# Exploring Care Home Workers’ Views on Augmented Reality and Virtual Reality Hand Hygiene Training: A Realist Interview Study

Authors: Norina Gasteiger; Sabine N. van der Veer; Paul Wilson; Dawn Dowding
Journal: Health & Social Care in the Community
 (2023)

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## Abstract

Augmented reality (AR) and virtual reality (VR) hand hygiene training has been developed for healthcare workers, but has not yet been applied to care homes. This qualitative realist study seeks to capture care home workers’ theories concerning how and in what contexts AR or VR training delivered via smartphone apps might work in promoting their hand hygiene practice. Semistructured interviews were conducted with 25 care home workers across three residential and three nursing care homes in Northern England. The interviews explored hand hygiene practices and training in care homes. Participants also provided feedback on an existing programme theory that explains how, for whom, and in which contexts AR/VR might be used to upskill health and care workers. Data were analysed on NVivo using a combined deductive and inductive approach. Participants had varying experiences with hand hygiene training, highlighting an opportunity to refresh skills. Repeated practice, interactive learning, feedback, reminding, and perceived task realism were considered important for hand hygiene and could be trigged by AR/VR. There was less support for other mechanisms including deep immersion, practice in a safe environment, visualisation of personal anatomy (hands) and mistakes, and perceived realism of the imagery and environment. Expected outcomes were effective learning, learner satisfaction, enhanced hand hygiene skills, and infection control. Three themes explained how context matters when implementing AR/VR training: learners (e.g., comfort and preference), care homes (e.g., policies, staffing, and infrastructure), and technology (e.g., cost and using a VR headset). Overall, participants theorised that AR/VR could refresh hand hygiene and trigger repeated practice, interactive learning, feedback and reminding, and task realism. Future work should test the mechanisms and technology in care homes. Hand hygiene training in care homes should consider implementation factors by offering alternative technologies, providing technical support, and working with managers to determine the most appropriate choice of technology.


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## Body

## 1. Introduction

Care homes frequently experience outbreaks of infectious diseases [1, 2]. These can have devastating consequences, given that care home residents are a vulnerable group of the population who may be elderly, or experience overwhelmed immune systems, wound care, and invasive procedures. The COVID-19 pandemic has further exemplified the impact of outbreaks on older adults and those with preexisting conditions most at-risk [3, 4]. However, unlike acute and hospital settings, there is a lack of evidence that supports infection prevention and control (IPC) practices in home care and care home settings [5].Hand hygiene is an important IPC behaviour [6–8] and helps to prevent the transmission of infectious diseases. Previous clinical hand hygiene training has been critiqued to be passive, boring, and theoretical (Essity [9, 10]), leading to the introduction of interventions that use electronic reminders, workshops, monitoring, and visual cues [11, 12]. More recently, virtual reality (VR) and augmented reality (AR) technology have been identified as potential training tools (Essity [13–15]). However, no research studies have explored how these technologies might work, or whether they are effective in upskilling healthcare workers in hand hygiene. Previous interventions and qualitative work have also been limited to acute settings [11, 12, 16–19], while overlooking care homes [20, 21]. These perspectives cannot be generalised to care homes, as IPC training requirements differ for staff between the settings. Additionally, hand hygiene practices may differ as care home residents might be more mobile, require support for a wider range of activities, and live in diverse home-based environments.This study contributes to a project on if and how AR/VR can be used to upskill care home staff in hand hygiene. We have conducted a realist review to develop a programme theory on how AR/VR may be used to upskill healthcare professionals in technical and nontechnical skills [14, 22]. We found that realistic (high fidelity) simulations trigger perceptions of realism, enable easier visualisation of patient anatomy, and provide an interactive experience, which results in learner satisfaction and more effective learning. Immersive VR/AR was found to engage learners in “deep immersion” and consequently improve learning and skill performance. When transferable skills and knowledge were taught using VR/AR, skills were enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Lastly, when training novices, VR/AR-enabled repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The review also highlighted a gap in research, whereby AR/VR had not been used to upskill workers in community and care sectors, or for simple behaviours like hand hygiene [22].Consistent with the realist approach, a deeper exploration of care homes is vital, as mechanisms and intervention outcomes are context-dependent [23–25]. When applied to care homes, for example, access to resources (e.g., previous training), experience using VR or work experience may impact behaviours, attitudes, and resources that are triggered. These can influence the success of the intervention. Further research can explore how, for whom, and whether VR/AR may be appropriate in improving hand hygiene, from the perspective of care workers. It will also help to identify implementation considerations.


### 1.1. Aim and Research Question

This study seeks to capture care home workers’ theories concerning how and in what contexts AR or VR training delivered via smartphone apps might work in promoting hand hygiene practice. The research question was: how and in what contexts do care home workers think AR and VR training delivered via smartphone apps might work in promoting hand hygiene practice, and what might influence implementation (and maintenance)?


## 1.1. Aim and Research Question

This study seeks to capture care home workers’ theories concerning how and in what contexts AR or VR training delivered via smartphone apps might work in promoting hand hygiene practice. The research question was: how and in what contexts do care home workers think AR and VR training delivered via smartphone apps might work in promoting hand hygiene practice, and what might influence implementation (and maintenance)?


## 2. Materials and Methods

This study employed a qualitative realist approach, which aims to understand how, for whom, and in what circumstances/contexts an intervention may work [26]. This was achieved through a “learner-teacher” cycle, whereby a researcher presents a theory to participants, who share their opinions/experiences [26]. The research is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research [27] and the Realist and Metanarrative Evidence Syntheses: Evolving Standards guidelines [28].


### 2.1. Participant Eligibility and Recruitment

The University of Manchester’s Proportionate University Research Ethics Committee approved the study in October 2021 (Reference: 2021-12778-20788). Participants were English-speaking care home workers (carers and managers) in Northern England, aged over 18 years. Participants were compensated with a £20 voucher.Convenience sampling was used to recruit participants. However, we aimed to maximise the variation of our sample regarding characteristics such as job roles and years of work experience. Managers were identified through networks of colleagues and the Care Quality Commission website. Interested staff were interviewed during their shifts. Before being interviewed, participants signed a consent form.Recruitment and data collection occurred simultaneously, until theoretical saturation was met and the interviewer was confident that the theory could be refined [26]. Based on similar research studies [16–18, 29], a sample of 20–30 participants was expected.The Ph.D researcher who conducted the interviews (NG) was trained and experienced in qualitative methods. Experts in digital health, implementation sciences, and realist evaluation methods provided support, including a nurse with formal IPC training (DD). None of the research team had previously worked with the care homes.


### 2.2. Data Collection Procedures

The audio-recorded interviews took 29–59 minutes and were conducted in-person at care homes and via Zoom. The interviews were semistructured and similar to Rycroft-Malone et al. [30] that were guided by a schedule (see supplementary file) developed from an underpinning programme theory (see Table 1). The schedule was tailored to the care home context and explored the participant’s experience, hand hygiene training, and perceived barriers/facilitators to implementing AR/VR training. The largest component was dedicated to reflecting on the context-mechanism-outcome (CMO) configurations identified in the realist review and the applicability of this theory to AR/VR hand hygiene training in care homes.Table 1
How AR and VR training may work for upskilling healthcare workers.
Context/conditionMechanism (s)Outcome (s)Realistic (high fidelity) simulations/visualisation+Perceptions of realistic haptics and imagery=More effective learning (e.g., increased understanding/learning, enhanced skills, proficiency, and performance)=Learner satisfaction with tool and realism+Easier and more detailed visualisation of patient anatomy=More effective learning=Learner satisfaction with tool and realism+Interactive experience=More effective learningVR or AR that immerses learners+Engages learners indeep immersion=Improved learning, knowledge, comfort with knowledge, and skill performanceWhen teaching transferable skills or knowledge+Enhances skills=Knowledge and skill transfer to clinical practice and simulators+Practice in a safe environmentNovices+Repeated practice=Technical proficiency, skill acquisition, and improved performanceAs AR/VR hand hygiene training has not been implemented in care homes, images, a verbal summary and a video of theTork VR Clean Hands Training (Essity [13]), and the SureWash Hand Hygiene [15] AR app were shown to participants (see Figure 1). These apps were identified from our review of 90 hand hygiene apps available in the UK and scored highest in quality, functionality, and innovation [14].Figure 1
Images and descriptions of the virtual reality Tork VR Clean Hands Training app and the augmented reality SureWash app.The CMO configurations were then presented to participants who shared their own ideas (personal theories) and opinions on how the intervention might or might not work within care homes. This theory-driven approach was consistent with a realist interview study conducted by Randell et al. [31] and the learner-teacher cycle method [26] and is productive by using interviews as a vehicle for expanding/revising theory [31].Lastly, the interviewer summarised the key points and invited participants to clarify, correct, or contribute more information. Interview recordings were transcribed verbatim and identifying data were removed from transcripts. Participants could review their transcripts.


