|Year : 2021 | Volume
| Issue : 4 | Page : 229-235
The effects of virtual-augmented reality training on anxiety among operating room students attending coronary artery bypass graft surgery
, Athar Omid2
, Mohsen Mirmohammad-Sadeghi3
, Ahmad Ghadami4
1 Department of Operating Room, Student Research Committee, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Medical Education, Medical Education Development Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan, University of Medical Sciences, Isfahan, Iran
4 Department of Operating Room, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||01-Dec-2020|
|Date of Decision||16-Dec-2020|
|Date of Acceptance||25-May-2021|
|Date of Web Publication||25-Nov-2021|
Department of Operating Room, School of Nursing and Midwifery, Isfahan University of Medical Sciences, 2nd Floor, Hezarjerib Street, Isfahan.
Source of Support: None, Conflict of Interest: None
Background: Operating room (OR) students experience varying levels of anxiety during their internship program in the OR. Educational technology has the potential for reducing anxiety. Objectives: This study aimed at assessing the effects of training based on virtual-augmented reality (VAR) on anxiety among OR students attending coronary artery bypass graft (CABG) surgery. Methods: This randomized controlled trial was conducted in 2020. Thirty-six OR students were conveniently recruited and randomly allocated to an intervention (n = 18) and a control (n = 18) group. Participants in the control group received conventional training, whereas their counterparts in the intervention group received VAR training through watching a 360-degree VAR video of CABG surgery in addition to conventional training. The State-Trait Anxiety Inventory was used for anxiety assessment in both groups at three time points, namely before entering the OR on the first day of the internship program, after entering the OR but before scrub, and on the last day of the program. The data were analyzed through the independent-samples t test, the Chi-square test, and the repeated-measures analysis of variance. Results: There was no significant difference between the intervention and the control groups regarding the pretest mean scores of state anxiety (40.61 ± 7.63 vs. 41.59 ± 5.09; P = 0.66) and trait anxiety (39.17 ± 7.39 vs. 39.29 ± 6.05; P = 0.96). However, the mean scores of state and trait anxiety in the intervention group were significantly less than the control group at both the first posttest (33.17 ± 6.16 vs. 45.06 ± 8.69 and 33.56 ± 6.19 vs. 42.59 ± 6.62; P < 0.001) and the second posttest (32.39 ± 4.62 vs. 42.35 ± 6.14 and 32.94 ± 5.20 vs. 41.0 ± 5.58; P < 0.001). Conclusion: VAR training is effective in significantly reducing anxiety among OR students attending CABG surgery.
Keywords: Anxiety, Augmented reality, Cardiac surgery, Virtual reality
|How to cite this article:|
Sargolzaei F, Omid A, Mirmohammad-Sadeghi M, Ghadami A. The effects of virtual-augmented reality training on anxiety among operating room students attending coronary artery bypass graft surgery. Nurs Midwifery Stud 2021;10:229-35
|How to cite this URL:|
Sargolzaei F, Omid A, Mirmohammad-Sadeghi M, Ghadami A. The effects of virtual-augmented reality training on anxiety among operating room students attending coronary artery bypass graft surgery. Nurs Midwifery Stud [serial online] 2021 [cited 2022 Jan 26];10:229-35. Available from: https://www.nmsjournal.com/text.asp?2021/10/4/229/331298
| Introduction|| |
The OR students receive a large part of their education in clinical settings, particularly in the OR., The apprenticeship model, known as the Halsted’s model, is one of the basic training methods for these students. In this model, OR students acquire surgical skills through actual practice in the OR., The OR is the best environment for practical training, and it provides students with the opportunity to gain real-life professional experiences. However, practical training in the OR poses some challenges and limitations, such as the presence of a large number of students in a small environment, high levels of stress due to the unpredictability of surgical conditions, disturbed concentration, patient safety concerns, and non-repeatability of surgical procedures.,, These challenges and limitations reduce training effectiveness and increase students’ anxiety and stress.
Anxiety is an inner emotion that is characterized by a state of turmoil and a feeling of unease, leading to dysfunction and poor decision making. Some massive surgical procedures, such as CABG surgery, are associated with high levels of responsibility for OR students, provide limited opportunity and time for learning, and, hence, cause OR students high levels of anxiety. Unmanaged anxiety among students can negatively affect their learning, learning outcomes, performance, and patient care. Therefore, strategies are needed to reduce their anxiety, improve their clinical skills, and enhance their satisfaction before they attend a patient’s bedside in clinical settings.,
An important strategy for reducing anxiety among OR students is virtual training. Virtual training can provide students with excellent learning opportunities, particularly during the current pandemic of coronavirus disease 2019, which has suspended many university classes and internship programs. One of the methods for virtual training is VAR, which consists of virtual reality (VR) and augmented reality (AR).,, The VR is a simulated three-dimensional environment or image created using special electronic devices. It provides students with the opportunity to imagine physical presence in a nonphysical world. The VR was introduced by Jaron Lanier in 1987 and was first used in health care in the early 1990s to visualize complex medical data during surgeries and perform preoperative planning.
