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A key role of Occupational Therapists (OTs) is to carry out pre-discharge home visits (PHV) and propose appropriate adaptations to the home environment in order to enable patients to function independently after hospital discharge. However, research shows that more than 50% of specialist equipment installed as part of home adaptations is not used by patients. A key reason for this is that decisions about home adaptations are often made without adequate collaboration and consultation with the patient. Consequently, there is an urgent need to seek out new and innovative uses of technology to facilitate patient/practitioner collaboration, engagement, and shared decision making in the PHV process. Virtual reality interior design applications (VRIDAs) primarily allow users to simulate the home environment and visualize changes prior to implementing them. Customized VRIDAs, which also model specialist occupational therapy equipment, could become a valuable tool to facilitate improved patient/practitioner collaboration, if developed effectively and integrated into the PHV process.
The intent of the study was to explore the perceptions of OTs with regard to using VRIDAs as an assistive tool within the PHV process.
Task-oriented interactive usability sessions, utilizing the think-aloud protocol and subsequent semi-structured interviews were carried out with seven OTs who possessed significant experience across a range of clinical settings. Template analysis was carried out on the think-aloud and interview data. Analysis was both inductive and driven by theory, centering around the parameters that impact upon the acceptance, adoption, and use of this technology in practice as indicated by the Technology Acceptance Model (TAM).
OTs’ perceptions were identified relating to three core themes: (1) perceived usefulness (PU), (2) perceived ease of use (PEoU), and (3) actual use (AU). Regarding PU, OTs believed VRIDAs had promising potential to increase understanding, enrich communication and patient involvement, and improve patient/practitioner shared understanding. However, it was unlikely that VRIDAs would be suitable for use with cognitively impaired patients. For PEoU, all OTs were able to use the software and complete the tasks successfully; however, participants noted numerous specialist equipment items that could be added to the furniture library. AU perceptions were positive regarding use of the application across a range of clinical settings including children/young adults, long-term conditions, neurology, older adults, and social services. However, some “fine tuning” may be necessary if the application is to be optimally used in practice.
Participants perceived the use of VRIDAs in practice would enhance levels of patient/practitioner collaboration and provide a much needed mechanism via which patients are empowered to become more equal partners in decisions made about their care. Further research is needed to explore patient perceptions of VRIDAs, to make necessary customizations accordingly, and to explore deployment of the application in a collaborative patient/practitioner-based context.
With an anticipated rise in the demand for health care resources as a result of an ageing population [
A primary area of focus within the domain of Occupational Therapy is to enable patients to live independently within their homes. In order to facilitate this, a key role of an occupational therapist (OT), across Europe, Australia, and North America [
There is a need to seek out and develop new and innovative uses of technology that enable patients and practitioners to jointly understand and visualize the complexities and meanings associated with the home environment, to envisage the challenges that are likely to be encountered within the home, and to collaborate and contribute equally to developing solutions to these challenges [
Over the past decade, Virtual Reality (VR) has become a valuable tool that has been applied to a range of health care scenarios [
In light of the need for improved collaboration between OTs and patients, this research proposes to explore the use of VRIDA to aid the PHV process and gain insights into patient and practitioner experiences of its application in practice. The prospect of using VRIDA has potential to respond to a number of the issues that currently limit the effectiveness of PHVs. VRIDA would serve as a tool that enables occupational therapists to rapidly create the 3D representation of the patient’s home, allowing the patient and practitioner to jointly visualize the interior of the home and trial a range of adaptations and specialist equipment within it. This would enhance collaboration between clinician and patient and assist them in making shared decisions about how this sensitive and personalized space may be best adapted specifically to the patient’s individual needs. It would also provide an interactive simulation of the home, enabling the patient to “walk” through the home, via a personal computer or laptop, which could help therapists to better consider barriers to everyday performance and enhance the patient’s insight and motivation to participate in tailored interventions. VRIDA would provide the patient with the valuable opportunity to consult as an expert on their own needs, and participate as an equal partner in decision making, without feeling as if their mobility is being assessed, as is often the case when visiting the home in person with the practitioner. To date, however, the gains that VRIDA could bring to occupational therapy practice are yet to be capitalized upon, as little research has been carried out within this particular health care context.
Examples of virtual home environments, lounge (left), kitchen (right), produced using Virtual Reality Interior Design Applications (VRIDA).
