Students' Perceptions of Virtual Reality as Learning Tool in a Radiographic Technique Course

ABSTRACT

Introduction

Virtual reality (VR) has been increasingly recognised as a beneficial pedagogical tool in radiography education, particularly for skills training. This pilot study aims to gain insight into the viability of VR as a pedagogical instrument in a radiographic technique course within a Norwegian bachelor's programme in radiography by assessing users' experiences.

Methods

A cross‐sectional study was conducted involving all first‐year radiography students from a single bachelor programme in Norway. The study included a preliminary survey to gauge students' expectations prior to their first VR session and a main survey following the completion of the course. The surveys assessed demographics, prior VR experience, experiences with the use of VR as a learning tool and possible improvements. VR training was facilitated using Skilitics radiography simulation software across six stations equipped with Oculus Rift VR gear.

Results

Results indicated a significant difference between students' expectations and their actual experiences with VR in skills learning. While initial expectations were high, only 37% of students were content with VR training. Major issues highlighted included technical problems and limited pre‐session training. Students expressed a preference for more VR stations, teacher guidance and better software features.

Conclusion

Although VR holds potential as a supplementary tool in radiography education, the study identified several areas for improvement in the pedagogical approach. Pre‐session training, teacher assistance during the training sessions and feedback after the session are recommended to maximise the educational benefits of VR in radiography skills training.

This pilot study aims to gain insight into the viability of virtual reality (VR) as a pedagogical instrument in a radiographic technique course within a Norwegian bachelor's programme in radiography by assessing users' experiences. Results indicated a significant difference between students' expectations and their actual experiences with VR in skills learning. Although VR holds potential as a supplementary tool in radiography education, the study identified several areas for improvement in the pedagogical approach: pre‐session training, teacher assistance during the training sessions and feedback after the session.

1. Introduction

Virtual reality (VR) simulation bridges the gap between theoretical knowledge and practical application as skills acquired in simulation environments can be transferred to clinical practice [1, 2, 3]. Clinical education is a core component of medical radiation education programmes, and simulation is recognised as an important pedagogical tool for preparing students for clinical practice [4]. There is broad consensus that simulation should supplement clinical placements not replace them [2, 3, 4, 5, 6].

The most common simulation activities for pre‐clinical technical skill development in radiography programmes include performing X‐ray examinations on anthropomorphic phantoms to develop skills related to patient positioning, centring of the X‐ray beam, exposure parameter selection and image evaluation [4, 7, 8]. Role‐playing using the X‐ray imaging systems is used for improving palpation and patient communication skills [4, 7, 8]. These teaching strategies pose challenges to time‐tabling and resource availability and issues like access, maintenance and cost can potentially be solved by using VR simulation [3, 9].

VR is not a recent technology, nor is its application to education. The first recorded implementation of a digital VR system dates back to 1966 when a flight simulator was designed for training purposes for the United States Air Force [10]. Subsequently, this innovative teaching and learning technological strategy was successfully applied to a growing range of technical and workplace training programmes in areas such as equipment design, prototyping and operation, firefighting, law enforcement and hazard detection [2]. A literature review on VR in education found that 35% of the included articles addressed its use in health‐related domains [10] as pharmacy [11], laboratory medicine [12, 13] and surgery [14, 15, 16]. It was found that VR is applied in medical education in 25 countries [2], probably even more as the review only included articles written in English. VR was adopted as a learning tool also in medical imaging some time ago [7, 17].

Sustainability and radiation‐free training of X‐ray imaging procedures [8] and the opportunity to learn at their own pace in a safe environment where they can repeat examinations and learn from their mistakes [5] were mentioned as benefits of VR as an educational tool. An advantage of the VR educational tool is that it is less space demanding and costly compared to real medical equipment [2]. However, data regarding implementation costs were not provided in any of the included studies in a large literature review [5], while other studies mention that VR practice opportunities are often constrained by the large number of students and limited resources [2, 4]. Due to its limitations in simulating patient care interactions, VR is best utilised as a complement to traditional lab training.

While most studies reported high engagement and student satisfaction [4, 6, 8, 18], there is no consensus regarding VR training's benefits to achieving learning outcomes [5], the range goes from lower performance compared to classical lab training [8] and no statistically significant difference [19, 20] to better performance that justifies implementation of VR as a substitute for lab training [3, 18]. More pedagogical research is necessary to inform effective evaluation of the effect of VR on students learning as well as its clinical effectiveness [2].

