Imagine a patient approaching their first Magnetic Resonance Imaging (MRI) scan, overwhelmed with anxiety and unsure of what to expect. Now imagine they could virtually experience the entire process beforehand, easing their fears and preparing themselves emotionally. With MRI often needing to be experienced to be fully understood⁽¹⁾, this is where the use of Virtual Reality (VR) could help provide such patients the opportunity ahead of undergoing an actual scan. 

VR has developed considerably over the past 30 years alongside technological advances that have helped make it become more accessible and affordable ^(2,3). Its integration into healthcare is not a novel concept, continuing to grow and expand ⁽⁴⁾ with an over 20% increase in the number of publications relating to VR use in this setting ⁽⁵⁾. However, publications continue to be predominantly research based with limited demonstration of application and implementation into daily clinical practice^(4,6,7,8).

Specifically, within diagnostic imaging and radiotherapy, the use of VR tools that could support patient preparation remains in its infancy. Studies have demonstrated the potential for VR to transform patient care by reducing scan-related anxiety^{(9,10,11,12,13)}. The concern over MRI related claustrophobia has been shown to be present in around a quarter of patients prior to scanning, which then transpires to not be as bad as first thought after the event ^(14,15). Whilst written patient literature is considered effective in most cases⁽¹⁶⁾, it can lack depth in conveying the nature of the experience^(17,18) and be open to misinterpretation⁽¹⁹⁾. In contrast, audio-visual materials can provide clearer expectations and better familiarise patients with what is involved⁽²⁰⁾, reducing their anxiety^(21,22,23) and helping to better manage the experience^(21,24). This is where VR offers a unique opportunity to support patients by realistically simulating the MRI environment, helping them manage any anxiety and regulate their emotional response ahead of time, so that the scanning process is less daunting.

Another important consideration is the need to explore non-pharmacological means of supporting patients with their scans. Within practice there is a tendency to simply refer patients on to obtain prescribed anxiolytics⁽²⁵⁾, which is driven by not necessarily having sufficient time and seen as a quick fix. Whilst use of anxiolytics are effective⁽²⁶⁾, medications come with their own risks and increasing push back from general practitioners. Patients themselves also note effectiveness of medication to be low suggesting a preference for alternative means⁽¹⁶⁾, which again is where use of innovative approaches like VR could play a role.

Despite these apparent benefits for patients, the clinical adoption of VR tools into radiographic practice is sluggish, which is perhaps surprising in a technology focused field where new innovations are often implemented at pace. This highlights the need to better understand what the specific barriers to implementation might be so that these can be addressed. Only then could the adoption of VR tools to support patients attending for imaging be accelerated and their full potential be unlocked. This article therefore explores these barriers, asking how these could be addressed, and proposing actionable solutions that could help accelerate VR uptake within imaging and radiotherapy pathways. Thereby in turn ensuring its benefits are realised by patients, practitioners, and healthcare systems alike.

KEY BARRIERS TO VR ADOPTION

As with the introduction of any technology within healthcare, the system into which they are intending to be used is complex, and therefore there is a need to address the multifaceted barriers hindering such integration. The approaches to VR implementation appear to be poorly understood with limited research conducted in the health setting more generally⁽⁸⁾, let alone as a role within imaging and radiotherapy pathways. Nonetheless, there are some commonly acknowledged barriers to implementation of VR into wider clinical practice⁽²⁷⁾ that can be considered: 

Awareness

Whilst awareness of VR continues to increase, its application as a preparatory tool for patients remains unknown by patients themselves, radiographic practitioners, referring clinicians, and those commissioning services. Within our own research only one-third of participants had prior experience with VR, while practitioners, though familiar with the concept, were rarely users themselves. Therefore, this is one area where education on the role of VR is needed so that those involved better understand what it can offer as an adjunct and alternative to other support strategies. This could include patient testimonials, practitioner-led workshops, and demonstrations highlighting VR’s role in reducing scan-related anxiety.

Anticipated Benefits

Awareness alone is insufficient; the specific benefits of VR in reducing scan-related anxiety also need to be understood, as does the mechanism by which this is having effect. Studies specific to use in MRI have demonstrated early efficacy of such resources^(28,29) but these present limitations in terms of the sample sizes used and the representation of the populations, with a predominance in younger persons. Larger scale VR3 studies⁽³⁰⁾ would help support the evidence base and its positive outcomes so that the benefits are more measurable and better appreciated. One challenge here is funding to do so in order that research moves to the next level beyond small scale pilots and service evaluations. Feedback from participants and practitioners in our research have highlighted VR’s potential as a valuable preparatory tool, yet broader dissemination of these findings is required.

