VIDA-Nursing v1.0: immersive virtual reality in vacuum blood collection among adults

Objective: to develop and validate the first immersive virtual reality simulation addressing vacuum blood collection in adult patients - VIDA-Nursing v1.0. Method: methodological study to validate 14 steps of the vacuum blood collection procedure in adults, designed to develop the immersive virtual reality simulator VIDA-Nursing v1.0. It was assessed by 15 health workers and 15 nursing undergraduate students in terms of visual, interactive, movement simulation reality, teaching and user-friendly aspects. Results: the workers considered 79.6% of the items to be valid, while the students considered 66.7% of the items valid; most of the demands can be implemented in the system by improving future versions. Conclusion: the simulator was considered a promising and innovative tool to teach vacuum blood collection in adults as it can be combined with other resources currently used to introduce this topic and technique in the education of undergraduate nursing students.


Introduction
Peripheral venipuncture is defined as the insertion of devices through a peripheral vein to access one's bloodstream. It is a common, however, complex procedure performed in health care that demands competent workers to perform it (1)(2)(3) . A peripheral venipuncture is an essential stage in procedures for various purposes, among which intravenous therapy and the collection of blood samples for laboratory exams.
Inappropriately performing this stage may expose patients to site complications such as phlebitis, infiltration and/or hematoma and, when associated with incorrect procedures performed in other stages, complications may be systemic, such as thrombophlebitis and bloodstream infections, which are more frequently associated with the use of intravenous devices (1)(2)(4)(5)(6)(7) .
A peripheral venous puncture inadequately performed may also compromise the results of laboratory exams, which is one of the major aspects to be continuously addressed by the staff in the preanalytical phase of blood collection (8) and may reflect on improper conducts in a patient's treatment (9)(10)(11) .
There are many technologies to develop skills and competencies related to the collection of blood samples and peripheral venous catheterization that include conventional arm simulators, models with latex veins that can be attached with straps over a human arm, and non-immersive virtual reality simulators.
Various teaching institutions have increasingly incorporated the use of simulators in teaching strategies. Simulators can be used to develop technical skills, interpersonal relationships, promote specific competencies or problem-solving skills while various types of simulators and environments, including the virtual environment, are employed (12) . In this context, virtual refers to environments or elements synthesized by digital devices with the possibility to be immaterially replicated (13) .
Technological development has enabled interaction between person-machine to become increasingly advanced, facilitating the development of more realistic virtual environments. From this perspective, virtual reality (VR) promotes interactive and motivating simulators. VR is an advanced interface generated by computer-performed applications, through which users interact in real-time, stimulating the senses with elements of a three-dimensional environment such as visualization, movement, hearing and/or touch (14) .
VR simulations have proven to be feasible, as reported by recent international studies, with important results both to support human resources training and the treatment of patients. There are two clinical trials reporting results in the treatment of patients (15)(16) and five clinical trials addressing the training of human resources (17)(18)(19)(20)(21) .
There are also other types of study designs conducted in the field of human resources training (22)(23) .
Fifteen meta-analyses report VR simulators intended to support the treatment of patients (24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38) , while two other meta-analyses report its use in the training of human resources (39)(40) . In general, the studies present promising results in the use of VR simulations. The field of training focused on medical procedures in the surgical field in general and in laparoscopic surgery, hysteroscopy, mastoidectomy, and sutures. Criteria used to develop the simulator were based on evidence reported in the literature concerning the vacuum blood collection procedure in adult patients (8,(42)(43) .
Given the technological complexity of developing an immersive virtual reality simulator to train individuals for an invasive procedure, basic requirements were established to be applied in the short term, to test and verify the system feasibility, to be later complemented at the medium and long terms.
In total, 16 requirements were listed for the procedure to be performed in the short term, namely:  for the participants to receive information regarding the study, sign a free and informed consent form, take part in the simulation, and complete the forms concerning characterization and assessment of the simulator, so that, their performance could be assessed. The monitor screen was video recorded during the simulation to support analysis and clarify potential doubts regarding the participants' performance.
The theoretical framework used to support the development of the simulator was provided by Skinner.
Skinner's study on operant conditioning behavior has been used in educational games, entertainment games, and virtual simulations used in teaching (47)(48)(49) . Operant conditioning refers to an organism's response through differential reinforcement of successive approximations, in which a response generates a consequence, which affects the probability of it occurring again in the future (50) .

