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Shakeel Mohammed
Dunedin School of Medicine
Otago Medical School
University of Otago
Dr Phil Blyth
BHB MB ChB PhD
Senior Lecturer (eLearning in Medicine)
Otago Medical School
University of Otago
Dr Steve Gallagher
BA PGDip PhD
Lecturer and eLearning and Web
Support, Dean’s Department
Otago Medical School
University of Otago
Abstract
Individuals early in their medical career feel unprepared for acute
high-stress clinical situations such as managing a deteriorating patient.
Simulation-based learning (SBL) is a method used within medical ed-
ucation to prepare for the clinical environment. SBL has been suc-
cessfully integrated with virtual reality technology, however there is a
lack of literature regarding its use for replicating the stress of a clinical
environment and using 360° video to improve fidelity. Our non-spe-
cialist team aimed to develop and test the acceptability and feasibility
of an interactive 360° video-based virtual reality simulation of a high-
stress clinical situation. The simulation was developed within the ten
weeks allocated to this project, however standardised measures from
our sample could not be collected. Important information regarding
the development and creation process was obtained and alpha test-
ing of simulations were perceived acceptable and useful, thus, high-
lighting the merit of further research in this area.
Introduction
Newly-qualified doctors are likely to be exposed to a variety of
physically and emotionally demanding incidents, some of which in-
clude witnessing death, violence, and aggression, and participating
in resuscitation. 1,2 Factors such as emotional and physical distress
are likely to elicit a physiological stress response, which may affect
the performance of an individual in managing these situations. 3 It is
widely accepted that an individual’s self-efficacy is strongly linked with
work-related competence and clinical performance. 4–6 Self-efficacy
can be defined as an individual’s beliefs regarding their capabilities
to perform a behaviour or learn at a specific level. 7 Regardless of
accuracy, an individual’s judgment about their self-efficacy arises from
several information sources including emotional state. 7
Previous research related to clinical self-efficacy has indicated that
many newly-qualified doctors feel unprepared as they step into
their new roles, which are likely to involve managing stressful clinical
events. 8,9 An example of such an incident would include the man-
agement of a deteriorating patient. A deteriorating patient can be
defined as ‘a patient who moves from one clinical state to a worse
clinical state which increases their individual risk of morbidity, includ-
ing organ dysfunction, protracted hospital stay, disability, or death’. 10
Several studies have used self-reported questionnaires and inter-
views to investigate factors influencing a junior doctor’s management
of stressful clinical events. Concepts related to self-efficacy, such as
clinical knowledge, technical and non-technical skills, have been in-
vestigated and identified that there was a significant lack of self-per-
ceived competence and confidence among many junior doctors. 11,12
The acute stress elicited during stressful clinical events is identified in
a study by Paice et al. 13 In this study, a sample of junior doctors were
asked the open question, ‘please think of a particularly stressful or
difficult event that you have encountered during your house officer
posts’. The most common response was an incident that involved
professional responsibility beyond their self-perceived competence.
The lack of preparedness for the role of a junior doctor has caused
various mistakes in the past, some of which include delayed treat-
ment, delayed diagnosis, amputation, and death. 14
The literature highlights the issue that many newly-qualified doctors feel
unprepared for common stressful clinical situations and that the emo-
tional stress of certain situations may influence performance. Therefore,
our current methods of preparing medical students for these situations
may be improved to avoid the previously mentioned consequences.