### 2.3. Data Analysis

Data were analysed thematically in NVivo (version 12.7.0), using a combined deductive and inductive (open-coding) method [32, 33]. Concepts from the programme theory (Table 1) were used for the deductive analysis process, after which data were analysed inductively by looking for themes on the contexts, mechanisms, and outcomes [30].The researcher who conducted the interviews (NG) was familiar with the data identified initial codes as informed by the programme theory. The data from thirteen transcripts were first analysed by adding, changing, and moving codes and labels, with new codes identified for data that did not fit with preexisting codes. A second researcher (DD) double-coded 20% of the data. Final codes and initial themes were determined through discussion. The first researcher then coded the remaining transcripts and finalised the themes. Intercoder reliability was determined using Cohen’s kappa coefficient and a raw agreement rate.Lastly, representative quotes were identified. By drawing on the themes pertaining to contexts, mechanisms, and outcomes, similarities and differences were identified from the initial programme theory.


### 2.4. Upholding Rigour and Quality

Immediate and delayed member-checking helped to ensure that the findings are credible [34]. We also employed analyst triangulation for validation of interpretation and to ensure that the analysis is robust and rich. There was substantial agreement κ = 0.79 (raw agreement 98.78%) between the coders. Lastly, thick description helped to establish transferability. This requires contextualising findings [35]. We provided a detailed description of the phenomena and considered context, which is a focus of the study and central to a realist approach.


## 2.1. Participant Eligibility and Recruitment

The University of Manchester’s Proportionate University Research Ethics Committee approved the study in October 2021 (Reference: 2021-12778-20788). Participants were English-speaking care home workers (carers and managers) in Northern England, aged over 18 years. Participants were compensated with a £20 voucher.Convenience sampling was used to recruit participants. However, we aimed to maximise the variation of our sample regarding characteristics such as job roles and years of work experience. Managers were identified through networks of colleagues and the Care Quality Commission website. Interested staff were interviewed during their shifts. Before being interviewed, participants signed a consent form.Recruitment and data collection occurred simultaneously, until theoretical saturation was met and the interviewer was confident that the theory could be refined [26]. Based on similar research studies [16–18, 29], a sample of 20–30 participants was expected.The Ph.D researcher who conducted the interviews (NG) was trained and experienced in qualitative methods. Experts in digital health, implementation sciences, and realist evaluation methods provided support, including a nurse with formal IPC training (DD). None of the research team had previously worked with the care homes.


## 2.2. Data Collection Procedures

The audio-recorded interviews took 29–59 minutes and were conducted in-person at care homes and via Zoom. The interviews were semistructured and similar to Rycroft-Malone et al. [30] that were guided by a schedule (see supplementary file) developed from an underpinning programme theory (see Table 1). The schedule was tailored to the care home context and explored the participant’s experience, hand hygiene training, and perceived barriers/facilitators to implementing AR/VR training. The largest component was dedicated to reflecting on the context-mechanism-outcome (CMO) configurations identified in the realist review and the applicability of this theory to AR/VR hand hygiene training in care homes.Table 1
How AR and VR training may work for upskilling healthcare workers.
Context/conditionMechanism (s)Outcome (s)Realistic (high fidelity) simulations/visualisation+Perceptions of realistic haptics and imagery=More effective learning (e.g., increased understanding/learning, enhanced skills, proficiency, and performance)=Learner satisfaction with tool and realism+Easier and more detailed visualisation of patient anatomy=More effective learning=Learner satisfaction with tool and realism+Interactive experience=More effective learningVR or AR that immerses learners+Engages learners indeep immersion=Improved learning, knowledge, comfort with knowledge, and skill performanceWhen teaching transferable skills or knowledge+Enhances skills=Knowledge and skill transfer to clinical practice and simulators+Practice in a safe environmentNovices+Repeated practice=Technical proficiency, skill acquisition, and improved performanceAs AR/VR hand hygiene training has not been implemented in care homes, images, a verbal summary and a video of theTork VR Clean Hands Training (Essity [13]), and the SureWash Hand Hygiene [15] AR app were shown to participants (see Figure 1). These apps were identified from our review of 90 hand hygiene apps available in the UK and scored highest in quality, functionality, and innovation [14].Figure 1
Images and descriptions of the virtual reality Tork VR Clean Hands Training app and the augmented reality SureWash app.The CMO configurations were then presented to participants who shared their own ideas (personal theories) and opinions on how the intervention might or might not work within care homes. This theory-driven approach was consistent with a realist interview study conducted by Randell et al. [31] and the learner-teacher cycle method [26] and is productive by using interviews as a vehicle for expanding/revising theory [31].Lastly, the interviewer summarised the key points and invited participants to clarify, correct, or contribute more information. Interview recordings were transcribed verbatim and identifying data were removed from transcripts. Participants could review their transcripts.


## 2.3. Data Analysis

Data were analysed thematically in NVivo (version 12.7.0), using a combined deductive and inductive (open-coding) method [32, 33]. Concepts from the programme theory (Table 1) were used for the deductive analysis process, after which data were analysed inductively by looking for themes on the contexts, mechanisms, and outcomes [30].The researcher who conducted the interviews (NG) was familiar with the data identified initial codes as informed by the programme theory. The data from thirteen transcripts were first analysed by adding, changing, and moving codes and labels, with new codes identified for data that did not fit with preexisting codes. A second researcher (DD) double-coded 20% of the data. Final codes and initial themes were determined through discussion. The first researcher then coded the remaining transcripts and finalised the themes. Intercoder reliability was determined using Cohen’s kappa coefficient and a raw agreement rate.Lastly, representative quotes were identified. By drawing on the themes pertaining to contexts, mechanisms, and outcomes, similarities and differences were identified from the initial programme theory.


## 2.4. Upholding Rigour and Quality

Immediate and delayed member-checking helped to ensure that the findings are credible [34]. We also employed analyst triangulation for validation of interpretation and to ensure that the analysis is robust and rich. There was substantial agreement κ = 0.79 (raw agreement 98.78%) between the coders. Lastly, thick description helped to establish transferability. This requires contextualising findings [35]. We provided a detailed description of the phenomena and considered context, which is a focus of the study and central to a realist approach.


## 3. Results

### 3.1. Participant and Care Home Characteristics

We contacted 47 care homes, of which 11 were interested in participating (Figure2). Five were lost after recruitment, resulting in six homes participating. Two were in COVID-19 lockdowns during data collection. Three were residential, and three were nursing homes. Half were independent and half were part of a chain organisation. Four were medium-sized (24–49 beds) and two were large (50–60 beds). Two homes had an external VR training programme delivered to their staff for dementia awareness, and another delivered VR distraction therapy to residents.Figure 2
Flowchart showing the care home and participant recruitment process.We recruited 28 staff members from the six homes, of which three did not participate due to unavailability (n = 2) and language barriers (n = 1). The 21 carers and four managers/deputies had a mean age of 38.88 years (range 21–58) with 3 months to 26 years of work experience. The majority (92%, n = 23) of the participants identified as female and only two identified as male. Table 2 presents the characteristics.Table 2
Participant characteristics.
Participant characteristicsNumberAge rangeEthnicityRoleExperienceP135–44White BritishManager3.5 yearsP245–54White BritishDeputy manager26 yearsP335–44SikhCarer8 monthsP425–34White BritishCarer3 monthsP545–54Mixed CaribbeanSenior carer6 yearsP635–44White BritishDeputy manager3 yearsP745–54White BritishSenior carer5 yearsP835–44White BritishCarer; senior carera9 yearsP935–44White BritishSenior carer6 yearsP1035–44White BritishCarer7 yearsP1125–34White BritishCarer4 monthsP1255–64White BritishSenior carer10 yearsP1325–34Mixed African and whiteCarer9.5 yearsP1425–34Asian PakistaniCarer6 monthsP1525–34PakistaniSenior carer10 monthsP1635–44White BritishDeputy manager20 yearsP1745–54White BritishSenior carer3 yearsP1855–64White BritishCarer2.5 yearsP1925–34White BritishCarer2 yearsP2055–64White BritishCarer; senior carera26 yearsP2125–34White BritishCarer1 year and 2 monthsP2218–24British PakistaniCarer4 yearsP2355–64White BritishCarer2 yearsP2418–24British PakistaniCarer2 years and 2 monthsP2518–24White BritishCarer4 monthsNote. aWorked as senior carers in some shifts, as needed.


