Resus Today Autumn 2021


Resus Today Autumn 2021

Volume 8 No. 3

Autumn 2021

Resuscitation Today

A Resource for all involved in the Teaching and Practice of Resuscitation


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Acute Care

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particular product before using it.

The information presented is intended to demonstrate Stryker’s product offerings. A healthcare professional must always

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potential adverse events, before using any of Stryker’s products. Products may not be available in all markets because

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Resuscitation Today


6 FEATURE The opportunities of BLS self-directed learning

(SDL) in a post Covid world

10 FEATURE Resuscitating Cardiopulmonary Resuscitation

Training in a Virtual Reality: Prospective

Interventional Study


This issue edited by:

David Halliwell

MSc Paramedic

c/o Media Publishing Company



Upper Sapey, Worcester, WR6 6XR


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Publishing Company.

Next Issue Spring 2022

Subscription Information – Autumn 2021

Resuscitation Today is a tri-annual publication

published in the months of March, June and

September. The subscription rates are as



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This copy of the Resuscitation Journal features an original article by the team

behind the innovative Brayden manikin range.

Working closely with Resuscitation officers in the U.K. the team have been developed a platform

for “Remote” and “Self Directed” Resuscitation education strategies.

Classroom time has become a valuable resource, and with the advent of Covid 19 the skills

needing to be trained have been expanded, whilst group sizes have been reduced - for social

distancing reasons.


“We are

seeing a


growth in

AR and VR


being used

to enhance


prepare our


It’s great to see novel education activities and technologies being developed which support the

post covid world.

We also feature an article from a team in New South Wales which explores the use of Virtual

Reality as a solution for wide scale resuscitation training. We are seeing a continued growth in AR

and VR strategies being used to enhance and prepare our learners.

We are grateful to all who write articles and news features for the journal - please continue to

do so. Our Advertisers are a vital component and key to the success of this journal and we are

always grateful for support from this community.

We have adverts for key aspects of resuscitation equipment -

The Litescope from Intersurgical, the Lucas Chest Compression device from Stryker, the Brayden

manikin team and the EOlife Ventilation monitor from MDT Global Solutions.

Conferences have started to re-open in the U.K. and across Europe and next year sees a few key

dates for your Resuscitation Diary.

European Resuscitation Council congress

16 & 17 June 2022 Antwerp - this will be a Hybrid Conference allowing both Face to Face and

online access to sessions.

Emergency Services Show - Birmingham NEC

21 & 22 September 2022

American Heart Association congress -Chicago USA

5-7 November 2022

David Halliwell

MSc Paramedic



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Brayden Online supporting self-directed learning


The recent Covid-19 pandemic and the resulting backlog of

Basic Life Support (BLS) training is reportedly putting increasing

pressure on training departments that are struggling to meet their

BLS certification compliance targets. This article looks at the

Brayden Online system and how through close collaboration with

resuscitation educators and instructors, Self Directed Learning (SDL)

BLS training is now enabling high quality training and assessment for

a high throughput of trainees that is both cost and time efficient.

Self-directed learning is not a new pedagogical approach in healthcare

education having successfully been employed in a wide variety of

training programs across multiple clinical disciplines and related

curricula 1,2 . However, the teaching of Basic Life Support through SDL

has presented some unique challenges to the clinical community 3 . It

has been suggested that theoretical eLearning programs combined

with practical CPR skills training have not yet convincingly proven to be

consistent quality training experiences, whilst subscription costs and

reduced management controls for the instructor in some systems have

also been seen as prohibitive factors.

Commenting on the issues of integrating SDL systems into BLS training,

Kevin Mackie, Lead for Education at Resuscitation Council UK said,

‘We have steered away from SDL training through sole use of eLearning

because the muscle memory of practicing CPR skills on a manikin is

actually much more important than knowing the theory. The approach

we are looking at here is blended learning, which must include a

practical, hands-on component 4,5,6 . Instructors can direct their trainees

to extensive eLearning resources to cover BLS theory; resources which

are now highly engaging and immersive e.g. Healthcare Education

England, E-Learning for Healthcare (eLFH). Once completed, trainees

can then practice on a manikin at a time convenient to them. A good

SDL system gives the student easy to interpret, real-time feedback

on their performance allowing them to make instant improvements to

the quality of their CPR 7,8 . They can then progress to an assessment

that provides full debrief metrics, if successful, this sends a certificate

direct to their email and the organisation’s LMS (Learning Management

System) - all in one simple, streamlined process.’

Objective versus subjective assessment

‘One of the challenges of previous SDL systems has been the averaging

out of metrics, which gave trainees anomalous scores across the

different systems’, continued Mackie. ‘Working with Brayden on this

aspect of the system, we know the metrics have been inputted by UK

and Global professionals, where every single element of CPR has been

looked at and weighted accordingly – it’s the professional standard of

expected performance 9 .’

‘Objective and repeatable assessment is I feel pivotal to ensure

consistent, high standards of CPR from all healthcare staff required to

initiate BLS in cardiac arrests. Recent research 10 found that subjective

assessment has been shown to be inconsistent when compared with

objective assessment. Resuscitation trainers will be all too familiar with

the pressures of progressing large cohorts of BLS trainees in classroom

settings, where time and logistical constraints have meant that some

have been passed as ‘good enough’ rather than attaining the higher

standards we would all wish.

The 24/7, high frequency, low fidelity nature of this system’s set up,

enabling trainees to practice as their own schedules allow to reach the

standards we set, then be assessed and certified accordingly, makes a

compelling case for SDL BLS training, not just as a solution for present

training challenges in Covid times but as the standard training approach

for the future 11 .’

