Feasibility and Acceptability of a Virtual Reality Curriculum to Support Firearm Safety Counseling Skills Among Pediatric Residents

Firearm-related injury is the leading cause of death among US children and adolescents.¹  Secure storage (storing a firearm locked and unloaded separately from ammunition) can decrease unintentional and self-inflicted injuries.²  However, residents report low preparedness to provide firearm safety counseling due to limited knowledge, comfort, and skills.^3-5 

Prior curricular approaches, including handouts, workshops, quality improvement initiatives, and electronic health record prompts, have increased firearm screening rates.^6-10  However, even with training, discomfort with responding to a positive screen persists.¹¹  Investigators at Massachusetts General Hospital (MGH) developed a standardized patient curriculum to support residents’ skills that enhanced residents’ knowledge and comfort.¹²  However, the use of patient actors for training can be costly and variable, presenting feasibility challenges to broad dissemination.

Virtual reality (VR) is a computer-generated environment in which users interact with graphical characters and environments in a seemingly realistic manner. It can be delivered via a 3D-mounted headset or screen.¹³  VR has been effectively used to support residents’ skills at addressing vaccine hesitancy.^14,15  Thus, we sought to report feasibility and acceptability outcomes related to Resident Education And Counseling on Household (REACH) Firearm Safety, a novel screen-based VR curriculum using deliberate practice principles¹⁶  to support firearm safety counseling skills.

REACH was designed to increase residents’ skills at screening and counseling on secure firearm storage through practice of specific communication competencies. Competencies included embedding firearm safety within routine safety counseling, providing teaching on secure storage, screening for storage strategies, and discussing specific storage devices (eg, cable lock, trigger lock, lock box). Motivational interviewing competencies were also included to support collaborative decision-making (online supplementary data).^17,18  The REACH training occurred 1-on-1 with a resident and a facilitator (F.J.R.) via a teleconferencing network. Training included: (1) a brief didactic (15 minutes) that reviewed epidemiology, and (2) 4 VR scenarios (30 minutes) to practice competencies (online supplementary data). For each scenario, the VR environment was shared to occupy the resident’s full screen. The virtual characters responded in real time to the resident’s verbal counseling via verbal and nonverbal language. These responses were controlled by the facilitator following structured response flowsheets. The curriculum leveraged a deliberate practice model derived from Ericsson’s Theory on Expertise.¹⁶  As such, following scenario completion, the resident received immediate, personalized feedback from the facilitator that could then be applied to subsequent scenarios. A recorded example of a VR scenario is available as online supplementary data.

We recruited a convenience sample of third-year pediatric residents from Cincinnati Children’s Hospital Medical Center (CCHMC) and MGH. A total of 59 eligible residents were contacted via email to participate. Enrollment continued until a sample size of 15 was achieved aligning with recommended guidelines.¹⁹  Consent occurred electronically. Participation included completion of REACH with immediate debriefing via a semistructured interview (interview guide provided as online supplementary data). Residents also completed a demographic survey and the Measurement, Effects, Conditions Spatial Presence Questionnaire (MEC-SPQ), an instrument with prior validity evidence for evaluating immersion in a virtual environment (Table 1).²⁰  Interviews focused on users’ perspectives of the VR simulations and were led by co-authors (M.M., A.M.). Interviews were transcribed verbatim. Two authors (C.G., M.W.Z.) independently reviewed transcripts and inductively derived codes using Atlas.ti software (Lumivero/ATLAS.ti Scientific Software Development GmbH). Codes were subsequently sorted into themes via thematic analysis and were refined by co-authors who identified exemplar quotes.²¹ 

The study was approved by the institutional review boards at CCHMC and MGH.

VR scenarios were developed using the gaming platform Unity (Unity Technologies)²²  with repurposing of digital assets (ie, environment, characters) from prior curricula.^14,23,24  Fifteen residents completed REACH via a video conferencing platform between October and November 2022, during which the physician facilitator mirrored the view from a VR headset onto a shared 2-dimensional screen to allow residents to remotely participate in the VR scenarios. No residents experienced technical challenges requiring discontinuation of a session. REACH took 38 minutes on average to complete.