### 3.2. Hand Hygiene in Care Homes

Participants explained their current hand hygiene practice, training received, and monitoring processes. Supporting quotes are presented in Table3.Table 3
Supporting quotes on hand hygiene in care homes.
Hand hygiene practice(i) A lot of people probably do less than that (30 seconds). So it’s probably do, probably do for 10 seconds. (P5)Hand hygiene training(i) Okay so to be honest at the beginning of my career which was like nine/ten years ago now there wasn’t really much hand hygiene training at all….It wasn’t so much as you know the importance of hand hygiene as it is now because obviously with the impact of COVID it’s become a massive topic and it’s become a massive training subject. (P6)(ii) I don’t think I’ve ever thought much into hand hygiene in that sort of a sense, it’s more like a tick-box thing for a lot of people, but I think it’s definitely a good thing and implementing it into care homes is definitely another thing because like everything is in the hospitals. (P22)Hand hygiene monitoring(i) If we think someone’s not, we will hover around to-because when you’re stood over them, they know you’re watching them, so, you hover around. (P1)(ii) Every weekend we have a form that we have to fill in and we can go around and like watch the staff wash their hands and if they’re doing it wrong basically-I’m not saying they’re doing it wrong but if they do it, just correct them a little bit and just say this is how you do it… (P8)


#### 3.2.1. Current Practice

Participants prioritised hand washing with soap and water. There was no consensus for when to use sanitizer gel, which was mounted on walls, placed on tables, or clipped onto uniforms. Participants reported using sanitizer periodically (e.g., every 30 minutes), when it was impossible to use water or after wearing single-use gloves. However, of the 15 staff who mentioned using gloves, only 8 reported practicing hand hygiene before donning them.The focus was placed on keeping nails short and cleaning between fingers, palms, back of hands, under nails, wrists, and up elbows. Participants reported practicing from “a couple of seconds” to two minutes. However, the length varied depending on the situation and the carer. One participant explained that some carers only practiced for 10 seconds.Key moments included the following: before entering the building and kitchen, before and after activities or delivering care, between residents, after touching fluids, after a break or using the toilet, and before leaving the home. Only two staff reported practicing hand hygiene before exiting a resident’s room.


#### 3.2.2. Training

Most of the carers had received some hand hygiene training, with some of the experienced staff reporting an absence of formal training when they first started working. They reported that the COVID-19 pandemic had increased focus on hand hygiene. There was consensus that ongoing training is important, as hand hygiene is overlooked in care homes. One participant described hand hygiene in care homes as a “tick-box” exercise, and something that is more valued in hospitals.When training was provided, it was a short module during the initial training package. This was delivered in-person prior to the pandemic using demonstrations and pamphlets, and online during the pandemic, using videos, written descriptions, or remote demonstrations via teleconference. Some homes provided in-person training and occasional refresher sessions, ranging from every two months to annually. Some staff were unaware of training, as they were trained by another home and not retrained.Resources complemented training. All homes placed posters by basins to remind staff of the best practice technique, using visual cues such as diagrams. Three homes used a Glitterbug machine, whereby staff applied a gel containing fluorescent dye to their hands, simulated hand washing, and then placed their hands under an ultraviolet light to identify areas which had not been cleaned. However, problems were reported, such as running out of gel and the lights breaking.


#### 3.2.3. Monitoring

Participants across five homes reported that their hand hygiene practice was monitored. However, some newer staff had never experienced monitoring and were unaware of it. Poor practice was corrected through verbal explanations or demonstrations by the observing staff member or by refreshing training.Informal spot checks were conducted in four homes by senior carers, management staff, and the chefs. One manager explained that they discreetly observe their staff if they think they are not performing appropriate hand hygiene. Two homes conducted weekly or monthly formal monitoring sessions. Senior carers and management observed carers performing hand hygiene and completed a checklist or competency log to identify staff who require retraining.


### 3.3. Context and Implementation Considerations

Themes were evident on how context matters when implementing AR/VR training. The subthemes were categorised into broader themes on the learners (for whom), care homes (where and when), and technology (what). Table 4 presents the supporting quotes.Table 4
Supporting quotes on context and implementation considerations, mechanisms, and outcomes related to hand hygiene training delivered using augmented and virtual reality.
Context and implementation considerationsLearners(i) Well, when you get people coming in that’s never worked in a care home or in care work at all you ask somebody if they know how to wash their hands and they say, “yes.” And they just do a quick wash and that’s it, you know, it’s more involved than that. (P18)(ii) I do think with the residents, it might be a really good idea, because a lot of them, you know, I don’t want to sound rude, but they end up with faeces on them, and it is quite hard to get it from under the fingernails. So, it might be quite fun for them. (P4)Care homes(i) We don’t have work phones, so then staff would be expected to do it on their own phone, whereas they’re not expected to do their training on their own phones, they’re supposed to use our computers. We pay them for their time and things like that. (P13)(ii) It’s (VR) taking someone off the floor, whereas this one (AR) can be done on the floor with the service users as well. You wouldn’t have to leave. (P12)Technology(i) Probably the cost of it with the headset and things for a small business like ourselves we wouldn’t be able to go down that route… some virtual reality things you’re looking more like £100,000 but, no, for less than £100 if you can get it in-situ then that’s fine. (P1)MechanismsPerceptions of realism(i) In a hospital you’ve got all definite wipeable floors and everything in there is very clinical, whereas in a care home it’s a homely environment, it’s not necessarily like that. So you’d need to be transported into that environment for it to be effective. (P1)(ii) I don’t think we’re different to a hospital setting…. We do nine out of ten things the nurse staff do at the hospital, and we’ve got our own nursing ward upstairs…. If it’s okay for a hospital setting, I think it’s okay for a care home setting at the same time. (P9)(iii) I think it’s got to be realistic because otherwise, they don’t relate it to their work. (P1)Visualisation of personal anatomy(i) I think seeing what mistakes could happen if you didn’t do things right would also make people take a step back and think more about what they were doing. (P5)(ii) I think the top one (AR) is better than the bottom one (VR) because you can actually see your hands doing it. (P12)(iii) I think would be more relevant to hospitals especially if you’re dealing with wounds and injuries and blood and things like that than to a care home. (P22)Interactive learning experience(i) People zone out. It can be really boring to sit there for an hour while someone talks at you, whereas this is more interactive and you’re more likely to pay attention. (P13)(ii) You’re talking about what you’re doing, so I think you’re learning more as you’re talking…. We’d probably have a bit of banter and say, “Don’t forget to do your thumbs.” And I just think it makes you more relaxed. And I think the more you relax, the more you pay attention.Deep immersion in VR(i) I think when you’re transported to a different world, it makes you see things differently, and you might learn differently. (P4)(ii) I really agree with the idea that when you’re immersed in it when you don’t have the distractions of everything else going on, you’re paying attention. So if you’re just sitting on your phone and you’re looking at an app I don’t think you get the same sort of focus as you would do if you were, you know, had the headset on and you’re physically there….I’m not sure how high they would rate it on the scale of importance but I think if the ultimate goal was to get people to learn better. I think they’d be learning better if they were in there. (P25)Practice in a safe environment(i) It is more like you’re being hands-on without actually being hands-on. There’s no danger, rather than going in and like I said, spreading things around. There’s no danger with it and you’re learning before that happens. (P13)(ii) If you’ve learnt in like a safe environment where everything is calm and quiet and easy enough and there’s enough time, once you’re out there’s not always enough time- how are you going to make sure you’re still efficient? (P22)Repeated practice(i) You can get lackadaisical in anything, so yes, I do think repeated practice is needed for nearly all skills to be fair, not just hand hygiene. (P9)(ii) Obviously muscle memory - the more you’re doing it the more you’re sort of remembering that’s what I need to be doing….The more you do it the more you remember that’s what you are supposed to do and so naturally the more you’re going to do it. (P25)Feedback and reminding(i) You know, it’s just that reminder, like I say, even though I automatically do it, I do look at the boards that are in the toilets and that, just to double check myself, to say I am doing it correctly. So, having something, an app like that would be great on the phone, that I could do it myself. (P17)(ii) It’s quite easy for somebody to be watching you and miss it out themselves because humans are a bit more vulnerable to making mistakes than computers aren’t they? (P25)Outcomes(i) I think it would give a lot of carers a lot more, you know, understanding, make them a lot more aware of how and when they sanitise and wash their hands. (P6)(ii) I would expect that the staff wash their hands more and do it correctly every time. (P12)(iii) It is the learning and passing on the learning, but at the end of the day it’s best practice for the protection of residents, and for each other, so I think that would be the main thing for me. (P17)


#### 3.3.1. Learners-for Whom

All participants agreed that novice carers would benefit from AR/VR hand hygiene training. Participants explained that carers do not receive extensive training, unlike medical professionals. Hence, novices require training on the proper hand hygiene technique for care settings, which differs from day-to-day practice.Participants identified others who would also benefit, as they contribute to spreading infectious diseases: nurses, management, domestic staff (cleaners, kitchen staff, and laundry staff), emergency services (e.g., paramedics), activities coordinators, district nurses, general practitioners, maintenance staff, and visitors. Some participants explained that noncare staff (e.g., office staff) also help in delivering care when required, and they thus have direct contact. An opportunity to create a “fun” activity for residents who do not want to wash their hands was also identified. Beyond care homes, participants expected that children and schools, dentists, and NHS staff would also benefit from it.Participants generally expected staff to be receptive to one of the two technologies, stating that younger staff would be especially receptive to VR. However, seven participants identified that the training might not be suitable for older staff who may be uncomfortable with technology. It was agreed that a PC version or pretraining would help.Individual preferences for the technology were evident: 11 preferred AR, eight preferred VR, and six had no preference. There was consensus in one care home, where everyone preferred VR. Expectations of discomfort and not being able to use the technology, the environment differing from care homes, and the cost and time to use the headset deterred participants from VR. However, there was consensus that both technologies could be used frequently as “refresher” sessions and they would complement existing training sessions, including monitoring. There was also potential for carers to use the AR training in their spare time, as they have access to their own devices.


