John Luna

BACKGROUND Workplace violence (WPV)—including physical assaults, threats, and verbal/psychological aggression—disproportionately affects healthcare workers, particularly in high-acuity and behavioral health settings. Although many organizations provide WPV prevention education, training is often delivered through scalable didactic or online modules that may be limited in preparing staff for high-stress, interpersonal crisis encounters. Immersive virtual reality (VR) offers a safe-to-fail, experiential modality that can evoke realistic emotional responses and support repeated practice of de-escalation skills. However, evidence is limited regarding how debriefing format influences learning from VR-based WPV training. OBJECTIVE To evaluate the usability of DEFUSE, an immersive VR-based WPV prevention and behavioral management training, and to compare debriefing formats (individualized, in-headset VR debrief vs educator-led, in-person group debrief) with respect to changes in aggression attribution beliefs. METHODS Frontline clinical and nonclinical staff were recruited from three major healthcare institutions in Central Ohio. Using a quasi-experimental design with convenience allocation, participants completed a single DEFUSE training session consisting of two VR modules and one of two debriefing formats: (1) individualized, in-headset VR debriefing following each module (n = 44), or (2) educator-led group debriefing following completion of both modules (n = 47). Usability was assessed immediately after post-exposure. Beliefs toward causes of patient aggression and management were assessed using the Management of Aggression and Violence Attitude Scale (MAVAS) at pre-post exposure, and 4–6-week follow-up. Participants were also invited to semi-structured focus groups; interviews were audio-recorded and thematically analyzed. Quantitative outcomes were examined using ANCOVA and multilevel modeling. RESULTS Ninety-one participants completed the study, with 44 (52%) completing follow-up at 4–6 weeks. Overall VR usability was high (SUS-equivalent M = 78.44) and did not differ between debriefing conditions (p = .457). Baseline-adjusted ANCOVA indicated a significant advantage for the VR-based debrief on MAVAS environmental attributions at immediate post-exposure (p < .05), whereas other between-condition differences were nonsignificant. Multilevel models showed significant time effects for situational (B = 0.08, SE = 0.022, p = .001) and environmental (B = 0.10, SE = 0.029, p = .001) attributions across three assessments, while biological attributions showed no significant change over time. Condition effects were not retained in final longitudinal models. Qualitative findings indicated that emotional realism and behavioral fidelity supported experiential learning, and that individualized, emotionally paced debriefing with timely, action-linked feedback facilitated reflection and skill consolidation. Participants emphasized that scalability depends on minimizing interface friction for novice users and embedding VR training within onboarding and shift-based workflows. CONCLUSIONS DEFUSE demonstrated strong usability and supported changes in staff beliefs toward more contextual understandings of patient aggression over time. The VR-based, in-headset debrief produced outcomes largely comparable to educator-led debriefing, with indications of added benefit for environmental attributions.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Workplace violence (WPV) in healthcare is a significant issue that affects frontline providers, patients, and visitors. Healthcare systems and regulatory organizations seek to mitigate this problem by training frontline healthcare providers with essential skills for de-escalation procedures. Objective: This study assessed the usability of a proof-of-concept virtual reality (VR) training course for WPV prevention and intervention with frontline healthcare workers. Methods: A cross-sectional, mixed-methods study was conducted with 13 frontline healthcare providers. A multicomponent training consisting of four training modules on WPV was developed and deployed in a virtual reality environment. Participants engaged with each module while providing qualitative feedback. Qualitative feedback was analyzed using rapid qualitative analysis technique. After completing the training pilot, participants filled out surveys on usability (System Usability Scale), user experience (mini-Player Experience Inventory), and shared feedback via Reaction Cards. Results: We identified four themes from qualitative feedback: (1) Perceived Value, (2) Technical and Navigational Barriers, (3) User Preferences, and (4) Vision. Participants described the VR training modules as refreshing and noted areas for improvements in the tone and emotional responses from non-player characters. Participants perceived the VR training modules positively, with room for improvement towards the usability (M = 63.30, SD = 9.53). Participants found the VR training manageable and learned to operate VR quickly. Despite this, participants may have required technical support to initiate VR training. The user experience was overall engaging (M = 5.23, SD = 1.34), and participants described the VR content and their experience as "valuable," "engaging," and "creative” via the reaction cards. Conclusions: VR training has the potential to be a useful WPV training tool. Refining course content may improve the usability of VR while offering an immersive, hands-on, and safe learning environment for healthcare workers. Further research may compare VR WPV trainings with traditional trainings to evaluate short- and long-term training effectiveness.

