A Systematic Review of Immersive Virtual Reality for Nontechnical Skills T raining in Surgery

OBJECTIVE: Immersive virtual reality (IVR) can be uti-lized to provide low cost and easily accessible simulation on all aspects of surgical education. In addition to techni-cal skills training in surgery, IVR simulation has been uti-lized for nontechnical skills training in domains such as clinical decision-making and pre-operative planning. This systematic review examines the current literature on the effectiveness of IVR for nontechnical skill acquisi-tion in surgical education. DESIGN: A literature search was performed using MED-LINE, EMBASE, and Web of Science for primary studies published between January 1, 1995 and February 9, 2022. Four reviewers screened titles, abstracts, full texts, extracted data, and analyzed included studies to answer 5 key questions: How is IVR being utilized in nontechni-cal skills surgical education? What is the methodological quality of studies? What technologies are being utilized? What metrics are reported? What are the findings of these studies? RESULTS: The literature search yielded 2340 citations, with 12 articles included for qualitative synthesis. Of included articles, 33% focused on clinical decision -mak-ing and 67% on anatomy/pre-operative planning. Motion sickness was a recorded metric in 25% of studies, with an aggregate incidence of 13% (11/87). An application score was reported in 33% and time to completion in 16.7%. A commercially developed application was uti-lized in 25%, while 75% employed a noncommercial application. The Oculus Rift was used in 41.7% of stud-ies, HTC Vive in 25%, Samsung Gear in 16.7% of studies, Google Daydream in 8%, and 1 study did not report. The mean Medical Education Research Quality Instrument (MERSQI) score was 10.3 </n> 2.3 (out of 18). In all studies researching clinical decision-making, participants pre- ferred IVR to conventional teaching methods and in a nonrandomized control study it was found to be more effective. Averaged across all studies, mean scores were 4.33 for enjoyment, 4.16 for utility, 4.11 for usability, and 3.73 for immersion on a 5-point Likert scale. CONCLUSIONS: The IVR nontechnical skills applica- tions for surgical education are designed for clinical decision-making or anatomy/pre-operative planning. These applications are primarily noncommercially produced and rely upon a diverse array of HMDs for content delivery, suggesting that development is pri- marily coming from within academia and still with- out clarity on optimal utilization of the technology. Excitingly, users find these applications to be immer- sive, enjoyable, usable, and of utility in learning. Although a few studies suggest that IVR is additive or superior to conventional teaching or imaging methods, the data is mixed and derived from studies with weak design. Motion sickness with IVR remains a complication of IVR use needing further study to determine the cause and means of mitigation. ( J Surg Ed 81:25-36. (c) 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)