#### 3.3.2. Care Homes-Where and When

Some staff identified policies restricting personal phone use during work which could create barriers to using the apps. Others mentioned policies regarding payment and access to further education opportunities. For example, in some homes staff are paid for upskilling, while in others this is unpaid and optional, leading to staff resistance and poor uptake. The homes are also expected to provide learning equipment.Participants identified programme delivery considerations regarding infrastructure and staffing. Two participants from the same home identified potential issues with Internet access. Six participants identified that the VR training would require staff to leave the floor, which could create problems with short-staffing, compared to AR training which can be done without leaving.


#### 3.3.3. Technology-What

Two technology-related considerations were identified: cost and using the VR headset. Six participants (mostly from the smaller care homes) identified that technology costs would create barriers, given that the training budgets are small, or they would need to seek funding. Participants agreed that a cost of £30–100 per headset would be manageable and that the training could be conducted individually with shared equipment. No problems were identified with the AR app.Five participants were also hesitant about using a VR headset, as it can be unsettling and cause dizziness. Suggested strategies to overcome these problems were providing a nonimmersive PC alternative and conducting health prescreenings to identify anyone prone to vertigo.


### 3.4. Mechanisms

The programme theory from the realist review identified that AR/VR training can trigger perceptions of realism, visualisation of anatomy, an interactive experience, deep immersion, enhance skills, and enable practice in a safe environment and repeated practice [22]. Participants agreed with most of these mechanisms and applied them to hand hygiene training in care homes, however, they expected that “enhancing skills” was an outcome. A new mechanism, “feedback and reminding,” was identified. See Table 4 for supporting quotes.


#### 3.4.1. Perceptions of Realism (VR Environment, Imagery, and Task)

Participants spoke more about environmental and task realism, rather than the imagery. Ten questioned whether the hospital scenario in the VR app is relevant to hand hygiene in care homes, citing differences in the environment. These included carer roles differing from physicians, home environments not being wipeable, understaffing in care homes creating barriers to practice, and residents being mobile and able to touch things. However, 15 disagreed and did not perceive the differing environment to cause problems. They reported that nursing homes perform similar tasks (e.g., IVs and catheterisation), that some residents are bed-bound, and that care is the same regardless.Eight participants mentioned the realism of the imagery. Three participants thought it was important for the imagery to be realistic and not animated, so that it is taken seriously and more relevant to learners. In contrast, five did not perceive it as important, given that most of the training is already animated.It was clear that task realism was more important than the environment and imagery, whereby carers learn hand hygiene as they would practice it in their work. If this was not deemed realistic, participants expected that learners would lose interest, not take it as seriously, and not understand the relevance of their work.


#### 3.4.2. Visualisation of Personal Anatomy

Half of the participants agreed that visualisation could be important, but explained that this was about visualising personal anatomy (hands) and seeing their mistakes, rather than seeing a patient, as identified in the theory [22]. Participants stated that it would be helpful seeing how they should be performing hand hygiene and that visualising this, along with their mistakes and consequences of poor practice would help to facilitate understanding and awareness.Visualisation of hands was expected to be better in AR apps, where learners can see their own hands, compared to VR. Twelve participants were unsure about visualisation as an important mechanism. Some highlighted that visualisation might be beneficial for novices who have never seen a care home before or for other purposes, such as wound care in hospitals.


#### 3.4.3. Interactive Learning Experience

Twenty-one participants spoke about AR and VR training as more “hands-on” and “fun,” compared to “boring” passive learning via listening, reading, or watching. Aspects of VR/AR that facilitated interactivity included feedback, reminding, and immersion. Five participants identified that AR/VR can act as a catalyst for social interaction. For example, they can encourage conversation around hand hygiene between carers, making learners more relaxed and facilitating learning.


#### 3.4.4. Deep Immersion in VR

The importance of deep immersion was contested. Some staff indicated that it could be more helpful for complicated tasks within hospitals or for newer staff, who had no care home experience. However, others explained that immersion enables learners to see things differently. A carer explained that immersion can be important for eliminating distractions, and while possibly not the most important mechanism, it could be helpful for supporting learning.


#### 3.4.5. Practice in a Safe Environment

Participants disagreed on whether practicing hand hygiene in a safe environment (i.e., on AR/VR) away from the residents was important. Sixteen participants agreed that it was important to practice away from residents, to protect them from harm related to poor technique (e.g., spreading infectious diseases) and environmental considerations (e.g., residents consuming sanitizer gel or hot water splashing).Seven participants were unsure as to whether this mechanism was important and two disagreed with its importance. Reasons included that residents could be involved during practice and that practice is more challenging in real life when situations are not calm, quiet, and easy. Thus, on-the-job training is more important.


#### 3.4.6. Repeated Practice

All participants believed that repeated practice was important for hand hygiene and could be facilitated by AR/VR. It was reported that like any other skill, people can also become complacent and forgetful and develop poor practice.Participants explained that repeated practice and ongoing training via AR/VR may help to build muscle memory, whereby practice becomes subconscious and engrained. The practice was thus expected to be more important than listening to others speak about hand hygiene or learning via reading.


#### 3.4.7. Feedback and Reminding

AR/VR was expected to correct and improve hand hygiene practice through feedback and reminding. These mechanisms were expected to encourage all learners to adjust their practice, including novices and experienced carers who may have engrained poor practice. Participants reported that the apps can give carers feedback on their hand hygiene by identifying things that are incorrect or need to be improved. Additionally, the apps could remind learners of proper practice, like the posters by basins.The apps were also expected to be more reliable for identifying mistakes, compared to in-person monitoring. According to a carer, it is easy for humans to make mistakes and to miss errors when observing in-person, compared to computers.


### 3.5. Outcomes

The initial programme theory identified that AR/VR training can result in more effective learning, improved skill performance, learner satisfaction, and skill transfer to practice [22]. All participants agreed with these expected outcomes, including that hand hygiene skills learned on AR/VR could be enhanced and transferred to practice. Increased awareness about proper technique and the spread of infections was expected to help support learning and understanding of hand hygiene. Participants also expected that technique would be corrected and thus performed properly, every time.An expected long-term outcome was infection control, resulting in lower rates of COVID-19, norovirus, diarrhoea, and vomiting. One participant explained that resident protection and protecting care home staff, rather than learning, is the most important outcome. Supporting quotes are presented in Table4.


### 3.6. Revised Context-Mechanism-Outcome Configurations

Revisions were made to the programme theory to reflect the new CMOs (see Table5). The most important mechanisms were considered to be repeated practice, feedback and reminding, perceived task realism, and interactivity. There was less support for the importance of hand hygiene practice in a safe learning environment, deep immersion, environmental and imagery realism, and visualisation of personal anatomy and mistakes. Outcomes were related to effective learning, learner satisfaction, enhanced hand hygiene skill, and infection control.Table 5
Revised context-mechanism-outcome configurations for AR and VR hand hygiene training in care homes.
Context/conditionMechanism (s)Outcome (s)Realistic (high fidelity) simulations+Perceived task realism (relevance to work)=Effective learning (understanding and awareness of technique and spread of infections)= Learner satisfactionContested mechanisms:+Perceived realism of imagery+Visualisation of personal anatomy (hands) and mistakesImmersive VR+Perceived task realism (relevance to work)= Learner satisfaction=Effective learning (awareness of technique and spread of infections)+Interactive learning experienceContested mechanisms:+Engages learners in deep immersion+Perceived environmental realismNovice carers+Repeated practice=Effective learning (understanding and awareness of technique and spread of infections)= Learner satisfaction=Enhanced hand hygiene skills (improved technique and/or skill performance in care homes)Contested mechanisms:+Engages learners in deep immersion+Practice in a safe environmentCare homes that require ongoing hand hygiene training/refresher+Feedback and reminding=Enhanced hand hygiene skills (improved technique and/or skill performance in care homes)=Infection control and lower rates of infections; resident and staff safety+Interactive learning+Repeated practice


## 3.1. Participant and Care Home Characteristics

We contacted 47 care homes, of which 11 were interested in participating (Figure2). Five were lost after recruitment, resulting in six homes participating. Two were in COVID-19 lockdowns during data collection. Three were residential, and three were nursing homes. Half were independent and half were part of a chain organisation. Four were medium-sized (24–49 beds) and two were large (50–60 beds). Two homes had an external VR training programme delivered to their staff for dementia awareness, and another delivered VR distraction therapy to residents.Figure 2
Flowchart showing the care home and participant recruitment process.We recruited 28 staff members from the six homes, of which three did not participate due to unavailability (n = 2) and language barriers (n = 1). The 21 carers and four managers/deputies had a mean age of 38.88 years (range 21–58) with 3 months to 26 years of work experience. The majority (92%, n = 23) of the participants identified as female and only two identified as male. Table 2 presents the characteristics.Table 2
Participant characteristics.
Participant characteristicsNumberAge rangeEthnicityRoleExperienceP135–44White BritishManager3.5 yearsP245–54White BritishDeputy manager26 yearsP335–44SikhCarer8 monthsP425–34White BritishCarer3 monthsP545–54Mixed CaribbeanSenior carer6 yearsP635–44White BritishDeputy manager3 yearsP745–54White BritishSenior carer5 yearsP835–44White BritishCarer; senior carera9 yearsP935–44White BritishSenior carer6 yearsP1035–44White BritishCarer7 yearsP1125–34White BritishCarer4 monthsP1255–64White BritishSenior carer10 yearsP1325–34Mixed African and whiteCarer9.5 yearsP1425–34Asian PakistaniCarer6 monthsP1525–34PakistaniSenior carer10 monthsP1635–44White BritishDeputy manager20 yearsP1745–54White BritishSenior carer3 yearsP1855–64White BritishCarer2.5 yearsP1925–34White BritishCarer2 yearsP2055–64White BritishCarer; senior carera26 yearsP2125–34White BritishCarer1 year and 2 monthsP2218–24British PakistaniCarer4 yearsP2355–64White BritishCarer2 yearsP2418–24British PakistaniCarer2 years and 2 monthsP2518–24White BritishCarer4 monthsNote. aWorked as senior carers in some shifts, as needed.