The aim of this pilot study is to gain insight into the viability of VR as a pedagogical instrument that warrants further allocation of resources in a bachelor in radiography programme. The precise extent of use of VR in radiography education in Norway is unknown as there are no previously published studies regarding this aspect. The study investigates the user experience of radiography students through a preliminary survey, comparing their expectations for this new technology with actual experiences after its incorporation as an educational resource in a first‐year course in a radiography programme in Norway.

2. Methods

2.1. Procedure and Participants

This cross‐sectional study employed two stages: a preliminary survey to explore the students' expectations prior to the first VR session and the main survey after completing the course that included use of VR as learning tool. This cross‐sectional study included all 41 first‐year radiography students from a single bachelor programme at a Norwegian university. After the abovementioned course, the number of actively registered students decreased to 38, who were all invited to the main survey.

2.2. Incorporation of VR in the Course

The radiography students were introduced to VR as a supplemental learning tool for their skills training sessions in the university's X‐ray lab during their first year of study. They used Skilitics radiography simulation software (Figure 1), which allows students to select the type of X‐ray examination they wish to practice. This software enables them to carry out the entire X‐ray examination process from start to finish, with everything they do in the simulation accurately represented on the produced image.

FIGURE 1.

The image on the left is from the ‘Skilitics Radiography’ programme, depicting the VR interface seen by users. The image on the right shows a user equipped with VR gear.

After completing the X‐ray examination, the students automatically received the images and an image report by e‐mail (Figure 2). The report contained an overview of the applied exposure parameters (including tube current and voltage) and technique (collimation, use of AEC, tube angulation and rotation) in addition to radiation dose (dose area product (DAP) and effective dose per image, total DAP and effective dose per examination and exposure index (EI)) and the time used to complete the examination.

FIGURE 2.

Image report automatically sent to the students by e‐mail after completing the examination.

The software was installed on six stations equipped with Oculus Rift VR goggles and Oculus Touch hand controllers. The student cohort attended an introductory lecture featuring the VR software and equipment presentation. Subsequently, students were divided into groups of five to six individuals to collaborate on practising radiography procedures and developing their own procedure booklet the same way they work in the university's X‐ray lab. Each group chose a representative called ‘super user’ who received thorough training in the use of the software and was assigned the responsibility for training and guiding the other group members. Apart from the guidance provided by the group's ‘super user’, other students in the groups did not receive any pre‐session training on using the technology. The students had free access to the VR lab throughout the semester, and up to six students had the opportunity to practice at the same time.

2.3. Data Acquisition

Invitation e‐mails containing information about the study's purpose, ethical considerations and a link to the digital questionnaire hosted on ‘nettskjema.no’ (survey solution developed and hosted by the University of Oslo nettskjema@usit.uio.no) were sent to all first‐year radiography students. The survey was available for a period of 14 days and two reminders were published on the university's digital learning platform in addition to two oral reminders during the lectures. The same approach was employed in both the preliminary and the main survey, with data collection conducted in January 2023 and November 2023 respectively.

2.4. Questionnaires

The preliminary questionnaire consisted of four questions concerning the students' previous experience with VR equipment and their expectations regarding the use of VR in skills training in radiography.

The main questionnaire was based on the preliminary questionnaire and also included new elements, some of them from previously employed questionnaires [6, 8] that investigated the radiography students' experiences with VR as a learning resource. It included 14 questions from the following categories: demographics, experiences with the use of VR (Likert scale) and possible improvements. Questions with non‐exhaustive response options included the option ‘other’ where respondents could freely write an open answer. The questionnaire concluded with a free‐text field for general feedback related to the use of VR as a teaching tool (see Supporting Information).

2.5. Data Analysis

Data analysis was performed using Microsoft Excel spreadsheet editor (version Microsoft 365, Microsoft Company). The responses were analysed using descriptive statistics. Free‐text answers were analysed and sorted into categories.

2.6. Ethics Statement

The study was approved by the head of the study programme. Ethical considerations according to the Declaration of Helsinki were applied. The approval of the Regional Committee for Medical and Health Research Ethics was not required as the project did not involve patients or collect any health‐related information. The Norwegian Centre for Research Data confirmed that there was no reporting requirement for anonymous electronic questionnaire surveys without IP address tracking. An independent assessment was carried out by the leader of the university's Programme for Applied Ethics leader, particularly due to the fact that the study participants were students and some of the researchers were their lecturers. The participants received information about the study and assurance that participation was voluntary and confidential. Consent to participate was implied by the completion of the questionnaire.

