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Research Article – Advances in CKD 2019
Blood Purif 2019;47:265–269
Virtual Reality Simulation in Peritoneal
Dialysis Training: The Beginning of a
New Era
Panagiota Zgoura a Daniel Hettich b Jonathan Natzel b Fedai Özcan a
Boris Kantzow b
a Department of Nephrology, Klinikum Dortmund, Dortmund, Germany; b Weltenmacher GmbH,
VR Training-Application, Düsseldorf, Germany
Published online: December 6, 2018
Dr. med. Panagiota Zgoura
Department of Nephrology, Beurhausstrasse 40
Abteilung für Nephrologie und Notaufnahme
DE–44137 Dortmund (Germany)
E-Mail panagiota.zgoura @
© 2018 S. Karger AG, Basel
DOI: 10.1159/000494595
Peritoneal dialysis · Peritonitis rate · Virtual reality training
program · Standardization · Education
Background/Aim: Peritonitis rates in peritoneal dialysis (PD)
vary considerably not only across countries but also be-
tween centers in the same country. Patient education has
been shown to significantly reduce infection rates but up till
now training lacks standardization with patients being
trained using different methods and media (e.g., illustra-
tions, videos). As a result, patients may be insufficiently ex-
perienced in performing PD, which might be one of the
causes for high peritonitis rates. To address these issues, we
developed a PD training program based on virtual reality
(VR). Methods: To become acquainted with the PD proce-
dure, patients are equipped with a VR headset and control-
lers. They are presented with a virtual PD set, which simu-
lates the feeling of sitting in front of a real PD set. The patient
is enabled to run through the program as often as necessary
to become familiarized with the whole PD procedure. The
aim is to standardize, facilitate, and accelerate the individual
learning process. To compare the effect of the applied train-
ing method to traditional training, a randomized controlled
trial is underway. Conclusion: Previous studies on the effec-
tiveness of learning showed that VR training applications are
superior to traditional methods, such as text- or video-based
training. However, no study has been undertaken in the con-
text of dialysis. We believe that the implementation of VR
training programs in clinical practice will be beneficial in im-
proving the patient’s proficiency, and thereby the quality
and safety of PD. © 2018 S. Karger AG, Basel
Peritoneal dialysis (PD) is an effective and widely used
renal replacement therapy. One of the most common
complications linked to PD is peritonitis. Although peri-
tonitis rates decreased during the last years and decades,
there is continuous need for further reduction of infec-
tions [1]. Remarkably, there is a huge variation in the
Blood Purif 2019;47:265–269
DOI: 10.1159/000494595
prevalence of peritonitis rates across different countries
as well as across different centers in the same country [1].
In the last few decades, efforts for improvements primar-
ily focused on refinement of PD materials. Recently, how-
ever, voices have been raised to shift the scientific focus
toward standardization and optimization of training
methods (cf. International Society of PD [ISPD] Guide-
lines) [1]. Currently, the training comprises a variation of
methods, videos, and illustrations. This lack of standard-
ization might be one of the reasons for the discrepancies
in peritonitis rates across and within different countries.
This problem has been acknowledged by the ISPD
which hence started to create a syllabus for teaching PD.
Therefore, ISPD named 6 basic objectives for an improve-
ment in PD training: Who should be the trainer? Who is
the learner? What should be taught? Where should the
training occur? What should be the duration of training?
How should the patient be taught?
However, up till now many of these questions remain
With focus on “How” and “What” should be taught?,
we propose to add a new option to the traditional training
methods which uses immersive and interactive media to
achieve a more valid training quality. Therefore, we de-
veloped a training program based on virtual reality (VR)
headsets and gamification elements: the patient finds
himself in a virtual environment in which he is enabled
to move and interact with certain stimuli in a similar way
to the real world. The patient is accompanied by a virtual
trainer who guides him through the process and assists
him if he needs help. The program aims to familiarize the
patient with the procedure of performing PD and intends
to facilitate and accelerate the skill acquisition that is
needed in order to execute the real PD process. The pro-
gram is not only meant for patients but also for female
and male nurses and trainees.
Our aim is to standardize each step of the whole PD
procedure to improve the learning process and to control,
store, and reproduce the results of each user. As a first
step, we intend to implement this training concept in sev-
eral training centers and hospitals. By this, we also plan
to conduct a randomized controlled trial, in which we will
further investigate the effectiveness of our VR applica-
tion. Subsequently, we intend to develop VR applications
for training at home.
