Presentation
Implementing the PDSA Model of Change on Virtual Reality Simulation Education in the Emergency Department
SessionPoster Session 1
DescriptionIntroduction
In a previous research study, we explored the impact of interprofessional virtual reality (VR) simulation-based education on teamwork, communication, safety culture, and technology acceptance among emergency department (ED) clinicians at a large Level I Trauma Center (Vora et al., 2025). The study was conducted concurrently with the implementation of a VR platform within our organization. The research team identified that logistical challenges related to VR integration directly influenced both participant and facilitator usability. To address these challenges and enhance operational efficiency, several targeted strategies were employed. Using a Plan-Do-Study-Act (PDSA) model of change, the team achieved measurable improvements over a nine-month period of time.
There are numerous studies exploring the application of virtual reality (VR) in medical education, treatment, and cybersecurity training. Baniasadi et al. (2020) offers a comprehensive review of VR's benefits in healthcare, such as surgical simulation and therapy for various conditions, while also identifying general and specific challenges including cost, user attitudes, design complexity, safety concerns, and potential side effects, such as cybersickness (i.e., motion sickness caused by prolonged exposure to virtual reality headsets) (Baniasadi et al., 2020). In parallel, Kasurinen investigated the usability challenges of VR learning simulators within healthcare and cybersecurity contexts, highlighting that while the underlying hardware is capable, user immersion and the seamless integration of real-life tools remain significant challenges (Kasurian et al., 2017). The authors propose various VR interface solutions (e.g., no VR, semi-VR, full VR) for testing and aim to understand their impact on learning efficiency and user experience in various simulated threat scenarios (Kasurian et al., 2017). Both sources underscore the transformative potential of VR, but stress the importance of addressing usability, safety, and integration challenges.
Cognitive load theory plays also a crucial role in understanding how VR impacts learning; it identifies three types of cognitive load—intrinsic, extraneous, and germane—which must be managed effectively to optimize learning outcomes (Tokuno et al., 2025). VR training does not significantly increase cognitive load compared to computer-based training methods; the intrinsic load is kept manageable, while extraneous load is minimized through effective instructional design (Tokuno et al., 2025). This balance allows learners to focus more on germane cognitive load, which fosters deeper understanding and retention of skills.
This presentation aims to highlight the iterative PDSA model of change in implementing a novel VR modality in medical simulation education in the ED. With the latest advancements of various VR platforms, more simulation centers may consider using the technology to supplement their existing training curricula. In outlining our PDSA quality improvement process, our hope is that other institutions may learn and expand upon this work to further enhance user experience with VR.
Challenges
In an effort to increase understanding of our challenges we grouped them into Platform Usability, Network Instructure, and Physical Ergonomics. Platform usability was characterized by three types of challenges: interface, display, and cybersickness. Interface limitations included limited commands, difficulty with teleportation through the virtual world, and overall functionality challenges. Display (UX) issues included avatars that were not full-figured, and difficulty in individual identification when working in interdisciplinary teams. Cybersickness was present for some individuals during the study, further emphasizing its importance.
Additionally, the research team experienced challenges with the local network infrastructure and physical ergonomics. The network demonstrated issues such as slow download speeds, increased lag, and lack of smooth transitions within VR. Physical ergonomic shortcomings included the loss of physical awareness due to immersion-induced detachment from real world surroundings. It was also discovered that participants had difficulty in adapting to the virtual world based solely through learning with in-headset experiences.
Solutions
Corresponding solutions were developed for each challenge to assist Human Factors researchers working in this modality of simulation. Platform Usability solutions include: (1) a VR training course for instructors to provide training on VR best practices and the use of the SimX Moderator, (2) an initial in-headset orientation to orient each learner relative to others present in the virtual environment, and (3) proper instruction and fitting of the device to minimize disorientation and maximize comfort. To mitigate network infrastructure challenges, solutions included: (1) quitting and reentering the SimX Moderator application on the headset, (2) frequent maintenance of VR headsets including software updates and exiting out of unnecessary applications, and (3) preloading VR headsets to offer smooth participant transition into an immersive scenario, as well as offer insight into network stability prior to the education session.
To address physical ergonomic challenges, solutions included: (1) using stationary boundaries with the teleportation feature, which allowed participants to remain stationary in the physical space while still moving freely within the VR space and (2) optimizing orientation for VR simulation experiences by maximizing setup time, providing individualized headset fittings, and ensuring mastery of hand controls and teleportation features prior to beginning the VR case. This streamlined approach significantly reduced the complexity and stress typically associated with VR orientation. This strategy of allowing participants to exit at any time assured their physical and psychological safety in the event they experience cybersickness during the simulation.