A strong relationship exists between exposure to stressful events and
confidence to perform effectively in these situations. 15–17 Improved
practical skills and confidence are observed when junior doctors are
engaged in bedside clinical training, while shadowing experienced
doctors. 18,19 However, these experiences are often opportunistic and
therefore cannot always be deliberately arranged. A widely accept-
ed practice within medical education that allows individuals to have
experiences akin to real clinical situations is via SBL. SBL is a practice
that creates an artificial environment in which an individual can expe-
rience a representation of a real event in order to practice, test, learn,
evaluate, or gain an understanding of human actions or systems. 20
Some of the various modalities of simulations include manikin based,
computer based, and simulated patient based. The fidelity between
and among these different simulation modalities tends to vary. Fidelity
refers to the degree to which a simulation replicates the real events
and/or workplace, and impacts the quality of the simulation. 21 SBL al-
lows individuals to experience clinical situations, practice procedures
or physical manoeuvres, and practice examination skills, among vari-
ous other clinical situations. 22,23
Studies suggest that SBL contributes to improved self-efficacy and
performance, and eases the transition into clinical settings, along with
improving patient safety. 24,25 Junior doctors have specifically empha-
sised the importance of simulation in acquiring knowledge and prac-
tising skills for acutely stressful scenarios, such as managing deteriorat-
ing patients. 26,27 Most medical simulations are developed in order to
learn specific knowledge and clinical skills. 21 There is sparse literature
regarding simulations developed with the aim of inoculating the stress
that may be experienced during stressful clinical events. 28,29 However,
the literature that does exist suggests that the development of such
simulations may be useful in preparing newly-qualified doctors to bet-
ter manage acutely stressful situations. Specific barriers to including
such simulations may include operational challenges in developing and
running simulations, such as resources, cost, and time. These barriers
may be overcome by the utilisation of recent advancements in virtual
reality technology.
Virtual reality uses an artificial digital environment in which the wear-
er can be physically immersed using devices such as head-mounted
displays, and which can lead to the wearer feeling ‘present’ in the
experience. 30 There are variations regarding the definition of virtual
reality, however, most definitions highlight common elements. These
are immersion in a virtual environment, a subjective sense of pres-
ence, and interactivity. 31,32 There have been recent advancements in
virtual reality technology that have allowed for greater affordability,
accessibility, and quality. 33 Virtual reality technology has successfully
been integrated with SBL in various ways, some of which include
training for laparoscopic skills, gynaecological procedures, and nasal
endoscopy. 34 This integration allows for simulations to maintain the
benefits of SBL, while simultaneously providing an opportunity to
overcome limitations such as intense resource requirements and
ongoing operational costs for repeated simulations. 35 Virtual reality
can be used to improve the cost-effectiveness of SBL in medical ed-
ucation and may also be utilised to create high-fidelity simulations.
These simulations can be used to better prepare medical students
to become doctors capable of managing acutely stressful clinical
events. This study aims to assess the feasibility of developing a 360°
video-based virtual reality simulation of a stressful clinical event as an
education tool for senior medical students.
Materials and methods
This project used a multimedia instructional design process, which
involved identifying an appropriate scenario, creating a storyboard of
the experience, recording the simulation with a 360° camera (Ricoh
Theta S), editing the footage, developing an interactive simulation
using a game development platform (Unity), and evaluating the ac-
ceptability of the simulation. We intentionally selected hardware and
development tools that were affordable and commonly available as
a test of their capability to create a viable simulation. The simulation
context was designed for a final year medical student (trainee intern).
After consulting with four physicians and a nurse, who each had more
than four years of experience in managing deteriorating patients, we
concluded that the management of a seizure on a minimally-staffed
ward would be an appropriate and realistic scenario.
In this scenario, the trainee intern would typically call for senior sup-
port. There is a duration of time between calling for help and senior
support arriving to where the trainee intern is responsible for manag-
ing the situation. In our chosen scenario, this duration was extended
due to minimal staffing, which was believed to be a key factor in pro-
viding a stressful experience. Towards the end of the simulation, the
trainee intern would be expected to give a verbal summary of events
to senior support as they arrive. The verbal summary is common
practice and another potential source of stress. The simulation would
progress by the wearer interacting with the virtual environment to
make decisions. We decided to use a non-linear structure to create
a sense of realism and control, which allows the wearer to experience
the consequences of their decisions. The non-linear structure
creates complexity in maintaining the continuity of the narrative, as
there are several branching avenues that could be experienced. To
maintain adequate continuity and further develop the narrative, we
initially created a storyboard within a Microsoft Excel spreadsheet,
which contained information on each scene such as scene description,
dialogue, interactable objects, and the branching scenes that can be
triggered. We had difficulty assessing the continuity of the narrative
within the spreadsheet format and therefore developed a flow chart
using the open-source software Mermaid (https://mermaidjs.github.
io), to better visualise the process and assess the flaws within the sto-
ryboard. The flowchart and the spreadsheet had been revised several
times with consultation from physicians and nurses to improve clinical
accuracy and continuity flaws.
