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. 2022 Dec 3:1–13. Online ahead of print. doi: 10.1007/s10055-022-00728-1

Application of virtual reality for peritoneal dialysis exchange learning in patients with end-stage renal disease and cognitive impairment

Connie M S Lee 1,2, Kenneth N K Fong 1,✉, Maggie M Y Mok 3, M K Lam 4, Y Kung 4, Paven P W Chan 4, Maggie K M Ma 4, S L Lui 3, Lorraine P Y Kwan 3, W L Chu 3, P C Hui 3, Christina S F Yau 5, Ivan W L Kwan 5, Kelsey Y M Chan 5, T M Chan 4
PMCID: PMC9734863  PMID: 36533192

Abstract

Cognitive impairment is not uncommon in patients with end-stage renal disease and can make it more difficult for these patients to carry out peritoneal dialysis (PD) on their own. Their attempts to do so may result in adverse consequences such as peritonitis. PD exchange is a complex procedure demanding knowledge and skill which requires close supervision and guidance by a renal nurse specialist. In this study, a non-immersive virtual reality (VR) training program using a Leap motion hand tracking device was developed to facilitate patients’ understanding and learning of the PD exchange procedure before attempting real task practice. This study was a two-center single-blinded randomized controlled trial on 23 incident PD patients. Patients in the experimental group received 8 sessions of VR training, while patients in the control were provided with printed educational materials. The results showed that there were significant differences between the two groups in performance of the overall PD exchange sequence, especially on the crucial steps. VR had a patient satisfaction rate of 89%, and all patients preferred to have the VR aid incorporated in PD training. Our findings conclude VR can be a useful aid in the training and reinforcement of PD exchange procedures, with distinct merits of being free from restrictions of time, space, and manpower.

Keywords: Virtual reality, End-stage renal disease, Peritoneal dialysis, Cognitive impairment

Introduction

Chronic kidney disease (CKD) is a very serious non-communicable disease that affects many people worldwide. CKD is defined as kidney damage or glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2 for three months or more, irrespective of cause (Levey et al. 2005). There are five stages of CKD, with end-stage renal disease (ESRD) referring to the final stage of the disease, when GFR is less than 15 mL/min/1.73 m2. If uremia is present, patients with ESRD receive renal replacement therapy (RRT), which acts to replace some of the functions of a kidney, particularly removal of waste products and excess fluids. The three types of RRT are peritoneal dialysis (PD), hemodialysis (HD), and renal transplant. There were 8510 patients on RRT in 2013 as compared to 3312 patients in 1996 in Hong Kong (Leung et al. 2015). This increase in patients has occurred at the same time as the region’s implementation of a “Peritoneal Dialysis (PD) - first” policy, which has seen continuous ambulatory peritoneal dialysis (CAPD) provided to all patients as the default dialysis treatment option in the absence of medical contraindications (Kwong and Li 2015). As a result, more than 80% of ESRD patients requiring dialysis are put on PD, among whom 86% are on CAPD, while the remainder are on automated peritoneal dialysis (APD).

Furthermore, CKD itself is a significant risk factor for cognitive impairment, beginning with those at stage 3 (i.e., patients with GFR of 45–60 ml/min/1.73 m2) and becoming more prevalent among those who have reached ESRD (Kurella et al. 2005; Murry and Knopman 2010; Etgen et al. 2012). The major areas of cognitive deficit in ESRD patients on RRT are attention, memory, processing speed and executive function. Around 70% of patients aged over 55 have been found to exhibit moderate-to-severe cognitive impairment (Radic et al. 2010; Kalirao et al. 2011). Recent local studies also showed that cognitive impairment was common in those with ESRD, with a prevalence of 28.9% among patients who had recently started PD (Shea et al. 2016a, b). Being older than 65 and having lower levels of education were shown to be independent risk factors for cognitive impairment (Shea et al. 2016a, b). More significantly, one third of ESRD patients on PD demonstrate moderate-to-severe impairment in executive function, which poses a considerable risk of hazard during self-administered PD, particularly due to reduced abilities in organization, planning, sequencing and procedural memory (Kalirao et al. 2011).

