Introduction

As an essential component of their training, Medical Radiation Science students undertake study of Radiation Safety and Radiation Protection to engender an understanding and respect for radiation safety. Essential physical principles within this topic include the Inverse Square Law, Half-Value Thickness and X-ray scatter processes. Traditionally teaching of these principles is augmented with experimental sessions on real X-ray machines or radioactive sources to reinforce the practical application of the theory. Unfortunately increasing pressure on resource-intensive radiation facilities frequently restricts access. Virtual Reality software simulation has been used successfully in a range of professions to provide a cost-effective and safe learning environment in which students can practice essential and challenging skills [1–4]. In this work a software-based environment was developed, which is capable of providing practical training in medical radiation principles and safety. The Virtual Radiation Laboratory (VRL) application was developed to provide students with the opportunity to conduct virtual experiments using simulated diagnostic and radiotherapy X-ray generators. The experiments aimed to provide students with understanding of the radiation safety aspects of their work as well as opportunities to develop their collaborative working skills and better prepare them for clinical practice.

Methods

The Quest 3D (Act-3D, B.V) real-time 3D graphics engine was used to create a series of interactive simulated environments including radiation laboratory benches, kilovoltage imaging room and linear accelerator bunker as seen in Figs. 1 and 2. Calculations for the inverse square law, half value thickness and radiation scatter were derived from experimental data and implemented for each experiment with output from user interaction calculated in real-time. The experiments were designed to facilitate collaborative working in small teams using collaborative learning spaces. Piloting with volunteers from the previous cohort of students informed software development. The main evaluation phase was conducted after a full cohort of students (n = 126) had received teaching using the new software and sought feedback concerning the perceived value and limitations of the application. The aims of this evaluation phase were to monitor the impact of the software on students’ understanding, satisfaction and collaborative learning skills and also to determine potential further improvements to the software and guidelines for its continued use. Ethical approval for the evaluation was provided by the University Research Ethics Committee as part of a wider project into Course Improvement. Students were asked to complete an anonymous online survey consisting of a mixture of six Likert-style questions (seen in Table 1) and five short answer open questions seeking thoughts on advantages, disadvantages, potential improvements, use of the resource and any additional comments. Students were required to submit the survey as part of the Unit evaluation process, although they were advised that question completion was voluntary and all questions allowed for a “No Answer” response. Anonymity was assured by the Virtual Learning Environment survey tool.

Fig. 1
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Screenshot of the diagnostic virtual radiation environment

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Fig. 2
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Screenshot of the radiotherapy virtual radiation environment

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Table 1 VRL Evaluation Results
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Statistical analysis

All 126 student responses were collated and independent analysis of the qualitative data was performed by two researchers to minimise the effect of bias. A mixture of descriptive statistical tools (such as relative response rates and summary tools) for the Likert responses and simple thematic analysis (coding and grouping) techniques for the open questions was utilised. Correlation analysis of the quantitative data was performed using the Pearson product-moment correlation coefficient.

Results

A total of 126 responses were provided by the student cohort with a question answer rate of 99.3 % for the 6 Likert responses. The 5 open answer questions attracted a lower response rate ranging from 40 to 55 %. Table 1 summarises the results of the Likert questions where 80 % of students reported increased understanding of radiation protection principles, 72 % enjoyed using the software and 87 % felt that the project had facilitated collaboration within small groups. There were few disagreements with the positive Likert stems. Most of the students identified themselves as experienced computer users with only 6.5 % self-assessing as inexperienced. Correlation analysis demonstrated only weak or negligible correlation between computer experience and enjoyment, ease of use and understanding (all r < 0.25). Only the enjoyment correlation was statistically significant (p = 0.009). Themes arising from the qualitative analysis of the open answer questions triangulate well with the quantitative data with many students providing comments about the ease and enjoyment of use, facilitation of understanding and improved collaboration arising from the application. The main themes arising in the qualitative feedback comments related to efficiency and effectiveness of teaching, safety of environment, collaboration and realism as seen in Figs. 3 and 4. Further analysis of these themes follows in the Discussion section. In terms of resource implications, the software enabled large group teaching which reduced the number of group bookings from 7 to 2. For the 4 h of practical allocated per student this resulted in a time saving of 24 h.

Fig. 3
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Advantages of the VRL

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Fig. 4
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Disadvantages of the VRL

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Discussion

Most of the students identified themselves as experienced with software which is unsurprising for the modern undergraduate cohort [5]. The main themes arising in the qualitative feedback comments related to efficiency and effectiveness of teaching, safety of the environment, facilitation of collaborative learning and perceived realism. Further comments relating to best practice in use of the resource and potential improvements to the resource also form the basis for recommendations for future use. Representative comments supporting the discussion themes are presented in Table 2.

Table 2 Indicative comments supporting discussion themes
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Efficiency

When students were asked what were the potential benefits arising from the VRL the most commonly arising responses related to better use of time. Students could perceive the efficient nature of the software simulation in terms of the University resources and staff time as well as their own time. They also commented that the format allowed for better access to teaching staff and was likely to be more cost effective. From an academic perspective, as with other published findings [2, 6], the simulation led to a more efficient use of resources and personnel arising from reduced contact hours and use of collaborative learning spaces rather than resource-intensive radiation laboratories. This manifested itself in a reduced impact on specialist laboratory timetabling.