VR gains more and more clinical importance in the
medical area worldwide [2]. So far it has been used as a
training simulation method mainly in endoscopy and
surgery for students and trainees. There are some pub-
lished trials that tested the validity of VR training simula-
tion. Thereby, VR has shown potential to improve exist-
ing trainings in endoscopy and laparoscopic training pro-
grams [3, 4]. Additionally, studies showed that the
learning effect is higher when we actively do things rath-
er than only read, watch, or listen to them [5]. VR simula-
tions combine all these different methods and thereby of-
fer a better learning experience. Though studies have
shown the potential of VR simulations, sample sizes,
however, were limited in all of them [6–8]. Unfortunate-
ly, there is also no data existing about VR use in training
programs concerning renal replacement therapy.
We developed a VR training program for patients as well as
trainers and trainees, who must learn the whole procedure to con-
duct PD step by step. Our simulation offers a standardized learning
protocol in which the different steps can be trained separately and
put in the right order afterwards. Thereby, the training experience
relies on VR technology which enables the user to feel like being in
a different environment (immersion) and to interact with the items
and stimuli around her/him like in the real world (interaction).
To create the virtual environment, the user wears VR goggles
(Head Mounted Display) which are tracked precisely in the room
allowing him to visually and physically explore the surrounding
virtual world (Fig.1). For creating the virtual environment, it is
required to collect user input from the Head Mounted Display and
controllers in a continuous cycle to adjust the virtual world to real
actions and to display it preferably without any delay [9]. It is also
possible that a user can receive auditory and tactile feedback
through headphones and controllers. For instance, sounds from
different directions can be presented in the virtual space and sim-
ple tactile feedback can be send to the interaction devices (see be-
low), while the user interacts with virtual objects.
Fig. 1. Room-scale immersion and interaction with head-mounted
display, controllers, and gaming engine (copyright Weltenmacher
Color version available online
Virtual Reality PD Training
Blood Purif 2019;47:265–269
DOI: 10.1159/000494595
The user uses controllers with his hands allowing him to grab
and move virtual objects – to interact with the environment
(Fig.1). These interactions together with their associated compu-
tation are not pre-calculated, which allows real-time interaction,
one of the main features of VR [10].
VR enables immersion and interaction in a way no other me-
dium has been capable of, and it is thereby more engaging, im-
pactful, and realistic than any other simulation technique. Thus,
it is a new technology with huge potential for educational pur-
In the PD training application, we are using 3 different modes
to achieve the ISPD objectives (see above):
1. Guided: User will be guided to all the different steps of
2. Free-run: User executes all the necessary steps and will get
feedback on his performance after finishing the PD process.
Additionally, a distinction between different user groups with
different needs, such as patient and trainer and also left- and right-
handed users, is made.
The user can virtually train all the different steps that are re-
quired to perform the PD procedure safely and on his own. It is
also possible to include automated pitfalls and barriers to put em-
phasis on the most common mistakes and train those steps even
more intensely. Therefore, with our program, trainees and patients
do not only experience the whole PD process but also get instruc-
tions and learn from the mistakes they make.
Furthermore, they can run through the program, completely or
in parts, as often as it is necessary to internalize every single step
In addition, data about the individual learning progress can be
collected throughout training sessions to improve the learning ef-
fectiveness or to document whether the training has been com-
pleted successfully. Users’ progress, time, common mistakes, and
other data can be stored in a digital file.
We are planning to test our VR training program against tra-
ditional training regarding the effectiveness of the tool and the
learning progress of the user (e.g., number of mistakes made
through full PD). In the long run, additional studies on the re-
duction of errors that users commit during the execution of the
PD process are planned. Also, the relationship of the frequency
of committed errors and occurrence of peritonitis should be
The study design is still being worked out. It will be a random-
ized study including a large number of patients, trainees, and train-
ers. We expect to obtain the first results in 6 months.
The improvement and standardization of education
in PD has become a major issue during the last few years.
Problems have been noted primarily in teaching patients
before starting PD as a renal replacement therapy as well
as in teaching novice trainees. Users are first trained with
illustrations, video, and later they are instructed by nurs-
es who teach patients and novice trainees face-to-face.
So, training success depends on the abilities of the user
and the trainer. The use of a VR simulation for educa-
tional purposes in PD guarantees a standardization of the
whole process, and a faster and easier learning as well.
Several studies showed that the use of VR in training pro-
grams improves skill acquisition amongst patients, train-
ers, and trainees. Maximum benefit has been seen
amongst novice trainees [3]. Some reviews tried to deter-
mine the role of VR simulation within modern educa-
tional programs.
