Abstract
Background: Virtual reality (VR) has not been used in pharmacy education when teaching sterile compounding. Objective: The objective of this study was to describe the development of a VR 360 video for second-year student pharmacists. The secondary objective was to assess the VR experience, specifically on participants’ knowledge and performance in sterile compounding, as well as the VR video demands and efforts. Methods: This cross-sectional, open-label randomized study developed a VR 360 video introducing sterile compounding, created with Insta360 Pro and GoPro cameras. The video creation required two individuals to record and one individual to edit for approximately 12 hours of creation time. Participants’ knowledge and performance were assessed through ten knowledge questions and the class activity rubric. The NASA Task Load Index (TLX) measured the VR experience demands and efforts for the VR sterile compounding introduction. Results: Of the 98 second-year student pharmacists, 19 consented to the study with 7 in the VR group and 12 controls. Student knowledge increased from 6.33 (0.8) to 8 (1.2) for the VR group and 7 (0.7) to 8 (0.7) for the control group. Performance for the classroom activity was 23.71 (0.3) for the VR group and 22.96 (0.9) for the control group. The NASA TLX values demonstrated positive findings for the VR experience. Conclusion: With the limited study enrollment, comparative analysis between standard materials and the VR 360 video could not be determined. This article describes the creation of a VR sterile compounding 360 video with excerpts included. Future studies to compare traditional materials to VR will be completed in the future.
Keywords: virtual reality, sterile compounding, technology, pharmacy education, SoTL
Background
Virtual reality (VR) as a teaching tool has been available for 20 years, 1 and the majority of uses for VR in health care education center around the surgical suite 2 or anatomy simulations. 3 Virtual reality in pharmacy education has demonstrated success in increasing student empathy 4 and team-based learning 5 ; however, to date, it has not been represented in the literature for use in teaching sterile compounding. Sterile compounding is an ideal content area for a combination of VR and teaching, as noted by Coyne and colleagues, who note that VR could provide increased access to sterile compounding education, specifically for institutions without cleanroom suites. 6
Therefore, the Virginia Commonwealth University (VCU) School of Pharmacy created a VR 360 video to introduce student pharmacists to the cleanroom suite prior to their in-person activity. Virginia Commonwealth University School of Pharmacy has both resources in VR education tools and a fully US Pharmacopeia (USP) <797> compliant sterile compounding pharmacy suite. In addition to creating this teaching tool for other institutions and trainees not able to visit the in-person cleanroom suite, faculty considered an introduction to the cleanroom environment would support student learning. Anecdotally, many student pharmacists verbally identified feeling overwhelmed when first entering the cleanroom space; as Kurt establishes with Maslow’s Hierarchy of Needs in Education, a student’s environment affects their ability to learn. 7 When Lahiti and colleagues demonstrated the use of VR to introduce a dental suite to children prior to their appointments to decrease patient anxiety, 8 the faculty felt a VR video could be created to increase the student’s learning by first introducing them to the cleanroom space.
Objective
The objective of this study was to develop a VR sterile compounding introduction for second-year student pharmacists. The secondary objective was to assess the VR experience for the participants, including describing the impact on participants’ knowledge and performance within the cleanroom and the VR experience for the users.
Methods
A VR video was designed and recorded by VCU School of Pharmacy faculty performing sterile compounding practices, with a focus on garbing, personnel preparation, and aseptic technique. An Insta360 Pro camera was placed in various locations around the sterile compounding cleanroom suite and additionally a GoPro camera for in-lay image capture. Sterile room recording videos required 1 person who was knowledgeable of the VR camera to record the 1 faculty member teaching the concepts of sterile compounding. This was completed on-site at the institution in 1 recording session that lasted approximately 3 hours and included video design and recording. The 360 video was edited with DaVinci Resolve 18.1 software and voice over was applied as a new audio layer after sound correction in Audacity Version 3.2.1. Notably, the editing of the video to the final form took approximately a day of work. A demonstration excerpt from this VR video can be found at: https://www.youtube.com/watch?v=sejhdWy_Usw.