Discussion
The integration of virtual reality (VR) devices into medical interprofessional simulation represents a potential alternative to traditional computer-based training methods. Unlike computer-based training, VR provides an immersive and interactive environment, allowing learners to explore complex relationships between various aspects of clinical scenarios, thereby enhancing comprehension and retention (Liu et al., 2023). With the decreasing costs of VR technology, these devices are becoming more attainable for simulation centers that are already equipped with pre-built infrastructures, facilitating widespread adoption across medical training institutions (Tokuno, 2025). This affordability not only enables enhanced training experiences but also makes VR a practical alternative to traditional methods that often rely on cadavers or mannequins, which can be costly and ethically challenging (Mergen et al., 2024). Importantly, as the quality of VR simulations improves, research indicates that cybersickness is relatively low, further promoting its implementation in medical education (Pedram et al., 2024).
The findings suggest that well-structured VR training can facilitate learning without overwhelming participants, thereby enhancing the overall educational experience (Liu et al., 2023). Through our PDSA approach, we were able to work through, understand, and provide recommendations for the improvement of VR interfaces. The integration of VR technology not only enhances the realism and effectiveness of medical education but also supports the development of critical non-technical skills, such as communication and teamwork (Pedram et al., 2024). As healthcare education continues to evolve, VR stands out as a compelling alternative to traditional simulation methods, offering a more effective learning experience for future healthcare professionals.
Above, we have described methods of change for our VR simulation-based education among ED clinicians. A future direction for VR simulation-based education includes expanding implementation across multiple hospital sites within a health system to evaluate scalability and adaptability in varied institutional contexts. Moreover, there is a need for collaboration with the SimX platform to refine scenarios so they align with institutional standards, which can improve fidelity and clinician performance. Potential modifications to support these goals include customization of avatars within the platform, allowing users to define roles by team color, enabling clinicians to display an in-scenario name, and allowing full-body avatars rather than only the head and hands, thereby improving spatial awareness. Another important area of exploration involves examining the longitudinal impact of repeated VR exposure on the transfer of skills to real-world patient care and outcomes, which would provide stronger evidence for the platform’s educational effectiveness and sustainability.
In a previous research study, we explored the impact of interprofessional virtual reality (VR) simulation-based education on teamwork, communication, safety culture, and technology acceptance among emergency department (ED) clinicians at a large Level I Trauma Center (Vora et al., 2025). The study was conducted concurrently with the implementation of a VR platform within our organization. The research team identified that logistical challenges related to VR integration directly influenced both participant and facilitator usability. To address these challenges and enhance operational efficiency, several targeted strategies were employed. Using a Plan-Do-Study-Act (PDSA) model of change, the team achieved measurable improvements over a nine-month period of time.
There are numerous studies exploring the application of virtual reality (VR) in medical education, treatment, and cybersecurity training. Baniasadi et al. (2020) offers a comprehensive review of VR's benefits in healthcare, such as surgical simulation and therapy for various conditions, while also identifying general and specific challenges including cost, user attitudes, design complexity, safety concerns, and potential side effects, such as cybersickness (i.e., motion sickness caused by prolonged exposure to virtual reality headsets) (Baniasadi et al., 2020). In parallel, Kasurinen investigated the usability challenges of VR learning simulators within healthcare and cybersecurity contexts, highlighting that while the underlying hardware is capable, user immersion and the seamless integration of real-life tools remain significant challenges (Kasurian et al., 2017). The authors propose various VR interface solutions (e.g., no VR, semi-VR, full VR) for testing and aim to understand their impact on learning efficiency and user experience in various simulated threat scenarios (Kasurian et al., 2017). Both sources underscore the transformative potential of VR, but stress the importance of addressing usability, safety, and integration challenges.
Cognitive load theory plays also a crucial role in understanding how VR impacts learning; it identifies three types of cognitive load—intrinsic, extraneous, and germane—which must be managed effectively to optimize learning outcomes (Tokuno et al., 2025). VR training does not significantly increase cognitive load compared to computer-based training methods; the intrinsic load is kept manageable, while extraneous load is minimized through effective instructional design (Tokuno et al., 2025). This balance allows learners to focus more on germane cognitive load, which fosters deeper understanding and retention of skills.
This presentation aims to highlight the iterative PDSA model of change in implementing a novel VR modality in medical simulation education in the ED. With the latest advancements of various VR platforms, more simulation centers may consider using the technology to supplement their existing training curricula. In outlining our PDSA quality improvement process, our hope is that other institutions may learn and expand upon this work to further enhance user experience with VR.