Integration and instructor autonomy within

a hospital’s Learning Management System

(LMS) –

The Genk Experience

Sylvain Haekens, Head of Training and Development at Ziekenhuis

Oost-Limburg, Genk in Belgium looked at SDL BLS training solutions

six years ago with two primary needs in mind; a system that could be

integrated into the hospital’s new LMS and a training program that could

provide objective assessment to ensure high standards of CPR across

the hospital.

‘The hospital has approximately 4,000 employees and my department

is responsible for all education and development programs for

both doctors and nurses. I am constantly looking at opportunities

to maximise both cost and time efficiencies in our programs, while

maintaining the highest standards in both educational delivery and

outcomes,’ said Haekens.

‘The Brayden Online system caught my attention because it had the



operational flexibility I needed. The hospital’s LMS system organises

the scheduling of our trainees, who go to our CPR room where they

can learn or refresh their skills on the Brayden manikins (adult and/

or infant), take the assessment and a certificate is automatically sent

to their emails at the same time as updating our LMS system. Our

hospital LMS system also automatically sends staff renewal invites

within the time period we set. This automatic processing of staff records

through the integration of the Brayden Online system has significantly

reduced the administrative workload of our BLS training program saving

the department both time and money. This has allowed us to divert

resources to our more instructor intensive ALS programs. When the

parameters change for CPR performance, we can of course update

those markers on the Brayden system, but otherwise, our BLS program

virtually runs itself and ensures demonstrable high standards of CPR

competence at both an individual and organisational level.’

Introducing SDL has reduced the need for us to do face to face

teaching. The system has been easy to use and the staff like the SDL

method of practicing and taking their test. It has freed my staff up for

other things such as our ILS and ALS courses, which are also down on


We are a large NHS Hospital Trust with up to 9,000 staff. Since

introducing Brayden Online, we have recovered our compliance rating

of 85% far quicker than we could have done with our face-to-face

program. At the height of Covid we had dropped down to 62%, so the

Brayden Online system has been really beneficial.’

Catching up to pre-covid levels of BLS

compliance through self-assessment

The St. George’s Teaching Hospital NHS Foundation Trust


Jeannie Walls, Lead Resuscitation Officer at St. George’s Hospital

highlighted the significant impact of the pandemic on BLS compliance

targets in hospitals across the country. ‘We had a huge reduction in

compliance over Covid due to having to stop face-to-face sessions

during the peak wave periods. When we could resume, our class sizes

were reduced drastically in order to enable social distancing and our

training team was reduced by half with staff sent to work in the ITU.

We had to find other solutions. We decided on compression only CPR

to reduce the risk of having two people working so closely together. In

a hospital setting, the most important BLS learning objective is early

hands-on compressions as full resuscitation support will never be

more than three minutes away. We introduced the eLFH Level 2 online

module, so staff could cover the theoretical learning before attending

the practical sessions in our self-assessment pod on the Brayden Online

manikin system. Staff were noticeably more fully prepared prior to their

online self-assessment.

Greater efficiencies in BLS training that go

beyond the classroom

The District General Hospital Experience – Darent Valley Hospital

Rob Morrison, Resuscitation Officer at Darent Valley Hospital cited

similar challenges to St. George’s and comments on how quickly he

has been able to embed SDL into the hospital’s BLS training program.

‘It was the Covid situation that triggered the shift in our training. I was

not convinced about this type of training before, and it took me to use

the system to become convinced. I was told I had to stop mandatory

training for three months, which resulted in a significant backlog. I was

really struggling but Brayden’s SDL system has resolved most of my

problems for BLS. It’s easy- to- use and so the staff have been very

receptive to it. We now use the Brayden Online system for infant and

paediatric CPR certification as well as adult 12 . I can quickly identify




staff who are struggling to perform correct CPR and so run supervised

sessions for one-to-one instruction as necessary. The training room

is open 24/7 and I have had staff coming here on night shifts at 5am

to practice CPR. Clinical staff who need re-certification for BLS can

optimise their valuable time with patients by accessing refresher training

and assessment convenient to their shifts rather than attending a

scheduled class. This level of flexibility for training such a high number

of clinical staff has been an added benefit of the system.

The data trail the system provides for auditing, compliance and

governance has created much greater efficiencies in our BLS program.’

healthcare professionals and amongst students in Italy. Nurse

Education in Practice 2012 12, 153-158

3. Roppolo L, Heymann R, Pepe P, Wagner J, Commons B, Miller R,

et al. Wainscott M, Idris A. A randomised controlled trial comparing

traditional training in cardiopulmonary resuscitation (CPR) to selfdirected

CPR learning in first year medical students: The two-person

CPR study. Resuscitation 2011 82, 319-325

4. Gagnon M, Gagnon J, Desmartis M, Njoya M. The impact

of blended teaching on knowledge, satisfaction, and selfdirected

learning in nursing

undergraduates: A randomised,

controlled trial. Nursing Education

Perspectives 34(6) 377-382

5. Lotrecchiano G, McDonald

P, Lyons L, Long T, Zajiek-Farber

M. Blended learning: Strengths,

challenges, and lessons learned

in an interprofessional training

program. Matern. Child Health

2013 17 1725-1734

6. Lehmann R, Thiessen C, Frick

B et al. Improving paediatric basic

life support performance through

blended learning with web-based

virtual patients: randomised

controlled trial. J Med Internet

Res 2015 17:e17:e162, doi:http://


Commenting on the Brayden Online development project, Dr. Jonathan

Smart, Global Product Development Director concluded, ‘It has been

a privilege and as it has turned out, quite fortuitous in these Covid

times to have partnered so closely with key opinion leaders in the

resuscitation community. By listening and applying what we have

learnt to our Brayden Online system and adapting it for use in an SDL

teaching environment, we are proud to be helping restore high levels

of BLS competence amongst hospital staff in such difficult times.