PD exchange is a complex task that demands multiple aspects of cognitive function, including adhering correctly to procedures, sequencing, time estimation and safety awareness, and the detection of problems encountered during the exchange. Cognitive impairment among patients with ESRD who perform PD exchange themselves may leave them at risk of medical complications such as peritonitis resulting from errors in handling of the complex PD exchange procedure. Given these various requirements, and the risks involved in carrying out procedures incorrectly, it would be better for patients to learn using errorless learning, enabling them to make use of their learning ability using implicit memory through repetitive practice. This method reduces the burden on conscious and logical recall of learned materials (Baddeley and Wilson 1994). In current local practice, it is usual that ESRD patients learn and practice PD exchange in a clinical setting and under the instruction of a renal nurse 1 week prior to carrying out the procedure at home. Most patients do not acquire knowledge and understanding of the procedure or the necessary precautions until after formal training commences. There is no doubt that cognitively impaired patients face extra difficulty in handling this complex task, which requires both accuracy and strict adherence to safety procedures. However, the common remedies for this barrier to understanding among cognitively impaired patients are limited to the provision of visual cues (such as an instruction sheet listing a series of steps to be followed) and signage (e.g., attached to indicate the positions of items to be put), while the need for additional and needs-specific training on performing PD is not addressed. There is a limited amount of evidence on effective intervention for training cognitively impaired renal patients in self-administering PD.

VR can be viewed as an advanced computer-based technology that allows users to interact and immerse within a multi-sensory three-dimensional simulated environment and receive augmented feedback on performance (Rizzo et al. 1997; Costa et al. 2000). Interaction and immersion is a key characteristic of any VR system, offering the user total engagement in an activity’s characteristic features, including human interaction, tools and environment, and goal-directed actions and reactions that demand responses from multiple cognitive functions (Joseph et al. 2012; Panerai et al. 2019, 2021). Being actively engaged in the activity means that the user’s awareness and attention are enhanced. Moreover, less motor skill is demanded as compared with actual performance, meaning there are less barriers to engagement by users with physical disabilities (Zhang et al. 2003). Furthermore, practicing skills within simulated environments that bear close resemblance to real situations has several advantages. It allows for generalization of skills learned in the virtual training environment to the real-life environment (Costa et al. 2000). It also enables the user to practice procedures that are not easily deliverable and controlled in reality, and it reduces the manpower needed for supervision purposes while increasing the number of practice repetitions that can be undertaken in one session (Christiansen et al. 1998; Joseph et al. 2012). Moreover, controlled delivery of a wide range of VR environments during practice offers flexibility in the range of different training conditions under which patients can practice, which may not be feasible in reality. In addition, systematic and hierarchical presentation of challenges and augmented feedback on performance are believed to improve motivation and awareness, since these enable users to better understand their own performance and successes, hence improving their self-efficacy in performing tasks (Faria et al. 2016; Hwang and Lee 2017).

It is inevitable that cognitively impaired patients with ESRD will be required to perform CAPD by themselves. Since learning of the PD exchange procedure is complicated, and may pose risks if steps are missed or done incorrectly, particularly in patients with cognitive deficits; therefore, this study proposed and developed a non-immersive VR training program to serve as an innovative method in occupational therapy for restorative task-specific training within a simulated context that permits implicit learning of skills and explicit formation of knowledge about PD exchange, as well as optimizing transfer of training to real-life situations. The objective of this study was to investigate whether the application of a VR training program in learning PD exchange could assist ESRD patients with cognitive impairment more than a conventional educational approach using printed educational materials.

Methods

Participants

ESRD patients who were newly starting PD were recruited consecutively by convenience sampling from the Division of Nephrology at Queen Mary Hospital and from Tung Wah Hospital in Hong Kong over a 2-year period. The inclusion criteria were: (i) using the Ultrabag (Baxter) Dialysis Delivery system, (ii) Cantonese-speaking, and (iii) failed in “alternating trail making” or “verbal fluency”, or recall less than three “delayed recall” items on the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) (Yeung et al. 2014). The exclusion criteria were: (i) using automated peritoneal dialysis or other alternative dialysis systems, (ii) having previous experience in PD, (iii) requiring an assistive device during PD exchange, (iv) receiving cognitive rehabilitation elsewhere, and (v) incompetent to give their own consent.

This study was a two-center single-blinded randomized controlled trial, in which the outcome assessors were blinded to the group allocation. Written consents from eligible patients were obtained before the study began. Patients recruited into the study were randomly assigned to either the experimental group or the control group by an independent renal doctor. The randomization schedule was generated using the website Randomization.com (http://www.randomization.com). To assure a balanced allocation ratio across conditions, a block randomization method with block size of 10 was adopted for each research center. The allocation sequences were concealed, and only the researchers were informed of the group assigned to the participant. Ethical approvals were sought from the Human Subjects Research Ethics Committee of The Hong Kong Polytechnic University (Reference number HSEARS20180502004) and the Research Ethics Committee of the Hong Kong West Cluster/University of Hong Kong (IRB reference number UW 17-463).

