Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings

Kouijzer, Marileen M. T. E.; Kip, Hanneke; Bouman, Yvonne H. A.; Kelders, Saskia M.

doi:10.1186/s43058-023-00442-2

Implementation Science Communications

Table 2 Barriers to implementation and the number of publications they were mentioned in (n)

From: Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings

Category	Barrier	Definition	n	References
Category 1: Condition ( n = 13 barriers)
Condition	Cognitive limitations	A decline in cognitive capabilities, such as reasoning and problem-solving, could negatively affect VR use	6	[34,35,36,37,38,39]
	General decline	A decline in functional capabilities, such as mobility or communication, could negatively affect VR use	4	[35,36,37,38]
	Distress	VR use could induce distress and anxiety	4	[34, 38,39,40]
	Fatigue	Extreme fatigue in patients could negatively affect VR experience	1	[34]
	Dissociation	Experienced disconnection from themselves and the world could negatively affect VR experience	1	[34]
	Highly medicated	Effects of medication use could negatively affect VR use and experience	1	[39]
Physical limitations	Cybersickness	Motion- or cybersickness experienced while using VR	4	[13, 34, 39, 41]
	Issues with vision/hearing	Limited vision or hearing abilities could negatively affect VR use	3	[35, 36, 39]
	Epilepsy	VR use could trigger a seizure in patients with photosensitive epilepsy	2	[41, 42]
	Poor hand dexterity	Limited ability moving fingers and hands limits the use of VR controllers	1	[36]
	Wheelchair users	The use of a wheelchair can negatively influence movement in VR	1	[43]
Socio-demographics	Reluctance due to old age	Elderly can be less technology-aware and uncomfortable to use VR	7	[34, 37, 38, 44,45,46,47]
Socio-demographics	Language barriers	Language can form a barrier when software is in another language	1	[37, 42]
Category 2: Technology ( n = 11 barriers)
Technical functionality	Technical issues	Technical malfunctioning of VR hardware	9	[13, 40, 42, 43, 48,49,50,51,52]
	Lack of client safety	Lack of client safety due to unforeseen movement of patient in the treatment room while using VR	6	[13, 34, 44, 53,54,55]
	No reliable Wi-Fi	No reliable network connection which is necessary to use VR	4	[45, 46, 48, 50]
	Infection control issues	Difficult to control contaminations when using VR with multiple patients	3	[38, 39, 52]
	Data privacy and security	Lack of data privacy and security when using patient data in VR	2	[44, 51]
	System not charged	Battery of VR system is not charged and VR cannot be used	1	[50]
Usability	Lack of patient comfort	The use of VR headset and headphones could be uncomfortable	4	[34, 44, 52, 56]
	Usability issues	Issues with the usability and user-friendliness of VR	3	[34, 53, 55]
	Additional effort	The use of VR adds additional steps for healthcare providers during treatment	2	[13, 50]
Effect of VR on treatment	Isolation from contact	The VR headset can isolate patients from human contact	6	[40, 41, 45,46,47, 56]
Effect of VR on treatment	Lack of realism	Lack of realism and immersion experienced by patients in VR	4	[13, 40, 41, 57]
Category 3: Value proposition ( n = 8 barriers)
Influencing treatment	Lack of personalization	Lack of personalization to treatment goals and patients’ needs	6	[13, 44, 50, 51, 58, 59]
	Distract from goals	The fun and gamification aspects of VR could distract from treatment goals	1	[48]
	Disinterest therapeutic activities	The preference for VR treatment could cause disinterest in other therapeutic activities	1	[48]
	No translation into real-world improvement	Treatment improvements in VR do not directly translate into real-world improvements outside of the treatment room	1	[51]
	Avoid in-vivo exposure	The use of VR can be a way to avoid in-vivo exposure	1	[40]
	Biased attention in group therapy	When VR is used in group therapy, the attention of the healthcare provider is focused on one patient and not on the other participants	1	[50]
Practical resources	Financial costs	Costs of purchasing and time for maintaining VR	9	[34, 38, 41, 42, 44,45,46, 51, 53]
Practical resources	Time for maintaining	Lack of time for the maintenance and updating of VR software	3	[13, 42, 44]
Category 4: Adopter system ( n = 18 barriers)
Factors that influence	Lack of research	Perceived lack of research and evidence on the added value of VR	10	[13, 34, 37,38,39, 41, 43, 44, 46, 58]
Opinion towards VR—healthcare providers	Lack of experience	Perceived lack of experience in working with VR	7	[35, 40, 43,44,45,46, 49]
	Lack of suitable patients	Perceived lack of appropriate patients that can be referred to VR treatment or perceived lack of support in referring patients	3	[13, 43, 60]