## 3.2. Hand Hygiene in Care Homes

Participants explained their current hand hygiene practice, training received, and monitoring processes. Supporting quotes are presented in Table3.Table 3
Supporting quotes on hand hygiene in care homes.
Hand hygiene practice(i) A lot of people probably do less than that (30 seconds). So it’s probably do, probably do for 10 seconds. (P5)Hand hygiene training(i) Okay so to be honest at the beginning of my career which was like nine/ten years ago now there wasn’t really much hand hygiene training at all….It wasn’t so much as you know the importance of hand hygiene as it is now because obviously with the impact of COVID it’s become a massive topic and it’s become a massive training subject. (P6)(ii) I don’t think I’ve ever thought much into hand hygiene in that sort of a sense, it’s more like a tick-box thing for a lot of people, but I think it’s definitely a good thing and implementing it into care homes is definitely another thing because like everything is in the hospitals. (P22)Hand hygiene monitoring(i) If we think someone’s not, we will hover around to-because when you’re stood over them, they know you’re watching them, so, you hover around. (P1)(ii) Every weekend we have a form that we have to fill in and we can go around and like watch the staff wash their hands and if they’re doing it wrong basically-I’m not saying they’re doing it wrong but if they do it, just correct them a little bit and just say this is how you do it… (P8)


### 3.2.1. Current Practice

Participants prioritised hand washing with soap and water. There was no consensus for when to use sanitizer gel, which was mounted on walls, placed on tables, or clipped onto uniforms. Participants reported using sanitizer periodically (e.g., every 30 minutes), when it was impossible to use water or after wearing single-use gloves. However, of the 15 staff who mentioned using gloves, only 8 reported practicing hand hygiene before donning them.The focus was placed on keeping nails short and cleaning between fingers, palms, back of hands, under nails, wrists, and up elbows. Participants reported practicing from “a couple of seconds” to two minutes. However, the length varied depending on the situation and the carer. One participant explained that some carers only practiced for 10 seconds.Key moments included the following: before entering the building and kitchen, before and after activities or delivering care, between residents, after touching fluids, after a break or using the toilet, and before leaving the home. Only two staff reported practicing hand hygiene before exiting a resident’s room.


### 3.2.2. Training

Most of the carers had received some hand hygiene training, with some of the experienced staff reporting an absence of formal training when they first started working. They reported that the COVID-19 pandemic had increased focus on hand hygiene. There was consensus that ongoing training is important, as hand hygiene is overlooked in care homes. One participant described hand hygiene in care homes as a “tick-box” exercise, and something that is more valued in hospitals.When training was provided, it was a short module during the initial training package. This was delivered in-person prior to the pandemic using demonstrations and pamphlets, and online during the pandemic, using videos, written descriptions, or remote demonstrations via teleconference. Some homes provided in-person training and occasional refresher sessions, ranging from every two months to annually. Some staff were unaware of training, as they were trained by another home and not retrained.Resources complemented training. All homes placed posters by basins to remind staff of the best practice technique, using visual cues such as diagrams. Three homes used a Glitterbug machine, whereby staff applied a gel containing fluorescent dye to their hands, simulated hand washing, and then placed their hands under an ultraviolet light to identify areas which had not been cleaned. However, problems were reported, such as running out of gel and the lights breaking.


### 3.2.3. Monitoring

Participants across five homes reported that their hand hygiene practice was monitored. However, some newer staff had never experienced monitoring and were unaware of it. Poor practice was corrected through verbal explanations or demonstrations by the observing staff member or by refreshing training.Informal spot checks were conducted in four homes by senior carers, management staff, and the chefs. One manager explained that they discreetly observe their staff if they think they are not performing appropriate hand hygiene. Two homes conducted weekly or monthly formal monitoring sessions. Senior carers and management observed carers performing hand hygiene and completed a checklist or competency log to identify staff who require retraining.


## 3.2.1. Current Practice

Participants prioritised hand washing with soap and water. There was no consensus for when to use sanitizer gel, which was mounted on walls, placed on tables, or clipped onto uniforms. Participants reported using sanitizer periodically (e.g., every 30 minutes), when it was impossible to use water or after wearing single-use gloves. However, of the 15 staff who mentioned using gloves, only 8 reported practicing hand hygiene before donning them.The focus was placed on keeping nails short and cleaning between fingers, palms, back of hands, under nails, wrists, and up elbows. Participants reported practicing from “a couple of seconds” to two minutes. However, the length varied depending on the situation and the carer. One participant explained that some carers only practiced for 10 seconds.Key moments included the following: before entering the building and kitchen, before and after activities or delivering care, between residents, after touching fluids, after a break or using the toilet, and before leaving the home. Only two staff reported practicing hand hygiene before exiting a resident’s room.


## 3.2.2. Training

Most of the carers had received some hand hygiene training, with some of the experienced staff reporting an absence of formal training when they first started working. They reported that the COVID-19 pandemic had increased focus on hand hygiene. There was consensus that ongoing training is important, as hand hygiene is overlooked in care homes. One participant described hand hygiene in care homes as a “tick-box” exercise, and something that is more valued in hospitals.When training was provided, it was a short module during the initial training package. This was delivered in-person prior to the pandemic using demonstrations and pamphlets, and online during the pandemic, using videos, written descriptions, or remote demonstrations via teleconference. Some homes provided in-person training and occasional refresher sessions, ranging from every two months to annually. Some staff were unaware of training, as they were trained by another home and not retrained.Resources complemented training. All homes placed posters by basins to remind staff of the best practice technique, using visual cues such as diagrams. Three homes used a Glitterbug machine, whereby staff applied a gel containing fluorescent dye to their hands, simulated hand washing, and then placed their hands under an ultraviolet light to identify areas which had not been cleaned. However, problems were reported, such as running out of gel and the lights breaking.


## 3.2.3. Monitoring

Participants across five homes reported that their hand hygiene practice was monitored. However, some newer staff had never experienced monitoring and were unaware of it. Poor practice was corrected through verbal explanations or demonstrations by the observing staff member or by refreshing training.Informal spot checks were conducted in four homes by senior carers, management staff, and the chefs. One manager explained that they discreetly observe their staff if they think they are not performing appropriate hand hygiene. Two homes conducted weekly or monthly formal monitoring sessions. Senior carers and management observed carers performing hand hygiene and completed a checklist or competency log to identify staff who require retraining.


