Immersion Redefined: Deconstructing Behaviors in Virtual Reality Simulation - An Ethnographic Analysis (Preprint)
Authors: Loeb Daniel , Shoemaker Jamie , Ely Kelly , Zackoff Matthew 
Published: August 2024

BACKGROUND

Virtual Reality based (VR) simulation is an increasingly popular tool for simulation based medical education. VR places participants in a highly realistic, three-dimensional world where healthcare professionals can observe nuanced physical exam findings, such as subtle indicators of respiratory distress and skin perfusion. However, it is not known how the VR environment affects the behavior and attention of participants.

OBJECTIVE

Describe clinician attention and decision-making behaviors during interprofessional pediatric resuscitation simulations performed in VR. We employed video-based focused ethnography to describe how participant attention and behavior is altered in the VR environment and reflect how these changes may affect the educational profile of VR simulation.

METHODS

Fifteen recorded interprofessional VR simulations featuring a child with pneumonia and sepsis were evaluated. The research team analyzed the scenarios with the question: “How does a completely virtual reality environment alter participant attention and behavior, and how might these changes impact educational goals?" Video-based focused ethnography consisting of data collection, analysis, and pattern explanation was conducted by a team with expertise in critical care, resuscitation, simulation, and medical education until data saturation was achieved.

RESULTS

Three major themes and associated subthemes emerged: Source of Truth, Cognitive Focus, and Fidelity Breakers.
Source of Truth explores how participants gather and synthesize information in a VR environment. Participants utilized the patient physical exam over ancillary data sources, like the cardiorespiratory monitor. This preference returned to the monitor when the patient’s appearance did not change as expected after the intervention.
Cognitive Focus describes the interplay between thinking, communicating, and doing during a simulation in a virtual environment. The VR setting imposed unique cognitive demands, requiring participants to process information from multiple sources, make rapid decisions, and execute tasks in a simulated clinical scenario. Participants experienced increased task burden when virtual tasks did not mirror real-world procedures, leading to delays and fixation on certain actions.
Fidelity Breakers explores the ways in which participants are distracted from the main purpose of the simulation due to technological and environmental constraints. Navigational and interaction challenges, such as unintended teleportation and difficulties in interacting with the virtual patient and equipment, disrupted participant immersion. These disruptions highlighted the limitations of VR in replicating hands-on clinical skills.

CONCLUSIONS

The VR-based simulation environment prioritizes patient-centered data, enhancing focused clinical decision making. However, limitations in physical interaction and navigation suggest VR is best suited for specific training objectives. Complementary modalities, such as augmented reality-enhanced or traditional manikin-based simulations, may be better suited for hands-on skill development. These findings underscore the need for a targeted approach which integrates various simulation tools to optimize medical training to address specific learning objectives. Further research is required to explore how these modalities can be best leveraged to enhance educational outcomes.