There is no existing data focused on VR use in ne-
phrology so far. We can only comment on the findings
referring to VR simulation training programs in endos-
copy and laparoscopy for example. These results sup-
port the use of VR in training programs for endoscopy
in several points. Unfortunately, the designs of the avail-
able studies are so different in terms of sample size,
training time, participants, prior endoscopic experi-
ence, tasks included type of training, endpoints, and
comparison between them in reviews is difficult. De-
spite all these factors, improvement in skill level has
been demonstrated and the integration of VR simula-
tion programs in endoscopy training curriculum has
been advocated [11–14].
We are going to create a study design that will also give
us an answer to the questions regarding the optimal ex-
posure of VR simulation training. There are studies in
which the exposure within formalized teaching settings
was controlled. The total time trainees spent on VR simu-
lator varied from 5 till 10 h [15–18]. One study showed
that there is a need of a 20-h exposure for a novice train-
ee to reach the level of an expert in colonoscopy [18]. In
our case, we are going to have a look at how many hours
of exposure users need to do the whole procedure of PD
independently without help and mistakes. After that, we
Fig. 2. User interaction with PD gear within a virtual environment
from the user’s point of view.
Color version available online
Blood Purif 2019;47:265–269
DOI: 10.1159/000494595
will test the exposure time novice trainees need to reach
a well-defined expert level. We believe that VR training
will reduce exposure time compared to the existing train-
ing methods along with costs for materials and training
Another limitation across the published studies was
the variation in defining the “novice” and “experienced”
trainees. There were no uniform criteria for the definition
of advanced or top level expert.
Ferlitsch et al. [15] demonstrated that a training period
of 3 weeks with 2 h per day improves the performance of
beginners on the simulator. Virtual simulated endoscopy
seems to be a tool that could provide a validated and
much needed method for objective assessment of the us-
er’s skills too.
However, concerning all the mentioned points, there
is a limited number of studies and participants. Regarding
the effect of VR simulator training on clinical results, no
relevant data has been published.
Yiannakopoulou et al. [19] evaluated VR training pro-
grams as beneficial based on Kirkpatrik’s 4-level model.
The levels are as follows:
Level 1: reactions measure how trainees react to the
training program – face validity.
Level 2: learning assesses the extent to which trainees
have made progress to performance – construct validity.
Level 3: behavior/transfer – measures the change in
behavior due to the training program.
Level 4: results – assesses training in terms of clinical
results, i.e., reduction in the number of complications
Available data suggest that VR simulation training af-
fects the trainees positively to perform better in terms of
skill-based behavior and rule-based behavior. Skill-based
behavior is that kind of behavior that takes place without
conscious control. Rule-based behavior concerns task ex-
ecution which is controlled by rules or procedures, for
example, an operating protocol.
Thus, we need both types of behaviors for executing
PD, we are convinced that we can transfer these pub-
lished findings about VR training simulators to our ex-
pected findings in regard to our case. All the critical
points mentioned before should be inspected well and
all doubts about them should be clarified. Furthermore,
we want to use our training program in our clinical ev-
eryday life and provide clinical results in the next step.
VR simulation in training programs has been evalu-
ated in endoscopy and laparoscopy teaching. Despite
some limitations, these studies show evidenced benefit
and advocate the use of VR simulation for educational
purposes. VR simulation is capable of distinguishing be-
tween beginners and experts. It can detect progress and
also the shift from beginners to experts’ level. Because VR
simulation training affects the users’ performance in
terms of skill-based and rule-based behaviors positively,
we believe that it is an excellent tool for providing skills
concerning the execution of PD. Right now, no clear
model exists regarding the best way of VR training inte-
gration in the existing educational program. A combina-
tion of traditional teaching and VR simulator teaching
will surely be a great benefit.
We are convinced that VR simulator training in PD
alone is more effective and will reduce not only costs and
time but also peritonitis rates in the long run. Above all,
our training program offers the user standardization to a
high level.
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ResearchGate has not been able to resolve any citations for this publication.
Full-text available
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Being aware of controversies and lack of evidence in peritoneal dialysis (PD) training, the Nursing Liaison Committee of the International Society for Peritoneal Dialysis (ISPD) has undertaken a review of PD training programs around the world in order to develop a syllabus for PD training. This syllabus has been developed to help PD nurses train patients and caregivers based on a consensus of training program reviews, utilizing current theories and principles of adult education. It is designed as a 5-day program of about 3 hours per day, but both duration and content may be adjusted based on the learner. After completion of our proposed PD training syllabus, the PD nurse will have provided education to a patient and/or caregiver such that the patient/caregiver has the required knowledge, skills and abilities to perform PD at home safely and effectively. The course may also be modified to move some topics to additional training times in the early weeks after the initial sessions. Extra time may be needed to introduce other concepts, such as the renal diet or healthy lifestyle, or to arrange meetings with other healthcare professionals. The syllabus includes a checklist for PD patient assessment and another for PD training. Further research will be needed to evaluate the effect of training using this syllabus, based on patient and nurse satisfaction as well as on infection rates and longevity of PD as a treatment.
