Development of a Real-Time Adaptable Virtual Reality-Scenario

Training for Anaesthesiology Education, a User-Centered Design

Krista Hoek

, Christina Jaschinski

, Monique van Velzen

and Elise Sarton

Department of Anaesthesiology, LUMC, Albinusdreef 2, 2333ZA, Leiden, The Netherlands

Saxion University of Applied Sciences, M. H. Tromplaan 28, 7513AB, Enschede, The Netherlands

Keywords: VR-Simulation, Immersive Learning, Immersive VR, Proteus Effect, Medical Education, Crisis Resource

Management, User-Centered Design.

Abstract: Simulation training in medical settings has become pivotal in clinical education. Virtual reality (VR) presents

a novel approach to simulation, offering numerous advantages for both trainers and trainees by facilitating

high-fidelity practice in situational awareness, decision-making, and multitiered response systems within a

safe yet stressful environment. This paper outlines the development of a multiplayer VR simulation prototype

tailored for anaesthesiologist-intensivists, with input from a multidisciplinary expert team throughout the

process. Trainers can dynamically adjust patient physiological parameters, enabling training in crisis resource

management under pressure. Following a user-centered design (UCD) methodology, iterative design cycles

involve experts adapting a Failure Modes and Effects Analysis (FMEA) to prioritize trainee and trainer needs.

User feedback, gathered through various qualitative and quantitative UCD techniques such as interviews,

focus groups, and prototype testing, informs each iteration. Three simulation prototype versions underwent

evaluation, incorporating simulation settings, debriefing sessions, and FMEA analysis. Feedback informed

iterative design improvements until thematic saturation was reached, culminating in the creation of an initial

prototype. This paper aims to detail the development process of a VR scenario training program, geared

towards immersive simulation learning.

1 INTRODUCTION

One of the cornerstones of medical training is clinical

scenario training using an environment to learn

effectively (Anthony, 1996; Yunoki & Sakai, 2018).

Simulation based learning provides a safe learning

space where healthcare providers can gain experience

on medical emergencies or rare complications in a

controlled setting without putting real patients at risk.

Especially for anaesthesiologists/ intensivists,

management of a patient who is acutely deteriorating

requires excellent technical and non-technical skills

in a highly stressful and chaotic environment.

Technical skills may include tracheal intubation,

difficult airway management, vascular catheter

placement and regional anaesthesia. Also, sufficient

medical knowledge of differential diagnoses, drug

https://orcid.org/0000-0003-1984-3182

https://orcid.org/0000-0002-7940-7684

https://orcid.org/0000-0002-0289-6432

https://orcid.org/0009-0007-4403-3815

dosages, triages of possible actions, and crisis

resource management are crucial and may be

lifesaving. Situation awareness, decision making,

teamwork, communication and leadership are

indispensable skills in clinical practice outlining the

importance of human factors (Institute of Medicine

Committee on Quality of Health Care in, 2000).

Improvement in patient outcome may come from

multitiered rapid response systems.

Knowledge is constructed in social contexts and

students need to be active learners rather than passive

recipients of knowledge (Anthony, 1996). Although

several studies have shown the effectiveness of

simulation-based training over the last decade

(Dorozhkin et al., 2017), increasing pressure son

budget and logistic limitations, needs for alternative

methods of simulation have emerged. Also, current

simulation programs may not have scenarios with

Hoek, K., Jaschinski, C., van Velzen, M. and Sarton, E.

Development of a Real-Time Adaptable Virtual Reality-Scenario Training for Anaesthesiology Education, a User-Centered Design.

DOI: 10.5220/0012755600003693

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 16th International Conference on Computer Supported Education (CSEDU 2024) - Volume 1, pages 751-757

ISBN: 978-989-758-697-2; ISSN: 2184-5026

751

real-time adaptation possibilities which are seemed to

be required in order to create an immersive

environment with unlimited training possibilities for

personalization of the scenario (Bracq et al., 2019;

Tursø-Finnich et al., 2023; Yunoki & Sakai, 2018).