## 3.3. Context and Implementation Considerations

Themes were evident on how context matters when implementing AR/VR training. The subthemes were categorised into broader themes on the learners (for whom), care homes (where and when), and technology (what). Table 4 presents the supporting quotes.Table 4
Supporting quotes on context and implementation considerations, mechanisms, and outcomes related to hand hygiene training delivered using augmented and virtual reality.
Context and implementation considerationsLearners(i) Well, when you get people coming in that’s never worked in a care home or in care work at all you ask somebody if they know how to wash their hands and they say, “yes.” And they just do a quick wash and that’s it, you know, it’s more involved than that. (P18)(ii) I do think with the residents, it might be a really good idea, because a lot of them, you know, I don’t want to sound rude, but they end up with faeces on them, and it is quite hard to get it from under the fingernails. So, it might be quite fun for them. (P4)Care homes(i) We don’t have work phones, so then staff would be expected to do it on their own phone, whereas they’re not expected to do their training on their own phones, they’re supposed to use our computers. We pay them for their time and things like that. (P13)(ii) It’s (VR) taking someone off the floor, whereas this one (AR) can be done on the floor with the service users as well. You wouldn’t have to leave. (P12)Technology(i) Probably the cost of it with the headset and things for a small business like ourselves we wouldn’t be able to go down that route… some virtual reality things you’re looking more like £100,000 but, no, for less than £100 if you can get it in-situ then that’s fine. (P1)MechanismsPerceptions of realism(i) In a hospital you’ve got all definite wipeable floors and everything in there is very clinical, whereas in a care home it’s a homely environment, it’s not necessarily like that. So you’d need to be transported into that environment for it to be effective. (P1)(ii) I don’t think we’re different to a hospital setting…. We do nine out of ten things the nurse staff do at the hospital, and we’ve got our own nursing ward upstairs…. If it’s okay for a hospital setting, I think it’s okay for a care home setting at the same time. (P9)(iii) I think it’s got to be realistic because otherwise, they don’t relate it to their work. (P1)Visualisation of personal anatomy(i) I think seeing what mistakes could happen if you didn’t do things right would also make people take a step back and think more about what they were doing. (P5)(ii) I think the top one (AR) is better than the bottom one (VR) because you can actually see your hands doing it. (P12)(iii) I think would be more relevant to hospitals especially if you’re dealing with wounds and injuries and blood and things like that than to a care home. (P22)Interactive learning experience(i) People zone out. It can be really boring to sit there for an hour while someone talks at you, whereas this is more interactive and you’re more likely to pay attention. (P13)(ii) You’re talking about what you’re doing, so I think you’re learning more as you’re talking…. We’d probably have a bit of banter and say, “Don’t forget to do your thumbs.” And I just think it makes you more relaxed. And I think the more you relax, the more you pay attention.Deep immersion in VR(i) I think when you’re transported to a different world, it makes you see things differently, and you might learn differently. (P4)(ii) I really agree with the idea that when you’re immersed in it when you don’t have the distractions of everything else going on, you’re paying attention. So if you’re just sitting on your phone and you’re looking at an app I don’t think you get the same sort of focus as you would do if you were, you know, had the headset on and you’re physically there….I’m not sure how high they would rate it on the scale of importance but I think if the ultimate goal was to get people to learn better. I think they’d be learning better if they were in there. (P25)Practice in a safe environment(i) It is more like you’re being hands-on without actually being hands-on. There’s no danger, rather than going in and like I said, spreading things around. There’s no danger with it and you’re learning before that happens. (P13)(ii) If you’ve learnt in like a safe environment where everything is calm and quiet and easy enough and there’s enough time, once you’re out there’s not always enough time- how are you going to make sure you’re still efficient? (P22)Repeated practice(i) You can get lackadaisical in anything, so yes, I do think repeated practice is needed for nearly all skills to be fair, not just hand hygiene. (P9)(ii) Obviously muscle memory - the more you’re doing it the more you’re sort of remembering that’s what I need to be doing….The more you do it the more you remember that’s what you are supposed to do and so naturally the more you’re going to do it. (P25)Feedback and reminding(i) You know, it’s just that reminder, like I say, even though I automatically do it, I do look at the boards that are in the toilets and that, just to double check myself, to say I am doing it correctly. So, having something, an app like that would be great on the phone, that I could do it myself. (P17)(ii) It’s quite easy for somebody to be watching you and miss it out themselves because humans are a bit more vulnerable to making mistakes than computers aren’t they? (P25)Outcomes(i) I think it would give a lot of carers a lot more, you know, understanding, make them a lot more aware of how and when they sanitise and wash their hands. (P6)(ii) I would expect that the staff wash their hands more and do it correctly every time. (P12)(iii) It is the learning and passing on the learning, but at the end of the day it’s best practice for the protection of residents, and for each other, so I think that would be the main thing for me. (P17)


### 3.3.1. Learners-for Whom

All participants agreed that novice carers would benefit from AR/VR hand hygiene training. Participants explained that carers do not receive extensive training, unlike medical professionals. Hence, novices require training on the proper hand hygiene technique for care settings, which differs from day-to-day practice.Participants identified others who would also benefit, as they contribute to spreading infectious diseases: nurses, management, domestic staff (cleaners, kitchen staff, and laundry staff), emergency services (e.g., paramedics), activities coordinators, district nurses, general practitioners, maintenance staff, and visitors. Some participants explained that noncare staff (e.g., office staff) also help in delivering care when required, and they thus have direct contact. An opportunity to create a “fun” activity for residents who do not want to wash their hands was also identified. Beyond care homes, participants expected that children and schools, dentists, and NHS staff would also benefit from it.Participants generally expected staff to be receptive to one of the two technologies, stating that younger staff would be especially receptive to VR. However, seven participants identified that the training might not be suitable for older staff who may be uncomfortable with technology. It was agreed that a PC version or pretraining would help.Individual preferences for the technology were evident: 11 preferred AR, eight preferred VR, and six had no preference. There was consensus in one care home, where everyone preferred VR. Expectations of discomfort and not being able to use the technology, the environment differing from care homes, and the cost and time to use the headset deterred participants from VR. However, there was consensus that both technologies could be used frequently as “refresher” sessions and they would complement existing training sessions, including monitoring. There was also potential for carers to use the AR training in their spare time, as they have access to their own devices.


### 3.3.2. Care Homes-Where and When

Some staff identified policies restricting personal phone use during work which could create barriers to using the apps. Others mentioned policies regarding payment and access to further education opportunities. For example, in some homes staff are paid for upskilling, while in others this is unpaid and optional, leading to staff resistance and poor uptake. The homes are also expected to provide learning equipment.Participants identified programme delivery considerations regarding infrastructure and staffing. Two participants from the same home identified potential issues with Internet access. Six participants identified that the VR training would require staff to leave the floor, which could create problems with short-staffing, compared to AR training which can be done without leaving.


### 3.3.3. Technology-What

Two technology-related considerations were identified: cost and using the VR headset. Six participants (mostly from the smaller care homes) identified that technology costs would create barriers, given that the training budgets are small, or they would need to seek funding. Participants agreed that a cost of £30–100 per headset would be manageable and that the training could be conducted individually with shared equipment. No problems were identified with the AR app.Five participants were also hesitant about using a VR headset, as it can be unsettling and cause dizziness. Suggested strategies to overcome these problems were providing a nonimmersive PC alternative and conducting health prescreenings to identify anyone prone to vertigo.


## 3.3.1. Learners-for Whom

All participants agreed that novice carers would benefit from AR/VR hand hygiene training. Participants explained that carers do not receive extensive training, unlike medical professionals. Hence, novices require training on the proper hand hygiene technique for care settings, which differs from day-to-day practice.Participants identified others who would also benefit, as they contribute to spreading infectious diseases: nurses, management, domestic staff (cleaners, kitchen staff, and laundry staff), emergency services (e.g., paramedics), activities coordinators, district nurses, general practitioners, maintenance staff, and visitors. Some participants explained that noncare staff (e.g., office staff) also help in delivering care when required, and they thus have direct contact. An opportunity to create a “fun” activity for residents who do not want to wash their hands was also identified. Beyond care homes, participants expected that children and schools, dentists, and NHS staff would also benefit from it.Participants generally expected staff to be receptive to one of the two technologies, stating that younger staff would be especially receptive to VR. However, seven participants identified that the training might not be suitable for older staff who may be uncomfortable with technology. It was agreed that a PC version or pretraining would help.Individual preferences for the technology were evident: 11 preferred AR, eight preferred VR, and six had no preference. There was consensus in one care home, where everyone preferred VR. Expectations of discomfort and not being able to use the technology, the environment differing from care homes, and the cost and time to use the headset deterred participants from VR. However, there was consensus that both technologies could be used frequently as “refresher” sessions and they would complement existing training sessions, including monitoring. There was also potential for carers to use the AR training in their spare time, as they have access to their own devices.


## 3.3.2. Care Homes-Where and When

Some staff identified policies restricting personal phone use during work which could create barriers to using the apps. Others mentioned policies regarding payment and access to further education opportunities. For example, in some homes staff are paid for upskilling, while in others this is unpaid and optional, leading to staff resistance and poor uptake. The homes are also expected to provide learning equipment.Participants identified programme delivery considerations regarding infrastructure and staffing. Two participants from the same home identified potential issues with Internet access. Six participants identified that the VR training would require staff to leave the floor, which could create problems with short-staffing, compared to AR training which can be done without leaving.


## 3.3.3. Technology-What

Two technology-related considerations were identified: cost and using the VR headset. Six participants (mostly from the smaller care homes) identified that technology costs would create barriers, given that the training budgets are small, or they would need to seek funding. Participants agreed that a cost of £30–100 per headset would be manageable and that the training could be conducted individually with shared equipment. No problems were identified with the AR app.Five participants were also hesitant about using a VR headset, as it can be unsettling and cause dizziness. Suggested strategies to overcome these problems were providing a nonimmersive PC alternative and conducting health prescreenings to identify anyone prone to vertigo.


## 3.4. Mechanisms

The programme theory from the realist review identified that AR/VR training can trigger perceptions of realism, visualisation of anatomy, an interactive experience, deep immersion, enhance skills, and enable practice in a safe environment and repeated practice [22]. Participants agreed with most of these mechanisms and applied them to hand hygiene training in care homes, however, they expected that “enhancing skills” was an outcome. A new mechanism, “feedback and reminding,” was identified. See Table 4 for supporting quotes.


