Many people view "learning" only in the contexts of education and training applications. This report focuses on the use of virtual reality to enhance learning across healthcare. We begin with a rigorous definition of the term “learning” and show that learning is broadly applicable in healthcare, going well beyond just education and training. Next, the neurobiology of learning is reviewed. Finally, three use cases in healthcare learning are outlined. In each case, we take a storytelling approach by introducing the reader to a hypothetical individual with a problem for which virtual reality can be of service. Finally, we end with closing remarks and areas for further discussion.
The Definition of Learning
Learning is defined as “a process that leads to changes in brain structure and function through experience”. There are two key aspects of this definition. First is the fact that learning requires experience. A famous quote from Albert Einstein embodies this fact.
Simply put, we learn best through experience.
Second, learning involves changes in brain structure and function. This follows directly from research on the neurobiology of learning.
The Neurobiology of Learning
Research on the neurobiology of learning shows that there are at least four distinct learning systems in the brain. Each is “tuned” to a particular type of learning. These are the cognitive, behavioral, emotional, and experiential learning systems. The most effective learning occurs when the experiential system is highly engaged and in synchrony with engagement of the other learning systems. Each of these systems has different operating characteristics, and thus the “experiences” that most effectively engage each system are different.
Interestingly, if you ask the average person to define learning in healthcare, they almost always talk about education and training applications in healthcare. For example, they might describe education around acquiring knowledge about medication, disease states, or HIPAA compliance usually through reading and mental repetition. Similarly, they might talk about training in which you acquire some behavioral skill like care and maintenance of a dialysis machine or insulin pump usually through practice and physical repetitions.
Clearly learning is much broader affecting all aspects of the human condition associated with changes in brain structure and function through experience. Thus, learning is relevant to mental health, wellness, resilience, performance enhancement, empathy, rehabilitation, pain management, and much more. So much of what we do leads to learning!
VR as a Learning Machine
Given the importance of learning to the human condition, one might ask what tools will be most effective for learning. As suggested by Einstein, tools must be experiential to be effective for learning. As suggested by the neuroscience of learning, the best learning tools broadly engage multiple learning systems in synchrony thus spreading the wealth of the learning while minimizing the cognitive load on the learner’s brain.
Virtual reality (VR) meets these challenges and more. VR is grounded in experiential learning. Users have a sense of immersion and presence in VR that broadly engages experiential learning centers in the brain and captures attention. VR content can be developed that engages emotional, behavioral and cognitive learning centers in synchrony.
Most importantly, VR is consistent, scalable, and available on-demand.
Consistency means providing the best experience for every user, every time. Scalability means providing these learning experiences without capacity constraints. On-demand availability means providing these learning experiences when and where users need it most. This is what is needed to provide the mental and physical repetitions needed for effective learning.
VR is a learning machine that can be broadly applied in many healthcare domains. It can enhance learning in patients, providers, and in the patient-provider interaction.
Wellness and Resilience
Joanna is a 35-year old mother of two. Her oldest, Aiden is in middle school, and her youngest, Henry is in elementary school. Joanna is a Marketing Director at a medium sized business in the Midwest.
Like all Americans (and many across the globe), Joanna’s life changed drastically in the early months of 2020 with the outbreak of the coronavirus pandemic. She went from recovering from the winter holidays and planning a family trip during Spring Break, to sheltering in place with her spouse and children.
Joanna realizes that she has it better than many. She has a roof over her head, a good job, schools who have been proactive in developing virtual classroom activities, and a spouse who is supportive and loves to cook and clean.
At the same time, her company had to lay off a number of employees so she and her fellow employees are taking on additional, new responsibilities, with steep learning curves. Her kids are struggling to cope with the physical and social isolation, and Joanna is having a hard time developing a routine so that she can get her work done while meeting her family needs. She also worries about her elderly parents in Queens, and her sister in Boston. Simply put, she struggles to get through the day, she feels the chronic stress and anxiety growing, and she worries about the uncertain future.
Joanna longs for an outlet to address her bouts of anxiety and stress, and to help her build the coping strategies that she knows she will need going forward. She has done yoga for years, and has stepped up the frequency, even including her kids on occasion. She has introduced meditation and mindfulness into her daily routine as well and finds it useful. Even so, the time commitment to these two activities is challenging given her heavy “remote” workload, and her responsibilities to her family. She also finds it very difficult to “clear her mind” of her daily life so that she gets the most value from these two activities. Sometimes she can, and sometimes she can’t, but even when she succeeds it takes precious additional time to “get in the zone” that she simply does not have.
She longs for something that can quickly and effectively capture her attention without effort, and can provide an immediate and effective “escape” from her everyday life. She wants something that can immediately calm her anxiety and reduce her stress without having to think about it, and that can build the coping mechanisms that she needs and can use in a pinch.
Simply put, she wants a tool or technology that helps her mind and body quickly reduce anxiety and stress, while simultaneously building the mental and behavioral coping skills that she needs long term.