The footage was recorded using a Ricoh Theta S camera. It was es-
sential for us to understand the capabilities of the technology avail-
able in order to capture high-quality footage. We elected to record
360° video, rather than developing a virtual reality model of the sim-
ulation, for practical reasons. This development approach required
much less time and we thought might also enhance the realism of the
simulation. We tested recording footage from a variety of camera
positions in order to assess the location where the footage best sim-
ulated a first-person experience. These test shots were also analysed
to assess the field of view, distortions, and viable object placement.
The camera also enabled us to capture four-channel audio, which
allows for the sound to be mapped according to the virtual space
during development.
With the permission of clinical and ward staff, we filmed the scenario
in a ward room within Dunedin Hospital. Two medical students and a
senior ward nurse had volunteered to act for the roles of patient, sen-
ior nurse, and junior nurse. We believed that their clinical experience
would play a valuable role in creating a realistic clinical simulation. The
footage recorded was then processed through the Ricoh Theta app
and subsequently in Adobe Premiere.
The Vive headset can be used to experience a virtual world by view-
ing images through the head-mounted display. By using sensors, which
track movement and subsequently modify the displayed image, the
wearer is immersed within the virtual world. The setup also uses
two controllers that are tracked and used to point and, hence, in-
teract with the virtual environment. The simulation was built using
the Unity game engine (http://unity3d.com/) and programmed using
C# for logic control. Unity allows for videos of different stages of the
simulation to be systematically linked together and triggered following
interactions driven by the wearer.
Wearers interact with the simulation using the hand-held control-
lers. This involves pointing and then clicking on an object of interest
(e.g. patient, blood glucose monitor), which then activates an opaque
menu with options on how to utilise the object of interest. This allows
for an array of interactable objects in which the wearer can decide to
interact without being prompted. The interactions had consequences
that either progressed the simulation to a new scene or provided
feedback to the wearer through text within the virtual environment.
A training tutorial was developed to orient wearers to the virtual
environment, and the entire simulation was piloted on three mem-
bers of the research team. Informal feedback on early development
versions (alpha testing) was gathered from a convenience sample of
medical students.
Results
Our non-specialist team successfully developed a 360° video virtual
reality simulation of a clinical event. We underestimated the time
required for development, due to the difference between 360° VR and traditional multimedia design. This limited our ability to collect
objective data within the ten weeks available for this study. However,
important information about the process of developing such a simula-
tion was discovered. We had determined a process for utilising Unity
to integrate components of 360° video, interactivity, and virtual real-
ity to create the simulation. Information about the virtual experience
was also obtained during feedback from ad-hoc simulations during
and post-development for alpha testing.
Anecdotal feedback from the three members of the research team
who piloted the simulation suggested that it was successful in achiev-
ing a sense of presence in the wearer, and may have the potential to
influence self-efficacy for managing clinical emergencies. Alpha testing
was done with four medical students with clinical experience and six
medical students with no clinical experience. It was identified that
students with no clinical experience seemed less likely to feel stressed
or to feel more self-efficacious regarding their ability to manage the
deteriorating patient. This is contrasted by the individuals with clinical
experience who suggested a higher degree of stress and felt more
self-efficacious. All individuals commented on the potential and use-
fulness of the simulation concept.
Discussion
This study has indicated that a non-specialist team can develop an
interactive virtual reality simulation using 360° videos. These simula-
tions can be made at a low cost and therefore, may ease operation-
al issues associated with traditional simulation-based learning. Our
results have suggested that these simulations may inoculate against
stress, may influence self-efficacy, and may be useful within medi-
cal education. Preliminary results suggest a degree of acceptability
and feasibility, and therefore, justify further research in testing the
acceptability and feasibility of this simulation concept. A formal eval-
uation of this simulation and its impact on stress and self-efficacy will
be conducted by the research team in the future.
References
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of nurses and doctors. Emerg Nurse. 2011;19(4):31–7.