We look forward to further supporting all those who teach or practice

resuscitation by continuing to learn and develop new training solutions,

as we work together towards improving patient outcomes.’

For further information about Brayden Online please contact:


1. O,Shea E. Self-directed learning in nurse education: a review of the

literature. Journal of Advanced Nursing 2003 43(1), 62-70

2. Cadorin L, Suter N, Dante A, Williamson S, Devetti A, Pales A.

Self-directed learning competence assessment within different

7. Yeung j, Meeks R, Edelsen D,

Gao F, Soar J, Perkins GD et al.

The use of CPR feedback/prompt

devices during training and CPR

performance: A systematic review.

Resuscitation 2009 80 743-751

8. Smart J, Kranz K, Carmona F, Lindner T, Newton A. Does real-time

objective feedback and competition improve performance and

quality in manikin CPR training – a prospective observational study

from several European EMS. Scandinavian Journal of Trauma,

Resuscitation and Emergency Medicine 2015 23:79

9. Smart J. Brayden Pro – lessons learnt to help develop the ideal CPR

training manikin. Resuscitation Today 2017 4(2) 3-4

10. Abelsson A, Gwinnutt C, Greig P, Smart J, Mackie K. Validating

peer-led assessments of CPR performance. Resusc Plus. 2020 3

(100022). Published 2020 Aug 6. doi:10.1016/j.resplu.2020.100022

11. Yeung J, Djarv T, Hsieh M, Sawyer T, Lockey A Finn J, Grief R.

Spaced learning versus massed learning in resuscitation – A

systematic review. Resuscitation 2020 (156) 61-71

12. Abelsson A, Szarpak L, Morrison R, Smart J. Real-time objective

feedback for infant CPR using a novel new infant manikin: A

pilot study with paediatric nurses in the UK. 2021 IMSH Poster







with 2021 ARC,



The most complete CPR training system:

• Instructor-led learning

• Self-directed learning

• Remote learning (NEW)

Ensuring high standards

of CPR performance:

• Objective feedback

• Maintaining competence

• Integration with Learning

Management Systems

• Customisable training for

varied curricula and

individual trainee needs


Further information:






Janaya Elizabeth Perron 1 , BMed, MD; Michael Jonathon Coffey 1 , BMed, MD, PhD; Andrew Lovell-Simons 2 , BA,

MA; Luis Dominguez 3 ; Mark E King 3 , PhD; Chee Y Ooi 1 , Dip Paeds, MBBS, PhD

The Journal of Medical Internet Research (J Med Internet Res 2021;23(7):e22920) doi: 10.2196/22920 PMID: 34326040


Background: Simulation-based technologies are emerging to enhance

medical education in the digital era. However, there is limited data for

the use of virtual reality simulation in pediatric medical education. We

developed Virtual Doc as a highly immersive virtual reality simulation to

teach pediatric cardiopulmonary resuscitation skills to medical students.

Objective: The primary objectives of this study were to evaluate

participant satisfaction and perceived educational efficacy of Virtual

Doc. The secondary aim of this study was to assess the game play

features of Virtual Doc.

Methods: We conducted a prospective closed beta-testing study at the

University of New South Wales (Sydney, Australia) in 2018. All medical

students from the 6-year undergraduate program were eligible to

participate and were recruited through voluntary convenience sampling.

Participants attended a 1-hour testing session and attempted at least

one full resuscitation case using the virtual reality simulator. Following

this, participants were asked to complete an anonymous postsession

questionnaire. Responses were analyzed using descriptive statistics.

Results: A total of 26 participants were recruited, consented to participate

in this study, and attended a 1-hour in-person closed beta-testing

session, and 88% (23/26) of participants completed the anonymous

questionnaire and were included in this study. Regarding participant

satisfaction, Virtual Doc was enjoyed by 91% (21/23) of participants,

with 74% (17/23) intending to recommend the simulation to a colleague

and 66% (15/23) intending to recommend the simulation to a friend.

In assessment of the perceived educational value of Virtual Doc, 70%

(16/23) of participants agreed they had an improved understanding of

cardiopulmonary resuscitation, and 78% (18/23) agreed that Virtual Doc

will help prepare for and deal with real-life clinical scenarios. Furthermore,

91% (21/23) of participants agreed with the development of additional

Virtual Doc cases as beneficial for learning. An evaluation of the game

play features as our secondary objective revealed that 70% (16/23) of

participants agreed with ease in understanding how to use Virtual Doc,

and 74% (17/23) found the game play elements useful in understanding

cardiopulmonary resuscitation. One-third (7/23, 30%) found it easy

to work with the interactive elements. In addition, 74% (17/23) were

interested in interacting with other students within the simulation.

Conclusions: Our study demonstrates a positive response regarding

trainee satisfaction and perceived educational efficacy of Virtual Doc.