In this skills laboratory course, all second-year student pharmacists perform two sterile activity assessments in their spring semester of the 4-year Doctor of Pharmacy program. This takes place in the VCU’s Center for Compounding Practice and Research USP <797> compliant sterile compounding suite. The in-person activity requires approximately three faculty with eight teaching assistants and residents to facilitate approximately 90 students in three 2-hour sessions. Faculty who coordinate this activity each year report that for the majority of second-year students, this is their first exposure to sterile compounding in a cleanroom suite. Prior to the activity, students are provided the 24-point standardized performance rubric focused on 4 key areas: personnel preparation, preparation of primary engineering control, sterile compounding technique, and visual inspection and final compound verification (Figure 1). Students were also provided with their planned product and procedures for the activity. In addition, standard 2-dimensional (2D) videos were available for all students to reinforce garbing and compounding techniques. All standard materials were available on the course learning management system.
Figure 1.
Sterile compounding assessment rubric.
All second-year students were invited to participate in this VR study by completing a Qualtrics form, which included a written consent to the study, demographic questions (Table 1), and ten knowledge question assessments (Table 2). The ten knowledge assessment questions (multiple-choice questions with four options) were aligned with the four key areas of the performance rubric.
Table 1.
Student Demographic Comparison.
| VR group (n = 7) | Control (n = 12) | |
|---|---|---|
| No previous IV hood experience | 100% | 83.3% |
| Age, y Mean (SD) |
23.57 (1.0) | 25.3 (3.3) |
| Gender, female | 57.1% | 66.7% |
| Pre-knowledge score total Mean (SD) out of 10 (n = 6) |
6.33 (0.8) | 7 (0.7) |
| Post-knowledge assessment score total | 8 (1.2) n = 4 |
8 (0.7) n = 5 |
Abbreviations: IV, intravenous; VR, virtual reality.
Table 2.
Knowledge Assessment Comparison Between VR Group and Control Group.
| VR group | Control group | |||
|---|---|---|---|---|
| Pre-knowledge assessment (n = 7) |
Post-knowledge assessment (n = 4) |
Pre-knowledge assessment (n = 12) | Post-knowledge assessment (n = 5) | |
| 1. Which item can individuals continue wearing when in a sterile compounding area? (Answer: Glasses) |
100% | 100% | 100% | 100% |
| 2. What is the minimum duration for handwashing recommended by US Pharmacopeia (USP) 797? (Answer: 30 seconds) | 42.9% | 75% | 58.3% | 100% |
| 3. Once sterile gloves are donned, what step must individuals complete before entering the laminar airflow hood (LAFH) to gloved hands? (Answer: Apply sterile isopropyl alcohol) | 42.9% | 50% | 33.3% | 80% |
| 4. How far from the laminar airflow hood (LAFH) opening should all sterile compounding materials be kept ensuring appropriate “first air” ventilation? (Answer: 6 inches) | 28.6% | 100% | 91.7% | 100% |
| 5. What is the most appropriate cleaning agent to use first in a LAFH when dried drug or streaks are visualized? (Answer: Sterile water) | 14.3% | 100% | 41.7% | 20% |
| 6. What is cleaned last in a laminar airflow hood (LAFH)? (Answer: Work surface) | 42.9% | 100% | 58.3% | 100% |
| 7. You are preparing an order that calls for 8 mL of reconstituted drug. The drug comes in a 15-mL vial, and you are using a 10-mL syringe. How much air should you inject into the vial prior to withdrawing the dose of drug? (Answer: 8 mL) | 85.7% | 75% | 91.7% | 100% |
| 8. Once in the laminar airflow hood (LAFH), what part of the intravenous (IV) bag should be swabbed with alcohol prior to injecting any drug/medication? (Answer: Additive port) | 57.1% | 100% | 50% | 80% |
| 9. Where is the appropriate disposal location for syringes with needles? (Answer: Red Sharps bin) | 85.7% | 100% | 100% | 100% |
| 10. What is the beyond-use date (BUD) of a high-risk compounded-sterile product that is stored at room temperature (20°C-25°C)? (Answer: 24 hours) | 57.1% | 75% | 75% | 20% |
Abbreviation: VR, virtual reality.
Students who completed the consent form were randomized into the control group or the VR group with a simple number generator determining odd number (VR group) or even number (Control group). Both groups were provided the standard course materials, which included traditional 2D videos, the evaluation form for the sterile compounding assessment (Figure 1), and the procedure for the compounded sterile preparations.