The insight of practitioners is extremely valuable and should be employed at all stages of technology development and deployment. Research with health care practitioners has shown that they are more likely to adopt technologies if these are viewed as compatible with current practice [
Over the past two decades, much research effort has been invested into understanding end users’ reactions and motivations to technology acceptance, adoption, and use [
TAM proposes that when presented with a new technology, users’ behavioral intention to use and their Actual Use (AU) of technology are typically mediated by two key factors: Perceived Usefulness (PU), which is the extent to which the user perceives that the new technology will aid them in performing the task at hand, and Perceived Ease of Use (PEOU), which is the extent to which the individual believes using the technology would be free of effort [
The aim of this study is to explore occupational therapists’ perceptions of VRIDA and to gain insights into the feasibility of using VRIDA as a tool to aid the PHV process in relation to the key factors outlined in the technology acceptance model. The next section provides details of the study carried out to achieve this aim. The results of this study are then presented, followed by a discussion of the implications of the findings in the context of existing research literature and outlining the study limitations. Finally, the study is concluded and future research directions are considered in light of the findings.
The aim of this study was to explore the perceptions of OTs relating to the three TAM factors (PU, PEOU, and AU) and the potential feasibility of using VRIDA applications as an assistive tool that may be used within the PHV process.
A convenience sampling strategy was used for recruitment of participants for this study. The inclusion criteria were that participants were practicing OTs within the UK health sector and that they were familiar with using desktop computers and typical applications such as Microsoft Word and accessing email. Potential participants were primarily identified from the researchers’ existing social network contacts list (ie, LinkedIn contacts) and subsequently contacted by email in the first instance and invited to take part in this study. No financial incentives were offered to take part in the study, hence participation took place purely on a voluntary basis. A total of seven OTs were recruited and took part in the study. This number of participants is in excess of the recommended threshold of five participants typically required to carry out effective think-aloud interaction and usability testing [
Summary of participant profiles.
Participant | Gender | Years practicing | Area of specialty |
A | Male | More than 5 years | Social services (community) |
B | Female | More than 10 years | Senior Therapist Older Person |
C | Female | More than 5 years | Senior Therapist Older Person |
D | Female | Less than 5 years | Social services (community) |
E | Male | More than 20 years | Mental Health Team Leader |
F | Female | More than 10 years | Senior Therapist Acute Care |
G | Male | More than 5 years | Pediatrics |
On arrival, information sheets were distributed to users prior to participation in the session, the content of which was worked through with each participant individually. The information sheet provided a brief background and context and purpose to the study, and summarized the main activities that would take place during the course of the session. Participants were encouraged to ask questions throughout the process, and any questions were answered as they arose. Participants were then asked to complete a consent form in which their ethical rights were explained in terms of informed consent, withdrawal, and anonymity.
Participants were given the task of using a VRIDA to design the interior of a room that would typically represent a patient’s home environment. The VRIDA software application used for the purposes of this task was a customized version of SweetHome 3D [
The SweetHome 3D application interface is made up of four main functional quadrants: (1) furniture catalogue, (2) home plan, (3) home furniture list, and (4) 3D view. For the purposes of this study, the application has been customized to include a library of specialist OT assistive equipment necessary for OTs to make typical home adaptation recommendations as part of the PHV process. These artefacts were presented within the furniture catalogue quadrant of the application in a folder entitled “OT Objects”. Occupational therapy assistive devices featured in the library included ramps, a range of grab rails, a bath hoist, a wheelchair, toilet frame, and seat. The custom OT objects library folder, how this was integrated into the furniture catalogue navigation pane, and examples of some of these OT objects (wheelchair and toilet frame) are presented in
Prior to the main task of designing a typical patient room of their choice, participants were provided with basic written instructions, presented in
Printed screenshots of the SweetHome 3D interface and the 4-quadrant map of the software (similar to those presented in
Written instructions for initial familiarization and orientation with SweetHome 3D.
Instructions | |
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Draw floor in Quadrant 3 using the Floor button (follow instructions in pop-up box) |
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Draw walls in Quadrant 3 using the Walls button (follow instructions in pop-up box) |
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Choose objects from Quadrant 1 using the Select tool |
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Drag and drop into Quadrant 3, arrange using the Select tool |
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An inventory of these objects will appear in Quadrant 2 |
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Select a wall or floor in Quadrant 3, it will highlight in blue once it is selected |
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Right-click on highlighted wall or floor, select “Modify Walls” or “Modify Floor”, choose colors/textures |
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Go to “3D View” menu at the top menu, choose “Virtual Visit” |
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A figure will appear in Quadrant 3 and the view in Quadrant 4 will change |
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Move and click in Quadrant 4 to look around the room |
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Go to “File” at the top menu |
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Name your file and save to the desktop |
The customized SweetHome 3D application interface.