Accessibility 

How does referral for use of a virtual experience form part of the patient pathway to allow access when needed? It isn’t an approach for everyone and so a means of identifying  those who may benefit from use of VR in advance is needed. It is likely those with greater anxiety or claustrophobia would gain most benefit⁽³¹⁾ and whilst various screening tools have been proposed to help recognise patients who may be claustrophobic ahead of a scan^{(32,33,34,35)}, none appear to have made their way into routine use. At the same time, the level of information required or preferred by individuals will also vary and has influence over their ability to cope with the stress of a scan^(36). Similarly, patient suitability in terms of both physical and mental capability so that adverse consequences from VR are minimised. Therefore, an approach that helps identify patient suitability, tailored to their individual needs and preferences would appear to be the aspiration, as well as further supporting the desire for delivery of person-centred care. 

Once identified as appropriate, consideration is then around timely access, with the number of interactions with VR and over what timeframe ahead of an actual scan still needing answering. Moreover, delivery of such VR tools is via a head mounted display to support immersion into the virtual environment, however this can be via a smart phone display at home, or a commercially purchased headset used within a clinic setting. Our work suggests it is the supported use with someone in a clinic setting that is preferred and perhaps adds the real benefit for establishing rapport and building trust. Whilst arguably use at home means access is easier and at a time that suits, which could allow repeated exposures for familiarisation ahead of time. 

Availability

Operational barriers, such as staff availability and training in use of VR, pose significant challenges. With staffing being an issue in many departments and integration of VR use potentially adding to this. Practitioners have suggested clinical assistants could oversee VR sessions, optimising resource allocation⁽³⁷⁾. Likewise, psychologists could be involved in the preparation of patients through use of VR as a functional means of providing support. One way to negate the additional need for staff involvement would be exploring self-directed VR use, provided this approach remains effective and acceptable to patients given the apparent preference from our research towards supported use. 

Acceptability

This is a key area which is needed by patients, but also radiographic staff and referrers. The Technology Acceptance Model (TAM) is a useful means of assessing this, with perceived usefulness and ease of use informing actual intention⁽³⁸⁾. Whilst most seem to find VR acceptable, some do not wish to take up the offer⁽³⁹⁾ and there can be concerns about potential discomfort, such as simulation sickness, which can have a negative impact on acceptance⁽³⁷⁾. Yet these effects in this context are rare and short-lived due to the nature of the experiences used, supporting VR’s overall acceptance. Further validation through larger study designs within a clinical setting involving high-anxiety patient groups could address remaining concerns and strengthen confidence in VR as a preparatory tool.

Adaptability 

Whilst not necessarily essential in enhancing the reality of a virtual experience or its effectiveness, being able to personalise any use of VR would further support the tailoring to an individual. This could include capturing more of the patient journey, adapting the scanner appearances to be used, adding in elements from play therapy to support patient education, and the addition of a virtual radiographer to help guide them through the process. 

Adherence

This in part builds on acceptance and accessibility, addressing whether patients will in fact engage with the use of VR ahead of a scan. One consideration with regards to this is the avoidant behaviour that can be seen with those genuinely phobic who may disengage rather than face any fear or concerns they may have. This is where supported use may be more beneficial in ensuring patients do interact with the VR tool, rather than be left to their own devices at home where it may be all too easy to disengage. 

Affordability

Whilst supporting the patient experience is paramount, cost-effectiveness is a consideration in the current climate. The cost of VR equipment has decreased, but operational expenses remain a concern for departments and commissioners. However, the use of such VR preparatory tools could help reduce scan list inefficiencies and incomplete scans caused by those anxious or claustrophobic. Conducting a comparative cost analysis, weighing VR implementation expenses against savings from improved scan efficiency, could strengthen the economic case for adoption. An approximate calculation based on some assumptions around use and NHS tariff suggest that provision of a supported VR session ahead of a scan could be as much as 30-35% cheaper. 

Bridging the gap 

The concept of the “last mile” in technology implementation (the final steps needed to bring a solution into practical, widespread use) is particularly relevant here⁽⁴⁰⁾. While research and development have established VR’s potential and proof of concept, the challenge lies in translating this potential into routine clinical practice. This supports the need for carefully devised implementation strategies that help address barriers through systematic and structured approaches when it comes to informing practice. By carefully evaluating how well a VR tools is being adopted and used within a specific setting, a better understanding can be gained on whether the implementation process is successful ⁽⁸⁾. One such framework that has been proposed to help support and understand the roll out of healthcare technology is NASSS (non-adoption, abandonment, scale-up, spread, and sustainability)⁽⁴¹⁾.

Next steps

Conclusion

VR has demonstrated its capacity to enhance patient care by addressing scan related anxiety and improving preparedness. Integration of preparatory VR tool for patients into radiography practice may be challenging, but the potential rewards would appear to make it a goal worth pursuing. By addressing the barriers outlined, we can transform the medical imaging experience, making it less intimidating and more patient-centred. With radiography being both a technical and person focused profession, radiographers are well-placed to lead the development and implementation of such innovative technologies into imaging pathways for the benefit of our patients. 

Let us bridge the gap between innovation and practice, ensuring technologies like VR are not just novel tools of potential, but tools of transformation. With a collaborative approach, we can accelerate the adoption of such VR approaches and pave the way for a more innovative, patient-focused future in radiography. Now, it is up to healthcare leaders to act on this evidence and ensure these benefits are not left untapped.

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