Participants randomized into the VR group were scheduled with the Laboratory of Pharmacometabolomics & Companion Diagnostics to complete the VR 360 video in the technology laboratory with the Meta Quest 2 VR headset. During the VR 360 video, the students could look around the virtual space by moving their head, torso, or using a VR controller. During the video, they experienced a one-on-one session with the recorded faculty member explaining and moving to different spaces. Each time the students would need to access a different virtual space, they would be teleported to it. During the experience, students could be standing up or sitting.
At the conclusion of the VR 360 video, participants were provided NASA Task Load Index (TLX) tests 9 to assess the VR experience. After the in-class sterile compounding cleanroom activity, participants were emailed the post-survey which repeated the knowledge questions. Students’ first and second performance on the in-class sterile compounding activity was assessed for all participants. All second-year students were given access to the VR 360 video after the first in-person cleanroom activity had been completed, regardless of participation in study.
Data analysis of participant survey materials was completed with SPSS 28.0.1.1. Participant 10 knowledge questions were totaled and assessed with means and standard deviations. Individual knowledge questions were converted into binary (correct or incorrect) and described by the percentage of students who answered correctly. Student in-class sterile compounding performance activity assessments, both first and second activity, were overall totaled and totaled for each of the 4 sections, and then described with means and standard deviations.
The assessment of the VR experience for each individual in the VR Group was conducted using the NASA TLX, a well-established multidimensional rating scale that provides a comprehensive evaluation of the cognitive and physical workload experienced by participants during a task. 9 In this study, the NASA TLX was employed to assess the perceived mental demands, physical demands, temporal demands, performance, effort, and frustration associated with the VR sterile compounding introduction.
Prior to the VR session, each participant was briefed on the purpose of the assessment and provided with instructions on how to complete the TLX questionnaire. Following the VR session, participants were asked to rate their perceived workload in each dimension based on their VR experience. The questionnaire was administered through a web-based platform, ensuring anonymity and confidentiality of the participants’ responses. This study was approved by the VCU’s institutional review board.
Results
Of the 98 second-year student pharmacists invited to participate, 19 consented to the study (response rate 19.4%). Seven students were randomized into the VR group and able to complete the in-person VR 360 video prior to their sterile cleanroom activity; the remaining 12 students were randomized into the control group. One participant who was originally randomized into the VR group was transitioned into the control group when unable to travel to complete the on-site VR experience at the Laboratory of Pharmacometabolomics & Companion Diagnostics. After all students, regardless of participation in the study, were offered use of the VR 360 headsets, no additional students requested or viewed the VR 360 video.
The demographics of the study participants reflected the majority of participants having no prior sterile compounding cleanroom experience (Table 1). Knowledge questions improved for each group in both total knowledge assessment and increased for most of each question individually. The number of participants who completed the post-survey decreased for both the control and VR group (Table 2). From the ten questions, two questions demonstrated a decrease in correct answers (question 7 for VR group and questions 5 and 10 for the control group), question 1 remained at 100% for both pre- and post-assessment in both groups, and question 9 kept at 100% for the control at pre- and post-assessment, all other questions increased correct responses for both groups. Performance assessments of the activity were high scores for both groups. The VR group demonstrated a slightly higher mean in their first activity performance total points and each of the 4 sections with less standard deviation in the scores than the control group (Table 3). This continues with the second cleanroom activity performance assessment. The control group participants also demonstrated larger variation in their standard deviation of their total scores.
Table 3.
Performance Assessment Comparison.
| VR group | Control group | |||
|---|---|---|---|---|
| First IV activity | Second IV activity | First IV activity | Second IV activity | |
| Total assessment score (Total: 24 points) |
23.71 (0.3) | 23.64 (0.9) | 22.96 (0.9) | 23.08 (0.9) |
| Personnel preparation (9 points) | 8.86 (0.2) | 8.79 (0.6) | 8.33 (0.6) | 8.50 (0.6) |
| Preparation of primary engineering control (4 points) | 3.93 (0.2) | 4.00 (0.2) | 3.92 (0.2) | 3.92 (0.2) |
| Sterile compounding technique (6 points) | 5.93 (0.2) | 5.86 (0.6) | 5.79 (0.5) | 5.67 (0.6) |
| Final preparation virtual inspection and verification (5 points) | 5.00 (0.0) | 5 (0.0) | 4.92 (0.4) | 5.00 (0.0) |
Abbreviations: IV, intravenous; VR, virtual reality.
