Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty

Abstract

Introduction: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty.

Materials and methods: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety.

Results: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001).

Conclusions: For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world.

Keywords: Patient safety; Revision total knee arthroplasty; Simulation; Virtual reality.

Fig. 1

A Participant performing the iVR training with motion-tracked headset and controllers B participants view of the simulated rTKA equipment through the iVR headset

Fig. 2

Bar graphs demonstrating qualitative feedback in participants self-reported ability, anxiety and confidence, both before and after iVR training relating to A identification and understanding what components are used for B assembly of components C sequence of steps during surgery. Error bars denote a 95% confidence interval, significant differences (p < 0.05) highlighted with an asterisk (*)

Fig. 3

Column scatter graphs for iVR outcomes across the three unguided assessments—A operative time in minutes B assistive prompts C total errors committed D dominant hand motion in metres. The median is represented with the interquartile range. Individual data points labelled with participant identification number to the top right of the dot. Tukey outliers (data points 1.5 interquartile ranges above the 75th centile or below the 25th centile) demonstrated in red. For all outcomes, significant differences were detected between all of the assessment sessions (p < 0.05)

Fig. 4

Column scatter graph for the real-world assessments before the iVR training (left) and after (right). The median is represented with the interquartile range. Individual data points labelled with participant identification number to the top right of the dot. Tukey outliers (data points 1.5 interquartile ranges above the 75th centile or below the 25th centile) demonstrated in red. The difference between the two assessments was significant (p < 0.001)