settings in which VR was applied are general health clinics, mental health clinics, or clinics for specific disorders, e.g., eating disorder clinics or burn clinics. The goal of VR technology was often to be of added value as a treatment tool. It was used to improve movement in rehabilitation patients ( n  = 11) or decrease anxiety in patients with a stress-related disorder ( n  = 2). In addition, it was applied to offer distraction or relaxation during medical procedures ( n  = 4). In addition to the variety in settings and applications of VR, the type of technology that was applied differed as well: from interactive VR ( n  = 26), in which patients can be immersed in a virtual environment, such as a shopping street or a restaurant, via a VR headset and interact with this environment, to (360°) videos ( n  = 4) in which patients are immersed in a virtual environment shown on a (computer) screen, with limited to no possibility for interaction.

Implementation characteristics

An overview of the 29 included studies and the implementation characteristics, such as the use of an implementation model or the stage of implementation research are presented in Appendix 2 . In this review, 8 of the 29 studies used a theoretical framework to structure implementation or data analysis. The Consolidated Framework for Implementation Research (CFIR) [ 30 ] was used in 3 studies and the Decomposed Theory of Planned Behavior (DTPB) [ 31 ] was also used in 3 studies. In addition, the Unified Theory of Acceptance and Use of Technology (UTAUT2) [ 32 ] was used in a single study, and the Innovation Diffusion Theory [ 33 ] was applied in one study as well.

Of the 29 included studies, the data collection of 12 studies took place before actual implementation and focused on factors, expected by stakeholders, that could influence future implementation. The data collection of the other 17 studies took place after actual implementation and reflected on existing factors related to implementation. Thus, most identified barriers, facilitators, and recommendations stated in this review were observed in studies that evaluated an existing implementation process.

Barriers to implementation

Barriers to the implementation of VR were identified based on relevant fragments from the articles. In 26 records, a total of 69 different barriers were identified and divided into categories of the NASSS framework. All barriers are provided in Table 2 . The barriers are explained in the accompanying text below.

A broad range of barriers was relevant to the implementation of VR in healthcare. Most identified barriers were related to the organization category of the NASSS framework. These were mainly focused on the lack of practical resources for healthcare providers to use VR. For example, the organization does not schedule sufficient time for healthcare providers to learn how to use VR and how to integrate VR into practice. In addition to a lack of time, not enough technical support, treatment rooms for VR, and VR equipment to treat patients were mentioned as organizational barriers.

Frequently mentioned barriers related to the adopters were factors that negatively influence healthcare providers’ opinions of VR. First, a lack of research and evidence on the added value of VR was mentioned as a barrier. Second, a perceived lack of experience in working with VR was said to cause a lack of confidence and self-efficacy in healthcare providers to work with VR during treatment. The perceived lack of time and limited opportunities to learn how to use VR contributed to this feeling.

Furthermore, technical barriers were identified to hinder VR implementation. Functional issues, such as technical malfunctioning of VR hardware or software, or a lack of client safety while wearing a VR headset in the limited space of the treatment room that limits freedom of movement were most frequently mentioned as barriers. Related to the VR headset, a lack of physical comfort for the patient when wearing the VR headset and the feeling of isolation while wearing the headset were frequently mentioned as barriers.

Lastly, barriers related to the condition, value proposition, wider system, and embedding and adoption over time categories of the NASSS framework were less frequently identified. The conditions and physical limitations of patients that could negatively influence VR use, such as several cognitive limitations, distress, or cybersickness during VR, were mentioned as barriers. Related to the value proposition, barriers such as high costs to purchase VR equipment or the lack of time for maintaining the VR hardware were mentioned. In addition, the lack of personalization to patients’ needs and treatment goals was mentioned as a barrier. The barriers related to the wider system and adoption over time, such as organizations not being innovation-minded or the lack of insurance reimbursement to compensate for costs of VR use, were mentioned less frequently.

Facilitators to implementation

Besides barriers, a total of 53 different facilitators to the implementation of VR in healthcare were identified in 26 records. Facilitators were identified based on relevant fragments from the articles and are divided into categories of the NASSS framework. They are mentioned and explained in Table 3 and the accompanying text below.

In comparison to the barriers, facilitators to implementation were identified less frequently in the included studies. Similar to the barriers, most facilitators were related to the organization category of the NASSS framework. As an organization, providing support, time, room, and technical system support to healthcare providers to learn and use VR were mentioned most frequently as facilitators.

In multiple studies, it was mentioned that adopters of VR technology need training and education on how to use and integrate VR into treatment. Healthcare providers want to increase their knowledge, skills, and experience with VR to feel confident and increase self-efficacy in using VR in treatment with patients. Besides, as a facilitator in the adopter’s category, it is mentioned that having access to evidence on the added value of VR for treatment is a major facilitator in VR implementation because healthcare providers feel the use of VR is validated within the treatment.

Lastly, facilitators in the condition, technology, value proposition, wider system, and embedding and adoption over time category of the NASSS framework were identified less frequently. For example, when looking at the sociodemographic factors of patients, the young age of patients was identified as a facilitator since these people tend to be more open to new technology and treatments and feel more comfortable using VR. Related to technology, ensuring client safety was mentioned as a facilitator, that is creating a physically safe space in the treatment room for patients to use VR. This safe and controlled environment was also identified in the value proposition category. Meaning that healthcare providers can create a safe space for patients to practice challenging behavior. Lastly, being innovation-minded as an organization and VR becoming more and more commonplace and affordable to scale up were both mentioned as facilitators in the wider system category and the adoption over time category of the NASSS framework.

Implementation strategies, objectives, and outcomes

An overview was created of the implementation strategies, objectives, and outcomes that were extracted from the included studies (see Appendix 2 ). In two studies, a clear implementation objective was mentioned [ 13 , 43 ]. These objectives both focused on designing an implementation intervention, the knowledge translation (KT) intervention, to translate knowledge about the use of VR to the healthcare provider. In addition, they aimed to identify factors that influenced VR adoption and healthcare providers’ support needs.

Of the 29 included records, 8 studies described actual implementation strategies [ 13 , 34 , 35 , 43 , 44 , 48 , 53 , 60 ]. Most were mentioned in studies that collected data after implementation and reflect on existing implementation processes. In the included studies that described expected implementation factors, implementation strategies were most often not described. These studies focused on identifying potential barriers and/or facilitators in preparation for the implementation phase and did not evaluate the used strategies.

A summary of the described implementation strategies mentioned in the included records is displayed below in Table 4 . Examples of strategies focused on practical resources were VR equipment to be used in treatment, treatment rooms in which the VR technology can be set up and used, and time for healthcare providers to learn about VR use. In addition, training and education on VR use were mentioned as important strategies. Hands-on interactive training, e-learning modules, mentorship for support and troubleshooting, and matching protocols and guidelines on how to use VR were mentioned. To set up VR treatment, an identified implementation strategy is to give support to healthcare providers in selecting appropriate content in VR that fits the patient’s needs and give information on how to instruct the patient about VR treatment. Lastly, implementation strategies that help to increase the motivation of healthcare providers to use VR were addressed. For example, having sufficient time to discuss the potential and added value of VR or having support from champions or mentors, experienced healthcare providers who share their experience with VR, to motivate others to integrate VR into their treatment practice were used during implementation.

The explicit conceptualization of implementation outcomes and the use of these outcomes to formulate implementation objectives or design implementation strategies was not described as such in the included records. The concepts of acceptability, adoption, uptake, or feasibility were mentioned in 12 records (see Appendix 2 ); however, they were not integrated as outcomes into a systematic implementation process.

Recommendations for implementation

In Table 5 , an overview of the 51 different recommendations for the implementation of VR in healthcare that were mentioned in 20 records is provided. These recommendations were inductively coded and divided into seven categories: (1) Increase understanding of patient suitability, (2) Improve knowledge and skills on VR use, (3) Improve healthcare providers’ engagement with VR, (4) Have support staff available, (5) Points of attention for developing VR treatment, (6) Support functionality of VR hardware and software, and (7) Design and development of implementation.

The first recommendation was to increase the understanding of patient suitability. In other words, it should be clear for healthcare providers how they can determine for which patients VR treatment is a fitting option. One way to determine patient suitability is to take into account the functional limitations of patients, such as their level of mobility or communication skills, before referring patients to VR treatment. Next to functional limitations, one should take into account cognitive limitations and any sensitivity to cybersickness. Patient suitability can be dependent on the goal of VR treatment, as some functional or cognitive limitations are not always a barrier to VR use.

The second recommendation was to improve the knowledge and skills of healthcare providers on VR use. Training programs and other educational resources, such as training days, online meetings, or instruction videos, that should be developed and disseminated to healthcare providers were mentioned as key elements to improving knowledge and skills.

The third recommendation was to improve healthcare providers’ engagement with VR. To accomplish this, the benefits of VR use and its possible contributions to treatment should be communicated to healthcare providers and patients. The use of successful example cases and disseminating supportive evidence of the added value of VR were mentioned as options to increase the engagement of healthcare providers with VR.

The fourth recommendation was to have sufficient support staff available to support VR use during treatment and maintain VR equipment. In addition, champions or mentors, healthcare providers experienced in VR treatment, were mentioned to promote uptake and increase the self-efficacy of other healthcare providers in VR use.

The fifth recommendation was related to developing VR treatment. The included studies gave some inconsistent suggestions on the frequency of use, from daily to once a week. Important aspects of developing a VR treatment are to set clear treatment goals, let the patient become familiar and comfortable with the VR equipment and software, and increase the treatment difficulty step by step.

The sixth recommendation was to support the functionality of VR hardware and software and ensure that it fits the user. Software should be appropriate for the patient’s needs, and age, and should fit the treatment setting. For example, VR software for forensic mental healthcare patients with aggression regulation problems should be able to let patients practice self-regulation strategies in virtual environments in which their undesired behavior is triggered. This could be a bar or supermarket with strangers for one patient, or a more intimate setting with a partner at home for another. The hardware needs to be adaptable for the limited mobility of patients, for example, patients that are wheelchair-bound. In addition, the VR hardware should still give the possibility for healthcare providers and patients to interact during the use of VR. The patient needs to be able to hear the voice of the healthcare provider.

The seventh and last recommendation was related to the design and development of the implementation of VR in practice. In multiple studies, it was advised that healthcare organizations use a structured, multi-model implementation intervention to support the needs of stakeholders and address barriers to VR use. The key stakeholders should be engaged during the development process of implementation interventions. It was recommended to use a theoretical framework, such as the Consolidated Framework for Implementation Research (CFIR) [ 46 ] or the Decomposed Theory of Planned Behavior (DTPB) [ 47 ] to guide the development of relevant implementation strategies to enhance the uptake of VR in healthcare practice.

Principal findings

This scoping review was conducted to provide insight into the current state of affairs regarding the implementation process of virtual reality in healthcare and to identify recommendations to improve implementation research and practice in this area. This review has resulted in an overview of current implementation practices. A broad range of study designs was identified: from qualitative studies that described expected factors of implementation, to quantitative methods that summarized observed factors. From the included studies, it can be concluded that the main focus of the implementation of VR is on practical barriers and facilitators, and less attention is paid to creating a systematic implementation plan, including concrete implementation objectives, developing suitable implementation strategies to overcome these barriers, and linking these barriers or facilitators to clear implementation outcomes. Only two studies described objectives for implementation and the practical strategies that were used to reach these objectives. Most implementation strategies that were described were related to practical resources and organizational support to create time and room for healthcare providers to learn about VR and use it in treatment. Despite differences in the type of VR technology, healthcare settings, and study designs, many studies identified the same type of barriers and facilitators. Most identified barriers and facilitators focused on the adopter system and organization categories of the NASSS framework [ 24 ], e.g., the needs of healthcare providers related to VR use and the organizational support during the implementation of VR. The most frequently mentioned barriers were a lack of practical resources, a lack of validated evidence on the added value of VR, and a perceived lack of experience in working with VR. This review showed that facilitators were studied less than barriers. Most of the included studies only described the implementation barriers. However, in the studies that did mention facilitators, similar themes were found between identified barriers and facilitators, mostly related to practical resources, organizational support, and providing evidence of the added value of VR were found. The content of the recommendations for the implementation of VR fits with the foregoing.

