Virtual reality therapy uses a computer-generated environment to simulate realistic situations, immersing user sensations within a safe and controlled environment with the aim to provide cognitive, emotional, and behavioural experiences. As part of an investigation into the feasibility to provide a complementary inpatient strategy for patient-controlled access to distraction, information, resources, and support to promote wellbeing during complex care, this study demonstrated the safety, acceptance, and potential utility of readily available VR technology for patients, their supporters, and staff. Our findings in haemato-oncology patients is supported in other patient groups[24] but experience in prolonged inpatient complex care is limited.[2]
Virtual reality has been applied in the management of mental health conditions, coaching, rehabilitation, pain management, health education, procedure and process familiarisation with some promising results. [27] Where VR has been evaluated in several settings with mixed findings, this likely reflects wide disparities in populations being assessed, acute versus chronic care settings, and the outcome measures used for assessment.[38] ,[1, 48] Positive effects have been seen for measures such as pain and sleep,[35] especially related to clinical procedures.[38],[1] However, the number of scoping reviews significantly outweigh trials and descriptions of VR in service integration. The use of VR for preoperative relaxation has been shown to reduce anxiety.[15, 19] Use of VR relaxation prior to burn debridement reduces the perception of pain.[11] Pre-emptive VR education of the expected patient journey has been associated with reductions in fear and anxiety.[23] Pain perception and anticipative stress have strong psychological components modulated by patient thought and conscious attention. With VR being an illusion, users are drawn into an alternate world, distracting attention resulting in a reduced ability to process feelings of pain, fear and anxious anticipation.[21] Conscious attention focuses users experience within the VR realm, whereby the real events surrounding patient care can become perceived as an annoyance trying to distract from exploring the virtual world.[40] A clear methodology and documentation of the patient experience[4],[9] in trials utilising VR in terms of equipment and access to applications is very important, particularly as such a novel technology is rapidly evolving perhaps more rapidly than patient clinical care experiences. The initial focus of any VR research should be to encourage familiarisation so that patients and staff become familiar with the technology before trying to assess outcome measures[44] and ensure a carefully planned and successful introduction into the clinical environment.[18, 26]
In using readily available VR systems, minimising the risks of injury and discomfort are paramount. There are increasing reports of participant safety in the use of VR systems, [5, 12, 35] however, each patient group and context of use may be associated with different safety profiles, so each clinical application requires thorough assessment.[33] Patients’ perception of safety, control and comfort can be augmented when provided with a simulated familiarisation.[40] Our study found few side effects in using the VR system with no reports of nausea. However, the potential for eyestrain needs to be appreciated especially in older patients, perhaps by limiting the time of usage to under 20 minutes. Our study did not record the participant use of glasses. Use of VR systems has been reported to increase near point accommodation and convergence in the short term[46] with patients with pre-existing eye problems more likely to experience eye related symptoms with the use of VR.[47] The perception of head “fullness” is intriguing and a separate experience to headache and dizziness which were rare in our study. Perhaps the richness of the sensory experience and the possibility of sensory overload in unwell patients. Motion sickness in generally prevented in the design of VR systems to match user movements to the response of the VR environment. [8] Infection control concerns related to repeated clinical use of equipment seem to be readily dealt with as in our study.[31]
Implementation problems need to consider the cost which maybe a barrier in low income countries or poorly resourced health systems.[17] As such a tangible benefit of such therapy with limited patient adverse effects is needed. To this end, further study of applications tailored to the specific patient care context including cost effectiveness analysis are required. Group accessibility and the use of publicly available applications as used in this study may reduce costs. In our study, the partnership with a not-for-profit charity gave a focus and a mission to the program with practical resources available for implementation. The application of VR therapies needs to accommodate patients with disabilities and those from diverse cultural and age backgrounds.[17] This may require assistance or adaption of headsets, captions for hearing impairment, a range of cultural and age appropriate languages and content. Virtual reality experiences are not just the realm of the young. Increasingly, VR has been used in the management of health conditions of the elderly, especially those in institutional care.[37] Such approaches have been used to gain and entertain as well as track and analyse therapeutic outcomes in our senior citizens. Such specific applications have included, stroke rehabilitation[10], cognitive impairment[28], balance training[36], mobility[32], falls reduction[25], and the management of mood, anxiety and dementia[7, 14, 16, 43], generally with good acceptance of the technology.[41] As such, VR should be applicable to a wide range of patient ages and applications. In designing VR therapies, meeting the needs of the patient are paramount.[6] Technical problems are potentially common, principally network connection speeds, and may lead to discomfort, distraction and frustration which could affect the patients experience limit the effectiveness of therapy.[3] Uniform technical standards for the provision of VR therapies are still to be developed. The purpose of the therapy must be clear with the content engaging, interactive and entertaining as attention maintenance is important to provide distraction from the real-world environment. Where VR use is part of a distraction program, a tailored program to patient preferences and interests is important. Our study found that patients visited a wide range of places available within the application, however, they were keen to visit home, family, and friends in addition to visiting world venues and events. Such needs to visit family and friends requires consideration for the range of application to include in a distraction therapy inpatient program. The patient experience in VR is crucial to usability and effectiveness.[34] High quality graphics and audio in addition to providing a sense of presence are current consumer expectations and vital to achieve a realistic distraction from clinical therapy. Systems need to be comfortable, encourage initiative, and easy to use. Our study using readily available applications and hardware demonstrated that such therapy programs could be readily implemented with minimal expertise and cost, but explicit instruction remains important. There was a general ambivalence noted in the experience of navigating in the VR environment. In this feasibility study, we noted by the end of a training session most participants were comfortable using the technology with the expectation that ongoing experience with VR will improve participant navigation with the potential to derive greater benefit from the applications. There also was a general experience across participants in our study of realism and immersion. However, the long-term effects of such therapies are not known but acutely it is positively received with effectiveness depending on the type of program provided patient age and other factors. Ethical issues of addiction, desensitisation and therapist disengagement directly due to the VR experience also need to be considered in program development.[39] Context specific programs are defined for pain management, rehabilitation, clinical orientation and education.[45] From this preliminary work which has defined VR and an acceptable and safe tool, further development of patient context programs to improved well-being are worth exploring for use in prolonged inpatient care.