### 3.4.1. Perceptions of Realism (VR Environment, Imagery, and Task)

Participants spoke more about environmental and task realism, rather than the imagery. Ten questioned whether the hospital scenario in the VR app is relevant to hand hygiene in care homes, citing differences in the environment. These included carer roles differing from physicians, home environments not being wipeable, understaffing in care homes creating barriers to practice, and residents being mobile and able to touch things. However, 15 disagreed and did not perceive the differing environment to cause problems. They reported that nursing homes perform similar tasks (e.g., IVs and catheterisation), that some residents are bed-bound, and that care is the same regardless.Eight participants mentioned the realism of the imagery. Three participants thought it was important for the imagery to be realistic and not animated, so that it is taken seriously and more relevant to learners. In contrast, five did not perceive it as important, given that most of the training is already animated.It was clear that task realism was more important than the environment and imagery, whereby carers learn hand hygiene as they would practice it in their work. If this was not deemed realistic, participants expected that learners would lose interest, not take it as seriously, and not understand the relevance of their work.


### 3.4.2. Visualisation of Personal Anatomy

Half of the participants agreed that visualisation could be important, but explained that this was about visualising personal anatomy (hands) and seeing their mistakes, rather than seeing a patient, as identified in the theory [22]. Participants stated that it would be helpful seeing how they should be performing hand hygiene and that visualising this, along with their mistakes and consequences of poor practice would help to facilitate understanding and awareness.Visualisation of hands was expected to be better in AR apps, where learners can see their own hands, compared to VR. Twelve participants were unsure about visualisation as an important mechanism. Some highlighted that visualisation might be beneficial for novices who have never seen a care home before or for other purposes, such as wound care in hospitals.


### 3.4.3. Interactive Learning Experience

Twenty-one participants spoke about AR and VR training as more “hands-on” and “fun,” compared to “boring” passive learning via listening, reading, or watching. Aspects of VR/AR that facilitated interactivity included feedback, reminding, and immersion. Five participants identified that AR/VR can act as a catalyst for social interaction. For example, they can encourage conversation around hand hygiene between carers, making learners more relaxed and facilitating learning.


### 3.4.4. Deep Immersion in VR

The importance of deep immersion was contested. Some staff indicated that it could be more helpful for complicated tasks within hospitals or for newer staff, who had no care home experience. However, others explained that immersion enables learners to see things differently. A carer explained that immersion can be important for eliminating distractions, and while possibly not the most important mechanism, it could be helpful for supporting learning.


### 3.4.5. Practice in a Safe Environment

Participants disagreed on whether practicing hand hygiene in a safe environment (i.e., on AR/VR) away from the residents was important. Sixteen participants agreed that it was important to practice away from residents, to protect them from harm related to poor technique (e.g., spreading infectious diseases) and environmental considerations (e.g., residents consuming sanitizer gel or hot water splashing).Seven participants were unsure as to whether this mechanism was important and two disagreed with its importance. Reasons included that residents could be involved during practice and that practice is more challenging in real life when situations are not calm, quiet, and easy. Thus, on-the-job training is more important.


### 3.4.6. Repeated Practice

All participants believed that repeated practice was important for hand hygiene and could be facilitated by AR/VR. It was reported that like any other skill, people can also become complacent and forgetful and develop poor practice.Participants explained that repeated practice and ongoing training via AR/VR may help to build muscle memory, whereby practice becomes subconscious and engrained. The practice was thus expected to be more important than listening to others speak about hand hygiene or learning via reading.


### 3.4.7. Feedback and Reminding

AR/VR was expected to correct and improve hand hygiene practice through feedback and reminding. These mechanisms were expected to encourage all learners to adjust their practice, including novices and experienced carers who may have engrained poor practice. Participants reported that the apps can give carers feedback on their hand hygiene by identifying things that are incorrect or need to be improved. Additionally, the apps could remind learners of proper practice, like the posters by basins.The apps were also expected to be more reliable for identifying mistakes, compared to in-person monitoring. According to a carer, it is easy for humans to make mistakes and to miss errors when observing in-person, compared to computers.


## 3.4.1. Perceptions of Realism (VR Environment, Imagery, and Task)

Participants spoke more about environmental and task realism, rather than the imagery. Ten questioned whether the hospital scenario in the VR app is relevant to hand hygiene in care homes, citing differences in the environment. These included carer roles differing from physicians, home environments not being wipeable, understaffing in care homes creating barriers to practice, and residents being mobile and able to touch things. However, 15 disagreed and did not perceive the differing environment to cause problems. They reported that nursing homes perform similar tasks (e.g., IVs and catheterisation), that some residents are bed-bound, and that care is the same regardless.Eight participants mentioned the realism of the imagery. Three participants thought it was important for the imagery to be realistic and not animated, so that it is taken seriously and more relevant to learners. In contrast, five did not perceive it as important, given that most of the training is already animated.It was clear that task realism was more important than the environment and imagery, whereby carers learn hand hygiene as they would practice it in their work. If this was not deemed realistic, participants expected that learners would lose interest, not take it as seriously, and not understand the relevance of their work.


## 3.4.2. Visualisation of Personal Anatomy

Half of the participants agreed that visualisation could be important, but explained that this was about visualising personal anatomy (hands) and seeing their mistakes, rather than seeing a patient, as identified in the theory [22]. Participants stated that it would be helpful seeing how they should be performing hand hygiene and that visualising this, along with their mistakes and consequences of poor practice would help to facilitate understanding and awareness.Visualisation of hands was expected to be better in AR apps, where learners can see their own hands, compared to VR. Twelve participants were unsure about visualisation as an important mechanism. Some highlighted that visualisation might be beneficial for novices who have never seen a care home before or for other purposes, such as wound care in hospitals.


## 3.4.3. Interactive Learning Experience

Twenty-one participants spoke about AR and VR training as more “hands-on” and “fun,” compared to “boring” passive learning via listening, reading, or watching. Aspects of VR/AR that facilitated interactivity included feedback, reminding, and immersion. Five participants identified that AR/VR can act as a catalyst for social interaction. For example, they can encourage conversation around hand hygiene between carers, making learners more relaxed and facilitating learning.


## 3.4.4. Deep Immersion in VR

The importance of deep immersion was contested. Some staff indicated that it could be more helpful for complicated tasks within hospitals or for newer staff, who had no care home experience. However, others explained that immersion enables learners to see things differently. A carer explained that immersion can be important for eliminating distractions, and while possibly not the most important mechanism, it could be helpful for supporting learning.


## 3.4.5. Practice in a Safe Environment

Participants disagreed on whether practicing hand hygiene in a safe environment (i.e., on AR/VR) away from the residents was important. Sixteen participants agreed that it was important to practice away from residents, to protect them from harm related to poor technique (e.g., spreading infectious diseases) and environmental considerations (e.g., residents consuming sanitizer gel or hot water splashing).Seven participants were unsure as to whether this mechanism was important and two disagreed with its importance. Reasons included that residents could be involved during practice and that practice is more challenging in real life when situations are not calm, quiet, and easy. Thus, on-the-job training is more important.


## 3.4.6. Repeated Practice

All participants believed that repeated practice was important for hand hygiene and could be facilitated by AR/VR. It was reported that like any other skill, people can also become complacent and forgetful and develop poor practice.Participants explained that repeated practice and ongoing training via AR/VR may help to build muscle memory, whereby practice becomes subconscious and engrained. The practice was thus expected to be more important than listening to others speak about hand hygiene or learning via reading.


## 3.4.7. Feedback and Reminding

AR/VR was expected to correct and improve hand hygiene practice through feedback and reminding. These mechanisms were expected to encourage all learners to adjust their practice, including novices and experienced carers who may have engrained poor practice. Participants reported that the apps can give carers feedback on their hand hygiene by identifying things that are incorrect or need to be improved. Additionally, the apps could remind learners of proper practice, like the posters by basins.The apps were also expected to be more reliable for identifying mistakes, compared to in-person monitoring. According to a carer, it is easy for humans to make mistakes and to miss errors when observing in-person, compared to computers.


## 3.5. Outcomes

The initial programme theory identified that AR/VR training can result in more effective learning, improved skill performance, learner satisfaction, and skill transfer to practice [22]. All participants agreed with these expected outcomes, including that hand hygiene skills learned on AR/VR could be enhanced and transferred to practice. Increased awareness about proper technique and the spread of infections was expected to help support learning and understanding of hand hygiene. Participants also expected that technique would be corrected and thus performed properly, every time.An expected long-term outcome was infection control, resulting in lower rates of COVID-19, norovirus, diarrhoea, and vomiting. One participant explained that resident protection and protecting care home staff, rather than learning, is the most important outcome. Supporting quotes are presented in Table4.