Equipment

The VR computer program used in this study is a non-HMD type that participants use to interact with a simulated three-dimensional environment presented on a notebook computer monitor. The virtual environment simulates the layout of PD exchange, with standard equipment and device displayed for each step. The user navigates and interacts with the environment through the Leap motion hand tracking device, as illustrated in Fig. 1. The VR application was developed using the software Unity 3D game engine version (version 2017.4.20f2, Unity Technologies, San Francisco, US). It was a cross-platform game engine designed to support and develop 2D and 3D video games, and virtual reality in desktop and mobile devices. The control functions in the VR environment were coded by the Unity3D using the C# programming language. The model objects for the VR application were designed and constructed base on real equipment set for renal dialysis by using the software 3D Studio Max version 2017 (Autodesk Inc., San Rafael, US). The VR program was designed by the investigators based on the comments from an expert panel, which consisted of 10 persons including 2 nephrologists, a renal nurse consultant, 2 renal nurse specialists, 2 occupational therapists, and 3 patients receiving PD exchange, and was written by an IT programmer. Multiple user testing was done to refine the sensitivity of the device in capturing user’s response and graphics displayed on the screen. The program composed of three modules (i) real case video demonstration of the whole PD exchange, (ii) VR PD assessment mode, and (iii) VR PD training mode. The content was based on real task of PD exchange using Ultrabag (Baxter) Dialysis Delivery system. The whole PD exchange procedure is divided into eight sub sections, and each sub section consists of multiple steps. Patients are requested to complete the steps of each section in a correct order. The total number of correct responses is recorded as the assessment result.

Fig. 1.

Fig. 1

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The experimental setup

The objects used in each step are presented on the computer monitor, and the user is required to initiate each action in the sequence within 10 s. The object selected by the user will be highlighted (Fig. 2a), and any transfer of the object from one place to another will be demonstrated on the screen as immediate visual feedback. A vocal message is produced to notify the user that an action has been successfully completed, for example, “The blood pressure is taken.” An image of a timer is also displayed in the right-hand lower corner of the screen, which indicates the time remaining for the user to react (Fig. 2b). If the user fails to make a correct response within 10 s, a pop-up written message of the action that should be taken will show on the screen together with a vocal message, serving as a reminder to the user (Fig. 2c). However, if either no response or an incorrect response is made by the user within the subsequent 10 s, the program will automatically execute the correct step and move to the next step (Fig. 2d). This design guarantees that the program proceeds through to the final step of the PD exchange procedure, at which point the user’s total score is calculated. Figure 2 shows screenshots of selected steps of the program.

Fig. 2.

Fig. 2

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a–d Samples of the VR training steps

The only difference between the training mode and the assessment mode is that the former does not assign scores to the user’s response. Apart from its training purpose, the training mode can also be used to familiarize patients with the VR program and so that the occupational therapist can identify an optimal environment before actual assessment starts.

In assessment mode, patients’ performance at each step is evaluated, with scores assigned in the form of total score (0–96 points) and sub section scores (Preparation of workstation: 0–24, checking of new dialysate: 0–18, connection to new dialysate: 0–16, drain-out: 0–6, wash drain: 0–4, drain-in: 0–6, disconnection: 0–14, completion: 0–8). A higher score indicates more correct responses made by the user. The scoring system is based on the number of correct responses made with or without cues at each individual step, with a maximum of three cues available per step (Fong et al. 2010). A brief description of the scoring system is given in Table 1.

Table 1.

Scoring system of the assessment mode

Points User’s performance at each step
2 Correct response is made without any cue
1 Correct response is made with visual cue and auditory message
0 No response, or an incorrect response, is made by the user, even following visual cue and auditory message; the program automatically executes the correct step
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Intervention

At the beginning of the study, patients in both groups watched a real case video demonstrating the whole PD exchange process. They then underwent a set of pre-treatment outcome measurements within the same week. All patients received routine twice-weekly intermittent peritoneal dialysis (IPD) in the hospital for 8–10 weeks. Patients in the control group were given at the first IPD session educational materials concerning management of CAPD, including knowledge of the disease, various kinds of renal replacement therapy, multidisciplinary support, and common problems encountered by patients, etc. Patients in the experimental group were given, apart from usual IPD, an additional minimum of eight sessions of VR training on PD exchange, with one to two sessions per week given by an occupational therapist during their hospital stay for IPD. Since patients undergoing IPD were restricted to bed, the VR training was conducted at bedside, with the Leap motion sensor and notebook computer set up there for use. Patients in the experimental group also received the same educational materials as the control group. Upon completion of IPD, all patients received 1 week of CAPD training at the day center, where they were instructed in the PD exchange procedure by the renal nurse specialist. Patients engaged in sufficient practice sessions in carrying out PD exchange under nurse supervision to ensure safe and accurate self-administering of CAPD following discharge. All patients underwent the same set of post-treatment outcome measurements, administered by the researchers, within this week, while their performance in carrying out the PD exchange technique was assessed by the renal nurse specialist at the final session of CAPD training. For the experimental group, a two-item patient satisfaction survey was conducted to collect information on patients’ perception of (i) the usefulness of the VR training in learning the PD exchange procedure and (ii) their preference for VR training as a technique for learning PD exchange. The survey used a four-point ordinal scale ranging from “strongly agree” to “strongly disagree”.