The NASA TLX questionnaire was divided into 21 gradation scales (Figure 2), the students averaged their answers in 5.26 (4.7) indicating a low demanding experience as higher levels, closer to 21 indicate higher demand and discomfort, and the box plot (Figure 3) displays the spread of each answer, where Performance has the highest values, as this was the only option where the wording was the following: “How successful were you in accomplishing what you were asked to do?” prompting the students to select high values for success, in all the other options high scores would mean high demand and discomfort. Anecdotally, after finishing the NASA TLX questionnaire, students positively commented about the feeling of having a “one-on-one” class with the professor and how they were immersed in the explanation instead of watching a 2D video.
Figure 2.
NASA TLX virtual questionnaire.
Abbreviation: TLX, Task Load Index.
Figure 3.
NASA TLX values box plot.
Abbreviation: TLX, Task Load Index.
Discussion
This project successfully developed a VR sterile compounding 360 video to introduce second-year student pharmacists to the cleanroom environment. This piece serves as the first in the literature to provide an example of utilizing VR in pharmacy sterile compounding. The second objective to assess the VR experience on improving student knowledge and performance, as well as analyze the participants’ VR experience, was unsuccessful due to the low participation. Due to the limited enrollment and sample size, comparative statistical analysis could not be reliably determined. With the low number of study participants, no summative conclusion can be made.
There are many reasons a study may not recruit enough participants. Carnegie Mellon lists many potential reasons why students seem to lack interest or motivation, 10 but the authors believe it was due to competing priorities with their time and attention. This activity fell during a busy week for the students and was not available during their regularly scheduled class time. Instead, students had to schedule time to meet at the Laboratory of Pharmacometabolomics & Companion Diagnostics to complete the activity. Coyne identifies this as a challenge in VR education of “securing enough sites for all students” 6 and it was a challenge for this study as well. All second-year students also were guaranteed by the course design to be in-person in the cleanroom space; therefore, the novelty of a VR experience might have been less valued. In addition, the content was available on the 2D videos, so they were not required to complete the VR to access classroom content.
The planned project to recruit 98 students was ambitious, considering that the largest healthcare VR tutorial study has a study population of 173 students with 73 students at follow-up. 11 The majority of studies with VR in education are either recommendations2,6 or smaller groups. 5 Due to these low numbers of participants, the study is not powered to provide conclusions or suggestions from the data.
The VR experience for the participants showed a relatively low difficulty for students to utilize the VR video. The NASA TLX box-plot categories of Mental, Physical, and Temporal Demand, together with Effort, and Frustration received low values, showing that students felt less stressed, physically strained, and frustrated during the VR 360 video (Figure 2). All VR programs have inherent limitations, this VR 360 video was immersive but passive education; other programs in the future may offer interactive VR options, however, these videos may then have increased user difficulty and higher production times. 12
Additional limitations of this study include that it was completed at a single institution as a cross-sectional study in time. This was a designed proof-of-concept study and future studies will include additional students and additional programs.
Plans for future offerings of this VR 360 video at this institution are to designate specific class time to rotate through the VR video prior to the in-person activity. In addition, participants will be asked to complete the post-activity assessment at the end of the first sterile compounding activity while in person, in lieu of an email invitation. Once created, the VR introduction to the cleanroom 360 video only requires one facilitator to assist students in utilizing the VR, which may decrease as students become more familiar with this technology. Future studies will continue with 2D videos to accommodate learner access to technology, but the faculty plan to continue to include the VR 360 videos and measure the impact.
This article serves to share the creation of a VR 360 video to introduce a cleanroom suite to second-year student pharmacists.
Conclusion
This study shows the feasibility of creating a VR 360 video in sterile compounding pharmacy education. Future research with larger cohorts can further validate the benefits of VR in enhancing students’ knowledge and performance in sterile compounding, as well as the cognitive burden on the user. In addition, future studies will determine the cost-benefit of utilizing VR in pharmacy higher education.
Footnotes
Authors’ Note: For inquiries regarding educational research please contact Dr Caldas and for inquiries regarding virtual reality please contact Dr Wijesinghe.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Silas Contaifer 
https://orcid.org/0000-0002-1091-8144
Lauren M. Caldas
https://orcid.org/0000-0002-2149-0796
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