The simulation was widely accepted by the majority of users and may

have the potential to improve educational learning objectives.


pediatrics (72); cardiopulmonary resuscitation (11); virtual reality (147);

medical education (129)



Simulation-based education plays a significant role in developing vital

clinical assessment and management skills, especially in emergency

scenarios such as a sudden cardiac arrest (SCA). SCA is an uncommon

but life-threatening condition within the pediatric population [1,2] that

includes the potential catastrophic consequences of mortality and

poor neurological morbidity. An estimated 16,000 [3,4] children in the

United States experience out-of-hospital SCAs and 5800 [4] experience

in-hospital SCAs every year. Overall, survival rates are better for inhospital

arrests compared with out-of-hospital arrests [5], which is

unsurprising considering that the most significant predictor of survival

is early initiation of adequate cardiopulmonary resuscitation (CPR)

[6]. However, junior doctors often have limited real-world learning

experience managing an acutely ill and vulnerable child [7], especially

in emergent scenarios, where active participation is often reserved

for more experienced practitioners. In addition, many pediatric health

care professionals feel inadequately prepared to manage a critically

ill child, increasing the risk of medical errors [8]. Therefore, simulation

training forms the cornerstone of resuscitation education, providing an

opportunity for trainees to prepare for real-world clinical practice without

risking patient safety [9-11]. However, in-person simulation training

sessions are expensive and resource-intensive [12], and, therefore, the

efficacy of alternative modalities should be explored.

The revolutionary development of highly immersive digitized learning

resources such as virtual reality simulators harness the advantages

of simulation while offering a cost-effective and widely accessible

educational platform. Several studies have provided evidence for

the use of virtual reality simulators for procedural skills training in the

surgical field, with improved intraoperative performance [13] and

accuracy [14] and a reduction in operating times [13] and errors [15-

18]. One study investigated the use of virtual reality for CPR education

compared with traditional mannequins and found virtual reality could

be a valid and acceptable training method [19]. Furthermore, in a

study by Wong et al [20], clinical CPR instructors outlined the limits

of traditional education and noted the potential beneficial features of



Discipline of Paediatrics, School of Women’s and Children’s Health, University of New South Wales, Randwick, Australia


Medicine Education Development Unit, Faculty of Medicine, University of New South Wales, Sydney, Australia


Educational Delivery Services, Office of the Pro Vice-Chancellor (Education), University of New South Wales, Sydney, Australia



In the knowledge that conferences and exhibitions may be difficult to attend we are delighted to

offer you the opportunity to listen to the following presentations listed on

FREE OF CHARGE with further presentations being added on a regular basis (average Podcast

time is 30 minutes):

Sepsis - Kevin Rooney

Permissive Hypertension - James Hale

Its Good To Talk - Andy Elwood

Damage Control Resuscitation - Pete Davis

Head Injuries - Dr Jonathan Hanson

Drowning and cold water - Paddy Morgan

Post Resuscitation Care - Paul Rees

This unique section on our web site also gives you the opportunity to see the following products being


• I-view(tm) video laryyngoscope

• Water Rescue toddler

• EOlife Ventillation Monitor

• Quantum Life Warmer


We are also seeking further presentation/podcasts to add to this exciting new educational concept

therefore if you have anything to submit that would interest those working in Pre Hospital Care,

Resuscitation and Simulation please forward it to

Volume 35 No. 5




October 2020

Discover the Quantum


THE Prehospital Blood &Fluid Warming Solution

Volume 30 No. 4

Winter 2020

Gastroenterology Today

New Ways of Working

within Endoscopy

One of the impacts of Covid-19 is

the way the NHS is accepting and

encouraging new ways of working.

But is this true in endoscopy?

In this edition, we look at insourcing

with 18 Week Support as a solution,

the actual experience of our nurses

and clinicians working on these

short-term contracts and explore

the differences in working life with

18 Week Support compared to their

day to day jobs in their home trusts.

Volume 7 No. 2

Autumn 2020

Resuscitation Today

A Resource for all involved in the Teaching and Practice of Resuscitation

Volume 2 No. 2

Autumn 2020


A resource for all involved in the teaching and practice of simulation


Blood &












Train critical skills required for your most vulnerable patients



See reverse for Simulation Today

See reverse for Resuscitation Today



virtual reality as an additional learning tool. The experiential nature of

virtual reality may also be conducive to developing procedural skills

such as CPR, as repetitive hands-on practice permits the development

of muscle memory [21], leading to technical skill competence. CPR

involves the activation of declarative memory to recall the sequential

steps and procedural memory to perform the active steps such as chest

compressions [22], both of which may be developed and reinforced

through the use of virtual reality.

To the best of our knowledge, there are no highly immersive virtual

reality simulators for pediatric CPR training. As such, we developed

Virtual Doc, a highly immersive and experiential 3D multimedia sensory

virtual environment designed to teach pediatric CPR skills to medical

students and junior doctors. We performed a prospective closed betatesting

study on undergraduate medical students with the primary aim

to evaluate participant satisfaction and perceived educational efficacy

of Virtual Doc. The secondary aim of this study was to assess the

gameplay features of our simulation. We hypothesized that Virtual Doc

would be an enjoyable and highly educational learning experience. We

also hypothesized that the gameplay features would be beneficial in the

facilitation of a realistic hands-on clinical learning experience.


Study Design

We conducted a prospective, uncontrolled, interventional closed betatesting

study in 2018 to assess the usability, acceptability, and perceived

educational effectiveness of Virtual Doc as a method for teaching

pediatric CPR to medical students. All participants provided implied

consent by expressing interest in the study, attending a 1-hour closed

beta-testing session, and completing an anonymous postsession

questionnaire (Multimedia Appendix 1). The study was approved by

the University of New South Wales Human Research Ethics Committee



Participants were eligible to partake in this study if they were currently

enrolled in the 6-year undergraduate medical program at the University

of New South Wales, Sydney, Australia. All medical students from the

6-year program were eligible and invited to participate in this study

through an information email sent out by the University of New South

Wales Medical Society administration. Students were instructed to

contact the study investigators with their expression of interest. They

were subsequently allocated to a 1-hour session in which they would

engage with Virtual Doc and complete the postsession questionnaire.