Outcome measurements

Outcome measurements were taken at baseline (pre-treatment), within the first week after recruitment into the study, and at post-treatment, within the week that patients received CAPD training at the day center. All outcome measurements were conducted by blinded researchers, except in the case of the PD exchange technique assessment, which was carried out by the renal nurse specialist. The study employed three primary outcome measures to assess the task domain. These measured knowledge proficiency, procedure competence and self-efficacy in PD exchange. (i) Knowledge proficiency regarding peritoneal dialysis was measured by a PD knowledge test composed of ten key questions about PD exchange in the format of multiple choice questions. Each correct answer earns respondents one point, with total score ranging from 0 to 10. (ii) Procedure competence was measured by using the PD steps sequence test, administered through the VR computer program. The total number of correct responses is recorded as the assessment result. Apart from the total score, we further categorized the eight sub sections into three sections—“Start”, “Main” and “After” with these section scores analyzed in this study. The “Start section” included preparation of workstation and checking of new dialysate, which was a setup phase; the “Main section” included connection to new dialysate, drain-out, wash drain and drain-in, which were considered as the critical steps; the “After section” included disconnection and completion, the final stages of the procedure. (iii) Self-efficacy of PD exchange was assessed using the Chinese General Self-Efficacy Scale (Chinese-GSE) and four-item self-constructed supplementary questions. The Chinese-GSE scale consists of ten items measuring how confident a person is in dealing with novel or demanding situations regarding their abilities and employs a four-point ordinal scale. Total score ranges from 10 to 40, with a higher score indicating higher confidence. The scale was found to have excellent internal consistency (0.92–0.93) and very good to excellent test re-test reliability (0.75–0.94) in schizophrenia (Chiu and Tsang 2004). The four-item self-constructed supplementary confidence questionnaire was specifically designed for assessing patients’ self-efficacy in PD exchange, using a 10-point scale to measure “knowledge of PD exchange steps and sequence”, “knowledge of key points in PD exchange”, “ability to self-administer CAPD” and “incorporation of CAPD into daily living”. Zero represents the least confidence, while 10 represents absolute confidence. Total score ranges from 0 to 40, with higher scores indicating greater confidence in PD exchange. (iv) The PD exchange technique assessment administered by the renal nurse specialist is a 10-item test addressing PD exchange preparation and procedure using a five-point Likert scale, with responses corresponding to “completely satisfactory”, “satisfactory”, “acceptable”, “dissatisfactory” and “completely dissatisfactory”. Patients were rated by the renal nurse specialist according to their ability in carrying out real PD exchange at the final session of CAPD training before discharge. Patients’ possible scores range from 10 to 50, with higher scores indicating more satisfactory performance.

Two secondary outcome measures were used to assess the cognitive domain. These included an everyday memory scale and an executive functioning test. (i) The Rivermead Behavioural Memory Test—version 3 (RBMT-3) consists of eleven subtests addressing visual, verbal and visuospatial memory, with a total standardized profile score ranging from 0 to 24 (Wilson et al. 2008). The Hong Kong version of the assessment we used in this study showed excellent internal consistency (with a Cronbach’s alpha of p = 0.859), high inter-rater reliability (with correlation coefficient ranging from 0.74 to 0.95, p = 0.000), and test–retest reliability (t = − 3.4, p = 0.002) (Fong et al. 2017). The Sum of Scaled Scores (SSS) and the General Memory Index (GMI) were both analyzed. (ii) The Wisconsin Card Sorting Test—Computer version 4 (WCST-CV4) is a measure of executive function that is administered on-screen. It tests the ability to shift mental sets and to update and monitor working memory representations. Patients are requested to sort cards according to matches in either color, form or number of figures, and according to different criteria that change discreetly without the patient being informed (Heaton et al. 1993). The WCST has been employed extensively in the study of multiple kinds of disease, including focal and diffuse brain damage. The validity of WCST as a measure of executive function in adults has been supported, with the preservative errors of the instrument found to load on the factor of operational reasoning ability (Shute and Huertas 1990), while preservative responses (r = 0.63) and total number of errors (r = 0.62) were related to attribute identification (Perrine 1993). Total number of trials administered, total correct responses and total errors made were each analyzed in this study. Figure 3 summarizes the workflow of the study.