One individual did not complete the survey. Residents were mostly women (11 of 14, 79%) and between 25 and 29 years of age (13 of 14, 93%). Residents identified as White (10 of 14, 71%), Asian (2 of 14, 14%), and Black (1 of 14, 7%), with one resident preferring not to answer. Most residents (13 of 14, 93%) agreed or strongly agreed that it seemed as though they actually took part in the action of the VR simulations (Table 1). Themes from interview data are included below with additional supporting quotes in Table 2.

Residents reported a lack of knowledge, comfort, and time as barriers to counseling. One resident noted, “I can’t counsel families on what to do with their guns if I don’t know how guns work and how to store them…But I think a lot of us don’t.” (P3) Another resident reported “anxiety about getting the conversation started.” (P13)

Residents reported that VR provided a lifelike setting. One resident noted, “You have to sort of suspend disbelief in a sense, but like the responses were appropriate. I feel like they were saying things that people would say…nothing could be real life, but it [VR] was pretty close.” (P4)

Residents felt the duration of REACH was appropriate and appreciated its increasing complexity. One resident said, “I liked that we built on things. So, we started out with like just the topic of conversation, and then we did the motivational interviewing, and then we applied it to like preventing suicides. It was a very stepwise approach.” (P5)

Residents identified the ability to practice as a critical component of REACH. One resident said, “I liked the opportunity to practice with patients multiple times, especially to do it once and then receive some feedback and education and then go back and do it again.” (P4)

Residents reported that REACH helped address barriers related to knowledge, comfort, and time. One resident noted, “I think I’m more comfortable talking about it now. Like I think the stigma for me is gone as I have ways that I can introduce it and feel comfortable with it.” (P5) Another reported that REACH “allows me to then deliver that information in a concise and brief manner.” (P14)

In this study, we collected feasibility and acceptability data to explore residents’ perceptions on a novel VR curriculum to support their firearm safety counseling skills. Overall, residents reported that REACH was immersive, informative, appropriately structured, and supported behavior change highlighting its acceptability. Moreover, by using a communication framework, REACH may support efficient counseling.

Simulation allows for direct observation of skills with individual coaching to ensure skill acquisition.^6,12  In terms of feasibility, VR might prove advantageous over traditional simulation strategies (eg, standardized patients) by providing a safe, realistic, and standardized experience while avoiding costs related to patient actors and physical training spaces. Moreover, VR allows for purposeful design of graphical characters to monitor for biased behaviors.²⁵  VR also allows for unlimited replay of scenarios with repurposing of digital assets for novel content.^14,23,24  As REACH utilized a teleconferencing network, residents also did not require specialized VR equipment. However, residents did report lower scores on the MEC-SPQ related to possible actions in the environment. Thus, though acceptable for communication training, a screen-based VR platform may be less suitable for scenarios requiring interactions with digital objects (eg, physical examinations, procedures). A notable limitation to the scale of REACH is that it requires human facilitation. However, though a physician faculty member facilitated training in this study to achieve ideal settings, a range of educational backgrounds have demonstrated capacity to facilitate VR with high fidelity.^15,23  Future automation through artificial intelligence would greatly expand the potential adoption of curricula such as REACH by removing the need for human facilitation and decreasing costs. However, work is needed to understand how automation may impact the effectiveness of VR interventions.

This study had limitations. First, there is the possibility of selection bias as residents with increased interest in VR or firearm safety may have opted to participate. Second, we did not assess the impact of this curriculum on residents’ real-world behaviors—an important next step to understand its effectiveness. Further research that compares VR to other training modalities considering cost-effectiveness will be important to identify optimal curricular approaches.

Among pediatric residents, VR simulations utilizing deliberate practice principles proved a feasible and acceptable approach to training on firearm safety counseling.

The online supplementary data contains competencies included in REACH firearm safety, an overview of REACH firearm safety curriculum scenarios, a video demonstration of a REACH firearm safety virtual reality scenario, the interview guide used in the study, and a visual abstract.

Funding: This work was supported through the Stepping Strong Center for Trauma Innovation. Funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Conflict of interest: The authors declare they have no competing interests.

A portion of this work was previously presented at the Pediatric Academic Societies Annual Meeting, April 27-May 1, 2023, Washington, DC, USA, and the Academy Health Annual Research Meeting, June 24-27, 2023, Seattle, Washington, USA.

* Denotes co-first authors.