Immersive Virtual Reality uses a Head-Mounted-

Display (HMD) project in front of the eyes allowing

users to focus on display without interaction of the

outside world. It offers novel capabilities providing

new qualitative support for educators and trainees as

it can be used independent of geography, time and

space, and it is cost-effective (Pottle, 2019).

Immersive VR can produce a visceral feeling of being

in a simulated world, a form of spatial immersion

called Presence (Fuhrt, 2008; Pottle, 2019)Also, in

virtual interactions, participant’s avatars can affect

their attitude, perception and behaviour in a conscious

or unconscious matter known as the Protheus Effect

(Bian et al., 2015; Navarro et al., 2022). However,

there are also potential drawbacks such as limited

haptic (tactile) feedback (Ruthenbeck & Reynolds,

2015) and the absence of non-verbal cues in the

trainees’ digital avatars (Pottle, 2019).

The main objective of this study is to develop a

prototype of a VR-scenario training program for

anaesthesiologists-intensivists. The VR-scenario

training program is tailored to the needs and

experience of the trainees and simulation trainers with

a multidisciplinary expert team involved throughout

the development process and guide all design

decisions. This paper will describe the development

phase of our prototype.

2 METHODS

2.1 Study Design

We’ve adapted a user centered design as it employs

scientifically proven methodologies of human

sciences to optimize designs of human-technology

interface improving its proficiency and performance

and is easy to use (Walden et al., 2020).

During the development phase, three simulation

prototype iterations were made, each evaluated with

a simulation setting, debriefing and Failure Modes

and Effects Analysis (FMEA) (Davis et al., 2008).

After every simulation, feedback was provided to the

development team responsible for the VR

environment. This feedback loop encompassed

evaluation of the simulation setting, debriefing

sessions, and analysis through FMEA. The VR

developers then utilized this feedback to iteratively

enhance the VR simulation. Subsequently, design

iterations were made, and the modified prototype

underwent testing and adaptation until thematic

saturation was achieved. We adapted FMEA as it

identifies possible system failures and vulnerabilities

in complex processes to make a system more robust

before an adverse event or problem occurs (Davis et

al., 2008). It is a method to identify parts of the

process most in the need of change. A

multidisciplinary expert team for the FMEA process

was selected including 5 steps: (1) team selection, (2)

process identification, (3) process flow diagram

preparation, (4) failure mode identification, and (5)

determination of an action plan.

For the evaluation phase which is beyond the

scope of this article, we will assess content validity

through qualitative and quantitative measures in an

exploratory sequential design.

2.2 Participants and Setting

The protocol was approved by the Institutional

Science Committee of the Anaesthesiology science

department and obtained a waiver from the

Institutional Review Board (NWMO-LUMC).

Informed consent was obtained prior to inclusion,

participation was voluntary and privacy rights were in

alignment with the Declaration of Helsinki and

GDPR guidelines. The multidisciplinary expert team

for the FMEA process was designed to include

anaesthesiologists-intensivists, trainers, human factor

specialists and software VR design technical experts.

Participation was voluntary. Exclusion criteria

included physical incapacity to use VR which was not

encountered during the study. Participants did not

receive a financial compensation.

2.3 Sample Characteristics

Three healthcare providers participated of whom one

the project manager. Two were anaesthesiologists-

intensivists, one was a resident. Together with two

developers and one experienced researcher they

assembled as the multidisciplinary expert team for the

FMEA process.

2.4 Conceptual Framework

Commonly, simulation consists of three components:

an initial briefing with explanation of the upcoming

scenario, the simulation experience and a debriefing

where learners are provided with a crucially

important opportunity to reflect on themselves and

their team in order to improve future practice

(Pacheco Granda & Salik, 2023).

ERSeGEL 2024 - Workshop on Extended Reality and Serious Games for Education and Learning

752

Today’s VR simulation programs often use preset

scenarios put into practice (Bracq et al., 2019;

Brammer et al., 2022; Macnamara et al., 2021).

Standardized patients (SPs) or standardized scenarios

have been utilized for procedural skills assessment

and non-technical skills development.

