Virtual Reality in Health Education - Usability Testing

Mitchell Ward and Viet Le

Health Care Informatics, University of San Diego

May 17, 2021

 Virtual Reality in Health Education - Usability Testing

Abstract

Virtual Reality (VR) provides a visual simulation that gives users the ability to interact

with their environment. It has a long history and is being applied in many industries such as

entertainment, design, and educational training to enhance the user’s experience. Similar tools

include augmented reality (AR) and mixed reality (MR). VR’s advancements in technology and

popularity are explored as many major organizations continue to develop new devices and

software to improve the virtual reality experience. VR in medical education has been

implemented to combat the challenges of traditional clinical experience. The applications of VR

in healthcare education have been growing along with the technology to provide a standardized

and convenient immersive learning experience to simulation. Working to expand active learning

across more disciplines and overcome the current limitations, VR aims to improve education

and practice in the medical field. The design and outcomes are portrayed to establish how the

project is structured and what the team aims to achieve. Determining a low-cost alternative for

clinical experience required usability testing to compare advantages and disadvantages. These

evaluations include discovering the valuable qualities of each physical device and the videos to

build the best scenarios possible for our users. Recommendations based on the usability testing

and review of VR in education are provided to enhance our scenarios and user experience.
 Introduction

Virtual Reality (VR) is an emerging tool for multiple purposes where users are equipped

with special devices to immerse themselves in simulated environments. Uses include

entertainment, design, and educational training. It has a decades long history of development

that has led to advanced capabilities today. Currently VR devices range from the simple Google

Cardboard that requires an attached smartphone to the Oculus Rift which has LCD screens and

handheld controllers. Medical education has used VR simulations for student training to provide

a fully immersed safe but realistic environment to learn and practice. It also provides

accessibility in training where conventional methods such as using real patients is not available.

         The University of San Diego (USD) School of Nursing has several degree

programs where students train to be professionals and clinicians in health care. The goal of the

USD VR project is to bring VR education training to these programs to enhance learning

capabilities. 2 prototype VR simulation videos will be developed to preview how it is used in this

setting. USD Healthcare Informatics faculty, staff, and students are working together to create

scripts, storyboards, usability testing, filming, and editing the videos. The final product will be

presented to the USD School of Nursing programs to show the potential that VR simulations

have on education. 

Literature Review

What is Virtual Reality and How is it Different? 

Virtual reality (VR) is a general term for computer generated simulation that mimics real

or artificial environments and situations. Using special VR devices, users are immersed in a

virtual world where there is a sense of spatial presence and may have the ability to interact with

the objects in the environment (Cant et al., 2019). VR simulations can be created with
stereoscopic vision which imitates vision from two eyes and gives users an impression of 3-

dimensional depth and solidity. VR can also give users a 360° view of the surrounding area. A

variety of devices exist to experience VR such as headsets, 3D projection on walls, and hand

held controllers. VR has many applications including educational training, treating mental

disorders, and entertainment (Bambury, 2019).

Other technologies exist that are similar to VR but have differences that sets them apart.

For example, unlike VR where the vision of the user is replaced, augmented reality (AR) allows

users to see reality but have an added layer which displays additional information on top of it

(Greenwall, 2021). AR devices include AP apps, headsets, and smart glasses. Examples of AR

uses are medical training, gaming entertainment, and travel assistance (Paine, 2021). A

combination of VR and AR is mixed reality (MR). MR allows users to see the real word, like AR,

but does not have a simple layer of information on top of it. Instead, an additional layer is

created by taking in information from the surrounding objects and environment of reality and

places digital information above it. Similar to VR, users are able to interact with the digital

information seen (Bray et al., 2020). 

History of Virtual Reality

Concepts and variations of virtual reality have existed for decades. One of the first VR

devices is the “Sensorama”, invented In 1962 by Morton Heilig.This was a mechanical device

that had a stereoscopic color display, fans, odor emitters, stereo-sound system, and a montional

chair. Scenes in the film would trigger these elements, giving the user the experience of being in

the film (Brockwell, 2016). 

From the 1970’s to 1990’s, VR was mostly used for medical training, flight simulation,

automobile industry design, and military training. In 1978, the first navigable virtual environment

of Aspen was developed where users could tour the city (Mead, 2012). In 1979, Eric Howlett

developed the Large Expanse Extra Perspective (LEEP) optical system.  This device included a

stereoscopic image with a field of view that gave a sense of dimension and space (Howlett,
1992). Later, NASA redesigned this device to develop the Virtual Interactive Environment

Workstation (VIEW). Many modern day VR headsets rely on this technology. VR became more

popular in the 1980’s which saw the development of more VR devices including the DataGlove,

EyePhone, AudioSphere, and Power Glove which are similar to present day devices (Rosson,

2014).