Participants were excluded from the analysis if they did not complete the


Virtual Doc

Virtual Doc is a virtual reality simulation developed for Oculus VR

(Facebook Technologies LLC; Figure 1). The Virtual Doc app was

developed using Unity3D software (Unity Technologies), and models

were developed using open-source Blender modeling software. The

simulation was conducted using the hardware of the Oculus Rift

system linked to Alienware laptops (Alienware Corp). Virtual Doc is

a first-person active learning experience through immersion within a

multimedia sensory environment. Users wear a headset and use 2 hand

controllers and are able to use these controllers, which are equipped

with haptic technologies, to interact with the virtual environment. This

simulation enables users to perform a series of actions including picking

up objects, pushing buttons, and turning dials. They are also fully

immersed with audiovisual aids such as auscultation of the heart and


The scenario in this study involved an SCA in a young child that required

appropriate and timely management. The required cardiac arrest

management was in keeping with the Advanced Pediatric Life Support

Australia guidelines [23]. Students were provided with a brief written

clinical history on the main screen in the virtual environment and were

then instructed to begin CPR. To complete the case, participants were

required to assess the surroundings, check for a response, signal for

senior help by pressing a call button, and then begin resuscitation by

assessing the airway, breathing, and circulation; bagging and masking

the patient (Figure 2); performing adequate chest compressions;

and defibrillating the patient. As this scenario featured a shockable

rhythm, this patient was defibrillated as part of the SCA management

algorithm; however, this step may not be required for all pediatric

SCA presentations. Shortly after the participant signaled for help, a

senior physician arrived in the virtual environment to resume chest

compressions while the user prepared for defibrillation. For successful

completion of the case, all steps must have been completed correctly

within 10 minutes.


Figure 1. The Virtual Doc environment.

Outcome Measures

Validating the use of highly immersive and experiential virtual reality

simulators as a form of active learning can be achieved by assessing

various outcomes through the Kirkpatrick model of evaluation [24]. This

4-tiered hierarchy includes a scaffolding evaluation of reaction (level

1), learning (level 2), behavior (level 3), and results (level 4) [24]. As the

levels progress, there is an increase in conclusively defining the efficacy

of the educational activity [25].

The primary outcomes of this study were participant satisfaction

(Kirkpatrick level 1) and the perceived educational value of Virtual Doc

(Kirkpatrick level 2). Participant satisfaction was assessed through 1

Likert-style question and 2 trichotomous questions regarding enjoyment

of the game and whether the participant would recommend the game to

a colleague or friend. The perceived educational efficacy was assessed

through 3 Likert-style questions including whether participants improved



Study Population

All 23 of the included participants completed the demographic

characteristics section of the questionnaire. Overall, the median age

of participants was 22.0 (interquartile range 21.5-23.0) years, and 70%

(16/23) of participants were female. In 2018, 61% (14/23) of participants

were in year 4, 13% (3/23) were in year 5, and 26% (6/23) were in year

6. A total of 87% (20/23) of participants were local students, while 13%

(3/23) were international students.

Figure 2. User is ventilating the patient with a bag-valve mask as per

the resuscitation algorithm.

Outcome Measures

Participants responded to 10 Likert-style, trichotomous, or dichotomous

questions regarding their experience with Virtual Doc. The results of

these questions are summarized by question type in the horizontal

stacked bar graphs in Figures 3-5.

their understanding of the simulation objectives, whether engaging with

Virtual Doc prepares students for a similar real-life clinical scenario, and

whether different clinical cases would be beneficial for learning.

The secondary outcome was an evaluation of the gameplay features.

Here, subjects were asked to respond to 3 Likert-style questions and 1

dichotomous question regarding the ease of understanding how to engage

with the simulation, the level of ease to work with the interactive elements,

whether the interactive elements were useful for learning, and whether the

user would like to interact with other students in the virtual world.

Testing Session

All interested participants were allocated to a 1-hour in-person session.

Attendees were invited to attempt at least one full clinical scenario using

the virtual reality simulator. They were offered an unlimited number of

attempts within the 1-hour session. After engaging with Virtual Doc,

participants were invited to complete an anonymous questionnaire that

evaluated the primary and secondary outcomes.

Data Collection and Statistical Analysis

Each postsession questionnaire was assigned a unique identification

number and was completed anonymously by participants. The

responses were collated and outcome measures were analyzed

using descriptive statistics. The 7-point Likert scale responses were

streamlined to 3 categories of agree (included all responses indicating

strongly agree, agree, and mildly agree), neutral, and disagree (included

all responses indicating mildly disagree, disagree, and strongly

disagree) for the data analysis. Trichotomous questions requiring a

response of yes, not sure, or no and dichotomous questions requiring a

response of yes or no were analyzed as such. The data were analyzed

using the statistical software R (version 1.1.423, R Foundation for

Statistical Computing) [26].


A total of 26 participants were recruited and attended 1-hour in-person

closed beta-testing sessions. A total of 88% (23/26) of participants

completed the anonymous questionnaire and were included in the

analysis, and 12% (3/26) attended the testing session but declined

to complete the questionnaire and were therefore excluded from the

analysis. They were not required to provide a reason for declining to


Participant Satisfaction

Respondents completed 1 Likert-style question and 2 trichotomous

questions to evaluate satisfaction with Virtual Doc as an assessment

of Kirkpatrick level 1. Virtual Doc was enjoyed by 91% (21/23) of

participants. Furthermore, 74% (17/23) would recommend this

simulation to a colleague, and 66% (15/23) would recommend this

simulation to a friend.

Perceived Educational Value

Participants completed 3 Likert-style questions to assess the perceived

educational efficacy of Virtual Doc, evaluating Kirkpatrick level 2, and 70%

(16/23) of participants agreed they had an improved understanding of CPR

following the use of Virtual Doc. In addition, 78% (18/23) agreed that Virtual

Doc will help them prepare for and deal with real-life clinical scenarios.