For the main task, participants were asked to design a room of their choice, which they believed represented a typical room within a patient’s home. They were also welcome to insert assistive equipment where they deemed necessary. Participants were asked to design the room of choice from scratch, while adopting a ‘think-aloud’ approach, which enabled them to verbally share their thoughts while interacting with the application [
Template analysis was used to analyze the interview data. This is a form of thematic analysis, which involves development of a coding template that represents a summary of the themes that are seen by the researcher(s) as being of importance within the dataset [
As an initial step, all interview recordings were transcribed into text format. The textual dataset in its entirety was perused to conceptualize the data and its relationship to the
The study was reviewed and approved by the Brunel University Research Ethics Committee prior to any data collection. All participants taking part in the study were guaranteed confidentiality and anonymity. Signed consent forms were obtained from all participants prior to taking part in the semi-structured interviews. Participants were informed of their right to withdraw from the study at any time. This was done both in writing and verbally.
The results of the analysis of think-aloud responses and the discussions held at the end of each session are presented in this section in the context of the three key TAM themes used for analysis: PU, PEOU, and AU. A number of sub-themes were identified within these key TAM themes, these are presented as a thematic mind map in
Thematic mind map of themes and sub-themes.
Participants B, D, E, F, and G felt that 3D images were a good visual aid that enabled patients to have a better understanding of assistive technology or adaptations to be provided. It was felt that the rich visual representations and interactive environment provided by the application is preferable to the static hand-drawn examples that are often used in practice. The 3D images were also seen to somehow convey additional information that otherwise would be difficult to verbalize in their absence.
I think everyone could have a look and it’s much better than having drawings or trying to explain them.
Other participants perceived that it can give the patient “immediate feedback” on planned changes (Participants C, G), which is likely to improve shared understanding of proposed adaptations to the home and the extent to which patients and practitioners can engage in a meaningful discussion about a particular scenario. Participant A felt that comprehension and evaluation of items that might be difficult to determine when looking at an aerial or 2D drawing would be much clearer when presented as a 3D representation. This participant also felt that it would be helpful to spot additional issues that would be lost using 2D representations, such as the height of an oven for a wheelchair user.
Participants A, E, F, G spoke about the positive impact of client involvement. They suggested that the use of the application in conjunction with the patient would be likely to empower patients and enable them to share the expertise and knowledge that they have about their unique circumstances, how they manage their condition, and how they engage with their home environment.
They are the experts in their situation and so if we can get them to join in with the design process, it makes it easier for everybody.
The software was perceived as supporting shared decision making since patients would be more involved within the process (B, E) and understand the rationale behind the suggested adaptations. Hence, participants felt that the visualization afforded by the application would help to foster improved levels of engagement in the PHV process and reduce the levels of ambivalence and anxiety that sometimes surround the process of introducing assistive equipment into the home environment.
Most people are really a bit ambivalent about equipment. Obviously, first it’s a horrible reminder of things going wrong. And usually it’s because a lot of people can’t visualize it.
The application was also perceived as a tool that could be used for the independent assessment of technology and enable parents to design environments for their children (Participant A, C, G). In particular, the negotiation process for introducing new equipment into the home can sometimes be extremely resource intensive, requiring numerous visits to the home to explore concerns regarding space requirements and positioning of equipment. Utilization of the VRIDA application was seen to offer a solution that could potentially reduce the time and resources required to come to an agreement on home adaptations.
Because every parent says they don’t have the space, so when you can show you have room for that, it would be so different what you can do without going so many times in his house
One perception (Participant D) was that the software would not be suitable for persons with cognitive impairment. It was felt that such patients may find it challenging to make the connection between the virtual representation of the home environment and the home itself. However, some participants believed that the application would be very helpful when carrying out major modifications to the home environment (Participant B, E) and was more effective than the current method of taking photographs (Participant C, D) or paper drawings (Participant A). One of the advantages of the interactive 3D representations would be that the patients could immediately see the proposed changes, without having to worry about the quality or scaling of the photographs or hand drawings that have been used to come to a decision. It was felt that 3D representations were likely to offer peace of mind and foster better quality and more timely collaboration around a more accurate representation of the individual patient’s home setting.
If you can knock something like this up and send it to them, and even better these days when so many people are online, you can create something back at the office and send it through to them and say, right, this is what I think, what do you reckon?