Joanna needs a learning technology that broadly engages experiential, emotional, behavioral and cognitive learning centers in her brain in synchrony, and in the interest of reducing stress and anxiety all while building long-term coping mechanisms.
Yoga, meditation and mindfulness engage these systems in the brain, but the cognitive effort needed to get in the appropriate mindset is high. The load on the cognitive learning system is too great and failure to achieve the desired result is frequent.
What she needs is a technology that captures attention with no effort.
To achieve this lofty goal the learning machine must be immersive and must quickly capture her attention while transporting her into a novel, virtual world where stress and anxiety dissipate quickly. It must do this consistently and must be available on demand when and where she needs it.
Virtual reality (VR) learning tools focused on wellness and resilience meet this challenge. Unlike yoga and traditional meditation and mindfulness approaches that offer value, but take time to master, VR quickly captures Joanna’s attention without effort. Immersive content that allows Joanna to escape to a tropical beach, to float in outer space, or to explore the wilderness will immediately capture her attention and direct it away from day to day life. It will stimulate sensory, perceptual and emotion centers in her brain, all in the interest of stress and anxiety reduction.
Content can be constructed that teaches Joanna stress reducing breathing exercises that are guided by changes in the visual scene, or interactively by her pattern of breathing. Over time, her body can learn these coping skills that she can use outside of the VR headset and in her daily life.
If time is at a premium but a bout of anxiety emerges, a 5 to 10-minute VR experience is all that Joanna will need to reduce the stress. If more time is available, several VR experiences can be undertaken across the day, always one experience at a time.
Effective Communication and Empathy
Jerome is a 29 year old Registered Nurse who lives and works in the Heartland of America. Jerome received his R.N. in 2019 and immediately found employment in a local hospital. He was excited to put his knowledge and skills to work in the interest of patient health and well-being. As with so many first-time RNs he found the job exhilarating, but he also felt like there were some significant gaps in his training. In particular, he realized very quickly that socio-emotional and communication skills are central to providing high-quality healthcare, yet this was almost completely absent from his formal training. When he expressed this concern to his more seasoned colleagues they all nodded their head in agreement. He was told specifically, that effective communication and empathy training occurred, unfortunately on-the-job, although they all agreed that more emphasis on these critical skills is needed in school.
Jerome is proactive and a problem solver. He took matters into his own hands and began doing everything he could to educate himself. He scoured the internet to learn more about the characteristics of effective communication and empathy. He watched video examples of effective and ineffective communication, and people exhibiting high or low levels of empathy. He was amazed at the subtleties that distinguish an effective communicator from an ineffective one. So much of it is around body language and an ability to “read” another person.
His internet research and video watching was available on demand and he was able to educate himself during his breaks and on his own time at home. Despite the ready availability of these educational materials, he still found them lacking. He realized very quickly that it is one thing to know “what to do”, but something completely different to know “how to do it”. It was as if he was gaining a cognitive understanding of effective communication and empathy, but this did not translate very well into behavior and the important emotional aspects associated with effective communication and empathy.
To add insult to injury, the COVID-19 pandemic came crashing down on his hospital, the surrounding area and the whole country. For society in general this meant physical distancing was to become the norm. At the same time though, we needed to be closer than ever socially. [For an interesting discussion of the social vs. physical distancing follow this link.]. For healthcare professionals, this placed an even greater emphasis on effective communication, empathy and compassion. All the things that Jerome is still struggling with just became exponentially more important.
The need is clear. Jerome needs something more than the internet and videos. He needs a training solution that offers consistent, highly effective training. Time is more valuable than ever as he needs to focus on his patients. He needs the training solution to be brief but effective. Ideally, it can scale as Jerome is just one of thousands of healthcare professionals who could benefit. He needs it on demand, when he wants it, where he wants it.
The solution needs to do more than provide a cognitive understanding. It needs to help Jerome “feel” and “experience” empathy and effective communication in the first, and third person. Simply put, Jerome needs a solution that engages his brain in a way that builds the emotional and behavioral aspects of effective communication and empathy quickly and accurately.
Jerome needs a learning solution that broadly engages experiential, emotional, behavioral and cognitive learning centers in his brain in synchrony, and in the interest of building the emotional and behavioral skills associated with effective communication and empathy.
A learning solution of this sort must be immersive. It must consistent, high quality content and must be available on demand when and where Jerome needs it.
Virtual reality (VR) offers an ideal tool for building empathy and effective communication skills. With virtual reality one can “walk a mile in another’s shoes”. One can see through another’s eyes and can hear through another’s ears. One can be transported into the body of a COVID-19 patient and can see and feel their stress and anxiety. They can see the fear in their eyes as they are separated from their loved ones. Once can be transported into the body of the loved one and can experience the uncertainty and fear of the unknown without their loved one. These types of visceral experiences quickly and effectively build empathy.