Furthermore, 91% (21/23) agreed there was a learning benefit to developing

different cases within Virtual Doc, and 9% (2/23) were neutral.

Gameplay Features

Respondents completed 3 Likert-style questions and 1 dichotomous

question evaluating the gameplay features of Virtual Doc. In terms of

usability and gameplay, 70% (16/23) of participants agreed they had

ease in understanding how to use Virtual Doc, and 74% (17/23) found

the gameplay elements useful for understanding CPR. Furthermore,

30% (7/23) of participants found it easy to work with the interactive

elements, which provides a template for future software improvements.

In addition, 74% (17/23) would like the option to interact with other

students within the game.


Principal Findings

To the best of our knowledge, a prospective study on the use of a virtual

reality simulator to teach pediatric CPR to medical students has yet

to be conducted. In accordance with the Kirkpatrick model [24], the

results of our study demonstrated high trainee satisfaction (Kirkpatrick

level 1) and a perceived improvement in learning (Kirkpatrick level

2). In evaluating our secondary outcome of assessing the response

to the virtual reality gameplay features, the majority of participants

agreed with the ease in understanding how to use the simulation and

the usefulness of gameplay features in improving their understanding

of CPR and expressed a desire for interacting with others in the virtual

environment. Although some participants found it difficult to work with




Figure 3. Results of the Likert-style questions.

Figure 4. Results of the trichotomous questions.


Figure 5. Results of the dichotomous question.

the interactive elements, this closed beta test provided an opportunity Current data on trainee satisfaction, educational efficacy, and gameplay

to identify elements for future improvements, including the refinement of elements of virtual reality simulators for pediatric medical education is

the interactive elements and future considerations such as a multiplayer limited, and the encouraging results of this study will address the gap in

design which may further enhance the learning experience and element the literature and could have an integral role in transforming the culture

of realism given the significant role of teamwork in resuscitation.

of future medical education.



Immersive technologies provide users with an engaging and enjoyable

learning platform to train skills to proficiency without risking patient

safety. Our study illustrated high participant satisfaction as Virtual Doc

was enjoyed by almost all participants. This result parallels a study

by Kron et al [27] in which an evaluation of medical student attitudes

toward technology-based education was conducted and revealed that

almost all students liked the idea of using technology to enhance their

educational experience and thought that education should make better

use of new media technologies. Beyond satisfaction, a previous study

reported that experiential simulations offer a high level of interactivity

and engagement, which may increase user motivation to learn [28].

Providing a highly engaging environment, such as that of Virtual Doc,

is important for trainees as increased interest and satisfaction with the

learning modality may result in an increased level of motivation to learn;

one study showed that highly motivated students are more effective

learners [29]. The importance of satisfaction and effective learning

is reinforced by a study evaluating the effectiveness of virtual reality

versus traditional or other forms of digital learning in educating health

care professionals, in which a higher level of interactivity was more

effective for the development of postintervention knowledge and skills

[30]. The level of satisfaction with a learning experience also affects the

probability of a user recommending such an experience to their peers

[31]. The results of our study are congruent with this notion, as indicated

by most students enjoying the simulation and agreeing with the intention

of recommendation.

In this study, Virtual Doc was perceived as educationally efficacious by the

majority of the participants, as indicated by a positive response toward

improved understanding, preparation for real-world clinical scenarios,

and support for designing additional cases. An important component

of effective education in the adult learner involves the psychological

concept of flow. This term is defined as a state in which a learner is “fully

engaged, focused, and committed to the success of the activity” [32],

and this can be achieved through active engagement in an experiential

learning process. The use of highly immersive and interactive virtual

reality simulators can improve flow, which may lead to superior learning

outcomes and performance as echoed by the majority of participants

reporting an improved understanding of CPR. Additionally, engaging

sensory modalities including vision, haptics, and audition also promotes

active learning, which can improve memory retention [33]. Virtual Doc

includes sensory features through auscultation of heart and lung sounds

and palpation of the peripheral pulses, which the user will hopefully be

able to translate into the real-world clinical setting when assessing or

managing a similar patient presentation.

Being immersed in the virtual yet realistic hospital environment of Virtual

Doc provides users with a lifelike clinical experience. This digital-based

environment is an innovative tool with realistic features supporting

the recommendations of adult learning theories such as Knowles’

theory [34,35]. The responses in this study regarding the Virtual Doc

environment and its ability to prepare students for real-life clinical

scenarios showcases a facility in which the elements of adult learning

theories can be included. Active experimentation within a realistic

and immersive learning environment allows users to make clinical

decisions and experience the consequences of their actions in real time,

mimicking a real-world clinical environment. This element of realism is

important in encouraging intrinsic motivation to support the needs of an

adult learner.

Additionally, the Kolb cycle of learning encourages repetition, reflection,

and correction to improve learning outcomes [36]. Virtual Doc supports

this cyclical relationship as learners have the opportunity to engage

in repetitive practice until they achieve educational mastery in a safe

and controlled environment, which is an important benefit of simulation

as this is severely limited in real-world emergency patient encounters,

especially in the pediatric population [5]. The flexible design of virtual

reality may enable health care professionals to have more convenient

and frequent opportunities to practice and refine skills.

Several studies have demonstrated that junior doctors feel inadequately

prepared and lack confidence in their early training years [37-41].