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Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simulators and the long-term benefits of their use are also discussed.
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Skills in gastrointestinal endoscopy mainly depend on experience and practice. Patients upon whom trainees perform their first endoscopic examinations are likely to suffer more discomfort and prolonged procedures. Training on endoscopy simulators may reduce the time required to reach competency in patient endoscopy. Residents in internal medicine without experience of endoscopy were randomized to a group who trained on a simulator before conventional training (group S) or one that received conventional training only (group C) before starting upper gastrointestinal endoscopy in patients. After endoscopy, discomfort and pain were evaluated by patients, who were blind to the beginners' training status. Results in terms of time, technique (intubation, pyloric passage, J-maneuver), and diagnosis of pathological entities were evaluated by experts. From 2003 to 2007, 28 residents were enrolled. Comparing group S with group C in their first ten endoscopic examinations in patients, time taken to reach the duodenum (239 seconds (range 50 - 620) vs. 310 seconds (110 - 720; P < 0.0001) and technical accuracy ( P < 0.02) were significantly better in group S. Diagnostic accuracy did not differ between the groups. Fourteen residents (7 simulator-trained, 7 not simulator-trained) continued endoscopy training. After 60 endoscopic examinations, investigation time was still shorter in group S. Technical and diagnostic accuracy improved during on-patient training in both groups; here differences between groups were no longer observable. There were no significant differences in discomfort and pain scores between the groups after 10 and after 60 endoscopies. Discomfort and pain were higher than for endoscopy performed by experts. This randomized controlled trial shows that virtual simulator training significantly affects technical accuracy in the early and mid-term stages of endoscopic training. It helps reduce the time needed to reach technical competency, but clinically the effect is limited. Simulator training could be useful in an endoscopy training curriculum but cannot replace on-patient training.
Incorporation of screen based simulators into medical training has recently gained momentum, as advances in technology have coincided with a government led drive to increase the use of medical simulation training to improve patient safety with progressive reductions in working hours available for junior doctors to train. High fidelity screen based simulators hold great appeal for endoscopy training. Potentially, their incorporation into endoscopy training curricula could enhance speed of acquisition of skills and improve patient comfort and safety during the initial phase of learning. They could also be used to demonstrate competence as part of the future relicensing and revalidation of trained endoscopists. Two screen based simulators are widely available for lower gastrointestinal endoscopy training, with a third recently produced in prototype. The utility of these simulators in lower gastrointestinal endoscopy training has been investigated, and construct and expert validity has been shown. Novices demonstrate a learning curve with simulator training that appears to represent real learning of colonoscopy skills. This learning transfers well to the real patient environment, with improvements in performance and patient discomfort scores in subsequent initial live colonoscopy. The significant limitations of currently available screen based simulators include cost implications, and restrictions on a role in certification and revalidation. Many questions remain to be answered by future research, including how best to incorporate screen based simulators into a colonoscopy training programme, their role in training in therapeutic endoscopy and the impact of simulator training on patient safety.
The unique psychomotor skills required in laparoscopy result in reduced patient safety during the early part of the learning curve. Evidence suggests that these may be safely acquired in the virtual reality (VR) environment. Several VR simulators are available, each preloaded with several psychomotor skills tasks that provide users with computer-generated performance metrics. This review aimed to evaluate the usefulness of specific psychomotor skills tasks and metrics, and how trainers might build an effective training curriculum. We performed a comprehensive literature search. The vast majority of VR psychomotor skills tasks show construct validity for one or more metrics. These are commonly for time and motion parameters. Regarding training schedules, distributed practice is preferred over massed practice. However, a degree of supervision may be needed to counter the limitations of VR training. In the future, standardized proficiency scores should facilitate local institutions in establishing VR laparoscopic psychomotor skills curricula.