BACKGROUND Workplace violence (WPV) in healthcare is a significant issue that affects frontline providers, patients, and visitors. Healthcare systems and regulatory organizations seek to mitigate this problem by training frontline healthcare providers with essential skills for de-escalation procedures. OBJECTIVE This study assessed the usability of a proof-of-concept virtual reality (VR) training course for WPV prevention and intervention with frontline healthcare workers. METHODS A cross-sectional, mixed-methods study was conducted with 13 frontline healthcare providers. A multicomponent training consisting of four training modules on WPV was developed and deployed in a virtual reality environment. Participants engaged with each module while providing qualitative feedback. Qualitative feedback was analyzed using rapid qualitative analysis technique. After completing the training pilot, participants filled out surveys on usability (System Usability Scale), user experience (mini-Player Experience Inventory), and shared feedback via Reaction Cards. RESULTS We identified four themes from qualitative feedback: (1) Perceived Value, (2) Technical and Navigational Barriers, (3) User Preferences, and (4) Vision. Participants described the VR training modules as refreshing and noted areas for improvements in the tone and emotional responses from non-player characters. Participants perceived the VR training modules positively, with room for improvement towards the usability (M = 63.30, SD = 9.53). Participants found the VR training manageable and learned to operate VR quickly. Despite this, participants may have required technical support to initiate VR training. The user experience was overall engaging (M = 5.23, SD = 1.34), and participants described the VR content and their experience as "valuable," "engaging," and "creative” via the reaction cards. CONCLUSIONS VR training has the potential to be a useful WPV training tool. Refining course content may improve the usability of VR while offering an immersive, hands-on, and safe learning environment for healthcare workers. Further research may compare VR WPV trainings with traditional trainings to evaluate short- and long-term training effectiveness.

Background: Traumatic brain injury (TBI) poses a significant threat to children’s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. Objective: This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. Methods: The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. Results: Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. Conclusions: This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI.

Background: Children with hearing loss, even those identified early and who use hearing aids or cochlear implants, may face challenges in developing spoken language and literacy. This can lead to academic, behavioral, and social difficulties. There are apps for healthy children to improve their spoken language and literacy and apps that focus on sign language proficiency for children with hearing loss, but these apps are limited for children with hearing loss. Therefore, we have developed an app called Hear Me Read, which uses enhanced digital stories as therapy tools for speech, language, and literacy for children with hearing loss. The platform has therapist and parent/child modes that allow (1) the selection of high-quality, illustrated digital stories by a speech-language pathologist, parent, or child; (2) the modification of digital stories for a multitude of speech and language targets; and (3) the assignment of stories by a therapist to facilitate individualized speech and language goals. In addition, Hear Me Read makes the caregiver a core partner in engagement through functionality, whereby the caregiver can record video and audio of themselves to be played back by the child. Objective: This study aimed to evaluate the user experience of the Hear Me Read app through a focus group study with caregivers and their children. Methods: We recruited 16 participants (8 children with and without hearing loss and 8 caregivers) to participate in 1-hour focus groups. Caregivers and children interacted with the app and discussed their experiences through a semistructured group interview. We employed thematic analysis methods and analyzed the data. We used feedback from the focus group to improve the elements of the app for a larger clinical trial assessing the impact of the app on outcomes. Results: We identified three themes: default needs, specific needs, and family needs. Participants found the app to be esthetically pleasing and easy to use. The findings of this study helped us to identify usability attributes and to amend app functionalities to best fit user needs. Caregivers and children appreciated the enhancements, such as highlighting of parts of speech and caregiver reading of video playback, which were made possible by the digital format. Participants expressed that the app could be used to enhance family reading sessions and family interaction. Conclusions: The findings from this focus group study are promising for the use of educational apps designed specifically for those with hearing loss who are pursuing listening and spoken language as a communication outcome. Further investigation is needed with larger sample sizes to understand the clinical impact on relevant language and literacy outcomes in this population.