Comparison with prior work

Despite the importance of concrete strategies to successfully implement VR [ 20 ] and the conceptualization of implementation outcomes to understand the process and impact of implementation [ 22 ], there is a lack of research on this systematic implementation approach. In this review, only a few studies used a theoretical framework to structure implementation or data analysis. Frameworks that were mentioned most often were the Consolidated Framework for Implementation Research (CFIR) [ 30 ], and the Decomposed Theory of Planned Behavior (DTPB) [ 31 ]. However, none of the studies that mentioned the use of these models described an explicit link between the separate strategies, barriers, or facilitators and the integrated systematic implementation process. This illustrates the gap in research between identifying factors that influence implementation and linking them to practical strategies and implementation outcomes to form a coherent implementation intervention. The development of a coherent implementation intervention was only mentioned in two studies that were included in this review. To illustrate, one study set up an implementation intervention that promotes clinician behavior change to support implementation and improves patient care [ 63 ]. A coherent intervention could be an option to structure the implementation process and bridge the gap between knowledge of the use of VR to actual uptake in practice [ 63 ]. However, from implementation frameworks, such as the NASSS framework [ 24 ] or the CFIR [ 30 ], it is clear that the focus should lie on a coherent multilevel implementation intervention that focuses on all involved stakeholders and end-users, not only on one stakeholder.

The importance of focusing on the behavior change of all involved stakeholders, such as healthcare providers, patients, support staff, and managers, is reflected in the results of this review. Most barriers, facilitators, strategies, and recommendations are related to stakeholders within the healthcare organization that need to change their behavior in order to support implementation. For example, healthcare providers are expected to learn new skills to use VR and organizational management needs to make time and room available to support healthcare providers in their new learning needs and actual VR use during treatment. This highlights the importance of focusing on strategies that target concrete behavior of stakeholders for successful implementation. Identifying concrete behavior that is targeted in an implementation intervention can help describe who needs to do what differently, identify modifiable barriers and facilitators, develop specific strategies, and ultimately provide an indicator of what to measure to evaluate an intervention’s effect on behavior change [ 64 ]. The focus on behavior in implementation is not new, it is an important point of attention in the implementation of other eHealth technology [ 14 ]. However, based on the results of this scoping review, this focus is lacking in research on VR implementation.

To design implementation interventions that focus on the behavior change of stakeholders, existing intervention development frameworks can be used. An example is Intervention Mapping (IM). Intervention Mapping is a protocol that guides the design of multi-level health promotion interventions and implementation strategies [ 65 , 66 ]. It uses a participatory development process to create an implementation intervention that fits with the implementation needs of all involved stakeholders [ 65 ]. Eldredge et al. [ 65 ] and Donaldson et al. [ 67 ] IM can provide guidance on overcoming barriers by applying implementation strategies based on behavioral determinants and suitable behavior change techniques [ 65 ]. For example, when reflecting on the implementation strategies described in this review, providing feedback as a behavior change method can be used during the education or training on VR use to support the learning needs of healthcare providers. In addition, providing opportunities for social support could be seen as the behavior change technique behind the need for support and discussion of VR use during intervision groups with other healthcare providers.

Implications for practice and future research

The results from this review provide various points of departure for future implementation research and implications for practice. An important implication for both is the need for a systematic approach to the implementation process. Most studies identified in this review focused only on barriers or facilitators to implementation, not paying attention to the systematic process of developing an implementation intervention that specifies implementation objectives, describes suitable strategies that fit with these barriers and facilitators, and conceptualizes implementation outcomes to evaluate the effectiveness of these strategies. The development of an implementation intervention should preferably be supported by theoretical implementation frameworks such as the Consolidated Framework of Implementation Research [ 30 ], or the NASSS framework [ 24 ]. In this review, all implementation factors could be coded with and analyzed within the categories of the NASSS framework. Indicating its usefulness in structuring implementation research. Future research could focus on applying and evaluating such implementation frameworks to the implementation of VR in healthcare, specifying factors related to the implementation of VR and focusing on all phases and levels of implementation.

In addition, it could be valuable to focus on existing intervention development frameworks, such as Intervention Mapping, to guide the design of a complete implementation intervention. Future research could apply these existing frameworks in an implementation context, reflect on the similarity in working mechanisms and evaluate their influence on the implementation process and the behavior change of the involved stakeholders. This way, a first step in identifying the added value of systematic implementation intervention development can be made.

Furthermore, as being aware and convinced of the added value of VR within the treatment of patients is seen as an important facilitator of implementation for healthcare providers and organizations, it would be valuable for future research to focus on the evaluation of the efficacy of VR within healthcare practice. However, this raises an interesting paradox. Healthcare organizations and healthcare providers would like to have evidence of the added value of VR before investing in the technology for its implementation, but the efficacy of VR in practice can only be determined in an ecologically valid way when it is already thoroughly implemented in healthcare practice.

Strengths and limitations

This review set out to give an overview of factors that are related to the implementation practice of VR in healthcare. A strength of this study is that it used the NASSS framework to structure the analysis and review process. The use of an implementation framework contributed to systematic data collection and analysis, which can increase the credibility of the findings [ 68 ]. However, the use of the NASSS framework also revealed some drawbacks. Although all implementation factors were categorized within the categories of the NASSS framework, this coding was limited by the description of these categories and the overlap between some categories. For example, most barriers and facilitators that were categorized under organization, adopters, or technology were relevant for sustainable embedding and thus could fit in the category “embedding and adaptation over time” as well. In addition, the description of the category “condition,” the illness of the patient, and possible comorbidities, which are often influenced by biomedical and epidemiological factors [ 24 ], is too limited to describe all factors related to patient suitability for VR. The condition of a patient within mental healthcare is often related to other aspects, such as sociodemographic factors like age, technical skills, and feeling comfortable using new technology. All these factors could influence patient suitability for VR. Besides, in most included studies, the barriers or facilitators were not described in great detail, which made the coding process within the NASSS categories more difficult.

Furthermore, when titles of screened records did not focus on the implementation process of VR, e.g., studies that only focused on usability or effectiveness, they were excluded. Since usability studies could still partly focus on implementation, this may have caused us to miss publications that could provide interesting insights on implementation but whose main focus was other than that. We tried to overcome this limitation by selecting detailed inclusion and exclusion criteria for the literature search and abstract screening. The study was excluded only when there was no indication of a link between usability and implementation.

In addition, the full-text screening and data-extraction process were executed by one researcher. This could have caused us to miss information related to the topic. However, since the researcher used inclusion criteria that were thoroughly discussed during the title and abstract screening, and used a detailed data-extraction form, the chances of missing information are considered to be low. Furthermore, the first and second authors both extracted data from a few full-text articles, and in case of doubt, full-text were discussed with both authors.

Furthermore, because this scoping review aimed to provide an overview of the current state of affairs related to the implementation of VR in healthcare, all available studies were included, regardless of their quality and type of results. This is in line with the general aim of scoping reviews, which is to present a broad overview of the evidence on a topic. Since a quality assessment was not conducted, not all results of included studies might be valid or reliable. In addition, most of the barriers, facilitators, and recommendations stated in this review are observed in studies that took place after actual implementation. However, some of these factors were mentioned as potential factors related to implementation in studies that collected data before actual implementation. These factors were described as expected factors by involved stakeholders, but not observed. Therefore, these findings should be interpreted with care.

This scoping review has resulted in an initial overview of the current state of affairs regarding the implementation of VR in healthcare. It can be concluded that in the included publications, a clear focus on practical barriers and facilitators to the implementation of VR has been identified. In only a few studies implementation frameworks, specified strategies, objectives, or outcomes were addressed. To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., therapist-related barriers, but that it entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies, clear implementation objectives and predefined outcomes. This implementation process should be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice.

Availability of data and materials

All dataset(s) supporting the conclusions of this article are available in the included primary studies.

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Appendix 1. Full electronic search strategy

Search terms, search string.

TS = (implement* OR adopt* OR disseminat* OR introduc* OR “uptake”) AND TS = (“virtual reality” OR VR OR “virtual technolog*” OR “virtual environment”) AND TS = (health* OR “care” OR treat*)

Appendix 2. Study, technology, and implementation characteristics per study

Table 6 study characteristics, characteristics of vr technology, and implementation characteristics per study, rights and permissions.

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Kouijzer, M.M.T.E., Kip, H., Bouman, Y.H.A. et al. Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings. Implement Sci Commun 4 , 67 (2023). https://doi.org/10.1186/s43058-023-00442-2

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Current and future applications of virtual reality technology for cardiac interventions

• Edris A. F. Mahtab   ORCID: orcid.org/0000-0003-2647-5509 1 &
• Anastasia D. Egorova   ORCID: orcid.org/0000-0001-9312-2338 2  

Nature Reviews Cardiology volume  19 ,  pages 779–780 ( 2022 ) Cite this article

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• Congenital heart defects
• Interventional cardiology
• Patient education
• Rehabilitation
• Three-dimensional imaging

Virtual reality is a fast-evolving technology that already has several promising applications in medicine. In this Clinical Outlook, we discuss the current evidence and the future challenges for virtual reality applications in cardiac interventions. The incorporation of virtual reality in daily practice will inevitably make clinical care more robust, patient-centred and safe.

Right from its conception in studies of Ibn Sina (also known as Avicenna) and his contemporaries 1 , modern medicine has been and will always be subject to scientific and technological evolution. In the cyber era, the influences of extended reality modalities such as augmented reality and virtual reality (VR) are growing. VR platforms provide the user with the possibility of submerging into an alternative 3D environment and interacting with the surroundings in a real-time manner. A growing number of publications have described the potential applications of VR in medicine. However, randomized controlled trials involving VR in medicine are scarce, and robust evidence for the broad implementation of VR platforms in the clinic is limited. Several methodological and practical challenges need to be addressed in the near future before this highly promising technique can be fully implemented in the field of cardiac interventions (Fig.  1 ).

Several 3D virtual reality (VR) modules are in use in the field of cardiac interventions. The applications include skills simulation and training, periprocedural guidance and planning, enhanced 3D imaging visualization, patient education, pain management and rehabilitation. Although the use of VR applications is growing, many technological and methodological challenges remain. These challenges include addressing technical flaws such as the lack of haptic feedback, cyber sickness and the need for integration of multimodality imaging and real-time procedural visualization, as well as the need to tailor the module to the patient. Finally, international guidelines and protocols for the use of VR technology in scientific research and in the clinic are also needed.

Contemporary cardiac care includes increasingly complex percutaneous interventions and technical skills that require iterative practice and many working hours to acquire the necessary dexterity and clinical competency. Interventional cardiology is a continually evolving field associated with numerous technological advances over the past decades. Cardiac interventions are associated with a risk of major complications, which require adequate technical performance and effective team communication under stress to achieve positive outcomes. In this context, lifelong training and sufficient exposure to these cases are imperative, and VR technologies can have an important role in this process.