In AR, computer-generated models or virtual information, such as images, videos, texts, and audio, are superimposed on real images and videos in order to enhance users’ perceptions of their physical surroundings. In other words, AR technology integrates virtual objects into the real world to improve learners’ skills, such as critical thinking. The term “AR” was introduced by Tim Caudell in 1990.
The results of previous studies into the effects of VR and AR are contradictory. For example, a study showed that VR exposure training significantly reduced performance anxiety among musicians. Similarly, a study revealed that VR significantly reduced anxiety among dental patients during dental procedures. Moreover, a study showed that VR and counterstimulation had significant effects on dental anxiety among children undergoing pulpectomy. Contrarily, a study on 11 patients with combat-related posttraumatic stress disorder revealed that there was no significant difference between the effects of VR exposure therapy and control exposure therapy. Another study showed that human-based anesthesia simulator training caused acute stress and anxiety for nursing students.
The contradictory results of previous studies into the effects of VR and AR highlight the importance of further studies in order to produce more conclusive evidence in this area. Moreover, to the best of our knowledge, the effects of these methods had not yet been assessed on anxiety among OR students during CABG surgery. Therefore, the present study was conducted to address these gaps.
This study aimed at assessing the effects of VAR training on anxiety among OR students attending CABG surgery.
| Methods|| |
This single-blind randomized clinical trial was conducted on 36 undergraduate eight-semester OR students who attended their internship program in Shahid Chamran hospital from February to August 2020. This hospital is a leading teaching hospital in Isfahan, Iran. Inclusion criteria were having passed the theoretical course on Cardiac Surgery Technology and no history of hospitalization for anxiety disorders. Exclusion criteria were voluntary withdrawal from the study for any reason, failure to watch the VAR video in the intervention group, and the development of serious stress and anxiety during the study. Sampling was performed conveniently.
Participants were randomly allocated to a control (n = 18) and an intervention (n = 18) group. Randomization was done based on the last digit of the participants’ student number. Accordingly, participants with an odd digit at the end of their student number were allocated to the control group, and those with an even digit at the end of their student number were allocated to the intervention group. Sample size was determined based on the findings of an earlier study that examined the effect of a mobile VR device on anxiety in university students and reported that post-intervention mean anxiety in the intervention and control groups was 33.5 ± 9.1 and 44.0 ± 13.0, respectively. Then, using the formula for the comparison of two means, and with a type I error of 0.05, a type II error of 0.2, an S1 of 9.1, an S2 of 13.0, a µ1 of 33.5, and a µ2 of 44.0, the sample size was calculated at 18 per group.
Data collection instruments
Data were collected by using a demographic questionnaire (with items on age and gender) and Spielberger State-Trait Anxiety Inventory (STAI). The 40-item STAI consists of 20 items in a state anxiety subscale and 20 items in a trait anxiety subscale. The state anxiety subscale measures the level of temporary anxiety in response to a specific situation or stressor, such as exams or job interviews. However, the trait anxiety subscale of STAI assesses the general and long-term level of anxiety. Items are rated on a four-point Likert scale. For the items of the state anxiety subscale, respondents are asked to rate their feelings at the present moment using the following scale: “Not at all” (scored 1), “Somewhat” (scored 2), “Moderately so” (scored 3), and “Very much so” (scored 4). For trait anxiety items, they are asked to rate the frequency of their general feelings using the following scale: “Almost never” (scored 1), “Sometimes” (scored 2), “Often” (scored 3), and “Almost always” (scored 4). Consequently, the possible total score of each subscale is 20–80, with higher scores showing higher levels of anxiety. In the present study, state anxiety scores were interpreted as follows: 20–31: mild anxiety; 32–42: moderate anxiety; 43–53: higher than moderate anxiety; 54–64: relatively severe anxiety; 65–75: severe anxiety; and 76–80: very severe anxiety. Trait anxiety scores were also interpreted as follows: 20–31: mild anxiety; 32–42: lower than moderate anxiety; 43–52: higher than moderate anxiety; 53–62: relatively severe anxiety; 63–72: severe anxiety; and 73–80: very severe anxiety. STAI has acceptable consistency in assessing the essential qualities of anxiety, namely nervousness, tension, apprehension, and worry. A former study reported that the Cronbach’s alpha values of the inventory were 0.93 for the state anxiety subscale and 0.92 for the trait anxiety subscale. Two other studies in Iran also reported a Cronbach’s alpha of 0.94 and confirmed the acceptable validity and reliability of the inventory.,