All of the participants were able to complete the assigned tasks and vocalized the way they best learned the new tasks. Participants A, F, E, and G stated that they did not like or use the written instructions provided to assist them in learning how to use the application. All reported that they were able to make sense of the key application functions fairly intuitively without any assistance. Both participants F and G explicitly stated that they preferred to learn by playing with the software as opposed to following written instructions. In contrast, participants B, C and D favored the use of the written instructions for guidance and liked their conciseness and the narrative, which enabled them to engage in a simple task before moving on to designing a home environment of their own conception. Only one participant (Participant C) emphasized the overhead of effort required to practice utilizing the software before any significant progress was made.
A number of issues relating to its usability were identified by participants as a result of carrying out the main task. Participants A, B, and F all commented on how they had difficulty picking up or selecting an item of furniture in order to move it to a new position within the room while completing the task. Participants B, D, E, and F stated that the controls were sometimes tricky to operate. Participants B and G felt that the rotation of objects, in particular, should be done with a dedicated button that would move the object in 90 degree turns, similar to how photos are rotated in digital photo viewing applications. Participants A, B, C, D, E, and F experienced issues or confusion over how to apply a wall texture or color; specifically, the software terms of “left side” and “right side” to wall orientation were unclear. Similarly, Participants B, C, and F felt that the default white color for the floors, walls, and objects made it difficult to visually differentiate between them. Participants B, E, and F felt that the mouse controls were too sensitive.
Participants also made numerous suggestions about additional items that should be included in future versions of the furniture library and OT object catalogue. A summary of the additional items of furniture and assistive equipment suggested by participants are presented in
Suggested additional items for OTaobject library.
Participant(s) | Suggested item(s) |
A, E | Ceiling track hoist |
A | Drain (shower room) |
F | Folding door or “doors that go both ways” |
G | Mirror |
C | Non-slip mat |
D | OT items for bedroom |
C | OT items for kitchen |
G | OT items for children’s playroom |
A, C, D, E, F | Rails in multiple lengths/rotations |
A | Ramps (outdoor items) |
E | Sash window |
A | Wall-hung basin |
A, B | Wheelchair turning radius graphic |
aOT: occupational therapy
In general, most participants were positive about the use of the software. Some of the comments were: “it’s quite cool”, “My kids would love it”, and “it’s really great”. Some participants were positive about the value that this application could deliver to occupational therapy more generally and across a range of services.
I think it’s doing a great job. I was really impressed. I think that can really help many OTs throughout the country.
Two participants perceived that more work needed to be done if maximum benefits of the application were to be realized in practice. However, they noted that the majority of functionality currently offered is useful and that with only minor adaptations to the interface and functionality, the application would be beneficial to use in practice.
I’m sure it’s a case of fine tuning rather than significant changes.
Participants B and G felt that the look and feel of the digital home images needed enhancement to enable a client to connect with the 3D images more effectively. They felt that the home environments presented within the application felt slightly artificial in some way and could benefit from being softened or made to look more ‘lived-in’.
I think it’s got potential, but it still feels quite academic, quite sterile.
Some participants made suggestions relating to how the modelled environments could be made to feel more life-like and lived-in. For example, both Participants B and G suggested making simple additions, such as a rubber duck in the bathroom, to help to add a home-like element that was otherwise felt to be missing. Participant B also suggested a towel on the towel rail, bottles of shampoo, blinds/curtains on the windows, and houseplants.
If you have a bath, where is the bottle of shampoo? Because that’s going to make it look like it is someone’s home. It is easier, it opens up the ability to engage with people who maybe need that household.
Participants B and F felt that this technology, specifically the use of a computer and mouse, was outdated. They felt that perhaps delivering interventions using a VRIDA application may be better delivered on more mobile types of platform, such as a tablet computer or a laptop.
Participants emphasized the importance of measurement and having objects in pre-set sizes (Participants A, C). They felt that it is important to ensure that assistive pieces of equipment are modelled to scale within the environment.
Because at the moment you could end up with a design that looks wonderful but you can’t actually achieve it because you have dropped in a bath that is not actually on the market.
Indeed, Participants B and D thought that Sweet Home 3D with exact measurements could be a beneficial tool when communicating with assistive equipment installation technicians. They also felt the exact measurements in Sweet Home 3D would give clients a better representation of what they would be receiving and how it would be oriented. Participant A felt that standardized objects should be included and that the ability to resize or stretch objects in Sweet Home 3D may lead to errors, therefore, suggesting that the sizes of objects within the OT object library should be fixed and protected against being resized within the application.
There was a view that the software may be suitable for actual use by OTs working with a variety of clinical conditions.