BACKGROUND Traumatic brain injury (TBI) poses a significant threat to children’s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. OBJECTIVE This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. METHODS The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. RESULTS Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. CONCLUSIONS This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI.

BACKGROUND Children with hearing loss, even those identified early and who use hearing aids or cochlear implants, may face challenges in developing spoken language and literacy. This can lead to academic, behavioral, and social difficulties. There are apps for healthy children to improve their spoken language and literacy and apps that focus on sign language proficiency for children with hearing loss, but these apps are limited for children with hearing loss. Therefore, we have developed an app called Hear Me Read, which uses enhanced digital stories as therapy tools for speech, language, and literacy for children with hearing loss. The platform has therapist and parent/child modes that allow (1) the selection of high-quality, illustrated digital stories by a speech-language pathologist, parent, or child; (2) the modification of digital stories for a multitude of speech and language targets; and (3) the assignment of stories by a therapist to facilitate individualized speech and language goals. In addition, Hear Me Read makes the caregiver a core partner in engagement through functionality, whereby the caregiver can record video and audio of themselves to be played back by the child. OBJECTIVE This study aimed to evaluate the user experience of the Hear Me Read app through a focus group study with caregivers and their children. METHODS We recruited 16 participants (8 children with and without hearing loss and 8 caregivers) to participate in 1-hour focus groups. Caregivers and children interacted with the app and discussed their experiences through a semistructured group interview. We employed thematic analysis methods and analyzed the data. We used feedback from the focus group to improve the elements of the app for a larger clinical trial assessing the impact of the app on outcomes. RESULTS We identified three themes: default needs, specific needs, and family needs. Participants found the app to be esthetically pleasing and easy to use. The findings of this study helped us to identify usability attributes and to amend app functionalities to best fit user needs. Caregivers and children appreciated the enhancements, such as highlighting of parts of speech and caregiver reading of video playback, which were made possible by the digital format. Participants expressed that the app could be used to enhance family reading sessions and family interaction. CONCLUSIONS The findings from this focus group study are promising for the use of educational apps designed specifically for those with hearing loss who are pursuing listening and spoken language as a communication outcome. Further investigation is needed with larger sample sizes to understand the clinical impact on relevant language and literacy outcomes in this population.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Introduction : Needles are frequently required for routine medical procedures. Children with severe hemophilia can have hundreds of IV procedures per year. Fear of needle related procedures can cause avoidance of future health care. Virtual reality (VR) has shown promise as a distraction technique during procedures, but barriers to commercially available VR platforms have prevented widespread use. Objective: Objective : We hypothesized that we could create a VR platform that would be customized for pediatric hemophilia care, clinician orchestrated and feasible to use for distraction during intravenous (IV) procedures performed as a part of complex healthcare. Methods: Methods: We created a custom VR platform that consisted of a wireless, adjustable, disposable headset and a suite of VR games that could be orchestrated remotely. The platform was customized for a pediatric hemophilia population. Orchestration was performed by a hemophilia nurse observing the procedure. The primary endpoint of the trial was to assess feasibility of VR versus Standard-of-care (SOC) distraction during a planned IV procedure in the course of a comprehensive hemophilia clinic visit. Feasibility and usability of the platform was assessed in a single-center, randomized clinical trial from June through December 2016. Participants were children with hemophilia age 6 to 18 years. After informed consent 25 patients enrolled and were randomized. Each subject, 1 caregiver and 1 hemophilia nurse orchestrator assessed degree of pre-procedural nervousness/anxiety with an anchored, combined modified Visual Analog (VAS)/FACES scale prior to the IV procedure. Each participant then underwent a timed IV procedure with either VR or SOC distraction. Each rater assessed the distraction methods using a VAS/FACES scale at the completion of the IV procedure with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers and nurses were also asked to rate how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, the Mann-Whitney test was used. Results: Results: 25 children were enrolled and 24 were included in the primary analysis. The median procedure time was 10 minutes in the VR group (range 1-31 minutes) and was comparable to 9 minutes (range: 3-20 minutes) in the SOC arm (p=0. 764). Patients in both VR and SOC arms reported a positive influence of distraction on procedural anxiety and pain. Eighty percent of the children, caregivers and nurses reported that they would like to use VR for future procedures. No adverse events were experienced in either arm. Conclusions: Conclusion: We demonstrated that an orchestrated, VR environment could be integrated and used during pediatric hemophilia care during IV interventions without adversely disrupting clinic flow. This platform has the potential to improve the patient experience during medical procedures. Clinical Trial: Clinical Trials.gov NCT03507582