Participants in the control group were oriented to the OR environment just by receiving information from their instructor. Their counterparts in the intervention group received the same information from their instructor plus VAR-based training through a 360-degree instructional video. The video content was about CABG surgery, relevant surgical instruments, and cardiopulmonary bypass pump and it was developed through reviewing OR textbooks, such as Berry and Kohn’s Operating Room Techniques, and consulting a cardiovascular surgeon. Professional cameras were used to create a high-resolution video of a CABG surgery. Besides, a 360-degree panoramic camera was used to record all activities in OR. The camera simultaneously records all directions and creates a 360-degree video. The video of the surgery was later added to the 360-degree video. Moreover, textual data on cardiopulmonary bypass pump and audio commentaries on surgical procedure were added to the 360-degree video. The total length of the video was 21 minutes. The Gear 360 and the Adobe After Effects software were used for editing the video and adding AR content to it. Twelve VR head-mounted displays were used for presenting the video, and a VR media player application compatible with Android and iOS was installed on the mobile phones of participants in the intervention group. Participants in the intervention group watched the 360-degree video before scrub on the first day of their eight-day internship program in the CABG OR. The head-mounted display provided participants with the opportunity to move their heads around and look in different directions to see the different parts of OR. While watching the surgery, they could also listen to AR audio commentaries and read textual data about the names and the functions of the different components of the cardiopulmonary bypass pump and instruments on the surgical table.
Participants in the intervention group completed STAI before entering OR on the first day of their internship program, immediately after watching the video, and at the end of the program. Their counterparts in the control group also completed the inventory before entering OR on the first day of their internship program, before scrub on the first day of the program, and at the end of the program. Participants in both groups completed STAI in a large room in the study setting under the supervision of the first author.
The Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran, approved the study (code: IR.MUI.RESEARCH.REC.1398.661). Besides, the study was registered in the Iranian Registry of Clinical Trials (code: IRCT20150715023216N6). The authorities of the study setting were informed about the study, and study participants were ensured of the confidential management of their data. Study findings were provided to the authorities of the study setting as well as the authorities of the Faculty of Nursing and Midwifery of Isfahan University of Medical Sciences, Isfahan, Iran.
Data were analyzed through the SPSS software (v. 16.0, IBM Corp., Armonk, New York, USA). The Shapiro-Wilk test showed the normality of the main quantitative variables. The independent-samples t and the Chi-square tests were used for between-group comparisons regarding participants’ age and gender. Moreover, the independent-samples t test and the repeated-measures analysis of variance were used to compare the groups regarding the mean scores of anxiety at different measurement time points. P values less than 0.05 were considered statistically significant. The statistician who performed statistical analyses was blind to the study groups.
| Results|| |
In total, 18 students were recruited to the study. One participant was excluded from the control group due to voluntary withdrawal before the pretest, and the study was completed with 17 participants in the control group and 18 participants in the intervention group [Figure 1]. Participants’ age was in the range of 21–25 years, and they were mostly female (52.9%). The independent-samples t and the Chi-square tests revealed no statistically significant difference between the intervention and the control groups regarding participants’ age and gender (P > 0.05) [Table 1].
|Table 1: Between-group comparisons respecting participants’ age and gender|
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The pretest mean score of state anxiety was 40.61 ± 7.63 in the intervention group and 41.59 ± 5.09 in the control group, with no statistically significant between-group difference based on the results of the independent-samples t test (P = 0.66. However, the mean score of state anxiety in the intervention group was significantly less than the control group at both the first posttest (33.17 ± 6.16 vs. 45.06 ± 8.69, P < 0.001) and the second posttest (32.39 ± 4.62 vs. 42.35 ± 6.14; P < 0.001). However, the pretest mean score of trait anxiety in the intervention and the control groups was, respectively, 39.17 ± 7.39 and 39.29 ± 6.05, with no significant between-group difference (P = 0.96). Nonetheless, the mean score of trait anxiety in the intervention group was significantly less than the control group at both the first posttest (33.56 ± 6.19 vs. 42.59 ± 6.62; P < 0.001) and the second posttest (32.94 ± 5.20 vs. 41.0 ± 5.58; P < 0.001) [Table 2].
|Table 2: Within- and between-group comparisons respecting the mean scores of state and trait anxiety|
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In repeated-measures analysis for the state anxiety scores, Mauchly’s test was nonsignificant, showing that the assumption of sphericity has been met (χ2  = 4.67; P = 0.096). Then, the Sphericity Assumed test of within-subjects effects indicated that the difference between the means was statistically significant, indicating that over time, the intervention significantly decreased the state anxiety among the participants (F2,66 = 7.024, P = 0.002). Moreover, a significant interaction was observed between time and the mean anxiety scores (F = 17.12, df = 2, P = 0.001). Considering the observed interaction, the t test was used to conduct pairwise comparisons between the two groups at the three time points. The results revealed that the mean scores of the two groups were significantly different at the second (P < 0.001) and the third (P < 0.001) measurement time points [Table 2].