Results
The workers' ages ranged from 22 and 53 years old, with an average of 32.7 years old, while most were women (80%). About graduate programs, ten (66.7%) had a specialization; nine (60%) had a Master's degree; seven (46.7%) had a Doctoral degree, and one (6.7%) had attended a post-doctorate program. In terms of experience in vacuum blood collection, only one     The configuration of the equipment used in the simulation, initial screen, ambience setting, material, and procedure are portrayed in Figure 4.

Discussion
Technological resources in the teaching of nursing are developing constantly, however, the use of immersive VR simulation in the implementation of these strategies is seldom explored. One study analyzing the contributions of digital educational technologies in the teaching of nursing, reports that only two (6.7%) out of 30 studies involved the use of virtual reality (51) .
An analysis of the literature (52)  and fingers with high precision (53) . The Head-mounted Display (HMD) enables the total immersion of users in an artificial environment through two liquid crystal displays that allow for stereoscopic vision (13) . Using these devices together is beneficial to facilitate programming and also because of the great potential of these two devices when used together with the sensor system and in the field of teaching in the health field, especially in the training of specific procedures (41,54) .
In the workers' assessment, nine items in the Movement Simulation Reality Aspect were considered to require revision (Q33, Q34, Q37, Q40, Q41, Q43, Q44, Q45 and Q46). The assessment concerning the Userfriendly Aspect shows that two items (Q52 and Q53) need to be revised, while item Q54 was well rated.
The students' assessment shows that 18 items Therefore, this item will be revised.
Regarding the Movement Reality Simulation Aspect, improvements were suggested to the items that refer to the Arm tourniquet (Q37 and Q43), which in this first experiment was programed to be performed with one of the hands only and will be reconfigured for two hands.  Only two, out of the 30 participants were not able to complete the procedure though these were workers who draw blood samples using a vacuum tube almost daily.
The workers with extensive professional experience who do not perform this procedure daily were able to perform the simulation more easily; similar to those who had no practice in the technique, as was the case of the students.
Because the group of more experienced workers had performed this procedure numerous times, they wanted to see a simulation of patients' behavior (especially verbal communication) in addition to the procedure, to be also rapid and individualized, considering that each worker has a specific manner to perform the procedure according to recommended guidelines. When we analyze operant behavior, as proposed by Skinner (49) , lack of behavior in the simulator, as workers expected, generated a negative reinforcement, that is, they were not supported to carry on with the procedure. For students or inexperienced workers, facing difficulties to complete the simulation up to its end was positive reinforcement, a challenge for the users to end the simulation only after completing all the stages. Additionally, the less experienced, the greater the positive reinforcement on one's behavior to complete the procedure, as students' scores show. The students' mean number of correct answers was higher (2.5 correct answers/9.9 attempts) than that obtained by the workers (1.7 correct answers/7.5 attempts).
Another operant behavior response was that the longer a participant interacted with the simulator, the better his/her performance concerning the duration of use.
In addition to the various possibilities to make the simulator a more interactive and motivating tool among students, there are the priority items that need to be addressed in the next version: to add new devices to make the virtual simulation environment more adaptable to the students' environment such as the use of prescription glasses with the immersion device for those who need vision correction and adjust the system to be used by both left-and right-handed individuals. These and other improvements can be addressed in future versions as this study progresses and new demands and opportunities are identified.
Feedback will be provided to users in the simulator's final version at the end of the simulation, presenting adverse events that took place during the procedure to promote a positive reinforcement for the learning of users. Even though the current version provides little feedbacks to users, promising effects of positive reinforcement were identified during its use.
Among this study's potential biases and limitations, there is the fact that data collection indicated that, at the end of the day, the gesture sensor seemed to have its performance decreased, requiring pauses between simulations to improve its performance. The assessment form was considered comprehensive but required time and attention from the participants during its completion. Having left-handed participants as well as individuals wearing prescription glasses to be able to see nearby objects -without previously adapting the system -may have influenced how these individuals' assessed the simulator. These limitations had not been foreseen.

Conclusion
The development of the VIDA-Nursing v1.0 simulator revealed that obtaining a complete procedure simulator is a complex task. Numerous technological resources need to be used and incorporated during its implementation, which will be only achieved in the course of this study, by testing and improving research, so that we will be able to achieve a final product that can be incorporated as a teaching resource in nursing schools and meet the needs of this target population regarding the learning of this procedure.
The 14 steps performed during the simulation were assessed through 54 items. Even though according to the participants, approximately one-third of the items required revision, the VIDA-Nursing v1.0 simulator was considered a promising tool to teach the procedure of blood collection using a vacuum tube in adult patients. The reason is mainly that it can be combined with resources currently used to teach this procedure to undergraduate nursing students and therefore, provide better training to students so they develop the competencies needed to care for patients during supervised training and later, in their professional practice.