2. Paice E, Rutter H, Wetherell M, Winder B, McManus I. Stressful
incidents, stress and coping strategies in the pre-registration house
officer year. Med Educ. 2002;36(1):56–65.
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4. Mothabeng D. The relationship between the self-efficacy, academic
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6. Stajkovic A, Luthans F. Self-efficacy and work-related performance:
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8. Illing J, Morrow G, Rothwell nee Kergon C, Burford B, Baldauf B,
Davies C, et al. Perceptions of UK medical graduates’ preparedness for
practice: a multi-centre qualitative study reflecting the importance of
learning on the job. BMC Med Educ. 2013;13(1).
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How prepared are UK medical graduates for practice? A rapid review of
the literature 2009–2014. BMJ Open. 2017;7(1):e013656.
10. Jones D, Mitchell I, Hillman K, Story D. Defining clinical deterioration.
Resuscitation. 2013;84(8):1029–34.
11. Goldacre M, Taylor K, Lambert T. Views of junior doctors
about whether their medical school prepared them well for work:
questionnaire surveys. BMC Med Educ. 2010;10(1):1–9.
12. Bleakley A, Brennan N. Does undergraduate curriculum design
make a difference to readiness to practice as a junior doctor? Med Teach.
2011;33(6):459–67.
13. Paice E, Rutter H, Wetherell M, Winder B, McManus I. Stressful
incidents, stress and coping strategies in the pre-registration house
officer year. Med Educ. 2002;36(1):56–65.
14. Callaghan A, Kinsman L, Cooper S, Radomski N. The factors that
influence junior doctors’ capacity to recognise, respond and manage
patient deterioration in an acute ward setting: an integrative review.
Aust Crit Care. 2017;30(4):197–209.
15. Marel G, Lyon P, Field M, Barnsley L, Hibbert E, Parise A. Clinical
skills in early postgraduate medical trainees: patterns of acquisition
of confidence and experience among junior doctors in a university
teaching hospital. Med Educ. 2000;34(12):1013–5.
16. Fernandez G, Lee P, Page D, D’Amour E, Wait R, Seymour N.
Implementation of full patient simulation training in surgical residency. J
Surg Educ. 2010;67(6):393–9.
17. Campbell D, Shepherd I, McGrail M, Kassell L, Connolly M, Williams
B, et al. Procedural skills practice and training needs of doctors, nurses,
midwives and paramedics in rural Victoria. Adv Med Educ and Pract.
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18. McKavanagh P, Boohan M, Savage M, McCluskey D, McKeown P.
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19. Brennan N, Corrigan O, Allard J, Archer J, Barnes R, Bleakley A,
et al. The transition from medical student to junior doctor: today’s
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20. Lopreiato J. Healthcare simulation dictionary [Internet]. Rockville,
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safety-resources/research/simulation_dictionary/sim-dictionary.pdf
21. Owen H. Simulation in healthcare education: an extensive history.
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of virtual and augmented reality research: a network and cluster
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[cited 2019 May 30]. (Intelligent Systems, Control and Automation:
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com/10.1007/978-94-007-6910-6
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34. Reiner R, Harders M. Virtual reality in medicine. London: Springer; 2012.
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Acknowledgments
We would like to express our gratitude to Dr Sierra Beck, Dr John
Edmond, Dr Ohad Dar, Joanne Robertson, Paul Medeiros, Wibeke
Finkler, Judith Swan, Isabelle Lomax-Sawyers, Josh Dudley, Christy
Ballard, Dr Holger Regenbrecht, and the seventh-floor ward staff of
the Dunedin Hospital for contributing to this project.
Funding
This project was funded by a Summer Research Scholarship from the
Department of the Dean, Dunedin School of Medicine.
Correspondence
Shakeel Mohammed: mohsh590@student.otago.ac.nz
Shakeel Mohammed
Dunedin School of Medicine
Otago Medical School
University of Otago
Dr Phil Blyth
BHB MB ChB PhD
Senior Lecturer (eLearning in Medicine)
Otago Medical School
University of Otago
Dr Steve Gallagher
BA PGDip PhD
Lecturer and eLearning and Web
Support, Dean’s Department
Otago Medical School
University of Otago
Abstract
Individuals early in their medical career feel unprepared for acute
high-stress clinical situations such as managing a deteriorating patient.