3. Results

The response rate in the preliminary and the main survey was 73% (30 of 41 invited) and 58% (22 of 38), respectively (after the course, the number of actively registered students decreased from 41 to 38). Thirty‐six per cent of the respondents were men, 64% were women, 64% were 18–22 years old and 36% were 23–27 years old.

3.1. Expectations Versus Actual Experiences

None of the students had attended any previous VR sessions related to radiography skills training, and the majority did not have any previous experience with VR at all (53%) while 37% had used VR only once and only 10% had used VR multiple times.

Overall, the results show considerable difference between the expectations and the actual experiences of using VR in skills learning. Figure 3 presents students' opinions on learning by means of VR support before and after the course and Figure 4 their opinion on usefulness of VR before and after using it.

FIGURE 3.

Students' opinion on learning by means of VR support before and after the course.

FIGURE 4.

Students' opinion on the usefulness of VR as a supplement to skills training in the X‐ray lab before and after the course.

3.2. User Experiences

After using VR, 14% of the students declared that they were very content, 23% quite content, 45% neutral and 18% quite discontent with the use of VR in the course. Many students were neutral when asked if they would recommend VR to other students (Figure 5). The percentage of the students who experienced physical or psychological discomfort was rather low (Figure 5).

FIGURE 5.

Students' experience with using VR.

3.3. Improvement Potential

In addition to identifying elements that could improve the VR training setup (Figure 6), many students stated that they do not want VR as a training method and some of the students expressed complaints about the software in the free‐text box. One of the students complained about the system's reaction time and another one stated that ‘The software didn't let us practice much, everything is already set up and the images look exactly the same anyway’.

FIGURE 6.

Students' opinion on the possibilities for improvement of the VR training setup.

When asked about suggestions for software improvement (Figure 7) one of the respondents wrote ‘the images should reflect the patient positioning’ in the free‐text box.

FIGURE 7.

The students' opinion on the possibilities for improvement of the VR software.

The free‐text responses from the general comments box affirm the appropriateness of utilising VR as a supplement to X‐ray lab training but lab not as a replacement for it.

4. Discussion

This pilot study aimed to get insight into the viability of VR as a teaching tool in a radiographic technique course for advising decisions on future resource allocation.

The response rate decreased from 73% in the preliminary survey to 58% in the main survey. However, declining response rate between two survey waves is quite common as survey fatigue increases [21].

The results show a considerable difference between the expectations and the actual experiences of using VR in skills learning. Students reported higher levels of satisfaction and perceived value of VR as a training tool before actually experiencing it, a finding that comes in contradiction with Kato et al. [8] who reported an increased per cent of students with a favourable impression after testing VR. The possible impact of gaming experience on the perception of using VR was also mentioned in previous studies [6] and individual personality traits may also be an influencing factor [22]. That suggests that a possible explanation for the less favourable impression after using VR found in the present study could be the participants' limited previous experience with VR and presumably much more experience with gaming. This might have generated exaggerated expectations of more accurate modelling, better graphic quality and higher level of interactivity as 87% of the students identified better ability to move the patient and 45% better animation as elements of possible improvement of the software.

In other studies, confusing software and technical difficulties diminished the learning experience [4, 5, 7]. While confusing software was not a concern as most of the students found it easy to learn how to use the software (Figure 5), 40% of participants experienced technical issues, which may have contributed to their dissatisfaction. Another crucial aspect reported by Dietrich et al. [23] is the content of the simulated image database which needs to be aligned with users’ demands, learning outcomes and competency level, as well as operational considerations including financial capabilities.

The results presented in this study refer to students' perceived effect of VR on learning which is subjective, and the study does not include a knowledge or skills evaluation which could provide an objective measure of the efficiency of this teaching approach. However, very few articles in a literature study reported inefficient implementation [10] and the variance in user‐perceived effectiveness could demonstrate that people react to VR educational systems differently [10] and students' perceptions do not necessarily indicate their real‐world performance [18] and students' self‐evaluation tends to be overestimated when they lack clinical experience [8, 24]. While there is disagreement between studies regarding the effectiveness of VR compared to classical lab training [3, 8, 18, 19, 20], VR is considered a useful supplement to clinical skills labs and clinical placement [6].