Effective teaching

While gains in efficiency are valuable at an institutional level, these are of little value unless there is a positive impact on teaching and learning. Student feedback was highly positive in relation to the impact of the VRL on understanding of the topic with 80 % of students reporting that the project had increased their understanding of radiation protection principles. Along with increased understanding, 72 % enjoyed using the software; a finding common to many Virtual Reality applications [1, 7]. In addition, however, qualitative analysis suggested students particularly relished the increased opportunity for easy experimentation.The visualization of “invisible” physical principles was another significant benefit perceived by the students and it was clear that this had led to increased understanding in much of the cohort. Conversely some students felt that the VRL provided a less engaging environment citing the reduction in “hands-on” time as a contributing factor. There is a real danger that understanding of processes is replaced with a series of button clicks and such resources must be used in such a way as to limit this. It is also important to remember that this conflicting data reinforces the acknowledged variety in learning styles within modern undergraduate cohorts [8] and suggests that a mixed approach combining both virtual and real learning environments is most likely to satisfy these diverse needs.

Collaboration

A key finding from the evaluation was that 87 % of students felt that the project facilitated collaboration within small groups. Although the radiation laboratory format also utilised a group format this was largely due to resource availability rather than a pedagogical approach. The various group tasks and requirement for discussion on the experimental findings along with the ability to experiment with different settings naturally encouraged teamwork and this was echoed in the qualitative comments. For this cohort of students working towards multi-disciplinary teamwork-orientated professions [9] this is a most encouraging finding.

Safe environment

There were many comments from students regarding the enhanced facilitation of experimentation with students enjoying learning from mistakes and trial and error in a manner that would be discouraged in a radiation laboratory with live sources or expensive equipment. The benefits of the “safe” environment provided by simulation solutions have long been acknowledged in the literature [3, 10], although this is usually related to patient safety. In this paper it was interesting to see how simulation could potentially improve safety for learners too. Given the focus of the academic unit, it was reassuring to see students appreciating the potential dangers of radiation in their feedback (although it should be stated that students are not, in fact, routinely exposed in the radiation laboratory). Despite this, some students did cite the lack of risk as a potential disadvantage of the application with a reduction in learning about working safely with live sources. Clearly a balance must be struck between the learning arising from potentially dangerous situations and the benefits of an experimental problem-based learning approach.

Realism

The effectiveness of simulated teaching environments is often linked with the immersion or the sense of realism engendered [11]. Although this was a relatively low fidelity simulation students appreciated the simulated clinical environments and several responses cited the realism and close approximation to clinical practice as benefits of the VRL. There were a large number of students, however, that judged the simulation to be unrealistic, lacking the element of danger or hands-on practice. There was a clear need for students to experience the real clinical situation. This echoes findings from other pre-clinical simulation studies [7, 12] where the value of simulation in an academic environment lies in better preparing the students for real life clinical experience. It is recommended that this is emphasised in the workshop’s introduction session.

Facilitation

Student feedback strongly suggested that, as with many academic activities, successful learning depended to a great extent on the attitude of their tutors. While there is little that can be done about individual approaches to tutoring results from this study suggest that there is value in allowing multiple tutors to interact with the students in the collaborative learning space where they can each provide their own insight and experience. Student comments also suggested that introductory material provide a clearer message about the aims and outcomes of the experiments. Within the experiments themselves, however, there were mixed messages about the levels of support required with some students requesting further instruction and others feeling “spoon-fed”. Again this mixture of expectations reinforces the need for a mixed methods approach to provision of resources. When students were asked for suggestions to improve use of the resource there were several comments requesting additional individual access both on and off campus to the application. This has the potential to improve self-directed learning and encourage learner autonomy.

Limitations

There are several limitations associated with this study. As it was a developmental project there were still some software bugs present during the evaluation phase. These included some issues with time lag, a requirement for an additional factor to be added and some user interface confusion. Student comments from the evaluation are currently informing ongoing improvement to the resource as well as designing introductory and support materials. It is likely, however, that the developmental nature of the software could have led to perceived problems with realism and ease of use. In terms of the evaluation it must be acknowledged that in the absence of a control arm the student evaluation is hard to compare directly with the “real” radiation laboratory experiments. This can be ameliorated to some extent within this cohort as they all undertook a similar format of experiment in the previous semester. The anonymous nature of the survey tool and the use of an independent researcher should reduce interpretation bias but it should be acknowledged that the software development and evaluation was funded by a University Teaching and Learning Grant aimed at improving the student learning experience.

Conclusion

This work has demonstrated the value of software simulation for facilitating experimentation aiming to enhance understanding of radiation principles. Facilitation using a range of tutors can enhance the learning and where possible unsupervised access can be provided for students wishing to experiment further. Staff and students both report gains in efficiency and effectiveness associated with the virtual experiments. In addition students particularly value the visualisation of “invisible” physical principles and increased opportunity for experimentation and collaborative problem-based learning. Similar ventures will benefit from adopting an approach that allows for individual experimentation while visualizing challenging concepts.