Simulation-based learning (SBL) is a method used within medical ed-
ucation to prepare for the clinical environment. SBL has been suc-
cessfully integrated with virtual reality technology, however there is a
lack of literature regarding its use for replicating the stress of a clinical
environment and using 360° video to improve fidelity. Our non-spe-
cialist team aimed to develop and test the acceptability and feasibility
of an interactive 360° video-based virtual reality simulation of a high-
stress clinical situation. The simulation was developed within the ten
weeks allocated to this project, however standardised measures from
our sample could not be collected. Important information regarding
the development and creation process was obtained and alpha test-
ing of simulations were perceived acceptable and useful, thus, high-
lighting the merit of further research in this area.
Introduction
Newly-qualified doctors are likely to be exposed to a variety of
physically and emotionally demanding incidents, some of which in-
clude witnessing death, violence, and aggression, and participating
in resuscitation. 1,2 Factors such as emotional and physical distress
are likely to elicit a physiological stress response, which may affect
the performance of an individual in managing these situations. 3 It is
widely accepted that an individual’s self-efficacy is strongly linked with
work-related competence and clinical performance. 4–6 Self-efficacy
can be defined as an individual’s beliefs regarding their capabilities
to perform a behaviour or learn at a specific level. 7 Regardless of
accuracy, an individual’s judgment about their self-efficacy arises from
several information sources including emotional state. 7
Previous research related to clinical self-efficacy has indicated that
many newly-qualified doctors feel unprepared as they step into
their new roles, which are likely to involve managing stressful clinical
events. 8,9 An example of such an incident would include the man-
agement of a deteriorating patient. A deteriorating patient can be
defined as ‘a patient who moves from one clinical state to a worse
clinical state which increases their individual risk of morbidity, includ-
ing organ dysfunction, protracted hospital stay, disability, or death’. 10
Several studies have used self-reported questionnaires and inter-
views to investigate factors influencing a junior doctor’s management
of stressful clinical events. Concepts related to self-efficacy, such as
clinical knowledge, technical and non-technical skills, have been in-
vestigated and identified that there was a significant lack of self-per-
ceived competence and confidence among many junior doctors. 11,12
The acute stress elicited during stressful clinical events is identified in
a study by Paice et al. 13 In this study, a sample of junior doctors were
asked the open question, ‘please think of a particularly stressful or
difficult event that you have encountered during your house officer
posts’. The most common response was an incident that involved
professional responsibility beyond their self-perceived competence.
The lack of preparedness for the role of a junior doctor has caused
various mistakes in the past, some of which include delayed treat-
ment, delayed diagnosis, amputation, and death. 14
The literature highlights the issue that many newly-qualified doctors feel
unprepared for common stressful clinical situations and that the emo-
tional stress of certain situations may influence performance. Therefore,
our current methods of preparing medical students for these situations
may be improved to avoid the previously mentioned consequences.
A strong relationship exists between exposure to stressful events and
confidence to perform effectively in these situations. 15–17 Improved
practical skills and confidence are observed when junior doctors are
engaged in bedside clinical training, while shadowing experienced
doctors. 18,19 However, these experiences are often opportunistic and
therefore cannot always be deliberately arranged. A widely accept-
ed practice within medical education that allows individuals to have
experiences akin to real clinical situations is via SBL. SBL is a practice
that creates an artificial environment in which an individual can expe-
rience a representation of a real event in order to practice, test, learn,
evaluate, or gain an understanding of human actions or systems. 20
Some of the various modalities of simulations include manikin based,
computer based, and simulated patient based. The fidelity between
and among these different simulation modalities tends to vary. Fidelity
refers to the degree to which a simulation replicates the real events
and/or workplace, and impacts the quality of the simulation. 21 SBL al-
lows individuals to experience clinical situations, practice procedures
or physical manoeuvres, and practice examination skills, among vari-
ous other clinical situations. 22,23
Studies suggest that SBL contributes to improved self-efficacy and
performance, and eases the transition into clinical settings, along with
improving patient safety. 24,25 Junior doctors have specifically empha-
sised the importance of simulation in acquiring knowledge and prac-
tising skills for acutely stressful scenarios, such as managing deteriorat-
ing patients. 26,27 Most medical simulations are developed in order to
learn specific knowledge and clinical skills. 21 There is sparse literature
regarding simulations developed with the aim of inoculating the stress
that may be experienced during stressful clinical events. 28,29 However,
the literature that does exist suggests that the development of such
simulations may be useful in preparing newly-qualified doctors to bet-
ter manage acutely stressful situations. Specific barriers to including
such simulations may include operational challenges in developing and
running simulations, such as resources, cost, and time. These barriers
may be overcome by the utilisation of recent advancements in virtual
reality technology.