This is further supplemented by less favorable outcomes for neonatal

resuscitation being described in the summer when senior staff

physicians are less likely to be present and the overall volume of

staff members is reduced [42]. Lacking confidence and inadequate

preparation may translate into unsafe practice and poor patient

outcomes and is an especially important consideration when managing

emergency scenarios such as an SCA. Virtual reality simulators such as

Virtual Doc may provide an avenue to bridge the gap between trainee

and doctor through immersive gameplay by enabling users to master

foundational principles and basic management algorithms and apply

this knowledge to challenging simulated cases. In our study, the majority

of respondents expressed that this simulation game would aid in

developing clinical skills and preparing the user for dealing with real-life

clinical scenarios. In addition, almost all participants expressed benefit

in the development of different cases, indicating a positive response

toward the clinical educational value of the simulation.

The gameplay elements involved in virtual reality add entertainment to

the learning process, thereby motivating learners to engage in study.

The triad of immersion, interaction, and imagination, as described

by Burdea and Coiffet [43], are important factors of virtual reality

technology. Coupled with andragogical principles, a highly interactive

game design improves intrinsic motivation and creates a more

enjoyable and engaging learning experience with a consequential

potential to illustrate superior examination scores [44]. In our study,

the vast majority of respondents agreed that the interactive gameplay

elements were useful in understanding how to perform CPR and

found the process of the virtual reality simulation easy to understand.

This was further supplemented by almost all participants enjoying the

experience in the assessment of participant satisfaction. However,

some respondents did not experience ease in using the interactive

elements within the virtual environment. As this was a closed beta test,

the software was able to deliver its intentional value to the participants,

but there were some minor issues reported with ease in fully integrating

into the environment such as accurately picking up a stethoscope or

pushing the assistance button. This feedback is being considered as we

progress toward the final product and acts as identified areas for future


Finally, nontechnical skills such as teamwork and leadership are

paramount in successful resuscitation. The collegiality of the responding

team directly impacts predictors of postarrest survival as a coordinated

course of action is associated with improved patient outcomes [45].

Technology-based games such as Virtual Doc have the potential to

facilitate an atmosphere of teamwork, and in the digital era, medical

students have agreed with introducing multiplayer simulations if






they were fun and developed clinical skills [27]. Likewise, our study

demonstrated that the majority of participants were interested in

interacting with other players. A multiplayer design within the virtual

environment could afford an opportunity to rotate through different

resuscitation team roles, supporting an active and immersive learning

experience, with the potential to equip learners with the crucial teamwork

skills required for the effective management of a pediatric SCA.


Our study was limited by the small sample size and monocentric

design, which limits its generalizability and external validity. However,

participants from all years of study were eligible to participate,

providing a degree of generalizability. This trial is also limited by

voluntary convenience sampling, leading to a potential selection

bias. Furthermore, this study used a single intervention with no active

comparator, and therefore, the participants were not randomized and

were unblinded to the intervention, which may formulate a measurement

bias. However, the questionnaires were anonymized, providing a layer

of security for participants to provide uncoerced feedback. Moreover,

the final version of Virtual Doc will differ from the prototype used in this

study as this was closed beta-testing and we are improving the software

to address the feedback provided by the participants in this study. In

addition, the prototype design of Virtual Doc in this closed beta test did

not assess user hand technique or the quality of chest compressions.

This limitation will guide future software improvements to ensure users

are equipped with real-time visual and haptic feedback regarding the

technique and quality of chest compressions.

Future Research

Given the encouraging results of this study, future research should

include an investigator-blinded randomized controlled trial to objectively

evaluate the educational efficacy of Virtual Doc against traditional

simulation-based education or other digitized modalities such as serious

games or e-learning modules. Furthermore, an evaluation of translation

of knowledge into clinical practice (Kirkpatrick level 3) and the impact

of learned knowledge on changes within the organizational practice to

improve patient outcomes (Kirkpatrick level 4) should be performed,

with emphasis on a reduction in medical errors and improved patient

survival rates and overall health outcomes. This study does not assess

the higher levels of the Kirkpatrick model, and this limitation should be

the focus of future research to contribute to the quality of data for the

efficacy of Virtual Doc.


In summary, our study demonstrates a positive response regarding the

satisfaction and educational efficacy of Virtual Doc. Our findings reveal

that this virtual reality simulation was widely accepted by the majority of

users and has the potential to improve educational learning objectives.

As such, our results provide a promising contribution to the educational

revolution and may encourage the use of this emerging and versatile

technology in the transformation of the 21st century medical curricula.


The study team would like to acknowledge the participating medical

students for their involvement in this study, Reece Pahn (University of

New South Wales Medical Society secretary) for facilitating the invitation

of students, and Seiya Takeda and Zheyu Li for assisting with game


Authors’ Contributions

The study was conceived by CYO and MJC. The study design and

analysis were developed by CYO and MJC. CYO, MJC, ALS, and

LD contributed to the conception and design of Virtual Doc. Subject

recruitment and trial coordination were performed by JEP and MJC. LD

sourced and coordinated the required technological equipment for the

testing sessions. Data collection and statistical analysis were performed

by JEP, MJC, and CYO. The paper was first drafted by JEP and revised

in subsequent drafts by MJC, MEK, and CYO. All authors reviewed and

approved the final manuscript.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Questionnaire instrument.

DOC File , 236 KB (




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CPR: cardiopulmonary resuscitation

SCA: sudden cardiac arrest

Edited by G Eysenbach, R Kukafka; submitted 29.07.20; peer-reviewed

by T Canares, R Lundin, D Drummond; comments to author 18.09.20;

revised version received 16.10.20; accepted 11.03.21; published



©Janaya Elizabeth Perron, Michael Jonathon Coffey, Andrew Lovell-

Simons, Luis Dominguez, Mark E King, Chee Y Ooi. Originally published

in the Journal of Medical Internet Research (,


Corresponding Author:

Janaya Elizabeth Perron, BMed, MD

Discipline of Paediatrics

School of Women’s and Children’s Health

University of New South Wales

Centre for Child Health Research & Innovation

Level 8, Bright Alliance Building, Corner of Avoca & High Streets



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How to tackle the nursing


For many people the social restrictions

experienced during lockdowns will

have had long-lasting consequences,

increasing feelings of loneliness, stress

and depression.