According to the principles of Cognitive Load

Theory (CLT) (Reedy, 2015), there is a limit on how

much information one can process simultaneously,

impacting the information storage and retrieval. A

trainer may not know beforehand how the trainees

will perform during the scenario; hence he/she may

not know beforehand how they want the scenario to

evolve. This outlines the importance of the

adaptability of a scenario, enabling a more effective

and valuable learning experience.

We’ve hypothesized our real-time adaptable VR-

training program could fill in this gap as we wanted

to create a program where a trainer could change the

scenario in real-time.

2.5 Data Collection and Analysis

User feedback was collected through various

qualitative and quantitative UCD techniques

including contextual inquiry, interviews, focus

groups, observations, questionnaires, walk-throughs

and prototype testing.

3 RESULTS

Three simulation prototypes underwent evaluation by

the multidisciplinary expert team encompassing

FMEA sessions. An example of a FMEA session can

be found in Table 1.

3.1 VR-Simulation Requirements

The VR- simulation was designed to be a fully

immersive reality system, with auditory, visual, and

tactile feedback, in real time adaptable by the trainer.

This implies scenario’s to be adaptable online, during

the simulation. Patients’ clinical presentation (skin

color and rash, pupil dilation etc.), and paraclinical

presentation (arterial tension, pulse oximetry,

bispectral index measurements etc.) were available on

the trainer’s dashboard enabling a fully adaptable

simulation training.

With an initial analytic phase of the UCD design,

the multidisciplinary expert team produced a list of

basic requirements divided in five major themes as

shown in Table 2. The use of the MoSCoW

prioritisation technique further classified these

requirements (Miranda, 2022).

Table 1: Failure mode simulation session two.

Concern

Severity

category

Potential

Active

Failure

Action plan

Latency Perfor-

mance

impact

Participant

experience

Potential

Active

Failure

Purchase

powerful

server.

Bumping

into each

other

Perfor-

mance

impact

Dizziness IT

adaptations

within the

VR.

Telepor-

tation

Participant

experience

Failure to

immerse

Testing of

different

standalone

HMD with

limited

ace.

Onboard-

ing

Perfor-

mance

impact

Physical Use of

standalone

HMD

without

teleportation

tion,

Onboading Participant

safety

Failure to

immerse

Virtual

onboard area

with tutorial

Table 2: Basic requirements.

Visuals patients

Patient morphology, age sex

Anatomic details (facial hair,

neck size, chin size, intra-oral

anatom

Visuals avatars Automated avatars

Hand and e

e movement

Visuals surgery Laparoscopy

Laparotom

Equipment OR OR table

OR lights

Respiratory machine

Anesthesiologic equipment

Surgical equipment

Multi

1-5

ers

Trainer dashboard Adaptability of medical

conditioning

The static requirements consisted of materials

including airway devices, medication, and infusion

equipment, as well as operating room equipment such

as the operating table, lighting, and anaesthesiologic

and surgical instruments used for procedures such as

laparoscopy and laparotomy as shown in Figure 1.

Development of a Real-Time Adaptable Virtual Reality-Scenario Training for Anaesthesiology Education, a User-Centered Design

753

Figure 1: View of a photo (A), the digital design (B), and

the incorporation in the virtual OR environment (C).

Requirements of the visuals of the patients were

morphological features as shown in Figure 2.

Anatomic details such as facial hair, neck size, chin

size, intra-oral anatomy needed to be well designed to

enhance a high level of fidelity.

Figure 2: View of a patient with high resolution facial

details.

Furthermore, dynamic requirements

encompassed procedures such as intubation, both

standard and alternative techniques, and the

placement of intracorporal catheters such as an

intravenous line, intra-arterial catheter, stomach

siphon, or central venous catheter.

Additional dynamic requirements included

patient positioning, administration intravenous (IV)

medication, and other related considerations. An

extensive overview of these items can be found in the

Appendix.

3.2 VR-Simulation Requirements

The multidisciplinary expert team employed a

collaborative approach to construct flow diagrams to

depict dynamic interactions of which an example is

depicted in Figure 3. This iterative process involved

the utilization of various media, such as videos

captured in the operating room, detailed descriptions,

and photographs, among others, to facilitate

communication between the different parties

involved.