The repeated-measures analysis for the trait anxiety scores also showed that the Mauchly’s was nonsignificant, showing that the assumption of sphericity has been met (χ2  = 3.847; P = 0.146). Consequently, the Sphericity Assumed test of within-subjects effects was used and revealed that the difference between the means was statistically significant. In other words, over time, the intervention significantly decreased the state anxiety among the participants (F2,66 = 3.20, P = 0.047). As a significant interaction was observed between time and the mean anxiety scores (F = 14.96, df = 2, P = 0.001), the t test was used for pairwise comparisons between the two groups at the three measurement time points. The results revealed that the mean state anxiety of the two groups was significantly different at the second (P < 0.001) and the third (P < 0.001) time points [Table 2].
The least significant difference post hoc test revealed that in the intervention group, the mean scores of state and trait anxiety at both posttests were significantly less than their corresponding pretest values (P < 0.05), whereas the differences between the first and the second posttests were not significant (P > 0.05) [Table 3].
|Table 3: The results of the least significant difference post hoc test for pairwise comparisons in the intervention group|
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| Discussion|| |
Findings showed that at baseline, participants had moderate anxiety. This finding is attributable to many different factors, such as age, family backgrounds, social status, personality traits, and stressful internship environment.
The study findings also showed that the mean scores of state and trait anxiety in the intervention group were significantly less than the control group at both posttests. This is in line with many different studies that reported the positive effects of VR on anxiety. For instance, a study showed that immersive VR significantly reduced state anxiety among first-year occupational therapy students preparing for objective structured clinical examinations. Two other studies found that VR had significant positive effects on anxiety among university students and pediatric nursing students. Similarly, a study reported that VR can be effective in providing students with an imaginary safe environment and thereby, treating their public speaking anxiety, which is a highly prevalent condition among students. Moreover, a study revealed that simulation was effective in significantly reducing anxiety. Two other studies also highlighted that VR allows students to be in a controlled and safe virtual environment., Studies on patients with different health problems also confirmed the positive effects of VR. For instance, two studies showed that VR-based interventions significantly reduced anxiety among women with breast cancer and among patients with prostate cancer receiving radiation therapy. A study also showed that high-fidelity human simulation significantly decreased anxiety among nursing students before clinical attendance and interaction with a mentally ill patient. It seems that VR reduces students’ anxiety and improves their clinical skills by giving them a feeling of serenity and improving their self-confidence.
Contrary to our findings, some earlier studies reported the insignificant effects of VR-based interventions on anxiety. For example, a study showed that VR was not effective in significantly reducing anxiety among adult male patients undergoing cystoscopy. Moreover, a study reported that video- and booklet-based education had no significant effects on preoperative state anxiety among the candidates for CABG. Two studies on nursing students also reported the insignificant effects of high-fidelity human simulation on stress and anxiety. Similarly, a study showed that simulation-based training had no significant effects on anxiety among OR students during their internship program. These contradictory results are attributable to the differences among studies regarding their sample sizes and the characteristics of their samples or interventions. For example, some studies were conducted on students, whereas some others were conducted on patients.
This study had some limitations. One limitation was that although we attempted to control the effects of potential stressors in OR, some unknown stressors might have affected the level of participants’ anxiety. Another limitation of the study was its small sample size, though we recruited all eight-semester OR students in the study setting.
| Conclusion|| |
This study concludes that VAR training is effective in significantly reducing anxiety among OR students attending CABG surgery. Therefore, VAR-based training interventions are recommended for managing the stress induced by attendance at CABG surgery among these students. Moreover, studies with larger samples of students in different hospital settings are recommended to produce firmer evidence regarding the effects of VAR training.
This article sprang from a Master’s thesis in Isfahan University of Medical Sciences, Isfahan, Iran. The authors would like to thank all instructors of the Faculty of Nursing and Midwifery of the university, all staff of the cardiac surgery operating room of Shahid Chamran hospital, Isfahan, Iran, and all students who participated in the study.
Financial support and sponsorship
This study received financial support from Isfahan University of Medical Sciences, Isfahan, Iran.
Conflict of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]