VR technologies can revolutionize the practice of clinical and technical skills training in the field of cardiac interventions 2 . Many VR-based skills simulators have been described and implemented in practice, including ones for vascular catheter cannulation and angiography, rhythm device and percutaneous valve implantation procedures, procedural anatomy teaching, and patient education and involvement in decision-making. Our group is developing several VR-based simulators for extracorporeal circulation and cardiopulmonary resuscitation after cardiac surgery 3 . These simulations have the potential to boost individual as well as team skills in the setting of complex clinical multidisciplinary situations.

“VR technologies can revolutionize the practice of clinical and technical skills training in the field of cardiac interventions”

VR technology provides digital, online, remotely accessible and blended simulation and live modules. Such a platform can alleviate many of the restrictions imposed by inability to travel (whether owing to travel restrictions, such as during the COVID-19 pandemic, or financial limitations) and provides training support, as well as expert and technical external periprocedural support.

In the preprocedural period, VR technology can provide a diagnostic and planning tool that is both dynamic and interactive. VR simulators facilitate the visualization of complex anatomy and allow the clinician to select the optimal intervention strategy (either percutaneous or surgical), tools and team 4 , 5 . This utility is of particular importance in the field of structural and congenital heart disease, for which interactive 3D visualization of the complex and often unique anatomy is imperative for procedural success 6 , 7 . The first feasibility studies evaluating the integration of CT, MRI and cardiac ultrasonography with VR technology are ongoing. Such technology will allow the incorporation of real-time haemodynamic data in high-spatial-resolution 3D structures. The introduction of these VR modules is expected to change the utilization of diagnostic imaging tools and will enhance our understanding of complex pathoanatomy.

“VR simulators facilitate the visualization of complex anatomy”

The role of VR technology in periprocedural pain management and rehabilitation has also been studied 8 . VR has been shown to reduce patient-perceived pain levels and periprocedural anxiety, as well as contribute to faster post-procedural functional recovery in patients undergoing cardiovascular interventions 9 . Furthermore, VR applications might also be of use as an adjunct strategy in cardiac rehabilitation. However, methodologically robust studies are needed to tailor the technology to the patient group (to take into account factors such as sex, age and technical literacy). Given the growing evidence on the potential of VR modules in both in-hospital and home-based pain management, it is tempting to think that VR technology might indeed become a part of regular treatment plans in the near future 10 . Of note, VR technology incorporates the features of meditation, cognitive behavioural therapy and mindfulness, highlighting how these often underappreciated ‘soft’ concepts of modern medicine can contribute to ‘hard’ clinical outcomes. VR technology can also be incorporated into outpatient clinics to improve patient education and thereby enhance the shared decision-making process and increase patient compliance. Meticulous patient selection and evaluation of cost/benefit ratios require further investigation before VR modules can be successfully implemented in insurance-based health care systems.

The outlook on the use of VR technology for cardiac interventions and patient care is promising. However, several challenges need to be addressed before this technology can be successfully implemented in daily clinical care. Aside from the technical challenges, such as the development of haptic feedback, prevention of cyber sickness, integration of multimodality imaging and implementation of real-time procedural visualization, two drawbacks related to methodology require specific attention. First, the majority of the studies on VR technology have been observational in nature, mostly describing the pioneering work and feasibility of the concept. These studies have low case numbers, single-centre experiences, divergent study protocols and differences in techniques used. The lack of overall methodological standardization makes the comparison of results from these studies challenging and impedes the generation of solid conclusions. Second, no recommendations or a formal consensus is available to guide the incorporation of VR technology in cardiac interventions. The successful implementation of VR in clinical care requires a formalized and, at least to some degree, a standardized approach. To address these challenges, we propose an expert taskforce among international scientific communities (including the AHA, ESC and EACTS) to identify the most important gaps in evidence on the implementation of VR technology in the field of cardiac interventions, as well as to set priorities, standardize research protocols and formulate recommendations and guidelines.

To conclude, the application of VR technology in cardiac interventions is developing apace and is here to stay. These modalities are expected to improve clinical practice and make patient care more robust, patient-centred and safe. However, several technological and methodological challenges need to be addressed before VR platforms can be implemented in the clinic. International cardiovascular communities can have a key role in this process through a dedicated expert taskforce.

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Acknowledgements

We thank Amir H. Sadeghi for help with preparing this manuscript and Jette J. Peek for help with preparing the figure.

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Edris A. F. Mahtab

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Mahtab, E.A.F., Egorova, A.D. Current and future applications of virtual reality technology for cardiac interventions. Nat Rev Cardiol 19 , 779–780 (2022). https://doi.org/10.1038/s41569-022-00789-4

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The Impact of Virtual Reality Toward Telemedicine: A Qualitative Study

• Fan Zhao 12 ,
• Dustin Sochacki 12 ,
• Jonathan Witenko 13 &
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Telemedicine is quickly becoming an essential asset in the healthcare industry today. After COVID, the combination of virtual reality (VR) technology and telemedicine is quickly becoming a safe and effective solution for patients. Despite the advantages of employing VR in medical education and treatment, various problems and limits lead to the technology’s ineffectiveness or misuse. As a result, addressing potential problems associated with VR could be beneficial in the strategic decision-making process for implementing and developing this technology in the healthcare industry. This research used case study method to identify current issues of VR technology adoption at a large US hospital system. The findings of this qualitative study explore potential concerns and limitations of current VR technology. Suggestions and insights are highlighted to benefit researchers and practitioners.

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Zhao, F., Sochacki, D., Witenko, J., Kogan, R. (2022). The Impact of Virtual Reality Toward Telemedicine: A Qualitative Study. In: Duffy, V.G., Gao, Q., Zhou, J., Antona, M., Stephanidis, C. (eds) HCI International 2022 – Late Breaking Papers: HCI for Health, Well-being, Universal Access and Healthy Aging. HCII 2022. Lecture Notes in Computer Science, vol 13521. Springer, Cham. https://doi.org/10.1007/978-3-031-17902-0_15

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Original research article, opportunities and challenges of virtual reality in healthcare – a domain experts inquiry.

• 1 Human-Computer Interaction, Julius-Maximilians University, Würzburg, Germany
• 2 Research Group Health–Technology–Ethics, Protestant University of Applied Sciences, Ludwigsburg, Germany

In recent years, the applications and accessibility of Virtual Reality (VR) for the healthcare sector have continued to grow. However, so far, most VR applications are only relevant in research settings. Information about what healthcare professionals would need to independently integrate VR applications into their daily working routines is missing. The actual needs and concerns of the people who work in the healthcare sector are often disregarded in the development of VR applications, even though they are the ones who are supposed to use them in practice. By means of this study, we systematically involve health professionals in the development process of VR applications. In particular, we conducted an online survey with 102 healthcare professionals based on a video prototype which demonstrates a software platform that allows them to create and utilise VR experiences on their own. For this study, we adapted and extended the Technology Acceptance Model (TAM). The survey focused on the perceived usefulness and the ease of use of such a platform, as well as the attitude and ethical concerns the users might have. The results show a generally positive attitude toward such a software platform. The users can imagine various use cases in different health domains. However, the perceived usefulness is tied to the actual ease of use of the platform and sufficient support for learning and working with the platform. In the discussion, we explain how these results can be generalized to facilitate the integration of VR in healthcare practice.

1 Introduction

There is a wide range of potential applications of VR systems in the healthcare sector. Therapeutic support applications target, for instance, exposure therapy for patients with a fear of heights ( Gonzalez et al., 2016 ; Kaur et al., 2019 ), spiders ( Shiban et al., 2016 ; Mertens et al., 2019 ), or public speaking ( Herumurti et al., 2019 ; Glémarec et al., 2021 ). Others use the effects of embodiment to deal with body perception disorders that often come with obesity or anorexia ( Döllinger et al., 2019 ; Wolf et al., 2021 ). Physiological health can be supported by exercise-based training applications in which VR promises increased motivational and training effects. The same arguments apply to virtual physiotherapy measures, e.g. to recover from surgery or to counteract gait impairments ( Hamzeheinejad et al., 2019 ; Kern et al., 2019 ; Gianola et al., 2020 ). Patients who suffer from the consequences of a stroke can regain motor skills by practicing with virtual replacements of their limbs ( Wang W. et al., 2019 ; Moldoveanu et al., 2019 ) and even addiction scenarios can be simulated in virtual worlds which can serve as a basis for treatment ( Thompson-Lake et al., 2015 ; Wang Y.-g. et al., 2019 ).

The fact that the possibilities are so versatile also means that it is relatively difficult for healthcare professionals to get a hold of applications that are suitable for their clientele. While there have been various efforts to making the creation of VR applications easier and more accessible ( Latoschik and Tramberend, 2011 ; Fischbach et al., 2017 ; Neelakantam and Pant, 2017 ; Andone and Frydenberg, 2019 ; Santos and Cardoso, 2019 ; Zhang and Oney, 2020 ), they have not focused on the healthcare domain with its specific requirements. Moreover, these works had programmers and designers of virtual words in mind as the targeted users, whereas healthcare professionals likely lack both these backgrounds. In this study, we assume that there was a platform, similar to the concept presented by von Mammen et al. (2019) , that specifically allowed health professionals to compose VR experiences that are meant to help them in their daily work. Based on this assumption, we embark on the quest to find out whether such a software platform had the potential to be established in healthcare practice and what the conditions for its acceptance would be. In this work we will refer to this as our “envisioned software platform”. We see potential users of this platform mainly from four specific healthcare domains. In the 1) therapy domain the envisioned software platform can be used to create VR applications for the treatment of anxiety, obsessive-compulsive, and body-awareness disorders. For example, this work by Döllinger et al. (2019) investigates the usage of VR for modulated body image perception for behavior therapy that addresses obesity challenges. In the 2) rehabilitation domain the envisioned software platform can be used to create, for example, VR applications that assist in regaining physical and motor abilities after an accident, surgery, or a stroke. So, this area mainly concerns physiotherapists. Kern et al. (2019) ; Hamzeheinejad et al. (2019) have examined the impact of VR in gait rehabilitation, and Laver et al. (2017) ; Zhang (2020) used VR for stroke rehabilitation and helped patients to recover from the impacts after spinal cord injuries. In the domain of 3) training, the envisioned software platform can be used to create controlled and save virtual training environments for the healthcare domain, e.g. for schooling first-aid, nursing, or surgical procedures. An example here comes from Mathur (2015) who worked on a low-cost VR system for medical training and found it to be more effective than a normal setup. In the 4) prevention domain the envisioned software platform can be used to create simulations that showcase the dangers of drug abuse or help with relaxation to prevent stress-related diseases. For example, the work by Nemire et al. (1999) looked into the possibilities of using a Hi-Fi VR system to prevent teens from smoking. So when we talk about the “potential users” of the envisioned software platform or “healthcare professionals” we usually refer to people who are employed in these four domains. There are other relevant areas, but they are not in focus for now; as they affect fewer patients or for other reasons. This includes, for example, the use of VR for training cognitive skills in dementia or for distraction in palliative patients. In the first area, however, good technologically supported applications already exist ( Arlati et al., 2017 ; Zając-Lamparska et al., 2019 ). The second application area is smaller, and the provision of beautiful environments tends to be sufficient ( Niki et al., 2019 ), which is probably also an important prerequisite for the other application areas.

Surveying the literature, we found no information about the view of healthcare professionals on VR. In particular, we could not find any studies that shed light on the prioritization of aspects for adaptation of VR from the view of healthcare professionals. Yet, their assessment is an invaluable source of information that has not yet been sufficiently embraced. This lack of information motivates this study. We aim at understanding whether and under which conditions healthcare specialists without technical background would embrace VR as a medium to enhance the effectiveness of their work. We are specifically interested in their prerequisites to autonomously create and utilize VR applications. We also want to determine their acceptance of an according software platform that would empower them to do so. We want to capture their opinions and concerns, as well as their suggestions toward design specifics and ideas about requirements of the platform.