Fig. 3.

Fig. 3

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Workflow of the study. Note: CAPD continuous ambulatory peritoneal dialysis, Chinese-GSE Chinese General Self efficacy Scale, ERSD end-stage renal disease, HK-MoCA Hong Kong version of Montreal Cognitive Assessment, IPD intermittent peritoneal dialysis, OT Occupational Therapist, PD peritoneal dialysis, RBMT-3 The Rivermead Behavioural Memory Test—version 3, WCST-CV4 The Wisconsin Card Sorting Test—Computer version 4

Statistical analysis

Demographic and baseline outcome measurements for all patients were reported using descriptive statistics. Independent t testing (continuous data) and Chi-square testing (categorical data) were performed to compare any difference between the control group and the experimental group. Intention-to-treat analysis was applied using the last observation carried forward (LOCF) method for dropouts. Repeated measures analysis of covariance (RANCOVA) was used to analyze the within-subject effect (time effects) and between-subject effect (group effects) on the outcome measurements. The difference in PD exchange technique between the two groups was analyzed by independent t test. All statistical analyses were calculated using the statistical software SPSS version 21.0. The level of significance was set at p < 0.05 (two-tailed).

Results

Figure 4 shows the CONSORT flowchart of participants. A total of 25 patients with ESRD were assessed for eligibility, of whom two refused to join the study. A total of 23 patients were recruited and randomly allocated to control group (n = 11) and experimental group (n = 12). Among the 11 patients in the control group, there was one patient who did not complete the pre-treatment VR computer program and WCST; and there were four patients who completed only parts of the post-treatment outcome measurements due to change of mode of dialysis to either APD or HD. Among the 12 patients in the experimental group, two did not complete the pre-treatment WCST, and three did not complete the whole set of post-treatment outcome measurements. The data for a particular assessment were either excluded for analysis if the baseline could not be obtained back, or filled in using the group mean score if parts of the post-treatment outcome measurements were missing.

Fig. 4.

Fig. 4

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CONSORT flow diagram of patients recruited into the study. Note: ERSD end-stage renal disease, IPD intermittent peritoneal dialysis

The mean age ± standard deviation (SD) of patients was 63.6 ± 11.5 in the control group and 62.7 ± 5.5 in the experimental group. There were six males (55%) and five females (45%) in the control group and nine males (75%) and three females (25%) in the experimental group. The mean HK-MoCA score was 23.7 ± 4.5 for those in the control group and 23.3 ± 4.4 for those in the experimental group. The mean years of education was 8 ± 1.3 for those in the control group and 8.3 ± 1.3 for those in the experimental group. There was no significant difference in demographics or in any pre-treatment outcome measurements between the two groups (Table 2).

Table 2.

Comparison of demographics and baseline characteristics

Experimental group Control group p
(n = 12) (n = 11)
Demographics
Age (year), mean ± SD 62.7 ± 5.5 63.6 ± 11.5 0.82
Gender (%)
 Male 9 (75) 6 (55)
 Female 3 (25) 5 (45) 0.30
HK-MoCA, mean ± SD 23.3 ± 4.4 23.7 ± 4.5 0.80
Education level (year), mean ± SD 8.3 ± 1.3 8 ± 1.3
Pre-treatment assessment
mean ± SD
PD knowledge test 4.8 ± 2.0 5.7 ± 2.3 0.29
PD steps sequence test
 VR-total 63.0 ± 18.7 53.0 ± 25.1 0.31
 VR-start 32.7 ± 8.8 30.2 ± 12.4 0.60
 VR-main 17.6 ± 7.6 12.3 ± 7.7 0.12
 VR-after 12.8 ± 3.8 10.50 ± 6.5 0.35
Chinese-GSE 28.4 ± 5.6 29.0 ± 5.7 0.81
4-item supplementary confidence 25.7 ± 5.8 26.7 ± 6.2 0.70
RBMT-3
 RBMT-SSS 123.1 ± 20.1 125.0 ± 10.8 0.78
 RBMT-GMI 88.4 ± 13.2 88.8 ± 8.4 0.93
WCST-CV4
 WCST-administer 107.0 ± 33.0 115.5 ± 14.1 0.45
 WCST-correct 70.2 ± 13.4 77.3 ± 11.6 0.24
 WCST-error 46.8 ± 21.3 38.2 ± 18.1 0.33
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HK-MoCA Hong Kong version of Montreal Cognitive Assessment, VR-total total number of correct responses in VR program, VR-start total number of correct responses in VR program “Start” section, VR-main total number of correct responses in VR program “Main” section, VR-after total number of correct responses in VR program “After” section, Chinese-GSE Chinese General Self-efficacy Scale, RBMT-3 The Rivermead Behavioural Memory Test—version 3, RBMT-SSS Sum of Scaled Scores of RBMT-3, RBMT-GMI General Memory Index score of RBMT-3, WCST-CV4 The Wisconsin Card Sorting Test—Computer version 4, WCST-administer number of trials administered in WCST-CV4, WCST-correct total number of correct responses in WCST-CV4, WCST-error total number of errors in WCST-CV4