BACKGROUND Needles are frequently required for routine medical procedures. Children with severe hemophilia require intensive intravenous (IV) therapy to treat and prevent life-threatening bleeding and undergo hundreds of IV procedures. Fear of needle-related procedures may lead to avoidance of future health care and poor clinical outcomes. Virtual reality (VR) is a promising distraction technique during procedures, but barriers to commercially available VR platforms for pediatric health care purposes have prevented widespread use. OBJECTIVE We hypothesized that we could create a VR platform that would be used for pediatric hemophilia care, allow clinician orchestration, and be safe and feasible to use for distraction during IV procedures performed as part of complex health care. METHODS We created a VR platform comprising wireless, adjustable, disposable headsets and a suite of remotely orchestrated VR games. The platform was customized for a pediatric hemophilia population that required hands-free navigation to allow access to a child’s hands or arms for procedures. A hemophilia nurse observing the procedure performed orchestration. The primary endpoint of the trial was safety. Preliminary feasibility and usability of the platform were assessed in a single-center, randomized clinical trial from June to December 2016. Participants were children with hemophilia aged 6-18 years. After obtaining informed consent, 25 patients were enrolled and randomized. Each subject, 1 caregiver, and 1 hemophilia nurse orchestrator assessed the degree of preprocedural nervousness or anxiety with an anchored, combined modified visual analog (VAS)/FACES scale. Each participant then underwent a timed IV procedure with either VR or standard of care (SOC) distraction. Each rater assessed the distraction methods using the VAS/FACES scale at the completion of the IV procedure, with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers, and nurses also rated how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, Mann-Whitney test was used. RESULTS Of the 25 enrolled children, 24 were included in the primary analysis. No safety concerns or VR sickness occurred. The median procedure time was 10 (range 1-31) minutes in the VR group and was comparable to 9 (range 3-20) minutes in the SOC group (P=.76). Patients in both the groups reported a positive influence of distraction on procedural anxiety and pain. Overall, in 80% (34/45) of the VR evaluations, children, caregivers, and nurses reported that they would like to use VR for future procedures. CONCLUSIONS We demonstrated that an orchestrated, VR environment could be developed and safely used during pediatric hemophilia care for distraction during IV interventions. This platform has the potential to improve patient experience during medical procedures. CLINICALTRIAL Clinical Trials.gov NCT03507582; https://clinicaltrials.gov/ct2/show/NCT03507582 (Archived by WebCite at http://www.webcitation.org/73G75upA3)