As a result, we conducted an online inquiry based on a video that depicts our envisioned software platform. Our questions target the categories 1) perceived usefulness, 2) perceived ease of use, 3) general attitude, and 4) ethical concerns toward the envisioned software platform. Together, they address two aspects which are considered central in the context of technology development: The users and their needs in the sense of user-centered design (e.g., Karat and Karat, 2003 ) and a basis for ELSI-conform development, i.e., to reflect the ethical, legal, and social implications on individuals as well as on society and to engineer according measures (e.g., Greenbaum, 2015 ).

The gained knowledge can be used to spur the integration of VR into healthcare work routines and pave the way for VR out of the laboratory and into common practice. The captured requirements can immediately and effectively inform the development of a great number of health-related VR experiences, and be considered in according, generic authoring platforms for VR experiences. In addition, it can provide a basis for future research, especially considering concerns of the potential users.

The rest of this article is structured as follows: In the related work section, we report on VR authoring tools and technology-related acceptance and ethics studies. Then, in the methods section, we explain how the video prototype was created and how we structured and executed the online survey. In the fourth section, we list the results and in section five we discuss these results in terms of what they mean for the envisioned software platform and VR healthcare applications in general. Eventually, we will wrap the article up in the conclusion.

2 Related Work

This chapter presents preceding works that form the basis for our study. With regard to the technological background, this includes an introduction to previously developed systems similar to the envisioned software platform and a summary of their relevant components. To bolster the methodological and conceptual basis for the inquiry, preceding studies on the user acceptance of novel technologies by specific professional groups are presented. Moreover, we describe the Technology Acceptance Model and shed light on preceding research on the ethical aspects of using VR.

2.1 Evolution of Authoring Tools

Different from previous attempts, the market success of VR head-mounted displays and 3D controllers that started in the early 2000s has not been stopped short, yet. With pricing and capabilities making VR technology more accessible than ever and sales numbers growing rapidly ( Angelov et al., 2020 ), the need for authoring platforms of VR experiences has grown as well ( Ashtari et al., 2020 ).

The developments towards authoring tools started in the early nineties with technical libraries and toolkits. Scene graph libraries such as OpenGL Performer ( Rohlf and Helman, 1994 ), Open Inventor ( Strauss and Carey, 1992 ), and OpenSceneGraph ( Wang and Qian, 2010 ) were created to realize visual simulations, virtual reality environments and other real-time 3D graphics applications. But oftentimes, most of these libraries focused on performance over ease of programmability. Also, developers often found it difficult to use these general-purpose libraries for specific problems ( Bethel et al., 1999 ). Either these libraries were extended ( Hesina et al., 1999 ), or additional packages and frameworks were developed upon these toolkits that could be used to bridge this gap ( Kelso et al., 2002 ; Pavlik and Vance, 2012 ).

Further, many platforms supported networking and enabled the development of multi-user virtual environments ( Carlsson and Hagsand, 1993 ; Greenhalgh and Benford, 1995 ; Allard et al., 2002 ). Latoschik and Tramberend (2011) created the open-source research platform Simulator X that is targeted at developing real-time interactive systems. Fischbach et al. (2017) , for example, demonstrated how this platform can be used to increase the software quality of real-time interactive systems. Efforts like this made multiple developers and applications work in a common environment and communicate with each other without exposing the complex internal architectures. Frameworks like Avocado/Avango ( Tramberend, 1999 ; Kuck et al., 2008 ), MR Toolkit ( Shaw et al., 1993 ), or VR Juggler ( Bierbaum et al., 2001 ) provided high-level APIs to mask the system level architecture from the author. Also, the generality of the data-flow architecture used in these platforms enabled an easy exchange of data across modules, and their users were empowered to create a wide variety of virtual environments ( Figueroa et al., 2002 ; Allard et al., 2004 , 2010 , 2005 ).

These libraries and frameworks focused on software architectures and were thus to be used by programmers. A user without profound knowledge in software development would find it overwhelming to understand their respective workflows. The early developments, starting from the libraries and toolkits, slowly evolved into high fidelity authoring platforms over time. With the current advancements in technology and with the wide acceptance of VR, researchers and developers are innovating more sophisticated and effective solutions that can be used to produce more immersive and realistic content. A-frame 1 is a relatively new open-source framework from Mozilla to generate WebVR content ( Neelakantam and Pant, 2017 ). Creating a VR experience is cost-effective in A-frame, but the initial learning curve can be an insurmountable obstacle to novice users ( Santos and Cardoso, 2019 ). Many commercial and research solutions are addressing the design challenges faced by educators. CoSpaces 2 , InstaVR 3 , or WondaVR 4 are examples for commercial platforms primarily targeting the education sector. Among these, we found CoSpaces to be an easy-to-use, beginner-friendly tool, that allows the users to create simple VR environments using a drag and drop facility and allows to make the models interactive by employing a Scratch-like visual programming environment ( Andone and Frydenberg, 2019 ). FlowMatic ( Zhang and Oney, 2020 ) is a VR experience editor that uses a different approach to the design process by introducing a concept called immersive authoring. Most of the authoring platforms use 2D software to design the VR experience which takes off the freedom of using spatial information into consideration. FlowMatic makes use of VR, to create VR experiences taking advantage of the 3D spatial interaction. However, FlowMatic focuses only on making the newly created VR environment interactive using a visual programming tool. The above mentioned tools provide ways to facilitate the creation of VR experiences. However, there are some features that they are missing. Especially in terms of healthcare applications there could be the need for additional features such as, control over set stimuli and thus the experience, the ability to monitor the state of the end-user, or an easy creation process for virtual environments. These are also ideas that are part of our vision for a software authoring platform.

2.1.1 Content Creation

Many tools address the 3D asset creation process aimed specifically at novice users. For instance, 360proto ( Nebeling and Madier, 2019 ) and Lift-off ( Jackson and Keefe, 2016 ) are tools that allows users to create minimal AR/VR prototypes and 3D models just by drawing the intended diagram or a skeleton of the envisioned 3D asset on paper and directly importing it into the virtual environment, allowing further modification possibilities. On the commercial side, Google Tiltbrush 5 and Blocks 6, 7 , a VR drawing tool and virtual modeling tool respectively, are popular among artists and VR enthusiasts. Though it was released for hobbyists, they are now being used in both healthcare and education fields as well ( Ying-Chun and Chwen-Liang, 2018 ; So and Lu, 2019 ). Developments from the field of 3D asset creation can be used to enable people with no programming skills to create or adapt their own virtual environments.

2.1.2 User Measurements and User Assistance

Making use of physiological measurements in immersive technology alone is a vast area of study. Especially for therapy and training applications there are many possibilities. For a detailed elaboration of these possibilities refer to the literature review of Halbig and Latoschik (2021) . To our knowledge, user assistance is addressed in the surveyed authoring platforms and related tools only employing conventional methods, such as tooltips, web-based tutorials, community forums, etc. An intelligent system, that provides contextual assistance would make the user experience easy, and flatten the learning curve.

The major challenge we observed from the literature is that most of the high-fidelity authoring tools, for example, Unity3D, Unreal Engine, or even A-frame are targeted at experienced developers and designers. The other tools such as CoSpaces, which is relatively easy to use, restrict the users from making the most out of VR technology due to its limited designing capacities and experience control features. This obstructs most of the consumers from creating their content for specific purposes and relies on very limited choices of VR experiences developed by others ( Conway et al., 2000 ; Nebeling and Speicher, 2018 ; Ashtari et al., 2020 ). From a healthcare perspective, the authoring tools should additionally provide facilities to help the user fulfil a task completely, such as the provisions for monitoring an event or controlling the user’s experience in real-time. Most of the existing tools we came across are lacking those components. We have therefore come to the conclusion that the development of a specific software platform is necessary: A software platform that aims at facilitating the process that healthcare professionals can create and operate VR applications on their own.

2.2 User Acceptance Studies

Understanding a user and their perception of technology plays an important role in the user-centered software development process. A user acceptance study is a critical milestone to find out if users are convinced by the implementations, to see if their expectations are met, and to make it clear to developers and designers if the system is usable for the end user. It is generally carried out before the final release of the software system ( Leung and Wong, 1997 ). This seems to be an ideal procedure in a user-centered approach where the design process happens for the user. However, there is a shift towards participatory design approaches where users are a part of the design and development process from the very beginning till the release of the platform ( Sanders, 2002 ).

There is a vast literature that addresses technology acceptance studies. In the area of VR and healthcare, information from various acceptance studies are available. However, these studies tend to focus on specific applications that have already been completed ( Snoswell and Snoswell, 2019 ; da Costa and de Carvalho, 2004 ; Garcia-Palacios et al., 2007 ) or VR-acceptance overall ( Syed-Abdul et al., 2019 ). Some studies also set in at an earlier stage and used participatory approaches. In a study by Karaosmanoglu et al. (2021) healthcare professionals provided feedback via interviews before the development of a VR exergame to enhance physical activities by people suffering from dementia. In a study by Hilton et al. (2011) professionals’ feedback was gathered via questionnaires and focus groups to inform the development of a system for stroke rehabilitation. Such studies are very valuable because they ensure that applications meet the needs of users. Besides, they can serve as a guideline for future research in the fields of interest and are a stepping stone for any researchers who further want to explore a similar area with a similar user base. However, their conclusions are to some point limited to specific applications and user groups. Besides, while health professionals are consulted for the development of these applications, the ultimate focus is on their use by patients. To our knowledge, acceptance studies that focus on the needs of professionals in the healthcare domain and their use of VR applications have not been published so far.

One of the most used theoretical frameworks to assess an individual’s acceptance of any technical applications or devices is the Technology Acceptance Model (TAM), widely categorized under the umbrella of Information Systems ( Davis, 1989 ; Lee et al., 2003 ). It assesses how different features of a system affect the perception and attitude of a user toward using the actual system ( Balog and Pribeanu, 2009 ). The original TAM proposed two major variables to understand user acceptance, namely, Perceived Usefulness and Perceived ease of Use. Perceived Usefulness is defined as to what level a person thinks using a system would improve his or her work performance. Perceived ease of Use, is defined as the degree to which a user thinks using a system is effortless ( Davis, 1989 ). Over time, the TAM has gone through major revisions ( Lee et al., 2003 ). Even the original authors had extended it to TAM2, adding more constructs to evaluate user acceptance ( Venkatesh and Davis, 2000 ). Researchers have also combined other frameworks and added their questions and constructs considering the existing TAM as a base, to understand the users’ view better ( Lee et al., 2019 ; Fussell and Truong, 2021 ).

2.3 Ethical Implications

Ethical aspects play an important role for the acceptance of software. Numerous articles have already investigated ethical aspects for VR use in general (e.g., Kuntze et al., 2002 ), in health-impaired individuals in general (e.g., Kellmeyer et al., 2019 ), or in specific health domains (e.g., Lewis and Griffin, 1997 ). The focus of the majority of papers has been on ethical aspects of virtual reality in psychology/psychotherapy (e.g., Yellowlees et al., 2012 ; Kellmeyer, 2018 ; Marloth et al., 2020 ) and in rehabilitation ( Lewis and Griffin, 1997 ; Kellmeyer, 2018 ). The identified aspects of ethical relevance are manifold. In addition to aspects that concern the specifics of VR, differential ethical challenges arise depending on the health care setting (e.g., Lewis and Griffin, 1997 ) and patient groups (e.g., Kellmeyer et al., 2019 ). These papers are mainly theoretical. In contrast, empirical research on health professionals’ ethical evaluation of VR is scarce. A general assessment is desirable regarding ethically relevant principles, such as respect for autonomy or justice (e.g., Beauchamp and Childress, 2019 ), and how they are positively or negatively affected by VR from the perspectives of employees in health care areas. Positive and negative expectations need to be investigated for a wide range of health care areas, such as psychotherapy and palliative care. This will help to identify critical areas of VR usage, to get an impression of the awareness for ethical issues in the professional group and to assess the acceptance of the platform based on ethical criteria. This is particularly important since VR usage in healthcare is on the rise.