Figure 3: View flow diagram of a bolus gift medication.

4 DISCUSSION AND

CONCLUSION

This paper provides useful information on the

development of a prototype of VR-scenario training

program with the potency of experimental learning

with VR. It may contribute to further research and

healthcare educational programs avid to use

immersive simulation learning with VR. A real-time

adaptable program may fully optimize learning

processes and adds flexibility within the scenario’s.

Future research on the prototype, employing UCD

techniques, is crucial to further validate its

effectiveness through iterative cycles of evaluation,

utilizing Kirkpatrick's evaluation model (Cannon-

Bowers, 2008; Falletta, 1998; Smidt et al., 2009).

This evaluation model assesses the prototype's

potential impact on four levels: (a) participants'

reaction to the training, (b) participants' learning

outcomes from the training, (c) participants'

behavioral changes resulting from the training, and

ERSeGEL 2024 - Workshop on Extended Reality and Serious Games for Education and Learning

754

(d) the subsequent organizational impact stemming

from participants' changed behavior. Additionally, it

also considers (e) the economic benefits or overall

human welfare derived from the training (Cannon-

Bowers, 2008; Falletta, 1998; Smidt et al., 2009).

ACKNOWLEDGEMENT

This work was supported by the Tech For Future,

Centre of Expertise on research in High Tech Systems

and Materials.

REFERENCES

Anthony, G. (1996). Active Learning in a Constructivist

Framework. Educational Studies in Mathematics,

31(4), 349-369. http://www.jstor.org/stable/3482969

Bian, Y., Zhou, C., Tian, Y., Wang, P., & Gao, F. (2015).

The Proteus Effect: Influence of Avatar Appearance on

Social Interaction in Virtual Environments. HCI,

Bracq, M. S., Michinov, E., Arnaldi, B., Caillaud, B.,

Gibaud, B., Gouranton, V., & Jannin, P. (2019).

Learning procedural skills with a virtual reality

simulator: An acceptability study. Nurse Educ Today,

79, 153-160.

https://doi.org/10.1016/j.nedt.2019.05.026

Brammer, S. V., Regan, S. L., Collins, C. M., & Gillespie, G.

L. (2022). Developing Innovative Virtual Reality

Simulations to Increase Health Care Providers'

Understanding of Social Determinants of Health. Journal

of Continuing Education in the Health Professions,

42(1). https://journals.lww.com/jcehp/Fulltext/2022/

04210/Developing_Innovative_Virtual_Reality_Simulat

ions.11.aspx

Cannon-Bowers, J. A. (2008). Recent advances in scenario-

based training for medical education. Curr Opin

Anaesthesiol, 21(6), 784-789.

https://doi.org/10.1097/ACO.0b013e3283184435

Davis, S., Riley, W., Gurses, A. P., Miller, K., & Hansen, H.

(2008). Failure Modes and Effects Analysis Based on In

Situ Simulations: A Methodology to Improve

Understanding of Risks and Failures. In K. Henriksen, J.

B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances

in Patient Safety: New Directions and Alternative

Approaches (Vol. 3: Performance and Tools).

https://www.ncbi.nlm.nih.gov/pubmed/21249922

Dorozhkin, D., Olasky, J., Jones, D. B., Schwaitzberg, S.

D., Jones, S. B., Cao, C. G. L., Molina, M., Henriques,

S., Wang, J., Flinn, J., & De, S. (2017). OR fire virtual

training simulator: design and face validity. Surg

Endosc, 31(9), 3527-3533.

https://doi.org/10.1007/s00464-016-5379-7

Falletta, S. V. (1998). Evaluating Training Programs: The

Four Levels: Donald L. Kirkpatrick, Berrett-Koehler

Publishers, San Francisco, CA, 1996, 229 pp. The

American Journal of Evaluation, 19(2), 259-261.

https://doi.org/https://doi.org/10.1016/S1098-

2140(99)80206-9

Fuhrt. (2008). Immersive Virtual Reality. In B. Furht (Ed.),

Encyclopedia of Multimedia (pp. 345-346). Springer

US. https://doi.org/10.1007/978-0-387-78414-4_85

Institute of Medicine Committee on Quality of Health Care

in, A. (2000). In L. T. Kohn, J. M. Corrigan, & M. S.