But throughout the pandemic those employed

in hospitals and care settings have faced the

same issues, alongside having to deal with the

pressures of working on the front-line.

Covid-19 has stretched medical staff to their limit,

and with cases continuing to rise in some areas

and a growing backlog of patients with other

health problems, they are tired, stressed, underresourced,

and some are simply burning out.

So it is perhaps unsurprising that the sector

has reported a surge in Covid-related staff


As of June 2021, National Health Service

(NHS) vacancy statistics for England showed

there were an alarming 38,952 registered

nurse vacancies across the health service.

In a report by the Royal College of Nursing

(RCN), it was revealed that the NHS in

England recorded 73,209 more sick days

among nurses and health visitors in May 2021

compared to May 2019 - a rise of 18%.

The analysis showed that staff are now at

greater risk of mental health problems, chest

and respiratory problems and migraines than

before the pandemic.

The UK government has promised a nursing

recruitment drive – increasing the number

of nurses in the NHS by 50,000 by 2024-25

- and pledged to increase nurse pay by 3%

in recognition of the “extraordinary efforts” of

NHS staff during the pandemic.

But whether these measures have any real

impact on staff recruitment or retention remains

to be seen as nursing shortages are a global

issue and there simply aren’t surpluses of trained

nurses anywhere. Even if they were available,

employing more and more nurses is not a

sustainable solution to an ever-growing problem.

A recent article by the New York Times

headlined ‘Nursing is in crisis: Staff shortages

in US put patients at risk’, quotes an

emergency room nurse who describes her work

environment as being “like a war zone”, with

sick patients waiting to be admitted to hospital

and staff left physically and emotionally drained.

In the piece, Patricia Pittman, Director of the

Health Workforce Research Center at George

Washington University, says: “When hospitals

are understaffed, people die.”

The story paints a troubling picture – and

shows that the situation is not confined to

hospitals in the UK.

That’s why some providers have begun to

explore novel technological solutions to their

staffing challenges.

It’s an approach that has already attracted the

interest of UK government decision makers.

In a keynote speech during London Tech

Week, UK Health and Social Care Secretary,

Sajid Javid, said he hoped the healthcare

progress made during the pandemic under

“incredible strain” would pave the way for a

“long-awaited digital revolution”.

Javid said the building blocks of this revolution

would see out-of-date technology replaced

and the adoption of a “truly integrated system”

where health service employees can easily

access and share patient data.

“It’s only by allowing colleagues to see

patients’ information in one place, regardless

of what part of the system they use, that we

can have a truly integrated system for health

and social care,” he said.

While better and safely shared access to

patient data is essential, it raises the question

of whether even this will make much difference

to ever extending waiting times to see a doctor

or to get booked in for an operation.

What is needed are new connected digital

technologies that automate much of the

basic work in the wards, giving nurses more

time to care for their patients and doctors the

vital information they need to make fast and

accurate decisions about a patient’s treatment.

Systems such as Isansys Lifecare’s Patient

Status Engine (PSE) provide a way of relieving

pressure on staff and freeing up hospital beds.

The PSE is a Class II(a) CE and FDA certified

wireless patient monitoring platform that allows

clinicians to monitor patients in hospital and

at home by automatically collecting realtime

physiological data such as heart rate,

respiration rate, oxygen saturation, blood

pressure and body temperature.

This data is then transmitted via Bluetooth from the

Patient Gateway to a central server, then through

the nurses’ station, or remotely to clinicians.

This data is filtered and analysed at each point

so only the key clinical information is provided.

Smart notifications can alert care teams or

clinicians anywhere, any time on computers,

tablets or phones.

Patients are also free from wires and cables,

and can walk around or even go home, freeing

up much-needed hospital beds for those most

in need.

The technology reduces the amount of nurses’

time spent in mundane tasks and form-filling,

provides a safe way to check in on how those

with Covid-19 or other infectious conditions are

doing, and allows one nurse to safely monitor

several patients at once.

If a patient’s health starts to deteriorate, the

system will provide an early warning to nursing

staff so they can act on it in a timely and proactive


It’s an approach that has already seen

success in the field.

The Sorlandet Hospital in Kristiansand,

Norway, used the PSE to allow clinicians and

nurses to view vital sign measurements and

real-time calculations of patient health direct

from a wireless bedside gateway to their

nursing stations.

The hospital said the technology freed-up

nurses’ time and provided complete and

accurate information to support their care

decisions, allowing them to focus on a proactive

rather than reactive care delivery model.

Birmingham Women’s and Children’s NHS

Foundation Trust took part in the RAPID (Real

Time Adaptive and Predictive Indicator of

Deterioration) project, a ground-breaking study

to detect and respond to clinical deterioration

in sick children.

The Trust used the PSE platform to monitor

and care for children and babies in real-time,

helping staff to identify deterioration more

quickly so timely treatment could be given.

In all these cases the PSE worked in

conjunction with nurses and doctors to free up

time and improve efficiency – key areas when

care providers are trying to balance high patient

numbers with the wellbeing of their staff.

The goal of any care provider is to provide

staff with the right tools and optimal working

conditions to deliver the best possible care for

patients - and ultimately save lives. And that,

after all, is what we all want.



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