In the introduction, we described the target of understanding the prerequisites for healthcare professionals to autonomously operate and create VR applications. Literature on this question is missing to date. While there are regular acceptance studies for various soft- and hardware products, until now they have never focused on healthcare professionals’ views on VR. Therefore, we address an important gap. In order to proceed as systematically as possible, our study is based on two pillars: the Technology Acceptance Model (TAM) and the envisioned software platform. Thus, we have concrete categories available as well as novel ideas to be presented to potential users. In this way, people from the healthcare sector are encouraged to share their opinions and suggestions regarding our proposals.

3.1 Mockup Trailer

First, we had to solve the problem of measuring the acceptance toward a software platform that does not exist yet. Moreover, we had to assume that for some of the potential respondents, the topic of VR is little or not known at all. Therefore, the subject of our evaluation was a mockup trailer, which is supposed to bring our ideas closer to the potential users from the healthcare sector. It should give them an idea of what using and creating VR applications might look like in their everyday work. The use of a trailer and surveying at an early stage also have the advantage that the results are less dependent on details. Instead, at a more general level, the survey asks what the professional group’s needs are when using VR and how they would envision using it professionally.

First, the trailer shows examples of VR applications in the healthcare sector, i.e., a virtual knee rehabilitation exercise and an example for exposure therapy targeting pyrophobic patients. Moreover, the trailer depicts potential features of the envisioned software platform. The first one would be a supervisor monitor that allows the supervisor of a healthcare application to keep track of the current state of the patient and adapt the virtual environment accordingly. Next, the trailer shows how users of the software platform can create their own VR applications by choosing from standard templates of virtual environments. Those templates are then adapted by creating virtual objects and by altering the sequence of events and interactions. Prototypical user interfaces and example interactions are shown for these operations. Another idea that is depicted in the trailer is the possibility to scan people via the smartphone and thus create custom avatars of a patient as described in Wenninger et al. (2020) . So with the fire-exposure therapy and the knee rehabilitation exercise we chose two fundamentally different areas of application, which can nevertheless be presented in a relatively short duration and in an easily understandable way. However, both concepts are transferable to other areas and are thus intended to stimulate further ideas. By showing possible features like creating an avatar, we wanted to show viewers possibilities of VR that they might not have thought of on their own. Combined with expertise in their respective fields, we hope that participants will be stimulated to think about how such opportunities might be applied in their field. Hence, the mockup trailer introduces different facets of VR healthcare applications and gives the viewer a quick and concise impression of it.

Such a mockup trailer has previously been used to give study participants an impression of a new technology (e.g., Haugstvedt and Krogstie, 2012 ). The biggest advantage of this method is that it provides a good overview that conveniently can be distributed to a large group of people, accordingly supporting gathering larger samples than individual presentations could. Figure 1 shows the screenshots of above mentioned features from the mockup trailer. The trailer is available in an English and a German version. The English version of this trailer can be viewed at https://www.youtube.com/watch?v=HWXp6ke93_w .

FIGURE 1 . The screenshots from the mockup video used for the study that shows different features of the envisioned software platform. (A,B) Demonstration of virtual leg coordination therapy. (C,D) Demonstrations of Supervision monitor and how it is used to control a fire exposure therapy session. (E) Demonstrations of Behaviour editor used to configure assets. (F) VR environment editor. (G) Avatar scanning process using a mobile phone. (H) Representation of the assistance system.

For the actual study, we adopted the TAM that we already introduced in the related work section ( Davis, 1989 ; Lee et al., 2003 ). From this model, we adapted categories and corresponding questions as the basis for our study. These three categories are the perceived usefulness of the platform, the perceived ease of use, and the user’s attitude toward the platform. We adopted Likert-type questions from the TAM model that capture these categories. Furthermore, we added additional open-ended questions to the categories in order to gather valuable feedback on the prerequisites for the acceptance or rejection of the software platform and VR in general. Moreover, we wanted to get specific feedback on the idea of a supervisor monitor, which allows to surveil and control a VR session. In an additional question, we wanted to find out what kind of support potential users are hoping for when creating their own VR application. Then, questions were asked about ethical aspects of VR use. One question was on overall positive expectations regarding the effect of VR on people and society. Ultimately, expectations and concerns regarding the use of VR in different health areas were inquired.

That means in summary, six questions were asked about the perceived usefulness, four questions were asked about the perceived ease of use, four questions were asked about the attitude toward using the envisioned software platform, two questions were asked about a supervisor monitor, one question was asked about assistance, and three questions were asked on ethical topics. The final survey also included a demographics section. An overview of the categories and the asked questions can be found in Table 1 .

TABLE 1 . Questions that were asked in the online survey and their corresponding categories and types.

3.3 Execution

The survey was conducted using LimeSurvey. It is an online tool that allows users to create their own surveys from a wide variety of question types and edit them at will. Before the actual survey started, participants confirmed their voluntary participation and the use of their anonymized data for research purposes. With the help of LimeSurvey, we were also able to integrate the trailer directly into the survey. That means participants first watched the trailer and then answered the questions right after. The tool was hosted on a university server to protect the corresponding data. Closed-ended questions were answered on a 7-point Likert scale. Survey participants could skip questions or stop answering at any time if they wanted. Before the actual survey started, we asked the participants for permission to store their data anonymously. The language of the survey was German. The link to the survey was distributed to potential users via email, either directly or via mail distribution lists. Each invitation email was also accompanied by a request to forward the survey to colleagues. The link was also shared in Facebook groups to which only persons of the respective professional groups had access. In addition, a professional association’s website invited participation in the survey. In this way, we ensured that we surveyed a broad user group. At the same time, we were able to comply with pandemic containment regulations, which is of course a priority when working together with people from the healthcare sector.

3.4 Data Analysis

The analysis of the quantitative data was done using SPSS. For the qualitative analysis, we transferred all the answers to MAXQDA 8 , which is a software that helps with transcribing, ordering, and analyzing qualitative data. In this software, an entry for each subject was created which included all their respective statements. Subsequently, we developed a code system according to a methodology following Mayring (2015) . In an iterative process, we analyzed the statements and grouped them by content. This created categories, which we also grouped again until a hierarchical system of categories and statements emerged. The coding was checked a second time after some weeks to uncover inconclusive categorizations. With this procedure, qualitative data could be converted into quantitative data. The frequency with which certain topics were mentioned can serve as one indicator of their importance.

In this paragraph, we will first explain the demographic characteristics of the study participants, especially in terms of their professional roles in healthcare and their prior experience with VR. We then report the results on the three categories of the TAM; perceived usefulness, perceived ease of use, and attitude toward the envisioned software platform. Here we first explain the answers to each of the closed-ended questions and then the answers to the open-ended questions. We then explain the results for the questions on the supervisor monitor and the required assistance. We conclude with the results of the ethics-related questions. For the quantitative questions, means and the t- and p -values for one-sample t-tests are reported that indicate whether the means deviate significantly from the mean of the scale. Thus, we appraise whether the evaluations are above or below the average. For the answers to the open questions, we indicate in parentheses how often the respective statement was made and what proportion of all answers to the respective question that makes.

4.1 Demographics

A total of 102 participants took part in the survey. In order to ensure the voluntary nature of the survey, it was possible not to answer each question. This resulted in different numbers of cases for the various questions. The average age of the participants was 42.4 years and varied between 24 and 73. Of the participants, 58 were female, 42 were male, and 2 did not provide this information. Just under half of the participants in the overall sample were working in psychotherapy, 24 were working in physical therapy, and 11 were working in training and teaching. The rest of the participants were distributed among research, development, consulting, prevention, and other discrete medical fields. Another important piece of information to us was the extent to which participants were using technology to support their daily activities. Forty participants had prior experience with VR. Of these forty participants, 16 had experience with VR applications that were related to medical applications such as physical therapy, exposure therapy, various simulators, or anatomy studies. The rest of the participants that had prior VR experience had seen demos during exhibitions, worked on research projects, or just experienced common entertainment applications. Merely eight of the participants use VR frequently and only three of them for their work. In addition, 58 participants regularly use computers to support their work. Due to the voluntary nature of the study and also because the ethical aspects were addressed at the end of the survey, up to 54 valid answers were provided for the ethical questions.

4.2 Perceived Usefulness

The envisioned software platform is intended to serve as a tool that people can use to create VR environments without major hurdles. From the demographic data we collected, we found that only three of the participants use VR for their work. For most of the other participants, VR is new territory. Especially here it is important to see if the potential users even consider the concept of the envisioned software platform as useful for their own work. For this exact purpose, the TAM offers questions about the perceived usefulness of a product. Thus, participants were asked whether the envisioned software platform could improve their work effectiveness, enhance their work performance, increase their work productivity, and whether it could prove useful for their work.

An exact overview of the distribution of responses in this category can be found in Table 2 . On a Likert scale of 1−7, the mean score in this category for 64 participants was 4.4, indicating that they regard the envisioned software platform as a potentially useful tool for their work ( t (63) = 2.00, p = 0.050).

TABLE 2 . Summary of the results regarding the perceived usefulness of the envisioned software platform.

4.2.1 Use Cases of VR in Healthcare

Since there is a wide range of potential use cases of VR in healthcare, we first wanted to know from the participants what specific use cases they foresee in the context of their areas of work.

Exposure therapies for anxiety and trauma were mentioned most frequently ( n = 39 (43.3%)). Scenarios that are not easily representable in real life were emphasized, e.g., heights, crowds, job interviews, or animals.

Another mentioned therapy area was the treatment of eating and body image disorders ( n = 4 (3.6%)). For example, virtual therapy applications could reinforce an examination of one’s own body image by having a subject embody avatars with different characteristics. In addition, coping with potentially stressful situations could be simulated and practiced, such as grocery shopping or observing one’s own body in the mirror.

Survey participants also saw the potential to use VR to foster teaching scenarios ( n = 9 (10%)). For example, the teaching of cardiac catheter interventions or the training of future physiotherapists and physicians was mentioned. Simulation of the anatomy via 3D models was mentioned to be helpful here. The training for the acquisition of various competencies was also mentioned quite often ( n = 14 (15.6%)). Here, VR was suggested to be used to simulate critical interpersonal situations. There is potential here in the training of all personnel who have contact with customers or patients. In VR, these critical situations could be represented with the help of virtual agents. This simulation of social situations also has the potential to enable a change of perspective. Roleplays were mentioned that could, for example, be used in couple therapy to increase understanding of others. If people had the opportunity to take both positions in a conflict, this could also help to reduce discrimination.

Participants also emphasized the potential of VR for physiotherapy and rehabilitation ( n = 8 (8.9%)). Physiotherapists also hope that VR could provide relief in everyday work. Patients could perform exercises from home or independently in the virtual world, thus avoiding 1-to-1 supervision. This idea could potentially counteract staff shortages.

4.2.2 Desired Functions

In the second open question in the category of perceived usefulness, we asked the participants to name features and functions that a VR authoring platform must bring along in order to have a benefit for their personal work.