For the analysis of primary outcomes, several factors were considered as covariates, including age, gender, baseline cognitive performance measured using HK-MoCA, years of education and duration of training received in terms of attendance at training sessions. After being entered as covariates in RANCOVA, only age and gender were found to be significant covariates (p = 0.005 and p = 0.014 respectively) and kept for further analysis. There were between-group effects in VR-total (F = 4.59, p < 0.05), VR-main (F = 6.55, p < 0.05) and VR-after (F = 5.94, p < 0.05). The mean scores for VR-total, VR-main and VR-after at pre-/post-treatment occasions are presented in Table 3. Patients in the experimental group performed significantly better than patients in the control group in performance of the overall PD exchange procedure, especially in the crucial steps of connection and disconnection of the tenckhoff catheter with the dialysate, correct sequence of opening and closing of clips during drain-in and drain-out processes, and rounding up of the whole procedure. No significant differences in between-group effects were observed in other primary outcomes such as PD knowledge test, GSE and self-constructed supplementary confidence questionnaire. Though there was no statistically significant difference between the two groups in the secondary outcome measurements across the two occasions (Table 3), there were gains in RBMT-SSS, RBMT-GMI and WCST-correct scores among patients in the experimental group, whereas there were losses in these scores among patients in the control group at post-treatment time. There were no overall significant within-subject effects in either primary or secondary outcome measurements.

Table 3.

Comparison of outcomes for the two groups across two occasions

Outcomes Experimental group Control group F p
(n = 12) (n = 11)
Primary outcomes
PD knowledgea
 Baseline 4.8 ± 2.0 5.7 ± 2.3
 Posttreatment 7.4 ± 2.2 6.7 ± 2.0 0.11 0.75
PD steps sequence test
VR-totala
 Baseline 63.0 ± 18.7 53.0 ± 25.1
 Posttreatment 76.6 ± 21.8 57.7 ± 32.7 4.59 0.05*
VR-starta
 Baseline 32.7 ± 8.8 30.2 ± 12.4
 Posttreatment 32.9 ± 13.1 29.6 ± 15.9 1.62 0.22
VR-maina
 Baseline 17.6 ± 7.6 12.3 ± 7.7
 Posttreatment 24.4 ± 8.9 16.3 ± 10.8 6.55 0.02*
VR-aftera
 Baseline 12.8 ± 3.8 10.5 ± 6.5
 Posttreatment 16.5 ± 4.5 11.8 ± 7.2 5.94 0.03*
Chinese-GSEa
 Baseline 28.4 ± 5.6 29.0 ± 5.7
 Posttreatment 30.3 ± 5.5 30.0 ± 4.6 0.03 0.86
4-item supplementary confidencea
 Baseline 25.7 ± 5.8 26.6 ± 6.2
 Posttreatment 31.4 ± 5.7 30.6 ± 6.1 0.00 0.97
PD technique assessmentb
 Baseline NA NA
 Posttreatment 41.3 ± 5.4 45.8 ± 4.7 − 1.85 0.08
Secondary outcomes
RBMT-3
RBMT-SSSa
 Baseline 123.1 ± 20.1 125.0 ± 10.7
 Posttreatment 125.9 ± 21.1 122.8 ± 13.3 0.01 0.92
RBMT-GMIa
 Baseline 88.4 ± 13.2 88.8 ± 8.36
 Posttreatment 91.5 ± 15.6 87.7 ± 10.4 0.11 0.75
WCST-CV4
WCST-administera
 Baseline 107.0 ± 33.0 115.5 ± 14.1
 Posttreatment 103.3 ± 34.7 108.9 ± 20.9 0.72 0.41
WCST-correcta
 Baseline 70.2 ± 13.4 77.3 ± 11.6
 Posttreatment 74.7 ± 11.9 75.7 ± 8.4 1.94 0.18
WCST-errora
 Baseline 46.8 ± 21.3 38.2 ± 18.1
 Posttreatment 38.6 ± 20.3 33.2 ± 17.4 0.41 0.53
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*p ≤ 0.05; aBetween-subject effects between the two groups (with age and gender as covariates); bIndependent t test between two groups