One participant perceived that if the technology improved, they would “take it on all of my visits” (Participant G). Another participant perceived that if the technology was to be used in practice, then it must be used with a tablet computer (Participant B).
However, one participant worried about the impact on the profession and was concerned that introduction of such technology could potentially result in less OTs being employed within the profession.
But the one thing I would say, this isn’t necessarily criticism, but it’s just whether not – because it’s been so easily done, whether that actually de-skills OTs and actually kind of takes their jobs away. You won’t need them anymore because you’ve got a whiz-bang computer that can do it for you.
Suggested clinical areas.
Participant(s) | Suggested clinical usage |
B, F, G | Children/Young Adults |
B | Clients that are difficult to engage |
B, D | Long-term Conditions |
F | Neurology |
F | Older Adults |
D | Social Services |
In this study, occupational therapists viewed the VRIDA software as being a potentially important and useful visual aid to facilitate shared understanding and shared decision making about home adaptations with patients. This is particularly valuable given that, to date, insufficient explanation and notification of home adaptations during home visits has resulted in some users feeling dissatisfied with their experience, resulting in equipment abandonment levels in excess of 50% [
OTs perceived that the VRIDAs may also reduce anxiety and empower patients. Therefore, the use of VRIDA is likely to encourage therapists to consider new mechanisms to promote health literacy, which is a key enabling factor for patients to be empowered, take ownership, and be involved in the decisions that are made about their care. Health literacy is defined as the ability to “access, understand, evaluate, and communicate information as a way to promote, maintain, and improve health in various settings over the life-course” [
VRIDA applications such as SweetHome 3D were perceived by OTs as having the potential to address miscommunications that typically occur as part of the PHV process, as it gives patients immediate visual feedback on proposed home adaptations. Therapists appeared to believe that patients may prefer visual aids to facilitate understanding as opposed to more traditional methods of communication. To date only one study appears to exist within the research literature which explores the use of visual aids, in the form of photographs, within the process of occupational therapy home modifications or provision of assistive technology. Daniel et al [
All the participants in this study were able to use the software, thus giving support to the notion that the majority of therapists can utilize technology and not just Generation X [
Unlike many VR studies, this research was not tied to a specific clinical context, condition, or desired outcome such as learning surgical reconstruction [
A limitation of this research is that a follow-up interview was not carried out separately to the trial session itself; however, interviews were carried out at the end of the think-aloud sessions. This provided them with a chance to share any additional comments and reflect on the experience of using the software application. Qi [
This study has gained valuable insights into the value and utility of using VRIDA software applications such as SweetHome 3D within the occupational therapy setting and more specifically within the PHV process. OTs appeared to be positive about the utilization of VRIDAs within a range of clinical settings and that it would serve as a valuable collaborative tool that could empower patients and facilitate more effective patient/practitioner engagement. The study also revealed that VRIDAs have the potential to facilitate decision making and could serve as a valuable tool to demonstrate ideas and put them into a visual context that is personalized and intuitive for the patient. Furthermore, using VRIDA could better facilitate shared decision making and empower patients to play more of a role in the decisions that are made about their care. This is especially important given the complex emotions that can be tied to conditions leading to home modifications or the need for equipment. Furthermore, many studies look at the patient experience without noting the experience from the point of view of the clinician. It is often assumed that clinicians have/do not have the ability to learn to use new technology in practice. Without gathering and documenting the clinician’s perspective, research is missing the valuable insights that clinicians can bring as a result of their range of clinical experience and that can be fed back into the development of technology that is tailored to the clinicians needs. This study has identified a number of issues that now can be addressed in order to ensure that the proposed VRIDA technology is suitably adapted and made to be fit for purpose, if it is to be introduced as a tool to facilitate more effective PHV interventions. Ultimately, new tools and strategies that enable improved patient/practitioner communication and collaboration must be identified and deployed, if significant levels of equipment abandonment seen as a result of PHV interventions are to be addressed and overcome. The use of VRIDA as a tool to facilitate improved communication and collaboration within this process has been perceived to be promising by practitioners.
Further research is needed to explore patient perceptions of VRIDA and to better understand the effectiveness of using such applications jointly and collaboratively with patients and practitioners. Further development work is also needed to incorporate the requirements suggested by practitioners as a result of this study and to identify patient specific requirements, which will ensure that both patients and practitioners are able to optimally benefit from using this application in practice.
actual use
human activity assistive technology
information and communication technology
National Health Service
occupational therapist
personal digital assistant
perceived ease of use
pre-discharge home visit
perceived usefulness
technology acceptance model
virtual reality
virtual reality interior design application
None declared.