Many of the potential users asked for individual customization in the creation and use of virtual applications ( n = 18 (21.7%)). Participants described a desire to be able to customize the intensity of virtual stimuli, for example, by selecting specific fear stimuli in an exposure, changing the degree of realism of the graphics, or by adjusting the necessary repetitions in a physical rehabilitation exercise ( n = 5 (6.0%)). Other specific requests included the ability to simulate different times of day, the ability for users to observe themselves in the virtual world (mirror), the ability to interrupt stimuli (by switching to a relaxation room), or an automatic collection and analysis of data. All these examples reflect the desire for customizability. A feature that was also requested more often was the embedding of avatars ( n = 6 (7.2%)). End users should see their own virtual representations or the representations of other users in shared VR experiences. This would be an important factor in simulating and practicing various social situations, e.g., a dispute between two sides.

Participants emphasized that they would like to be provided with certain standard scenarios and templates in which one only has to add minor components or change a few settings ( n = 19 (22.9%)). Such standard scenarios could exist for common types of disorders, for example, the most common anxiety scenarios. Examples that were mentioned are train rides, narrow spaces, elevator rides and crowded or wide places. In addition to the standard scenarios already mentioned, some users here suggested a modular system, i.e., a kind of building block system that allows individual adaptation of the applications to the clients.

Some of the participants also demanded assurance of a certain basic quality and support when it comes to medical applications ( n = 7 (8.4%)). The envisioned software platform should be aligned with medical guidelines and even offer warnings or corrections in case someone wants to create an incorrect or potentially dangerous application. In addition, the logging of progress over several sessions was mentioned. In general, certain technical requirements were named, which should be fulfilled ( n = 13 (15.5%)). This includes a low error susceptibility, stable performance, the possibility to do remote sessions, and compliance with data protection guidelines.

4.3 Perceived Ease of Use

Next, we wanted to find out if potential users can imagine that the envisioned software platform could be useable for them. Therefore, we asked two questions from the TAM that focus on the perceived ease of use of a product. Here we asked how easy the potential users thought it was to use the envisioned software platform and how easy they imagined the learning process of the platform.

An overview of the responses to this category can be found in Table 3 . On a Likert scale of 1-7, the mean of responses for all questions about the perceived ease of use was 5.30 ( t (68) = 9.86, p < 0.001). When asked if potential users would find it easy to learn how to use the envisioned software platform, 54 of 69 people responded with a 5 (somewhat agree) or higher. This indicates that users tend to be confident that they can master the use of a software platform that allows them to create their own healthcare applications.

TABLE 3 . Summary of the results regarding the perceived ease of use of the envisioned software platform.

4.3.1 Support for Learning

With the first open question in the ease of use category, we wanted to find out what features the envisioned software platform must have to easily learn its usage.

As before, one of the most central points that very often resonates here is that the learning process should not be too laborious ( n = 26 (13.3%)). Many participants demanded a certain simplicity from the platform ( n = 30 (15.3%)). For example, there should be only a few setting variations or not too many preliminary settings should be necessary ( n = 10 (5.1%)), there should not be too much necessary equipment and in general, the learning process should be simple and short. This simplicity was also demanded on a technical level ( n = 15 (7,7%)). Here the point was mentioned that the platform should work on laptops with common operating systems to avoid the extra purchase of hardware. One suggestion for making it easier to incorporate VR in working routines was to provide templates, or demo versions ( n = 19 (9.7%). Many of the potential users would like to have ready-made scenarios where they only have to modify a few points. Such scenarios could be available for typical use cases and could also serve as a basis for the learning process. This idea was also mentioned in the desired functions in paragraph 4.2.2.

Another point that was raised repeatedly is intuitive usage ( n = 20 (10.2%)). The potential users do not want an intensive learning process, but an interaction that builds on their existing knowledge. A further specific aspect that was mentioned here is the language ( n = 16 (8.2%)). Many of the potential users explicitly pointed out that the user interface of the software platform should work with their native language. At the same time, the use of technical terms should be avoided.

Furthermore, ideas were put forward as to how learning to use VR could look in concrete terms. Some of the participants demand supporting materials ( n = 19 (9.7%)) like tutorial videos, a manual with extensive descriptions, or demo examples. Others wish for support through experts ( n = 17 (8.7%)), e.g. support via email and phone or through online/offline training. Seven people suggested that there could be support among the different users of the envisioned software platform, for example over community chats or forums.

4.3.2 Obstacles to Learning

Complementary to the previous question, we next wanted to know which aspects might rather prevent potential users from learning how to integrate VR in their working routines. However, the results here were very similar to those of the last question. A majority of the potential users emphasized that too much effort in learning and using the platform is a criterion for exclusion. The main warnings here were that it could be too time-consuming and too complicated to use.

In addition, some of the potential users expressed that not meeting prerequisites could be an obstacle in learning to create and operate their own VR applications. On the one hand, these prerequisites may be on the side of the users. They fear that they do not have the necessary technical knowledge and equipment to guarantee effective use of VR ( n = 11). On the other hand, these preconditions can also be on the software side. Frequent error messages, long loading times, hanging graphics, or poor usability ( n = 15) would be reasons not to learn how to use the envisioned software platform.

4.4 Attitude Toward Using

Next we wanted to know whether the respondents would actually use the platform to support their work - in essence, we wanted to find out about the attitudes toward using the platform. To understand this, two questions were asked. With one, we wanted to know if the participants thought that introducing the envisioned software platform into their daily work routine was a good idea, and with the other, if they were positive about using the software platform. These questions were also adopted from the TAM.

On a Likert scale of 1-7, the mean of all 65 responses was 5.66 ( t (64) = 11.45, p < 0.001)–indicating that participants agreed that the envisioned software platform can actually help them in their job. The results are depicted in Table 4 .

TABLE 4 . Summary of the results regarding the attitude toward using the envisioned software platform.

4.4.1 Reasons for the Use

In order to better understand how basic attitudes toward the envisioned software platform arose, we asked the participants what reasons they see for using the platform.

Many of the participants expect an advantage for their clients from the use of the platform. It was frequently stated that the virtual applications could increase the clients’ motivation ( n = 24 (22.0%)). Especially the variety and novelty of the virtual therapy and exercise systems could contribute to this motivation boost. At the same time, potential users also believe that the use of virtual applications can increase the fun factor for clients. In particular, gamification of content can help to increase the fun and at the same time create new incentives.

Many of the participants also simply hope for practical benefits in implementing their treatments. Here, the creation of conditions was frequently mentioned that would be impossible or very difficult to realize in the real world ( n = 6 (5.5%)), e.g., the realization of a (virtual) flight in the treatment of aviophobia. In addition, many of the potential users hope that it will be easier to create new treatment options that are adapted to the clients and thus simplify current processes ( n = 8 (7.3%)). This is also hoped to increase the effectiveness ( n = 5 (4.6%)) and flexibility ( n = 10 (9.2%)) of treatments. Another opportunity to increase one’s own treatment options with the help of the envisioned software platform is seen by many of the participants in the fact that the virtual applications could function regardless of location ( n = 22 (20.2%)). Here, the idea that clients could run the applications themselves in their own homes was frequently described. In this way, the workload for therapists and trainers could be reduced and inflexible or limited clients could be more easily involved. Especially in times of a global pandemic, this is an interesting aspect for some of the respondents.

4.4.2 Reasons against the Use

Of course, it is also important for us to understand why some participants would rather refrain from using VR. Therefore, we asked the potential users what reasons they have against using the envisioned software platform.

For some participants, the use of virtual applications means too much mechanization of their work ( n = 13 (10.1%)). The importance of direct interaction and the associated relationship with clients was often emphasized. Psychotherapists in particular stated that direct interaction and direct face-to-face conversations are of great importance for their work. Therefore, they view the virtual component rather critically. Another disadvantage that many psychotherapists mentioned is the danger of a blurring between reality and VR or an escape from reality ( n = 6 (4.7%)). Clients would flee into a virtual world and thus have even more problems dealing with reality. In the treatment of depression, for example, it is more important for clients to go outside and establish activities there. Escaping into a virtual world could be more of a hindrance to this.

Another aspect that was also frequently mentioned here is the fear of too much extra effort that would come with using VR. The participants fear that the possibilities would be too diverse and thus the learning process and the creation of new applications would be too time-consuming ( n = 41 (31.8%)). This fear was also expressed with regard to the technical equipment. Procuring and setting up the hardware could be too costly, which would make the envisioned software platform unattractive for certain users ( n = 9 (7.0%)). Also, financial concerns were expressed with regard to hardware procurement ( n = 12 (9.3%)).

Some participants expressed that they simply do not work with the right target audience that would be eligible to use a virtual application ( n = 8 (6.2%)). The use of VR technology for severely affected patients or patients in intensive care units is not conceivable for the respective participants. Potential users who work with elderly people, for example, also fear a lack of acceptance of VR among their clients ( n = 4 (3.1%)).

Some participants expressed the fear that virtual therapies might be too ineffective, e.g., because clients get used to them too quickly ( n = 8 (6.2%)). Furthermore, some even fear negative consequences for the clients when using virtual applications ( n = 8 (6.2%)). This could lead to an aversion to VR if the technology is used improperly by laypersons. Hazards from cybersickness, dizziness, improper use, or falls were mentioned. In general, there were still some concerns about an unsuitable design of the software platform ( n = 13 (10.1%)). These included that the platform could be too inflexible, that it could communicate in an incomprehensible language, or that too many pre-settings were necessary.

The results in concerning the three surveyed categories of the TAM can be found in Figure 2 and Table 5 . Overall, the TAM shows a mean score of 5.19 on a scale of 7 which is significantly above the mean ( t (66) = 7.14, p < 0.001).

FIGURE 2 . Summary of the results regarding the three surveyed categories of the Technology Acceptance Model (TAM).

TABLE 5 . Summary of the results regarding the TAM and its surveyed dimensions.

4.5 Supervisor Monitor

The planned implementation of a supervisor monitor was also part of our acceptance study. For this purpose, the participants once again saw a short clip of the trailer showing a prototype of the monitor.

4.5.1 Components of the Supervisor Monitor

Subsequently, we wanted to find out which components this monitor must have from the perspective of potential users.

Many of the participants’ suggestions related to the recording and display of the client’s condition. For example, the desire to display the client’s view through the head-mounted display in the monitor was expressed in some cases ( n = 11 (15.7%)). In addition, physiological parameters were mentioned as important information ( n = 16 (22.9%)). First and foremost, the display of the heart rate was mentioned, but also the display of the skin conductivity, the movement parameters, and the pupil reactions were desired. The recording of the users does not always have to refer to the current situation. Participants also asked for a display of progress over several applications ( n = 3 (4.3%)). For example, for a movement exercise in the physiological domain, the monitor could display the intensity and number of repetitions of past sessions. For anxiety therapy, the intensity of the anxiety stimulus achieved could be documented.

In addition to the display of the patient’s condition, many of the potential users would also like to be able to intervene in the current application via the supervisor monitor ( n = 13 (18.6%)). This includes, above all, the adjustment of the set stimulus in order to control the intensity of the current application or the activation of assistance. Often, even the possibility to completely switch off the current situation was desired, i.e., to get clients out of the situation immediately if necessary. Some suggested, for example, switching to a relaxation environment.

Other ideas for the supervisor monitor included displaying a map of the virtual environment and the possibility of operating the monitor via a tablet or smartphone. In general, a clear layout with simple operations was desired ( n = 10 (14.3%)).

4.5.2 Capturing the User State

To be able to monitor a VR application really effectively, a supervisor needs information about the state of the client immersed in the virtual environment. Therefore, we wanted to know from the participants what tools they usually use to capture the state of their clients. This provides us with a basis for discussing which of these tools could also find their way into VR healthcare applications.