VR-total total number of correct responses in VR program, VR-start total number of correct responses in VR program “Start” section, VR-main total number of correct responses in VR program “Main” section, VR-after total number of correct responses in VR program “After” section, Chinese-GSE Chinese General Self-Efficacy Scale, RBMT-3 The Rivermead Behavioural Memory Test—version 3, RBMT-SSS Sum of Scaled Scores of RBMT-3, RBMT-GMI General Memory Index score of RBMT-3, WCST-CV4 The Wisconsin Card Sorting Test—Computer version, WCST-administer number of trials administered in WCST-CV4, WCST-correct total number of correct responses in WCST-CV4, WCST-error total number of errors in WCST-CV4

Regarding patient satisfaction with the use of VR training as a method of learning PD exchange, 89% of participants in the experimental group agreed that it was helpful, and 100% said they would like it to be incorporated into conventional PD exchange learning.

Discussion

Our study showed that patients who had received VR training sessions demonstrated significantly more correct responses in performing the PD exchange procedure than patients who had not received such training. This shows that VR training is an effective method of procedural learning for use as an adjunct to conventional PD exchange education, particularly for ERSD patients with cognitive deficits. The non-immersive VR applied in this study provided a type of interactive experience, based on “learning-by-doing,” the efficacy of which is supported in the findings of previous studies (Panerai et al. 2021; Dalgarno and Lee 2010). Training within a virtual environment that explicitly displays the PD exchange process allows patients to see themselves completing the task, which in turn better enables them to problem solve their way out of difficulties and gradually improve their method. As well as being physically immersed in the task environment, the user’s mental immersion generates a sense of presence in the task that reinforces active engagement in the learning process (Jennett et al. 2008). This then has the effect of strengthening the user’s initial understanding of the PD exchange concept, including its multimedia representation through traditional forms of educational leaflet or videos (Fowler 2015). Moreover, the provision of instant performance feedback via vocal and written message further promotes learning from experience and reflective thinking, which are important in boosting learning outcomes (Zhang et al. 2017). Another distinguishing feature of VR training is its focus on learning-by-doing. This approach boosts users’ learning in various ways, including by providing opportunities to become familiar with the simulated environment, fostering memories through the performance of actions, and allowing users to go through the learning cycle of extending effort, making mistakes and reflecting on performance (Riva 2017). Furthermore, the study results demonstrated that patients in the experimental group performed significantly better in those crucial and critical steps of the PD exchange procedure, which are regarded to minimize risk of peritonitis. Therefore, we believed that the use of VR training can definitely be a helpful remedy to resolve the difficulties encountered by patients with cognitive impairment.

Regarding another outcome measuring knowledge proficiency, the PD knowledge test, the absence of significant findings in post-treatment assessment of the two groups did not tally with the results of the PD steps sequence test. The possible reason for this might be that the context of the PD knowledge test, composed of questions about both the PD exchange steps sequence as well as essential knowledge about PD exchange more generally, might not be explicitly manifested in the VR training program. In order to facilitate a more comprehensive learning of PD exchange, it is suggested that a minor modification be made to the current VR training program by revising vocal messages to offer detailed explanations and rationales to users upon successful completion of actions in the PD exchange sequence. This would enhance patients’ understanding and working memory in ways that have been shown to promote learning (Raw et al. 2019).

Despite that an insignificant difference between-group findings on real-life PD exchange technique was obtained as measured by renal nurse specialist assessment, the benefit of VR training on real task performance could not be overruled. A possible reason for this could be the time gap between the training sessions and real practice. Patients in both groups underwent 1-week CAPD training after the IPD period, during which time they were provided with equal opportunities to learn the task and to undertake intensive daily practice under nurse supervision at the day center. Patients were required to perform to a standard level in the PD exchange technique assessment in order to qualify for at-home CAPD. Since the VR training developed to serve as a supplementary mode of PD exchange learning, which was not expected to be equivalent to real task training provided by renal nurses. Conversely, the training efficiency between the groups was not taken into account in our study.