Virtual reality uses an artificial digital environment in which the wear-
er can be physically immersed using devices such as head-mounted
displays, and which can lead to the wearer feeling ‘present’ in the
experience. 30 There are variations regarding the definition of virtual
reality, however, most definitions highlight common elements. These
are immersion in a virtual environment, a subjective sense of pres-
ence, and interactivity. 31,32 There have been recent advancements in
virtual reality technology that have allowed for greater affordability,
accessibility, and quality. 33 Virtual reality technology has successfully
been integrated with SBL in various ways, some of which include
training for laparoscopic skills, gynaecological procedures, and nasal
endoscopy. 34 This integration allows for simulations to maintain the
benefits of SBL, while simultaneously providing an opportunity to
overcome limitations such as intense resource requirements and
ongoing operational costs for repeated simulations. 35 Virtual reality
can be used to improve the cost-effectiveness of SBL in medical ed-
ucation and may also be utilised to create high-fidelity simulations.
These simulations can be used to better prepare medical students
to become doctors capable of managing acutely stressful clinical
events. This study aims to assess the feasibility of developing a 360°
video-based virtual reality simulation of a stressful clinical event as an
education tool for senior medical students.
Materials and methods
This project used a multimedia instructional design process, which
involved identifying an appropriate scenario, creating a storyboard of
the experience, recording the simulation with a 360° camera (Ricoh
Theta S), editing the footage, developing an interactive simulation
using a game development platform (Unity), and evaluating the ac-
ceptability of the simulation. We intentionally selected hardware and
development tools that were affordable and commonly available as
a test of their capability to create a viable simulation. The simulation
context was designed for a final year medical student (trainee intern).
After consulting with four physicians and a nurse, who each had more
than four years of experience in managing deteriorating patients, we
concluded that the management of a seizure on a minimally-staffed
ward would be an appropriate and realistic scenario.
In this scenario, the trainee intern would typically call for senior sup-
port. There is a duration of time between calling for help and senior
support arriving to where the trainee intern is responsible for manag-
ing the situation. In our chosen scenario, this duration was extended
due to minimal staffing, which was believed to be a key factor in pro-
viding a stressful experience. Towards the end of the simulation, the
trainee intern would be expected to give a verbal summary of events
to senior support as they arrive. The verbal summary is common
practice and another potential source of stress. The simulation would
progress by the wearer interacting with the virtual environment to
make decisions. We decided to use a non-linear structure to create
a sense of realism and control, which allows the wearer to experience
the consequences of their decisions. The non-linear structure
creates complexity in maintaining the continuity of the narrative, as
there are several branching avenues that could be experienced. To
maintain adequate continuity and further develop the narrative, we
initially created a storyboard within a Microsoft Excel spreadsheet,
which contained information on each scene such as scene description,
dialogue, interactable objects, and the branching scenes that can be
triggered. We had difficulty assessing the continuity of the narrative
within the spreadsheet format and therefore developed a flow chart
using the open-source software Mermaid (https://mermaidjs.github.
io), to better visualise the process and assess the flaws within the sto-
ryboard. The flowchart and the spreadsheet had been revised several
times with consultation from physicians and nurses to improve clinical
accuracy and continuity flaws.
The footage was recorded using a Ricoh Theta S camera. It was es-
sential for us to understand the capabilities of the technology avail-
able in order to capture high-quality footage. We elected to record
360° video, rather than developing a virtual reality model of the sim-
ulation, for practical reasons. This development approach required
much less time and we thought might also enhance the realism of the
simulation. We tested recording footage from a variety of camera
positions in order to assess the location where the footage best sim-
ulated a first-person experience. These test shots were also analysed
to assess the field of view, distortions, and viable object placement.
