A Realist Synthesis on how, for whom and in which Contexts or Conditions Augmented and Virtual Reality Training ‘Works’ in Upskilling Healthcare Workers

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Background: Training opportunities to upskill healthcare workers using traditional simulators (e.g., cadavers, animals or actors) are becoming less common due to ethical issues, commitment to patient safety, cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood, and warrants further investigation.

Objective: To develop, test and refine an evidence-informed program theory on how, for whom and to what extent training using AR/VR ‘works’ for upskilling healthcare workers and to understand what facilitates or constrains their implementation and maintenance.

Methods: A realist synthesis using a three-step process: theory elicitation, theory testing, and theory refinement. We first searched seven databases and 11 practitioner journals for literature on AR/VR used to train healthcare staff. Eighty papers were identified and information regarding contexts (C), mechanisms (M) and outcomes (O) were extracted. We conducted a narrative synthesis to form an initial program theory consisting of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases as in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration.

Results: Of the 41 CMO configurations we identified, we had moderate to high confidence in nine (22%) based on 46 empirical studies reporting on VR, AR or mixed simulation training programs. These stated that realistic (high fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy and an interactive experience, which results in increased learner satisfaction and more effective learning. Immersive VR/AR engages learners in ‘deep immersion’ and improves learning and skill performance. When transferable skills/knowledge are taught using VR/AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Lastly, for novices VR/AR enables repeated practice, resulting in technical proficiency, skill acquisition and improved performance. The most common barriers to implementation and maintenance were upfront costs, negative attitudes and experiences (i.e., cyber-sickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included: decreasing costs through commercialization; increasing the cost-effectiveness of training; a cultural shift toward acceptance; access to training opportunities; and leadership and collaboration within and across institutions.

Conclusion: Technical and non-technical skills training programs using AR/VR for healthcare staff may trigger perceptions of realism and deep immersion, and enable easier visualization, interactivity, enhanced skills and repeated practice in a safe environment. This may improve skills and increase learning/knowledge and learner satisfaction. Future testing of these mechanisms using hypothesis-driven approaches is required. More research is also required to explore implementation and maintenance considerations.

Keywords: Realist synthesis; realist review; review; virtual reality; augmented reality; simulation; training; health; health personnel; education

Bibliographical metadata

Original languageEnglish
JournalJMIR Serious Games
Publication statusAccepted/In press - 12 Oct 2021