Methods in written form were mentioned most frequently. Primarily questionnaires ( n = 20 (19.0%)) and the writing of protocols ( n = 15 (14.3%)) were named. In addition, standardized rating scales were mentioned ( n = 8 (7.6&)). Here, also specific examples were mentioned sporadically, like the Borg scale Borg (1998) for recording subjective exhaustion or the SUD score Hartanto et al. (2012) for recording subjective anxiety. Probably the simplest form of assessing the user’s condition is observation. Many of the potential users report that direct observation of body language, behavior, facial expressions and gestures is an important indicator of the state of the current treatment ( n = 22 (21%)). Especially on the side of the psychotherapists, the conversation or interviews are often used to find out about the course and the effect of the treatment ( n = 8 (7.6%)).

Physiological parameters were also mentioned as a method for recording the user’s condition ( n = 19 (18.1%)). Among the mentions were heart rate, motion data, skin conductance, eye tracking, or blood pressure.

4.6 Assistance System

If people from the healthcare sector should really be able to integrate VR into their everyday work, then they need to be supported as well as possible. To better understand how assistance should look like we asked potential users what kind of support they would want when creating a virtual environment.

Users want continuous information about the next steps to take ( n = 8 (36,4%)). There should therefore be as linear a process as possible when creating VR applications, with the next step always being clearly indicated. This support was requested across the whole process, e.g., support in designing the virtual environment, or help in finding suitable applications and templates.

Again, some of the participants took the opportunity to express that they would like templates provided to them ( n = 7 (31.9%)). Frequently used standard applications should be identified and made available as a basis for further adjustments. Other features that were requested are the explanation of the different functions, the highlighting of often-used applications, or the linking to further help.

While few actionable responses were provided here, the answers to previous questions also offer many insights into what type of support is necessary when people want to create their own VR applications. More on this is outlined in the discussion.

The questions on ethical issues covered two topics: an evaluation of how several ethical principles are affected as well as an assessment of benefits and concerns expected for different health areas. Due to the novelty of the research, a principle-based approach provides an excellent starting point for an ethical assessment. This approach relates to a range of ethical principles that were previously defined as being important with regard to innovative health technologies ( Walker and Morrissey, 2014 ). Principles considered relevant were quality of life as the key outcome of all health care activities ( Musschenga, 1997 ), respect for autonomy and justice drawn from the four principles of biomedical ethics ( Beauchamp and Childress, 2019 ), safety/security, privacy, participation, and a positive self-conception delineated in a model for the ethical evaluation of age-appropriate assistive systems, ambient-assisted living (AAL), and other health-related technologies ( Manzeschke et al., 2015 ; Nelles et al., 2016 ), as well as transparency (e.g., Turilli and Floridi, 2009 ). The term support substituted the principle of beneficence ( Beauchamp and Childress, 2019 ) because it was considered more concrete and tangible. Due to the wide range of areas in which VR is used, it was considered important to compare benefits and concerns for VR use in different health care areas. Examining professionals’ views of benefits and concerns reveals areas where VR use requires particular caution, for example for vulnerable persons with psychiatric symptoms like psychosis ( Rizzo et al., 2003 ) or adolescents and children ( Kaimara et al., 2021 ). For all questions, 7-point scales were utilized. The endpoints for the question on the agreement to how VR would support the selected ethical principles were 1- totally disagree , 7- totally agree . For the questions on expectations, the endpoints were 1- very low expectations/morally very low concerns ; 7- very high expectations/morally very high concerns . T - and p -values are reported to indicate whether the single means deviate significantly from the mean of the scale to appraise whether the evaluation is above or below the average.

4.7.1 Effects on Different Ethical Principles

Participants agreed most that VR would provide support for its users ( M = 5.44, t (51) = 11.09, p < 0.001), which indicates that they overall expect benefits for their patients. Safety/Security was the second highest rated dimension ( M = 4.94, t (50) = 5.22, p < 0.001), which shows that health professionals were hardly worried that VR would do any harm. The evaluations of respect for autonomy, quality of life and positive effects on the self-conception were also quite positive (all p < 0.002). Privacy and participation reached values tightly and not significantly above the mean of the scale (both p > 0.102). The evaluations for transparency ( M = 3.94) and justice ( M = 3.88) were slightly, but not significantly beyond the scale’s mean (both p > 0.564), however indicating that there might be some concerns regarding the effect on these dimensions. All means are shown in Figure 3 and in Table 6 .

FIGURE 3 . Summary of the arithmetic means for the question how ethical principles are positively affected by VR in healthcare.

TABLE 6 . Results for the questions on how the selected ethical principles are positively affected by VR.

4.7.2 Benefits and Concerns for the Use in Different Health Care Areas

Expectations were for all health areas significantly above the mean of the scale ( p < 0.001) except for palliative care. Expectations were the highest for rehabilitation ( M = 5.96), education/academic studies/training/continuing education ( M = 5.77) and physical therapy ( M = 5.56). For these areas, concerns were also the lowest, resulting in an also highest positive balance between expectations and concerns. Expectations for all other areas except palliative care ranged between 4.83 and 5.13 and were accordingly quite positive. Expectations were considerably low for the area of palliative care ( M = 3.31), where they were significantly below the mean ( t (47) = −3.00, p = 0.004), and here, concerns were also highest, resulting in a negative balance ( M = −1.09). Concerns were second highest for psychiatry/psychotherapy, but did not differ significantly from the mean ( M = 3.76, t (48) = −0.96, p = 0.342). Here the positive balance between expectations and concerns was the second lowest ( 1.38 ). Concerns were third highest, but significantly below the mean, for pediatrics ( M = 3.46, t (47) = −2.10, p = 0.041). For all other areas, concerns were also significantly below the mean of the scale (all p < 0.005) indicating low concerns. The means are depicted in Figure 4 and in Table 7 .

FIGURE 4 . Summary of the arithmetic means regarding the questions on positive expectations and ethical concerns. Education/Academic studies includes training/continuing education.

TABLE 7 . Distribution of results in terms of ethical expectations and concerns with regard to various healthcare domains and VR.

5 Discussion

Overall, the three categories surveyed by the TAM showed a mean of 5.19. Since the TAM measures how likely a system is to actually be used, we can conclude, that our envisioned software platform and its features actually have the potential to be established in healthcare practice. That means a software platform that allows people to create and customize their own VR content could promote the actual use of VR in this domain. Many of the responses we received also gave us an idea of what such a platform should look like. But not only that, many of the answers can be generalized to show what should overall be considered in VR applications that are intended to be suitable for healthcare practice. We will discuss both facets in this section.

5.1 Insights About This Study

When we asked the participants about the potential use of VR in their field, the answers were fairly broad (see Section 4.2.1). This is very important for the basic motivation behind the envisioned software platform. If experts from different fields can imagine a concrete use of VR for their work, then this speaks for the potential of a broad-based software platform that can support many of them. It should also be considered that many of the study participants had no previous contact with VR. The fact that we received a total of 88 mentions about possible use cases for VR shows that the mockup trailer was successful in getting our ideas across.

In terms of the perceived ease of use, the figures also show that potential users tend to feel able to operate the envisioned software platform. This also shows a positive basic attitude of the participants toward the platform. However, questions and statements relating to the user-friendliness and operation of the system should always be treated with caution in this case. After all, the basis of this evaluation was a video. The actual usability of a user interface can only be determined on the basis of actual prototypes and in controlled test environments. Only then can we really make statements about what intuitive use of the platform could look like.

5.2 Customization and Simplicity

It is particularly interesting that there is a certain trade-off in desired functions. The people demand a certain amount of customization, as the multitude of different clients put different requirements to the VR applications. At the same time, they want the envisioned software platform to be very simple and straightforward without too much effort. In general, healthcare applications in VR have to manage this balancing act. Therefore, when implementing the envisioned software platform, we should ensure that standard applications and templates are available to users. We should thus prevent users from being forced to build their own applications from scratch and thus being overwhelmed with a multitude of options. At the same time, these standard applications must be modifiable in the right places so that they cover as many use cases as possible. So when implementing VR healthcare applications, one should always have an overview of what the most commonly used default scenarios and settings are. These must then be adaptable in the simplest possible way.

For exposure therapy, this could mean that common fear stimuli are available (animals, height, confinement, presentation in front of an audience), but that their peculiarities can be adapted. For example, with a virtual audience for virtual speech training, one should be able to modify the number of virtual agents, their degree of realism, and their behavior. At the same time, there could also be standard environments in which such an exposition can take place, e.g., in a large hall (for more stress) or on a beach (for more relaxation).

For physical rehabilitation, this could mean that one can choose between standard muscle groups that should be trained, e.g., the arm/shoulder area or the leg/knee area. Standard exercises could comprise the continuous lifting, holding up, or rotation of those extremities, while the number of repetitions or the time of the exercise could be adjustable and visible for the immersed person. Adaptability can also come into its own when it comes to embodiment. As mentioned before, it is possible to create custom avatars of people quite comfortably with just a smartphone Wenninger et al. (2020) . However, one could also provide standard avatars for those who find it too time-consuming to carry out a scan process. This could also be useful in some applications, as already the sense of embodiment toward a regular hand can be sufficient to alter emotional responses to virtual stimuli ( Gall et al., 2021 ). It would also be conceivable here to exploit the Proteus Effect, for example by providing athletic avatars when physical exercise is required.

5.3 Learn to Create and Operate VR Applications

The most important thing when it comes to the learning process of autonomously creating and operating VR applications is simplicity. For the envisioned software platform this means that we should refrain from overwhelming users with too many options. A large proportion of the participants in this survey had little to no prior experience with VR. This also explains the wish for close support. The potential users, therefore, attach less importance to having a large number of functions and options available. Rather, they want a relatively straightforward and simple path to their own virtual application. Again, this is generally true for healthcare applications in VR. One should not try to cover every extraordinary use case, but rather make standard use cases available quickly and easily. If it takes too long to learn how to use the VR application and to prepare it, it makes it more or less useless for practical use in the healthcare sector. Their already stressful working day does not allow for too much additional effort. This does not only apply to the software itself, but also to the equipment or hardware. Again, the fact that many of the participants had less prior technical experience comes into play here. On the one hand, this means that the requirements for operating VR applications should not be too high. On the other hand, one should make suitable hardware recommendations or minimum requirements for the applications. In this way, one can save potential users from having to search for their own hardware solutions. This can apply to both computers and head-mounted displays.

The desire for appropriate language is also relevant in this context. The focus should be on the use of the native language. Technical terms could additionally be provided with their own explanations via mouseover effect or in separate documentation. To be absolutely sure, one should test a VR application beforehand with potential users in the healthcare sector to find out whether the descriptions are comprehensible and appropriate. If one wants to ensure an intuitive and smooth user interaction, this step is inevitable anyway.

As far as the method of learning is concerned, there should definitely be documentation on the envisioned software platform. However, to further ease the burden on potential users, the suggestion of interactive tutorials is quite interesting. If the envisioned software platform provides the standard applications already mentioned, then these could also be used relatively easily as the basis for a tutorial. For each demo application provided, there could be a tutorial that shows where one has to change which parameters and what you achieve with them. This idea is also transferable to all VR applications that are to be used autonomously by people from the healthcare sector.

5.4 Support for the Supervisor

If healthcare professionals are to be truly capable of creating and operating VR applications on their own, they need support in different dimensions. Based on the answers to the survey, there are a few points that can be addressed. Based on our ideas for a software platform, an assistance system seems to be a really interesting solution. This system could offer personalized assistance, based on the experience of the user, the environment that needs to be created, or the type of treatment that is aimed for. The exchange of ideas with other users and communication with experts can also be supported by the assistance system. Ideas and approaches of other users on a certain topic could be shared and then, if relevant, suggested by the assistance system. The templates created by other users can also be shared if they have been published for reuse. The templates could be categorized via a tagging system and thus be found and tested more quickly by others. These tags could refer to diseases, forms of treatment, or medical specialties. This would also greatly facilitate an active search for relevant templates by potential users and optimize possible recommendations by the system. Thus, we could also fulfill the collaborative character that some of the participants have been asking for.