Analogously, one can be transported into the body of a patient struggling to follow the conversation with a healthcare professional. From the healthcare professionals perspective they may be conveying information effectively, but from the patient perspective the speech is too fast, it appears jumbled and incomprehensible, full of jargon. One can then be transported into the body of a patient who is clearly the sole focus of a different healthcare professional. That healthcare professional, although covered in PPE, is channeling all of their empathy and understanding into eye contact. They are speaking slowly and methodically, avoiding jargon, and stopping often to urge the patient to ask questions.
A broad array of content like this can be developed for healthcare providers. If time is at a premium, a single 5 – 10-minute VR module can be experienced. If more time is available, several VR experiences can be undertaken across the day. Across experiences, and over time, Jerome’s body learns these communication and empathy skills and they become second nature to him, something he and his patients greatly appreciate.
Addiction and Rehabilitation
Bill is a 60 year old former construction worker and Desert Storm veteran. He has been divorced for 20 years and has two grown children. He has struggled with alcohol addiction for nearly 40 years and it has affected his personal and professional life. He is estranged from his ex-wife and children, has difficulty with personal relationships and has been unable to find work for the past 5 years, in large part due to the negative impact of his addiction on his treatment of fellow employees. Bill is losing faith in himself, the healthcare system, and has contemplated suicide more than once.
Bill has been in and out of rehabilitation for years. In every case, he has been successful at curbing the desire to drink while in rehabilitation, but invariably falls “off the wagon” after leaving. Bill finds this incredibly frustrating because he leaves rehabilitation feeling like he has kicked the addiction and has the coping skills needed to stay sober. When he gets home though it is as if all of the learning in rehabilitation does not apply anymore, the coping skills don’t seem to work and he relapses.
It is as if rehabilitation causes the abusing behavior to disappear but only temporarily. Once out of rehabilitation and back in society, the abusing behaviors return.
The rehabilitation process temporarily suspends the bad behavior but does not induce true unlearning of the abusing behavior.
Bill is tired of this revolving door in and out of rehabilitation. He wants to kick this addiction, once and for all. He has been working with a mental health professional who has given him some amazing insights into the nature of addiction and is introducing Bill to a new therapeutic approach that utilized virtual reality.
Bill’s therapist has a background in the neuroscience of learning and addiction and informs Bill that the real culprit is context. Learning and unlearning are exquisitely sensitive to context. The idea is that the rehabilitation center serves as a new environmental context that causes new learning, rather than unlearning of the previously acquired addictive behavior. As a result, the addictive behavior reappears when the “rehabilitated” addict re-enters their original addictive environment.
What Bill needs is a learning solution that broadly engages experiential, emotional, behavioral and cognitive learning centers in his brain in synchrony, and in the interest of providing realistic contexts within which Bill can learn and develop coping skills. A learning solution of this sort must be immersive. It must utilize consistent, high quality content and must be available on demand when and where Bill needs it.
This is where virtual reality comes in to serve as a complement to the in person therapy that Bill receives from his therapist. The idea is to use VR to “transport” Bill into virtual environments that share many of the contextual cues associated with his typical “using” environment. With the help of his therapist, Bill can learn to apply behavioral extinction or unlearning coping skills within the VR environment.
This approach is effective because the virtual environment is similar in context to the “using” environment, but because Bill is not drinking in the environment, true unlearning of the addictive behaviors within this virtual “using” context takes place.
Bill not only uses the VR headset in his therapy sessions, but Bill also uses it at home. Because VR is available on-demand where Bill needs it, and when he wants it (e.g., when he has an urge to drink), Bill can get the necessary, targeted repetitions that are so critical to unlearning of destructive behaviors. In this way, Bill gets the best of both worlds. He obtains the critical hands-on therapy from his mental health professional that is so critical to his recovery. At the same time, when he is not with the mental health professional, he has a means to address his urges and to continue to fight against his addiction when and where it matters most.
Summary and Conclusions
This report focused on the use of virtual reality technology to solve important healthcare learning problems. Neuroscience is clear that VR is unique in its ability to broadly engage multiple learning, memory and performance systems in the brain in synchrony. Critically, VR allows the presentation of consistent experiences at scale and on demand when the user needs it and where the user wants it. This combination of broad neural activation, scalability and availability on demand make VR the ideal “learning machine” in healthcare.
This report focused on three use cases in wellness and resilience, addiction and resilience, and effective communication and empathy, but these are just three of many potential use cases for VR in healthcare. Numerous applications in mental health, pain management, situational awareness, performance enhancement and much more exist. As the number of applications of VR in healthcare grows, and as the price of VR systems continues to decline, more and more players in healthcare will reap the benefits. Whether in the interest of the patient, provider, or in the patient-provider interaction, VR can add value and enhance learning, one experience at a time.
We would love to hear your thoughts on this report and areas for further discussion, including new areas within healthcare where you believe virtual reality might offer a unique learning benefit. Are there areas you are aware of where these benefits are already taking place? What surprises you most about the learning process?
Feel free to share those examples and questions with us in the comments section below. Thank you for your continued curiosity and participation, we look forward to exploring new aspects of immersive learning with you in the future.