Principal Findings
To the best of our knowledge, a prospective study on the use of a virtual reality simulator to teach pediatric CPR to medical students has yet to be conducted. In accordance with the Kirkpatrick model [24], the results of our study demonstrated high trainee satisfaction (Kirkpatrick level 1) and a perceived improvement in learning (Kirkpatrick level 2). In evaluating our secondary outcome of assessing the response to the virtual reality gameplay features, the majority of participants agreed with the ease in understanding how to use the simulation and the usefulness of gameplay features in improving their understanding of CPR and expressed a desire for interacting with others in the virtual environment. Although some participants found it difficult to work with the interactive elements, this closed beta test provided an opportunity to identify elements for future improvements, including the refinement of the interactive elements and future considerations such as a multiplayer design which may further enhance the learning experience and element of realism given the significant role of teamwork in resuscitation. Current data on trainee satisfaction, educational efficacy, and gameplay elements of virtual reality simulators for pediatric medical education is limited, and the encouraging results of this study will address the gap in the literature and could have an integral role in transforming the culture of future medical education.
Immersive technologies provide users with an engaging and enjoyable learning platform to train skills to proficiency without risking patient safety. Our study illustrated high participant satisfaction as Virtual Doc was enjoyed by almost all participants. This result parallels a study by Kron et al [27] in which an evaluation of medical student attitudes toward technology-based education was conducted and revealed that almost all students liked the idea of using technology to enhance their educational experience and thought that education should make better use of new media technologies. Beyond satisfaction, a previous study reported that experiential simulations offer a high level of interactivity and engagement, which may increase user motivation to learn [28]. Providing a highly engaging environment, such as that of Virtual Doc, is important for trainees as increased interest and satisfaction with the learning modality may result in an increased level of motivation to learn; one study showed that highly motivated students are more effective learners [29]. The importance of satisfaction and effective learning is reinforced by a study evaluating the effectiveness of virtual reality versus traditional or other forms of digital learning in educating health care professionals, in which a higher level of interactivity was more effective for the development of postintervention knowledge and skills [30]. The level of satisfaction with a learning experience also affects the probability of a user recommending such an experience to their peers [31]. The results of our study are congruent with this notion, as indicated by most students enjoying the simulation and agreeing with the intention of recommendation.
In this study, Virtual Doc was perceived as educationally efficacious by the majority of the participants, as indicated by a positive response toward improved understanding, preparation for real-world clinical scenarios, and support for designing additional cases. An important component of effective education in the adult learner involves the psychological concept of flow. This term is defined as a state in which a learner is “fully engaged, focused, and committed to the success of the activity” [32], and this can be achieved through active engagement in an experiential learning process. The use of highly immersive and interactive virtual reality simulators can improve flow, which may lead to superior learning outcomes and performance as echoed by the majority of participants reporting an improved understanding of CPR. Additionally, engaging sensory modalities including vision, haptics, and audition also promotes active learning, which can improve memory retention [33]. Virtual Doc includes sensory features through auscultation of heart and lung sounds and palpation of the peripheral pulses, which the user will hopefully be able to translate into the real-world clinical setting when assessing or managing a similar patient presentation.
Being immersed in the virtual yet realistic hospital environment of Virtual Doc provides users with a lifelike clinical experience. This digital-based environment is an innovative tool with realistic features supporting the recommendations of adult learning theories such as Knowles’ theory [34,35]. The responses in this study regarding the Virtual Doc environment and its ability to prepare students for real-life clinical scenarios showcases a facility in which the elements of adult learning theories can be included. Active experimentation within a realistic and immersive learning environment allows users to make clinical decisions and experience the consequences of their actions in real time, mimicking a real-world clinical environment. This element of realism is important in encouraging intrinsic motivation to support the needs of an adult learner.
Additionally, the Kolb cycle of learning encourages repetition, reflection, and correction to improve learning outcomes [36]. Virtual Doc supports this cyclical relationship as learners have the opportunity to engage in repetitive practice until they achieve educational mastery in a safe and controlled environment, which is an important benefit of simulation as this is severely limited in real-world emergency patient encounters, especially in the pediatric population [5]. The flexible design of virtual reality may enable health care professionals to have more convenient and frequent opportunities to practice and refine skills.
Several studies have demonstrated that junior doctors feel inadequately prepared and lack confidence in their early training years [37-41]. This is further supplemented by less favorable outcomes for neonatal resuscitation being described in the summer when senior staff physicians are less likely to be present and the overall volume of staff members is reduced [42]. Lacking confidence and inadequate preparation may translate into unsafe practice and poor patient outcomes and is an especially important consideration when managing emergency scenarios such as an SCA. Virtual reality simulators such as Virtual Doc may provide an avenue to bridge the gap between trainee and doctor through immersive gameplay by enabling users to master foundational principles and basic management algorithms and apply this knowledge to challenging simulated cases. In our study, the majority of respondents expressed that this simulation game would aid in developing clinical skills and preparing the user for dealing with real-life clinical scenarios. In addition, almost all participants expressed benefit in the development of different cases, indicating a positive response toward the clinical educational value of the simulation.
The gameplay elements involved in virtual reality add entertainment to the learning process, thereby motivating learners to engage in study. The triad of immersion, interaction, and imagination, as described by Burdea and Coiffet [43], are important factors of virtual reality technology. Coupled with andragogical principles, a highly interactive game design improves intrinsic motivation and creates a more enjoyable and engaging learning experience with a consequential potential to illustrate superior examination scores [44]. In our study, the vast majority of respondents agreed that the interactive gameplay elements were useful in understanding how to perform CPR and found the process of the virtual reality simulation easy to understand. This was further supplemented by almost all participants enjoying the experience in the assessment of participant satisfaction. However, some respondents did not experience ease in using the interactive elements within the virtual environment. As this was a closed beta test, the software was able to deliver its intentional value to the participants, but there were some minor issues reported with ease in fully integrating into the environment such as accurately picking up a stethoscope or pushing the assistance button. This feedback is being considered as we progress toward the final product and acts as identified areas for future developments.
Finally, nontechnical skills such as teamwork and leadership are paramount in successful resuscitation. The collegiality of the responding team directly impacts predictors of postarrest survival as a coordinated course of action is associated with improved patient outcomes [45]. Technology-based games such as Virtual Doc have the potential to facilitate an atmosphere of teamwork, and in the digital era, medical students have agreed with introducing multiplayer simulations if they were fun and developed clinical skills [27]. Likewise, our study demonstrated that the majority of participants were interested in interacting with other players. A multiplayer design within the virtual environment could afford an opportunity to rotate through different resuscitation team roles, supporting an active and immersive learning experience, with the potential to equip learners with the crucial teamwork skills required for the effective management of a pediatric SCA.