The 1990’s saw an increase in VR devices used for entertainment and gaming. The

Sega VR which connected to the Mega Drive console was released in 1991. The device had

built-in LCD screens, stereo headphones, and sensors that allowed the system to track and

react to movements of the user's head. The Sega VR-1, released in 1994, was able to track

head movements and featured 3D polygon graphics in stereoscopic 3D (Horrowitz, 2004).

Another gaming system was released by Nintendo in 1995 called the Virtual Boy. This system

included an eyepiece and controller (Vincent, 2016). The first multiplayer networked virtual

reality gaming system was developed by Virtuality. Along with a headset, these systems

included joysticks to allow users to control and interact with the environment (Lapetina, 2008).

Unlike these devices that required users to wear a headset, a different variation of VR was

invented by Electronic Visualization Laboratory called the Cave Automatic Virtual Environment

(CAVE). The CAVE used projectors to direct images on the walls of a small room and users

wearing special 3D glasses could see 3D graphics which seemed like objects float in midair

(Wigmore, 2016). 

From 2000 to present day, hardware and software improvements allowed VR to become

more advanced and complex. In 2016, Oculus VR released the Oculus Rift, a line of VR

headsets with 1080p display. The device includes a headset, touch controllers, and 2 movement

tracking sensors. It is used for games, films, and other experiences. Currently, the Oculus Quest

2  is the latest in the Oculus line (Dingman, 2021). Unlike the advanced Oculus devices, Google

released the Google Cardboard viewer. As the name implies, the device is made of cardboard

and has two lenses. Users insert their smartphones into the viewer which allows them to
immersersed into virtual reality games, videos, and apps (Delfino, 2019). Other notable models

of VR devices developed during this time are the HTC Vive, Sony’s Project Morpheus, and

Valve Index. At Least 230 companies are developing VR-related products including Amazon,

Apple, Facebook, Google, Microsoft, Sony, and Samsung (Yang, 2021). 

Software and Hardware

Software and hardware varies for VR devices depending on their development and uses.

Virtual Reality Modeling Language (VRML) was developed in 1994 to create virtual

environments without the dependency of headsets. This led to the development of X3D which

was the open-source standard for web-based distribution of VR content (Slavin, 2015).

Oculus devices require the software Oculus Rift runtime and is supported by Microsoft

Windows, macOS, and Linux. SDK is used to develop content for the Oculus Rift and is

available for Microsoft Windows (Support). Content for the Google Cardboard can be developed

using software development kids. Applications can be created for Android devices using Java,

Unity game engine using C#, and iOS devices (Google Cardboard). 

Hardware specifications and requirements of VR devices vary and include but are not

limited to headsets, motion sensors, LCD screens for stereoscopic display, support straps, and

hand held controllers. Some minimum requirements for the Oculus Rift which requires

connection to a computer are Windows 10, NVIDIA GTX 1050 Ti graphics card, Intel i3

processor, 8GB+ RAM, USB ports and HDMI ports (Support). The Google Cardboard viewer,

which does not have electronic components, is made of AAA grade corrugated paper, 45 mm

focal lenses and compatible with 3.5”-6” smartphones. Velcro is used to hold parts in place. It

also includes a near field communication (NFC) tag which can be used as a control button in

apps (Google Cardboard). 

Virtual Reality in Medical Education

 A critical part of aspiring healthcare professionals learning experience is through clinical

hours and experience. Some of the issues with clinical practice such as limited sites or faculty,

access to electronic medical records and patient safety initiatives have proven challenging for

universities to overcome (Hayden et al., 2014). An additional concern is the learning experience

disparity amongst institutions based on their personnel and resources.

Virtual reality can assist students learn new skills in numerous areas including

emergency simulation, surgical and procedural training, and anatomy teaching (McCarthy &

Uppot, 2019). With multiple types of applications, simulation has the ability to replace many

traditional clinical training programs as there is no significant difference in nursing knowledge,

passing rates for the National Council Licensure Examination, and clinical competence (Hayden

et al., 2014). Furthermore, the use of VR can even improve the observers self-directed learning

and knowledge acquisition (Garrett et al., 2015). Another learning tool that VR brings to

students and educators is the ability to deliver scenarios that are not achievable in the real

world. While students cannot put live patients in harm’s way to learn from their mistakes, VR

allows learners to have those experiences without the consequences, giving them different

perspectives, exposing flaws, and identifying assumptions (Coyne et al., 2019). Freedom from

most of the burdens that come with live training, aspiring healthcare professions can gain

additional experience and confidence with their practices.