Donaldson (Eds.), To Err is Human: Building a Safer

Health System. National Academies Press (US)

Macnamara, A. F., Bird, K., Rigby, A., Sathyapalan, T., &

Hepburn, D. (2021). High-fidelity simulation and

virtual reality: an evaluation of medical students'

experiences. BMJ Simul Technol Enhanc Learn, 7(6),

528-535. https://doi.org/10.1136/bmjstel-2020-000625

Miranda, E. (2022, 2022//). Moscow Rules: A Quantitative

Exposé. Agile Processes in Software Engineering and

Extreme Programming, Cham.

Navarro, J., Peña, J., Cebolla, A., & Baños, R. (2022). Can

Avatar Appearance Influence Physical Activity? User-

Avatar Similarity and Proteus Effects on Cardiac

Frequency and Step Counts. Health Commun, 37(2),

222-229. https://doi.org/10.1080/10410236.2020.

1834194

Pacheco Granda, F. A., & Salik, I. (2023). Simulation

Training and Skill Assessment in Critical Care. In

StatPearls Publishing LLC.

Pottle, J. (2019). Virtual reality and the transformation of

medical education. Future Healthc J, 6(3), 181-185.

https://doi.org/10.7861/fhj.2019-0036

Reedy, G. B. (2015). Using Cognitive Load Theory to Inform

Simulation Design and Practice. Clinical Simulation in

Nursing, 11(8), 355-360. https://doi.org/https://doi.org/

10.1016/j.ecns.2015.05.004

Ruthenbeck, G. S., & Reynolds, K. J. (2015). Virtual reality

for medical training: the state-of-the-art. Journal of

Simulation, 9(1), 16-26.

https://doi.org/10.1057/jos.2014.14

Smidt, A., Balandin, S., Sigafoos, J., & Reed, V. A. (2009).

The Kirkpatrick model: A useful tool for evaluating

training outcomes. J Intellect Dev Disabil, 34(3), 266-

274. https://doi.org/10.1080/13668250903093125

Tursø-Finnich, T., Jensen, R. O., Jensen, L. X., Konge, L.,

& Thinggaard, E. (2023). Virtual Reality Head-

Mounted Displays in Medical Education: A Systematic

Review. Simulation in Healthcare, 18(1), 42-50.

https://doi.org/10.1097/sih.0000000000000636

Walden, A., Garvin, L., Smerek, M., & Johnson, C. (2020).

User-centered design principles in the development of

clinical research tools. Clin Trials, 17(6), 703-711.

https://doi.org/10.1177/1740774520946314

Yunoki, K., & Sakai, T. (2018). The role of simulation

training in anesthesiology resident education. J Anesth,

32(3), 425-433. https://doi.org/10.1007/s00540-018-

2483-y

Development of a Real-Time Adaptable Virtual Reality-Scenario Training for Anaesthesiology Education, a User-Centered Design

755

APPENDIX

This appendix gives an extensive overview of the

static and dynamic requirements of the VR

simulation.

The requirements are annotated with the of the

MoSCoW prioritisation.

Static requirements included anaesthesia supplies,

airway supplies, operating room supplies, surgical

procedures.

Table 3.

STATIC

Anaesthesia su

lies

Must

Intravenous infusion (IV) sets

in pink, green, blue, yellow,

and oran

Shoul

Subcutaneous needle

Coul

Tape

Will not have Intravenous deep cathete

Airway supplies

Must Size 6 oro

har

eal tube

Shoul

Size 7 oro

har

eal tube

Coul

Size 8 oro

har

eal tube

Will not have Size 3 laryngoscope

Operating room supplies

Must IV stan

Should

Infusion pump filled with

syringes

Coul

ECG electrodes

Will not have Blood

ressure cuff

Sur

ical

rocedures

Must

Laparotomy (in supine

osition): vertical incision

Should

Laparoscopy (in supine or

(anti)Trendelenburg)

Could

Laparotomy in pregnant

atients

(

horizontal incision

)

Will not have Limb surger

Table 4.