## 3.6. Revised Context-Mechanism-Outcome Configurations

Revisions were made to the programme theory to reflect the new CMOs (see Table5). The most important mechanisms were considered to be repeated practice, feedback and reminding, perceived task realism, and interactivity. There was less support for the importance of hand hygiene practice in a safe learning environment, deep immersion, environmental and imagery realism, and visualisation of personal anatomy and mistakes. Outcomes were related to effective learning, learner satisfaction, enhanced hand hygiene skill, and infection control.Table 5
Revised context-mechanism-outcome configurations for AR and VR hand hygiene training in care homes.
Context/conditionMechanism (s)Outcome (s)Realistic (high fidelity) simulations+Perceived task realism (relevance to work)=Effective learning (understanding and awareness of technique and spread of infections)= Learner satisfactionContested mechanisms:+Perceived realism of imagery+Visualisation of personal anatomy (hands) and mistakesImmersive VR+Perceived task realism (relevance to work)= Learner satisfaction=Effective learning (awareness of technique and spread of infections)+Interactive learning experienceContested mechanisms:+Engages learners in deep immersion+Perceived environmental realismNovice carers+Repeated practice=Effective learning (understanding and awareness of technique and spread of infections)= Learner satisfaction=Enhanced hand hygiene skills (improved technique and/or skill performance in care homes)Contested mechanisms:+Engages learners in deep immersion+Practice in a safe environmentCare homes that require ongoing hand hygiene training/refresher+Feedback and reminding=Enhanced hand hygiene skills (improved technique and/or skill performance in care homes)=Infection control and lower rates of infections; resident and staff safety+Interactive learning+Repeated practice


## 4. Discussion

This study has explored care home workers’ theories concerning how and in what contexts AR/VR training might work in promoting hand hygiene. Staff reported vast experiences with hand hygiene training and identified an opportunity to refresh skills and practice for all staff. There was consensus that the mechanisms of repeated practice, interactive learning, feedback and reminding, and perceived task realism were most important. There was less consensus that other mechanisms may be triggered. Staff theorised that effective learning, learner satisfaction, enhanced hand hygiene skills, and infection control were expected outcomes of AR/VR training.The realist approach enabled the refinement of our theory and for the emergence of new mechanisms, such as visualisation of personal anatomy and mistakes, and feedback and reminding. These theories only arose during the interviews because of the tasks reviewed in the existing literature, whereby previous work excluded care homes and hand hygiene, and mostly focussed on evaluating skills, rather than behaviour change [22]. The new mechanism of feedback and reminding was unsurprising, given that it is already being employed in care homes, using posters and monitoring.New mechanisms were also related to different forms of realism: environment, task, and imagery. This builds on previous categories of fidelity in simulation. Slater et al. [36] broadly distinguished between physical and psychological realism, whereby the former refers to the physical appearance of virtual features (e.g., imagery) and the latter is defined by a sensation that the virtual experience could occur in reality. Others have used five dimensions: the physical (e.g., environment), psychological (e.g., emotional response), social (e.g., instructor), group culture, and learner open-mindedness [37, 38]. In our study, it was apparent that task realism was most important. As explained by others, physical realism is not always required and is not associated with better educational outcomes [37, 39]. Instead, learners need to understand how the simulation experience is relevant to their clinical practice. This is referred to as the phenomenal mode by Laucken [39] and task realism in our study.Some of the mechanisms are evidence-based behaviour change strategies. Participants believed that feedback and reminding, repeated practice, and interactive learning could be triggered by AR/VR training. For interactive learning, participants spoke about social interaction which could include the exchange of social support and the training being more active. Previous research studies on digital health interventions has also identified the use of personalisation, feedback and monitoring, associations (i.e., reminders), self-monitoring, social support, and education/information as behaviour-change strategies [40, 41]. A review of hand hygiene interventions for children reported 32 strategies, including demonstrating/instructing how to perform the behaviour, and practice/rehearsal [42]. Additionally, our review of 90 hand hygiene apps found that personalisation (e.g., individual feedback), self-monitoring, social support, and feedback were used [43].The mechanisms of repeated practice, interactivity, and feedback and reminding are also supported by constructivist learning theories [44]. This states that learning is an active process which is constructed by learners and enabled through reflection, rather than being absorbed passively. In this context, carers build on their existing hand hygiene knowledge, practice, and experience, but are prompted to discuss and reflect on their practice through feedback and reminding. Further focus on these mechanisms is warranted, given their potential to change behaviour and improve learning.Importantly and consistent with realist perspectives [25], findings emphasised that hand hygiene interventions may not work for everyone equally and are context-dependent. Learnings from interventions in acute settings support this by acknowledging contextual factors that influence hand hygiene compliance and the success of interventions. These include crowding in the emergency department, organisational culture, and types of clinicians [12, 17]. Differences in physical environments may also impact interventions, given that unlike hospitals, hand sanitizer dispensers in care homes are not often attached to beds and residents are mobile [45]. Differences in education also exist, whereby nurses in nursing homes tend to be less educated than nurses in hospitals, thus requiring interventions with accessible language and interactive exercises [45].Lastly, our study highlighted differences between care homes, regarding policies, preferences, and comfort with technology. Considerations regarding upfront costs and cybersickness were reported in our realist review [22]. The restricted training budgets in care homes support the use of existing technology and smartphone applications. However, trade-offs might be evident between cybersickness, visual realism, and immersion. This is because more realistic virtual environments are more likely to cause cybersickness [46, 47] but are required for immersion. Low-cost VR headsets might also be less comfortable to wear and require smartphones with good resolution. A poorly fitting headset, flickering screen, or lagging/latency may induce cybersickness [46], while immersion requires a higher field-of-view, screen resolution, and higher frame rates [48]. Ultimately, while it is currently impractical to develop training using high-cost headsets, it is important to consider whether AR or nonimmersive VR might be more appropriate, and to measure the acceptability and tolerability of cheaper equipment.


### 4.1. Implications

This work has identified implementation and contextual considerations for AR/VR hand hygiene training, including care home infrastructure, policies, preferences, and health issues that may render the use of VR headsets as inappropriate. Future AR/VR interventions should offer alternative technologies (nonimmersive options), perform pretraining and health screenings, provide technical support, and work with managers when determining which technology to use. Future work should draw on these findings to design an intervention and test the most important mechanisms.Additionally, feasibility and acceptability testing are required as participants had not used the technology and to determine which technology is the most appropriate and to uncover implementation experiences. Future quantitative work should also explore the efficacy of AR/VR training in improving hand hygiene skills, knowledge, confidence, and learner satisfaction, such as by collecting objective performance data through the technology, self-reported measures, or observations. Those working in upskilling healthcare staff should consider the implementation considerations, as other settings will also have staff with technology preferences and policies regarding training and on-shift smartphone use.


### 4.2. Strengths and Limitations

The interview schedule was informed by an underpinning theory on how AR/VR might work. This meant that the interviews were informed by previous literature, resulting in findings that may be relevant to similar technologies. Member-checking helped to ensure the credibility of the findings while analyst triangulation helped to validate the interpretation of the data [34].This study was conducted in care homes in Northern England, with mostly (92%) female staff. Diversity was limited as 82.3% of staff in the adult social care sector in England are female, with women more likely to provide care (83%) and less likely to be in senior management (68%) [49]. The transferability of the findings to other settings might also be limited. Lastly, participants did not use the apps, which may have resulted in different responses to the actual experience.


## 4.1. Implications

This work has identified implementation and contextual considerations for AR/VR hand hygiene training, including care home infrastructure, policies, preferences, and health issues that may render the use of VR headsets as inappropriate. Future AR/VR interventions should offer alternative technologies (nonimmersive options), perform pretraining and health screenings, provide technical support, and work with managers when determining which technology to use. Future work should draw on these findings to design an intervention and test the most important mechanisms.Additionally, feasibility and acceptability testing are required as participants had not used the technology and to determine which technology is the most appropriate and to uncover implementation experiences. Future quantitative work should also explore the efficacy of AR/VR training in improving hand hygiene skills, knowledge, confidence, and learner satisfaction, such as by collecting objective performance data through the technology, self-reported measures, or observations. Those working in upskilling healthcare staff should consider the implementation considerations, as other settings will also have staff with technology preferences and policies regarding training and on-shift smartphone use.


## 4.2. Strengths and Limitations

The interview schedule was informed by an underpinning theory on how AR/VR might work. This meant that the interviews were informed by previous literature, resulting in findings that may be relevant to similar technologies. Member-checking helped to ensure the credibility of the findings while analyst triangulation helped to validate the interpretation of the data [34].This study was conducted in care homes in Northern England, with mostly (92%) female staff. Diversity was limited as 82.3% of staff in the adult social care sector in England are female, with women more likely to provide care (83%) and less likely to be in senior management (68%) [49]. The transferability of the findings to other settings might also be limited. Lastly, participants did not use the apps, which may have resulted in different responses to the actual experience.


## 5. Conclusion

Care home workers theorised that AR/VR may refresh hand hygiene training by triggering mechanisms that lead to effective learning, learner satisfaction, enhanced skills, and infection control. Implementation considerations were related to learners, care home policies, staffing and infrastructure, and technology. Future work should test the mechanisms and technology in care homes. It is crucial that programmes for upskilling care home staff draw on the implementation and contextual considerations by offering alternatives (nonimmersive options), providing technical support, and working with managers to determine the most appropriate technology. This will ensure that the intervention is appropriate for the context and minimises barriers to implementation.



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*Source: 7294808-2023-02-09.xml*