Healthcare teaching by VR offers institutions a cost effective and favorable alternative to

combat the many issues with higher education. Providing medical simulation through VR

enables universal content to be viewed portably giving convenience to the learner and allows for

tracking, storing and analysis of large amounts of performance data all without the presence of

an instructor (Chang & Weiner, 2016). Content given through VR can thereby decrease the

effort, coordination, resources, and cost associated with live training (McCarthy & Uppot, 2019). 
The Future of Virtual Reality in Healthcare

As VR technology improves, the quality and reach of the experience is expanding along

with it. Some of the most common complications with the use of VR have shown to be neck pain

with extended use of head-mounted displays and latency issues bringing about nausea and

vertigo at times however, it is likely that these concerns will continue to be addresses as the

technology advances (McCarthy & Uppot, 2019). VR is also a leader in the effort to increase

active learning by expanding beyond its common applications such as surgical and anatomical

visualizations to various simulations including obstetrical emergencies, patient experience

demonstrations like dementia, pharmacy dispensing, and drug memorization (Coyne et al.,

2019). According to Coyne et al. (2019) there could be VR use for activities as detailed as

following a drug through the body all the way down to the molecular level to see how the drug is

distributed, its structural changes, what organs it affects, and the body’s metabolism.

Further technological advancements that provide exciting potential to healthcare

education is the development of haptic gloves and the complementary inclusion of augmented

reality (AR) and mixed reality (MR). Students using haptic gloves would give the sensation of

touch to their environment: conducting physical exams, feeling a patient’s heart rate, or

experience with various point-of-care devices (Coyne et al., 2019). MR and AR have started to

be used more due to their ability to enhance real world situations. An example already used

today include overlays on a smartphone to provide useful information on map and design

applications. In healthcare, AR can be used to view live surgeries with the addition of relevant

patient or procedural information (Golab et al., 2016). Similar technology could be expanded for

more uses such as AR glasses that access drug information while verifying a prescription or

displaying instructions for preparing injectable drug administrations (Coyne et al., 2019).  
 A supplemental benefit of the widespread use of VR simulation is the potential for

collaborative networks to form. Instructors across organizations can work together to establish a

consistent expectation from the simulation creators to form a standardized student experience

(Dang et al., 2018). These collaborative efforts could help to reduce disparities in education by

growing the accessibility to institutions that have less educational resources or influence

towards supplier demands.

Project Goals and Outcomes

Goals and Approach

The goals of the USD VR Project are to promote and implement the use of VR as

educational resources in the University of San Diego’s (USD) School of Nursing. To do so, we

must obtain stakeholder buy-in from degree programs such as the Health Care Informatics

program, Doctor of Nursing Practice program, and the Master’s Entry Program in Nursing. 2 VR

education videos will be produced as prototypes to demonstrate how VR will be used.

The project team, led by Dr. Charisse Tabotabo, consists of HCIN faculty, staff, and

students. There are four phases in the project approach; planning, preparation, create/design,

and execution & project progression. The planning phase consisted of team members meeting

to communicate the project goals, action plans and assign roles. The following preparation

phase includes tasks such as VR orientation, familiarization of software, and researching for the

literature review of VR. Students will use the storyboarder software to create the storyboard of

each simulation. Virti is the program used to film and create VR videos.  After this, the

create/design phase began the composition of the literature review. It also involves usability

testing of the VR devices. Usability testing is having users interact with a product and observing

their behaviors and responses. The purpose of this step is to uncover problems in the product,

discover opportunities for improvement and learn about users. The goal of the usability testing
for this project is to determine the best cost-friendly VR goggles that will satisfy project goals.