Though we failed to find any significant improvement in the cognitive domain as measured by secondary outcomes such as RBMT-SSS, RBMT-GMI and WCST-correct, our results did show post-intervention improvements in these measurements among patients in the experimental group, whereas those in the control group performed worse (as compared with pre-treatment performance). These non-significant findings may be a result of small sample size and study power. Nonetheless, the possibility that VR training may have some impact on effecting improvements in cognitive functions should not be dismissed out of hand.

In terms of patient satisfaction, the feedback from patients on their experience of VR training was consistent with that collected in other studies on the use of non-immersive VR for the learning of functional living skills (Panerai et al. 2021). Perception of satisfaction is defined as one of the effective outcomes of learning experience in education and training (Sharda et al. 2004). The fact that all patients in the experimental group of this study enjoyed adopting VR training as one of the modalities for learning PD exchange indicates that it was an effective learning experience. However, it was observed that some patients, who may have lacked experience in the use of computerized devices, needed extra time and the expending of additional effort in order to familiarize themselves with either the motion sensor or the program, increasing the likelihood of fatigue and impatience, and thus leading to reduced focus on the task. To address this issue, familiarization training could be provided to help patients adapt to the system and give them the necessary time to determine an optimal setup. This would promote a smooth operation and improve patients’ engagement.

Limitations

This study has several limitations. First, the sample size was small. The data collection process was interrupted during the period of the COVID-19 pandemic, meaning that patient recruitment may be unrepresentative of ESRD patients with cognitive impairment. Furthermore, because of the small sample size, we could not stratify participants according to their levels of cognitive impairment for further analysis on whom might benefit from the VR training. On the other hand, given the improvements in patients’ performance of the PD exchange process after VR training, the conclusion that this positive finding is due to practice effect is inevitable. Regarding the transfer of skills to real-life practice, this was an area that was difficult to fully examine due to the high risk of hazard posed by improper PD exchange. It would be possible, however, for patients to undertake PD exchange technique assessments on a simulated dummy prior to the real task training, which minimizes the effect of real task training on the study result, and this is an approach that is recommend for consideration in future studies. Concerning the contents of the VR training program, improvements could be made through the provision of more detailed explanations of the rationale and precautions involved in each step of the PD exchange. This could enrich patients’ understanding and further enhance their learning experiences. In future, we can transfer the contents of the VR from using the Leap Motion hand tracking device to immersive head-mounted display based on the program written by Unity 3D. In addition, the findings of this study were based on a summative evaluation approach which focused on investigating the effectiveness of VR training on learning PD exchange by ESRD patient with cognitive impairment, in order to understand the successful elements as well as reasons of failure for further refinement of the intervention protocol, a formative evaluation approach is therefore suggested. Since the PD steps sequence test was developed based on the real task analysis and comments from an expert panel, it has the potential of becoming the “gold standard” for performance evaluation of PD exchange procedure, and further study on its standardization and validation is needed. Though an expert panel involving professional personnel and patients was formed to give comment and advice while developing the VR training program, a comprehensive process evaluation is important to understand any factor affecting the outcomes and reasons that induce discrepancies of expected and observed results, including the number of training sessions that can be done to perform the PD safely and independently, and to provide insights for further development.

Conclusion

PD exchange is a complex procedure requiring both accuracy and attention to safety concerns. Patients with cognitive impairments can encounter great difficulty in handling the task by themselves. The present study explored the application of VR training as a preliminary process for ESRD patients learning PD exchange and demonstrated its effectiveness in helping these patients to master the procedure sequence. While it is undoubtedly the case that patients must also acquire considerable skills and knowledge prior to a real task practice, we believe that the use of a non-immersive VR program, use of which is not constrained by considerations of time, space and manpower, and which is, more importantly, risk-free, should be fully adopted within clinical settings as an adjunct to conventional techniques for educating ESRD patients on PD exchange. Future studies, with larger sample sizes and a refined VR training program, are warranted to further examine the effect of VR training on cognitive function and the transfer of skills to real-life practice.

Acknowledgements

We thank the staff at the Division of Nephrology and the Department of Occupational Therapy at Queen Mary Hospital and Tung Wah Hospital for their collaboration in the study.

Funding

This research was partially funded by the Training and Research Assistance Scheme of Queen Mary Hospital, Hospital Authority, Hong Kong SAR (Reference Number: TRAS-18-03 (01/18/213)).

Data availability

Data cannot be made available for the reason of patients’ privacy in their consents for the study.

Declarations

Conflict of interest

All authors declared that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data cannot be made available for the reason of patients’ privacy in their consents for the study.

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