Evidence showed that students want more VR learning [2], and 100% of the students in a study expressed that [8]. Contrary to the expectations, the results of this study show that 40% of the students do not want VR as a training method, and the same per cent in a similar study [8] expressed negative impressions about using VR without teacher assistance in the future. In a study with successful outcomes [3], the students were given both pre‐session training and time to familiarise themselves with the software which was not the case in the present study and that might explain the students' dissatisfaction, as the level of guidance required when using a new learning tool is often underestimated by educators [4] and lack of engagement can be a result of poor educational design even when using innovative tools like VR [10]. Consistent with other findings [6, 8], the students expressed the need for teacher feedback, and the lack of it might be one of the causes of the students' disappointment, as the automatic report might not be enough for inexperienced students [6] and self‐learning requires timely and appropriate evaluation [8]. Mandatory VR training sessions were proposed by 18% of the students, which is in contrast with the results of a literature study which found that compulsory participation has a negative effect on both the students' acceptance of VR as a learning tool and the efficiency of VR training [2].

Another improvement suggestion from the respondents was more VR stations. Limited VR equipment reduces the amount of time students could spend using the VR simulation tool and this might also have negatively impacted students' perceptions [6]. In a similar study, 90% of respondents only used VR during their scheduled time and they indicated increasing the limited number of licences available as an improvement strategy [4]. An increased number of licences would also allow for greater flexibility including home use which in turn could increase the amount of time used for training [4] that might enhance learning outcomes [8].

A hindrance to increasing the number of VR stations and licences is the cost. Cost often limits educational VR adoption and was mentioned as a concern in 25% of the articles included in a review [10]. In addition to purchasing hardware and software, the costs of maintenance, support and training should be factored in. The total cost of implementing the VR training sessions evaluated in the present study was relatively similar to the purchasing and operating cost of a new X‐ray lab, considering the fact that VR would be used as a supplement to lab training and not a replacement for it, the expense might be difficult to justify. However, since most universities already possess VR simulation facilities with the necessary equipment, the primary costs associated with implementing VR in radiography training would be limited to software acquisition and instructor training. Thus, adopting VR in radiography can optimise existing resources, thereby enhancing educational quality and maximising the value of current infrastructure.

The survey data showed that 23% of students reported physical discomfort when using VR goggles. A literature review showed that many papers reported common issues such as nausea, dizziness [22] and other symptoms such as headache and blurred vision [2], referred to as cyber sickness [14] that might have a disturbing effect on the students' use of VR while other studies on radiographer students had no reports of students experiencing headaches or feeling dizzy [18] or any other kind of pain when using the VR [8]. However, physical and psychological discomfort are important ethical considerations when implementing VR [25, 26].

After the pandemic, the expansion of simulation in radiography education is decelerating [27], and one contributing factor is the lack of comprehension of optimal ways to utilise it [28]. The results of the present survey confirm Rowe's assertion that ‘coolness effect is not enough’ [3] and while VR's significant potential in radiography education is widely recognised, there is no universal model for its' implementation [29]. Another issue is the lack of guidelines on how to test the feasibility of VR use [30].

4.1. Limitations

This was a small‐scale pilot study with general questions. The participants reported satisfaction levels and perceived value of VR without having the possibility to outline either the factors affecting their enjoyment (or lack thereof) or the particular learning objectives where the potential usefulness of the software is highest and lowest. That might explain the ambivalence illustrated by the high percentage of neutral responses (30%), consistent with earlier findings [9].

Comparing individual student attitudes before and after using VR was not possible because the survey was conducted anonymously, making it impossible to match the preliminary and the main survey's responses.

5. Conclusion

The majority of students were positive about using VR as a learning tool before it was introduced, and the levels of satisfaction and perceived value decreased after actually experiencing it. The findings suggest that this may be due to limitations with the software used and shortcomings in the pedagogical approach. VR training is worth implementing as a formal component in radiography education and the pedagogical design could be improved by implementing pre‐session training, teacher assistance during the training sessions and feedback after the session.

Ethics Statement

The study was approved by the head of the study programme. The approval of the Regional Committee for Medical and Health Research Ethics was not required as the project was considered a pedagogical quality improvement project, and it did not involve collecting any health‐related information. The anonymity function of the survey software turns off IP address tracking.

Consent

Participants were informed about the purpose of the study, preservation of anonymity and that participation was voluntary; the questionnaire started with a checkbox where they could tick to agree to participate.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.The survey.

Data Availability Statement

Data available on request due to privacy/ethical restrictions.