	Lack of support	Perceived lack of support from management in using VR	3	[43, 60, 61]
	Dissatisfaction with VR	Not satisfied with the use of VR hardware or software	2	[38, 49]
	No interest in VR use	Not interested in using VR technology in treatment	1	[58]
	Negative patient response	Expected negative patient response towards VR	1	[46]
	Resistance to new treatment	A general resistance towards new therapeutic approaches	1	[34]
Factors that influence opinion towards VR—patients	Low patient motivation	Patient motivation is low for VR treatment	5	[13, 35, 43, 51, 58]
	Stress inducing	The new aspects of VR technology could be stress inducing because patients are exposed to a new form of treatment and new reality	2	[35, 47]
	Disorientation during VR	Patient could experience disorientation when present in VR scenario	1	[52]
	Mistrust in new treatment	Patient mistrust in new or experimental treatment options	1	[44]
	No support healthcare provider	Patient does not feel supported in VR use by healthcare provider	1	[50]
Integrating VR in routines	Difficulty combining VR with existing treatment	Perceived difficulty combining VR with existing treatments and integrating VR in existing protocols	2	[36, 48]
Knowledge and skills of healthcare providers	Lack of time to learn and use VR	Lack of perceived time and opportunities to learn how to use VR and integrate VR in treatment	8	[13, 38, 42, 45, 46, 48, 50, 58]
	Lack of knowledge/skills	Lack of knowledge and skills to feel confident using VR	5	[34, 44, 46, 52, 53]
	Difficulty explaining VR	Difficulty explaining the VR system to patients during treatment	2	[37, 43]
	Difficult to learn VR	Difficult to learn how to use VR in treatment with patients	1	[40]
Category 5: Organization ( n = 13 barriers)
Readiness to innovate	Other goals taking priority	Other goals that do not focus on VR taking priority within the organizational policy	1	[43]
Readiness to innovate	Negative culture towards innovation	Negative organizational culture towards innovation and new technology	1	[44]
Introducing VR to healthcare providers	No opportunity to try VR	Not giving an opportunity to healthcare providers to try out VR for themselves	8	[13, 34, 37, 38, 47, 48, 50, 54]
	Lack of education	Not organizing enough educational opportunities to learn how to use VR	2	[13, 37]
	Lack of training courses	Not offering enough standardized training courses to healthcare providers	2	[38, 41]
Providing support for healthcare providers	Lack of time to learn VR	Not making enough time available for healthcare providers to learn how to use VR	13	[13, 37, 38, 42,43,44,45,46, 48, 50, 53, 58, 59]
	Lack of technical support	Not offering technical support to help set up the VR system or help fix hardware or software malfunctions	12	[13, 34, 38, 42,43,44,45,46, 50, 53, 58, 60]
	Lack of rooms	Not having enough rooms available for VR treatment	8	[13, 35, 37, 38, 44, 48, 50, 58]
	Insufficient VR systems	Not having enough VR systems available for VR treatment	3	[13, 35, 38]
	No official channels to report performance issues	Not creating official channels to report performance issues experienced during VR treatment	1	[50]
Integrating VR in workflow	Lack of guidelines on patient suitability	Lack of guidelines on suitability of patients and medical indication for VR treatment	3	[34, 44, 50]
Providing conditions for use	Lack of treatment protocols	Lack of validated treatment protocols on how to use VR in treatment	2	[41, 42]
Providing conditions for use	Integration of VR	Not integrating VR in existing workflows and traditional treatment	1	[44]
Category 6: Wider system ( n = 3 barriers)
Societal development	Not innovation minded	Opinion leaders are not innovation-minded and do not support VR	2	[44, 46]
Societal development	Focus on well-being over treatment for specific conditions	Health industry’s focus on creating VR for general wellbeing over developing VR treatments for specific conditions	1	[44]
Regulatory/legal issues	Ethical or legal concerns	Ethical or legal concerns around the use of VR in treatment, such as cybersecurity, privacy and regulations	1	[51]
Category 7: Embedding and adoption over time ( n = 3 barriers)
Challenge to scale up	Lack of insurance reimbursement	Lack of insurance reimbursement to compensate costs of VR use	2	[44, 53]
	Sustainability	VR use is not sustainable over a longer period of time, because risk of hardware quickly becoming obsolete	2	[41, 59]
	Lack of technical support	Lack of technical support to maintain hardware limits upscale of VR use	1	[42]

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ISSN: 2662-2211

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