The desire of the potential users that some of the applications should also function without direct supervision, i.e. be carried out by the clients themselves, is quite interesting. In some areas, this could be an interesting approach to further relieve staff in the healthcare sector. People who want to make their VR applications more attractive might keep this option in mind. Suggestions in this direction came mainly from participants in the field of physiotherapy. This is probably less relevant for the treatment of mental disorders, as more intensive care is sometimes necessary here. For our envisioned software platform this means that it should allow users to decide which form of application they want to create. Either a form of application that is controlled by a supervisor or the form in which the clients themselves are responsible for the progress of the application. Automated logs could then still inform caregivers and clients of the achieved progress. In physiotherapy, this could result in some kind of scoreboard. Repetitions of lifting exercises or endurance exercises, e.g., of a treadmill or ergometer training, could serve as evidence of continuous training. Thus, the supervisor would have a convenient overview and clients could draw additional motivation from the introduction of gamification elements.

To make a VR application as attractive as possible for usage in healthcare, it should support the minimization of potential negative consequences and thus also take weight off the shoulders of a supervisor. This includes the definition of an exact play area to prevent falls. To prevent the symptoms of cybersickness, applications should give warnings when the frame rate is too low or the latency is too high. The dynamic restriction of the field of view ( Groth et al., 2021 ; Teixeira and Palmisano, 2021 ) or the adaption of navigation velocity and acceleration ( Plouzeau et al., 2018 ; Chardonnet et al., 2021 ) are possible automatic methods that can reduce the hazards of cybersickness. In this way, the supervisor could be further relieved.

The specification or recommendation of certain hardware can also help to ensure minimum quality. Another starting point is the collection of physiological data. It can help to detect cybersickness and general discomfort ( Cebeci et al., 2019 ; Islam et al., 2021 ). Here, too, the automatic recording, analysis, and visualization of the user’s condition can help to relieve the supervisor. More on this when we talk about the supervisor monitor in the next subsection.

5.5 Supervisor Monitor

The idea of implementing a supervisor monitor also seems to be a suitable measure to give people from the healthcare sector the necessary support and security to integrate VR into their work. Frequently requested was information about the current view of the VR users and information about their physiological state. Wearable sensors are particularly interesting here, as they have a very short setup time. Parameters like heart rate and skin conductivity can be conveniently captured with wristbands such as the Empatica E4 9 , that has been used before in VR studies ( Šalkevicius et al., 2019 ). Gaze and pupil behavior information could also be captured relatively conveniently using head-mounted displays. Eye trackers from tobii 10 or Pupil Labs 11 are commonly used to augment VR headsets. Different characteristics of experience can thus be classified automatically, e.g. stress ( Ham et al., 2017 ; Robitaille and McGuffin, 2019 ), anxiety ( Šalkevicius et al., 2019 ; Bălan et al., 2020 ), or cognitive workload ( Currie et al., 2019 ). Corresponding classification results can then either be used to directly control the virtual environment, can be visualized for the supervisor, or be used to determine the progress over multiple sessions. The various options that exist here are discussed in Halbig and Latoschik (2021) . In any case, the capture, analysis, and visualization of physiological data can help to give the supervisor more confidence in dealing with VR. In practice, of course, one has to weigh how much and to what extent this information is displayed at once. Dangers and unusual physiological signals must be presented in such a way that they can be perceived immediately, e.g. via acoustic signals and a salient layout. So, if possible, not all details should be shown to the supervisor, such as raw physiological or movement data. Rather, the supervisor should be shown the interpretation of the data (e.g., high or low stress) by default. Raw data could be displayed on request. The data and its interpretation could also be part of automated logs of the specific sessions.

Another interesting approach is the ability to intervene in what is happening in the virtual world via the supervisor monitor. Especially the attenuation or amplification of stimuli plays an important role in applications that are supposed to trigger fear or stress. Feedback from potential users also speaks in favor of a kind of emergency off switch on the display that allows the situation to be completely resolved. Here, more control and security can be brought to the supervisor.

The possibility to take notes and save them for the respective client and session could provide basic support for interviews and observations. Such a digital notepad could then also be helpful when documenting progress across multiple sessions. In addition, one has all the information about the stimuli that were set in the virtual environment. Automated logs can then be used to store information about the stimuli and the client’s behavior. In this way, it should be possible for therapists and trainers to analyze the progress of the treatments.

Overall, the results demonstrate that professionals expect positive outcomes for their patients with regard to ethical principles and for most health areas. Nevertheless, negative outcomes are mostly perceived for transparency and justice. Doubts with regard to transparency refer to the possibility that users might unconsciously be manipulated by VR ( Kool, 2016 ; Spiegel, 2018 ) or that wrong information about VR effectiveness is given ( Madary and Metzinger, 2016 ). With regard to justice, only privileged groups could benefit from VR ( Madary and Metzinger, 2016 ). These issues were previously mentioned in the literature. Future research needs to address the reasons for these concerns and derive conclusions to avoid these negative effects. Besides, psychiatry/psychotherapy and palliative care are the areas with the highest ethical concerns. These disciplines have previously been identified as ethically critical (e.g., Rizzo et al., 2003 ; Weijers and DiSilvestro, 2017 ), and the concerns should be addressed adequately. VR has already been proven beneficial in these areas, at least in certain contexts (e.g., Dellazizzo et al., 2020 ; Johnson et al., 2020 ). Accordingly, it is important to reflect on these concerns and to carefully consider potential applications, but also to resolve concerns by informing about proven positive effects and positive perceptions by users.

5.7 Limitations

Although this study provides many useful information, it also has limitations. Probably the most severe is that the findings of this study are based on a video and not on actual interaction with a prototype. It is therefore very difficult to make statements about what a functioning interaction with our envisioned software platform would look like. Nevertheless, it is important to collect the opinion of potential users at the very beginning. In addition, the video was also a suitable means to convey ideas of VR and its connection with healthcare to a wide range of people.

Another point to mention here is the fact that this is an online study. Interviews would have made it possible to get more in-depth information. In addition, ambiguities could have been explained. However, the decision to conduct the study online also had its advantages. First, it allowed us to reach more different people as we were able to send invitations around easily. These could then spread further and reach many experts to whom we would not have had access at all. Second, this also enabled us to comply with the pandemic restrictions and get in contact with healthcare personnel at the same time.

5.8 Prospects

In the course of the discussion, we elucidated how the knowledge gained in the present study can be used to develop VR applications that respect more of the requirements of healthcare practice. However, there is still a lot of unfinished work here, especially considering the concrete implementation of the discussed ideas. While it became clear that some kind of supervisor monitor should be helpful to spur the integration of VR into healthcare practice, it remains unclear how exactly this should look. It needs to be clarified how this monitor represents the current state of the immersed person, may it be the location in 3D space or the physiological status. This is accompanied by the question of how a supervisor would alter the sequence of events and how possible dangers are communicated perceptibly and understandably via the monitor.

Further research potential lies in the question of how exactly the support looks like that is received by a person that creates a VR environment. An AI could be designed that understandably supports laymen to create their own virtual applications. The exact solution of the trade-off between adaptability of such applications and low effort in their creation process is another unknown. While we have already shown possible approaches, the details of which features should be customizable and which not remain unclear. Just as with all the other open points, progress will only be made here with concrete user studies. Only a series of iterative tests with concrete interfaces and actual users can provide accurate information on what the implementation of the discussed features would look like. User studies with healthcare professionals and clients using demonstrator applications are planned as a next step.

6 Conclusion

The results of the three surveyed areas of the TAM show that the trailer left a positive impression on potential users. Overall, the TAM shows a mean score of 5.19 on a scale of 7, indicating that the majority of participants agreed with the concept that was depicted by the mockup trailer and that the envisioned software platform has the potential to be accepted by the target users. Of course there were also potential users that pointed out critical aspects about the integration of VR into their working routines.

Looking at the statements of the potential users, there is one point that could prevent almost all users from using our envisioned software platform. This is the potentially too high effort that could be associated with learning and using the platform. Since this is an online survey, we have not used direct quotes of respondents so far. At this point, however, there is a comment that illustrates the main threat for VR in healthcare vividly. The respondent with ID 102 describes it as follows: “We already maintain and document so much that I’m frankly just not into that platform. In the video, I dropped out after the third ‘Design … , Do…, Add … ”. This was one of the most negative comments we received and should not be seen as representative of all the respondents. Nevertheless, it sums up well what the biggest threat to the success of integrating VR applications into healthcare routines is. If users are confronted with too much complexity and too many options, it will discourage them from using it. The day-to-day work of most people in the healthcare sector simply does not allow for too much extra efforts. So when working on VR healthcare applications, one should not fall into aimless actionism and try to enable the users with a myriad of options and settings that allow them to cover every conceivable use case. Rather, applications themselves should take care of a lot of things and provide help wherever possible. This can be done, for example, by automatically analyzing the user’s state, by providing a supervisor monitor, or by providing customizable templates. The focus should rather be on standard use cases that are fast and feasible. This ensures that most people from the healthcare sector will even consider using a product for their work.

Of course, there is still a lot of work to be done to integrate VR into healthcare routines. For the future work we are planning to actually implement the envisioned software platform, taking into account the findings from this work. Studies based on actual prototypes will be necessary to see how well the actual integration into working routines works. Especially ideas like the supervisor monitor will require a close cooperation with the potential users in form of usability tests. Only if there is an understanding of potential users and how they work, the ambitious goal of promoting an autonomous use of VR in healthcare practice can be achieved. We have laid the foundation with this study.

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics Statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

SG and KB were responsible for the ethics part of the survey and the interpretation of the data. SG was responsible for the statistical analysis of the ethics part. AH and SB were responsible for the remainder of the survey and the corresponding evaluation and interpretation of the data. SvM, KB, and ML were supervising this project and helped with the structuring of the survey and with writing the article.

This publication was supported by the Open-Access Publication Fund of the University of Würzburg. The research has been funded by the German Federal Ministry of Education and Research in the project VIA-VR (project numbers 16SV8444 and 16SV8445).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors, and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1 https://aframe.io/

2 https://cospaces.io/edu/

3 https://www.instavr.co/

4 https://www.wondavr.com/

5 https://www.tiltbrush.com/

6 https://arvr.google.com/blocks/

7 All websites were accessed and checked on 16 November 2021

8 https://www.maxqda.de

9 https://www.empatica.com/research/e4/

10 https://www.tobiipro.com/de/anwendungsfelder/virtual-reality/

11 https://pupil-labs.com/products/vr-ar/

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Keywords: virtual reality, healthcare, therapy, rehabilitation, ethics, technology acceptance, authoring platform, healthcare professionals

Citation: Halbig  A, Babu  SK, Gatter  S, Latoschik  ME, Brukamp K and von Mammen  S (2022) Opportunities and Challenges of Virtual Reality in Healthcare – A Domain Experts Inquiry. Front. Virtual Real. 3:837616. doi: 10.3389/frvir.2022.837616

Received: 16 December 2021; Accepted: 03 February 2022; Published: 23 March 2022.

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Copyright © 2022 Halbig , Babu , Gatter , Latoschik , Brukamp and von Mammen . This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Andreas Halbig , [email protected]

This article is part of the Research Topic

Immersive Technologies in Healthcare