The camera also enabled us to capture four-channel audio, which
allows for the sound to be mapped according to the virtual space
during development.
With the permission of clinical and ward staff, we filmed the scenario
in a ward room within Dunedin Hospital. Two medical students and a
senior ward nurse had volunteered to act for the roles of patient, sen-
ior nurse, and junior nurse. We believed that their clinical experience
would play a valuable role in creating a realistic clinical simulation. The
footage recorded was then processed through the Ricoh Theta app
and subsequently in Adobe Premiere.
The Vive headset can be used to experience a virtual world by view-
ing images through the head-mounted display. By using sensors, which
track movement and subsequently modify the displayed image, the
wearer is immersed within the virtual world. The setup also uses
two controllers that are tracked and used to point and, hence, in-
teract with the virtual environment. The simulation was built using
the Unity game engine (http://unity3d.com/) and programmed using
C# for logic control. Unity allows for videos of different stages of the
simulation to be systematically linked together and triggered following
interactions driven by the wearer.
Wearers interact with the simulation using the hand-held control-
lers. This involves pointing and then clicking on an object of interest
(e.g. patient, blood glucose monitor), which then activates an opaque
menu with options on how to utilise the object of interest. This allows
for an array of interactable objects in which the wearer can decide to
interact without being prompted. The interactions had consequences
that either progressed the simulation to a new scene or provided
feedback to the wearer through text within the virtual environment.
A training tutorial was developed to orient wearers to the virtual
environment, and the entire simulation was piloted on three mem-
bers of the research team. Informal feedback on early development
versions (alpha testing) was gathered from a convenience sample of
medical students.
Results
Our non-specialist team successfully developed a 360° video virtual
reality simulation of a clinical event. We underestimated the time
required for development, due to the difference between 360° VR and traditional multimedia design. This limited our ability to collect
objective data within the ten weeks available for this study. However,
important information about the process of developing such a simula-
tion was discovered. We had determined a process for utilising Unity
to integrate components of 360° video, interactivity, and virtual real-
ity to create the simulation. Information about the virtual experience
was also obtained during feedback from ad-hoc simulations during
and post-development for alpha testing.
Anecdotal feedback from the three members of the research team
who piloted the simulation suggested that it was successful in achiev-
ing a sense of presence in the wearer, and may have the potential to
influence self-efficacy for managing clinical emergencies. Alpha testing
was done with four medical students with clinical experience and six
medical students with no clinical experience. It was identified that
students with no clinical experience seemed less likely to feel stressed
or to feel more self-efficacious regarding their ability to manage the
deteriorating patient. This is contrasted by the individuals with clinical
experience who suggested a higher degree of stress and felt more
self-efficacious. All individuals commented on the potential and use-
fulness of the simulation concept.
Discussion
This study has indicated that a non-specialist team can develop an
interactive virtual reality simulation using 360° videos. These simula-
tions can be made at a low cost and therefore, may ease operation-
al issues associated with traditional simulation-based learning. Our
results have suggested that these simulations may inoculate against
stress, may influence self-efficacy, and may be useful within medi-
cal education. Preliminary results suggest a degree of acceptability
and feasibility, and therefore, justify further research in testing the
acceptability and feasibility of this simulation concept. A formal eval-
uation of this simulation and its impact on stress and self-efficacy will
be conducted by the research team in the future.
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Acknowledgments
We would like to express our gratitude to Dr Sierra Beck, Dr John
Edmond, Dr Ohad Dar, Joanne Robertson, Paul Medeiros, Wibeke
Finkler, Judith Swan, Isabelle Lomax-Sawyers, Josh Dudley, Christy
Ballard, Dr Holger Regenbrecht, and the seventh-floor ward staff of
the Dunedin Hospital for contributing to this project.
Funding
This project was funded by a Summer Research Scholarship from the
Department of the Dean, Dunedin School of Medicine.
Correspondence
Shakeel Mohammed: mohsh590@student.otago.ac.nz