We tested 3 VR devices; the Topmaxions Cardboard VR, Funsparks VR Glasses 2.0, and the I

am Cardboard – Virtual Reality Viewer. The products were tested using 5 VR videos: 360 Video

Surgical Hand-Washing, 360 Hand-Washing Surgeon Ethiopia #covid19, Trauma Simulation

demo, Thyroid, and BHF Angioplasty. Using a Usability Testing Template, observations about

specific testing factors and user experiences were documented. This phase also includes

preparing for the 2 videos that will be created. The video topics are Barcode Medication

Administration (BCMA) and Psych Mental Health Nursing Practice (PMHNP). 2 teams are

assigned to each video. Preparation includes finalizing a script and creating a storyboard of

events. The BCMA scenario is the workflow of a nurse administering medication to a patient

using the barcode scanner.  The PMHNP storyboard includes branching scenarios where a

nurse practitioner evaluates a patient. The final phase is filming and editing the videos. This

includes recruiting and training actors to play specific roles. Simulated patients will portray their

roles in each scenario. The program Virti will be used to film and edit to create the final product. 

Usability Testing

There were several advantages and disadvantages when conducting our usability

testing with the multiple devices and scenarios. The Funsparks VR Glasses 2.0 and I am

Cardboard - Virtual Reality Viewer were almost identical in functionality and design other than

the I am Cardboard viewer having a QR code to establish a viewer profile, while the

Topmaxions Cardboard VR had a few differences that benefited operability. Not providing a

head strap, the Funsparks 2.0 and I am Cardboard goggles proved to be less suited for longer

sessions than the Topmaxions Cardboard which had a head strap with it. However, the single

horizontal strap on the Topmaxions Cardboard did allow for the headset to slide to some extent

over time and needed adjustment. The Topmaxions Cardboard also had padding around the

forehead and bridge of the nose that provided better comfort when in contact with the users’
face. All goggles provided a sturdy headset for the phones with no significant difference

between IOS and Android operating systems and there was not any noticeable overheating.

Although there was some variance in each scenario, all devices took some form of physical

adjusting to give a picture that was clear. An additional finding was that individuals with different

prescriptions for each eye may come across an increase in blurred vision with the goggles.

Five scenarios were available for usability testing to assess the mobile VR headsets and

each one gave insight to favorable aspects to put towards our own development. Both the 360

Video Surgical Hand-Washing and 360 Hand-Washing Surgeon Ethiopia #covid19 made

apparent that the viewing angle is something to be conscious of when filming scenarios.

Especially when scenarios call for looking down at a large angle for most of the video, neck

strain and sliding of the goggles occurred quickly. Another point was to ensure the audio is loud

and clear enough when there is a lot of background noise such as running water or other

activities going on in the room. The Virti scenarios consisted of the Thyroid, BHF Angioplasty,

and Trauma Simulation demos which conveyed multiple quality of life characteristics that

improved the VR experience. The option to download the scenarios to a mobile device with a

video quality selection was a welcomed feature to allow for convenient viewing when not

connected to an internet connection. Each Virti scenario also had informational pop-ups that

either guided the procedure or gave supplemental material on the task at hand. These pop-ups

were in an advantageous position that did not obstruct viewing, reassured the viewer of

progress or knowledge, and were infrequent enough to not be distracting.

Recommendations for improvement on the headsets are to provide an additional strap

over the top of the head to prevent the goggles from sliding down over time. It became a burden

to hold up the strapless headsets with prolonged use and the single horizontal strap on the

Topmaxions Cardboard was often not sufficient. An option to slightly move the mobile device or

smartphone within the headsets would also make for a more optimal experience by adjusting
the distance and consequently the quality for individuals with less than perfect vision. For

scenario building, being conscious of the viewing angle is an important factor in filming. Even if

the angle is not as realistic, the simulations could be less strenuous and deliver an improved

field of view for the user. Providing enough complementary information in the form of pop-ups or

as an introduction also improves the experience by bringing guidance and support to the

viewer. 

Conclusion

As technology advances, Virtual Reality (VR) continues to change and innovate. The

history and development of VR has set a path for many new possibilities. From early prototypes

and experiments to modern day entertainment devices, the uses of VR have allowed people to

experience environments and situations they otherwise would not have been able to. Variations

of VR such as augmented reality and mixed reality continue to challenge what is possible.

Additionally, Quality medical education is crucial in training new clinicians. And VR as a

teaching and educational resource has expanded students’ opportunities to learn in safe and

controlled settings.

The USD VR Projects’ goals to implement VR educational resources in USD’s School of

Nursing programs will further advance teaching and training capabilities. The project team

members allowed HCIN students to gain experience and develop leadership skills in

implementing a new product. The project approach served as a guide to defined goals,

objectives, specific tasks, and a timeline towards completion. Through usability testing, the use

of VR devices and VR videos were observed to discover problems and recommendations for

improvement. VR still has much potential in health care education, but this project is a step

towards improving student education and outcomes. 

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