Challenges
In an effort to increase understanding of our challenges we grouped them into Platform Usability, Network Instructure, and Physical Ergonomics. Platform usability was characterized by three types of challenges: interface, display, and cybersickness. Interface limitations included limited commands, difficulty with teleportation through the virtual world, and overall functionality challenges. Display (UX) issues included avatars that were not full-figured, and difficulty in individual identification when working in interdisciplinary teams. Cybersickness was present for some individuals during the study, further emphasizing its importance.
Additionally, the research team experienced challenges with the local network infrastructure and physical ergonomics. The network demonstrated issues such as slow download speeds, increased lag, and lack of smooth transitions within VR. Physical ergonomic shortcomings included the loss of physical awareness due to immersion-induced detachment from real world surroundings. It was also discovered that participants had difficulty in adapting to the virtual world based solely through learning with in-headset experiences.
Solutions
Corresponding solutions were developed for each challenge to assist Human Factors researchers working in this modality of simulation. Platform Usability solutions include: (1) a VR training course for instructors to provide training on VR best practices and the use of the SimX Moderator, (2) an initial in-headset orientation to orient each learner relative to others present in the virtual environment, and (3) proper instruction and fitting of the device to minimize disorientation and maximize comfort. To mitigate network infrastructure challenges, solutions included: (1) quitting and reentering the SimX Moderator application on the headset, (2) frequent maintenance of VR headsets including software updates and exiting out of unnecessary applications, and (3) preloading VR headsets to offer smooth participant transition into an immersive scenario, as well as offer insight into network stability prior to the education session.
To address physical ergonomic challenges, solutions included: (1) using stationary boundaries with the teleportation feature, which allowed participants to remain stationary in the physical space while still moving freely within the VR space and (2) optimizing orientation for VR simulation experiences by maximizing setup time, providing individualized headset fittings, and ensuring mastery of hand controls and teleportation features prior to beginning the VR case. This streamlined approach significantly reduced the complexity and stress typically associated with VR orientation. This strategy of allowing participants to exit at any time assured their physical and psychological safety in the event they experience cybersickness during the simulation.
Discussion
The integration of virtual reality (VR) devices into medical interprofessional simulation represents a potential alternative to traditional computer-based training methods. Unlike computer-based training, VR provides an immersive and interactive environment, allowing learners to explore complex relationships between various aspects of clinical scenarios, thereby enhancing comprehension and retention (Liu et al., 2023). With the decreasing costs of VR technology, these devices are becoming more attainable for simulation centers that are already equipped with pre-built infrastructures, facilitating widespread adoption across medical training institutions (Tokuno, 2025). This affordability not only enables enhanced training experiences but also makes VR a practical alternative to traditional methods that often rely on cadavers or mannequins, which can be costly and ethically challenging (Mergen et al., 2024). Importantly, as the quality of VR simulations improves, research indicates that cybersickness is relatively low, further promoting its implementation in medical education (Pedram et al., 2024).
The findings suggest that well-structured VR training can facilitate learning without overwhelming participants, thereby enhancing the overall educational experience (Liu et al., 2023). Through our PDSA approach, we were able to work through, understand, and provide recommendations for the improvement of VR interfaces. The integration of VR technology not only enhances the realism and effectiveness of medical education but also supports the development of critical non-technical skills, such as communication and teamwork (Pedram et al., 2024). As healthcare education continues to evolve, VR stands out as a compelling alternative to traditional simulation methods, offering a more effective learning experience for future healthcare professionals.
Above, we have described methods of change for our VR simulation-based education among ED clinicians. A future direction for VR simulation-based education includes expanding implementation across multiple hospital sites within a health system to evaluate scalability and adaptability in varied institutional contexts. Moreover, there is a need for collaboration with the SimX platform to refine scenarios so they align with institutional standards, which can improve fidelity and clinician performance. Potential modifications to support these goals include customization of avatars within the platform, allowing users to define roles by team color, enabling clinicians to display an in-scenario name, and allowing full-body avatars rather than only the head and hands, thereby improving spatial awareness. Another important area of exploration involves examining the longitudinal impact of repeated VR exposure on the transfer of skills to real-world patient care and outcomes, which would provide stronger evidence for the platform’s educational effectiveness and sustainability.
Authors
Event Type
Poster Presentation
TimeMonday, March 234:45pm - 6:15pm EDT
LocationRhinelander Gallery
Simulation and Education