DYNAMIC

Anaesthesia su

lies

Must have IV infusion sets in pink,

green, blue, yellow, and

oran

Should have Subcutaneous needle

Could have Tape

Will not have IV cathete

Airwa

lies

Must have Size 6 oro

har

eal tube

Should have Size 7 oro

har

eal tube

Could have Size 8 oropharyngeal tube

Will not have Size 3 laryngoscope

Operating room supplies

Must have IV stan

Should have Infusion pump filled with

rin

Could have ECG electrodes

Will not have Blood

ressure cuff

Surgical procedures

Must have Placement of IV line

Applying a tourniquet

Finding a visible vein

(lightly tapping on vein,

asking patient to make a

fist)

Cleaning the skin

Opening IV packaging

Placing IV catheter

Securing the catheter with

tape

Connecting IV bag to IV

line

Administration of bolus

medication

Opening the cap or valve

and attaching the syringe

Pushing the plunger

Administration of

continuous medication -

Medication is in a pump

that is connected to the IV

line

Selecting "speed" and

"amount" of medication,

then confir

Placement of vital

monitoring

(after connecting to the

monitor, values are also

visible on the screen)

BIS

-Placing BIS stickers on

forehead

-Connecting to BIS

monitoring

ECG:

Placement of 5 electrodes

-Connection to ECG

monitoring

Blood pressure

-Placement of blood

pressure cuff

-Connection to monitoring

Pulse oximeter

-Placement of finger probe

-Connection to monitorin

Intubation

Preoxygenation with

placement of a mask on

patient's face

Induction of anesthesia:

starting medication that

causes patient to fall asleep

ERSeGEL 2024 - Workshop on Extended Reality and Serious Games for Education and Learning

756

Bag-valve mask ventilation

Intubation

-With laryngoscope

-With glidescope

-different views:

View grade 1, View grade

2, View grade 3, View

grade 4, View with vomit

grade 1/2

Positioning:

Table in Trendelenburg

position

Table in Anti-

Trendelenburg position

Placement of an additional

rolled-up blanket under the

neck

(changes intubation

conditions)

Placement of arms along the

sides

Placement of arms on

armrests

Placement of sterile drapes

with attachment to the

anesthesia

ole

Should Placement of arterial line

Palpate for pulses (inside

pulse for radial artery)

Sterilize the skin

Injection of local anesthesia

(2cc syringe with lidocaine,

subcutaneous needle)

Opening of arterial needle

from packaging

Placement of arterial needle

(placement is successful:

red blood returns from the

hub)

Withdrawal of needle

Advancement of catheter

Close the red cap

Cover with tegaderm

Connect arterial line

Zeroing arterial line

(

tional

)

Removal of arterial blood

Draw blood into arterial line

hub

Withdrawal of arterial blood

Backflush blood from the

arterial line hub

Flush arterial line

Warming

Placement of upper body or

lower bod

Administration of

pressure infusion

Place the infusion in a

ressure ba

Squeeze the air pump under

the

ressure ba

Could have Placement of gastric tube

Placement of gastric tube

through the nostril

Advancement of the tube up

to 55cm

Suctioning the gastric tube

will either show nothing

(tube is likely misplaced) or

green gastric contents (tube

is in the right place)

the tube in

lace

Will not have Defibrillation

Placement of defibrillator

pads (rhythm visible on

defibrillator)

Charging the defibrillator

with adjustable joules

Rhythm chec

Should Placement of temperature

probe

Placement of temperature

probe through the nostril

Connection to the monito

Will not have Placement of central line

Placement of urinary

catheter

Placement of ultrasound-

guided IV

Placement of ultrasound-

guided CVC

Placement of ear oximetry

Placement of TOF-CUF

Measurement of

neuromuscular blockade

Blood draw from peripheral

site

Cell-saver

Warming Connection to

bear-hugger

Activation of bea

-hu

Development of a Real-Time Adaptable Virtual Reality-Scenario Training for Anaesthesiology Education, a User-Centered Design

757