Laparoscopic surgery is commonly used in many surgical procedures but requires a learning process to develop the necessary skills. Virtual reality simulators play an essential role within the training curricula. This paper aims to determine whether training in SINERGIA VR simulator allows novice surgeons to improve their basic psychomotor laparoscopic skills. Forty-two people participated in this study, including 28 unexperience medical students and 14 expert surgeons who developed previously more than 100 laparoscopic procedures. Medical students made a pre-training test in LapMentor II; then, they trained in SINERGIA and they finally accomplished a post-training test in LapMentor II. Experts just made one trial in LapMentor II. A statistical analysis was carried out and results of pre- and post-training tests of novices were compared with Wilcoxon signed-rank test. Pre- and post-training tests of novices were also compared with results of experts with Mann-Whitney U test. Most metrics provided by LapMentor II and included in this study show significant differences when comparing pre- and post-training tests of novices. Analysis of pre-training test of novices and experts results show significant differences in all analyzed metrics for all studied tasks. On the other hand, LapMentor was not able to distinguish between experts and novices after training in SINERGIA for any metric in the camera manipulation task and for some metrics of the other tasks. Training in SINERGIA VR simulator allows improvement of basic psychomotor laparoscpic skills and transferring them to another virtual simulator. Therefore, it could be used in laparoscopic surgery training programs.
Global Rating Scales (GRS) quantify and structure subjective expert assessment of skill. Hybrid simulators measure performance during physical laparoscopic tasks through instrument motion analysis. We assessed whether motion analysis metrics were as accurate as structured expert opinion by using GRS. A random sample of 10 consultant laparoscopic surgeons, 10 senior trainees, and 10 novice students were assessed on a Sharp Dissection task. Coded video footage was reviewed by two blinded assessors and scored using a Likert Scale. Correlation with metrics was tested using Spearman's rho. Inter-rater reliability was measured using intraclass correlation coefficient (ICC). Strongest GRS-Metric correlations were found for Time/Motion/Progress with Time (Spearman's rho 0.88; p < 0.05) and Instrument Handling with Path Length (Spearman's rho 0.8; p < 0.05). Smoothness correlated with Respect for Tissue in Rater 1 (rho 0.68) but not Rater 2 (rho 0.18). Mean GRS showed stronger inter-rater agreement than individual scale components (ICC 0.68). Correlation coefficients with actual experience group were 0.58-0.74 for mean GRS score and 0.67-0.78 for metrics (Spearman's rho, p < 0.05). Metrics correlate well with GRS assessment, supporting concurrent validity. Metrics predict experience level as accurately as global rating and are construct valid. Hybrid simulators could provide resource-efficient feedback, freeing trainers to concentrate on teaching.
Health professionals are often reluctant to value research into the effectiveness of educational interventions. As in clinical research, the need for an evidence base in the practice of medical education is essential. Choosing a methodology to investigate a research question in educational research is no different from choosing one for any other type of research. Rigorously designed research into the effectiveness of education is needed to attract research funding, to provide generalisable results, and to elevate the profile of educational research within the medical profession.
Skills in gastrointestinal endoscopy mainly depend on experience and practice. Training on endoscopy simulators may decrease the time needed to reach competency in endoscopy. The purpose of the study was to determine whether the GI-Mentor, a virtual reality endoscopy simulator, can distinguish between beginners and experts in endoscopy and to assess whether training improves the performance of beginners. A total of 13 beginners and 11 experts (more than 1,000 procedures) in gastrointestinal endoscopy were included. The baseline assessment consisted of virtual endoscopies and skill tests. The beginners were randomly allocated to receive training (n = 7) or no training (n = 6). The training group was allowed to practice using the simulator for 2 hours per day. After 3 weeks participants were re-evaluated with two new virtual endoscopy cases and one virtual skill test. Insertion time, correctly identified pathologies, adverse events and skill test performance were recorded. The baseline assessment revealed significant differences favoring the experts for virtual endoscopies and skill tests. Significant differences in favor of experts were found for successful retroflection during esophagogastroduodenoscopy (EGD) (P < 0.005); adverse events during colonoscopy (P < 0.02); insertion time (P < 0.001); correctly identified pathologies in gastroscopy and colonoscopy (P < 0.02); and skill test performance (P < 0.01). The final evaluation showed significant differences between training and no-training groups, in favor of the training group, for the number of adverse events during virtual endoscopy (P < 0.04), for the insertion time during colonoscopy (P < 0.03); and for skill test performance (P < 0.01). The training group improved its abilities on the simulator significantly. Differences between experts and the training group were no longer seen. This virtual endoscopy simulator is capable of identifying differences between beginners and experts in gastrointestinal endoscopy. A 3-week training improves the performance of beginners significantly. This quite fast improvement in endoscopic skills certainly cannot be seen in clinical practice; no conclusions can be made about the impact of virtual simulator training on real-life endoscopy, and this must be evaluated.