2.1. Background

2.1.1 The National Radiotherapy Advisory Group (NRAG) Report to the UK Government in 2007¹ identified a potential crisis in England in relation to radiotherapy education and training and an urgent need to reduce the attrition rate of student therapy radiographers.  The Report included a recommendation to introduce Hybrid Virtual Environment skills training facilities across the 10 education providers and 51 associated radiotherapy and oncology sites providing clinical training and experience.  The aim would be to improve retention by enhancing the student learning experience through provision of the opportunity to develop knowledge and skills in a ‘safe’ environment while limiting the impact on already stretched clinical resources.

2.1.2 A suitable virtual reality platform was readily available – the Virtual Environment for Radiotherapy Training (VERT) system – utilising immersive visualisation technology and software developed by Vertual Ltd². The VERT system provides a life-sized virtual radiotherapy treatment room and allows the user to interact with the virtual room, control the equipment and set up radiation treatments as if in the real world.

2.1.3 In response to the NRAG recommendation, the Department of Health and Cancer Action Team made £5 million available to fund:

• purchase of the VERT software and required hardware;
• refurbishment costs; and
• an 18-month project, led by the Society and College of Radiographers, to manage the implementation of the VERT technology and begin evaluating its impact.

2.1.4 Educational institutions providing pre-registration radiotherapy education and training in England and radiotherapy and oncology departments providing the associated student placements were invited to submit expressions of interest in participating in this supported VERT Project which ran from April 2008 to October 2009.

2.2. Project Aim and Outcomes

The aim of the 18-month VERT Project was to assess the potential use of the VERT technology – the projectors, screens, immersive and seminar auditoria and the software. It was designed to achieve the following specific outcomes through an integrated approach to the introduction of VERT into educational institutions and clinical radiotherapy and oncology departments:

• To assess the potential impact of VERT on student recruitment and retention, especially in year one;
• To investigate how students learn in virtual environments;
• To assess the impact of VERT on student confidence;
• To assess the impact of VERT on student enjoyment of their courses;
• To assess the extent to which VERT enhances students’ knowledge and understanding of relevant radiotherapy concepts;
• To determine the extent to which students’ psychomotor and practical skills can be developed using VERT;
• To share the learning outcomes associated with the use of VERT across all the universities and departments; and
• To appraise the long term potential of VERT, making recommendations regarding its impact on future curriculum design and teaching, learning and assessment strategies.

2.3. The VERT Technology

2.3.1 The VERT system and its functionality have been fully described elsewhere^{2, 3, 4}. Basically, however, high resolution stereoscopic projection on to a large screen produces a realistic, virtual environment of a radiotherapy treatment room.   It provides a life-size model of a linear accelerator with full functionality except for the production of radiation.  Users wear either liquid crystal display (LCD) shutter glasses or light polarising glasses (depending on the type of system being used) so that they are immersed in a three dimensional (3-D) image projected in the space around them.  The environment is a hybrid one in that a virtual linear accelerator is controlled using an actual hand-pendant.

2.3.2 It is possible to import images and radiotherapy treatment plans in DICOM format, thereby allowing a vast range of simple and complex treatment plans as well as the related anatomical data to be visualised in 3-D.

2.3.3 Different systems are provided in educational institutions and clinical areas.  Educational institutions use a system called ‘Immersive VERT’.  These systems are housed in a purpose-built, bespoke auditorium and employ rear projection using active stereoscopy requiring the user to wear LCD shutter glasses.  A tracking system is provided that enables the image to be projected according to the user’s position relative to the projection screen thus further enhancing the degree of ‘immersion’.  Radiotherapy and oncology departments use a system called ‘Seminar VERT’.  These systems can be situated in seminar or meeting rooms and require no significant refurbishment to support installation. Seminar VERT features front projection using passive stereoscopy requiring the use of polarising glasses.  User tracking is not provided.  At the time of the Project, the cost of Seminar VERT was approximately one quarter that of Immersive VERT, excluding room modification costs.

2.3.4 The large screen stereoscopic projection, faithful representation of the treatment room and linear accelerators, use of an actual hand pendant and, in educational institutions, use of a tracking system, all contribute to a high degree of physical and psychological ‘presence’ – the phenomenon whereby users are convinced they are part of a ‘real’ environment.

2.3.5 The VERT technology claims to offer a number of potential advantages:

• A cost effective alternative to training in clinical environments;
• Unlimited practice opportunities without risking harm to patient or equipment;
• Radiotherapy treatment rooms become more efficient as training demands are reduced;
• A realistic insight into the experience of using the equipment, but without the stress of being in a clinical setting;
• Enhance the understanding of those radiotherapy concepts that are often difficult to teach in a classroom and/or placement setting;
• Student attrition is reduced as the learning experience is enhanced.

2.4. Project Design

The Project had two distinct elements, each led by a Project Co-ordinator.

2.4.1 Implementation and Education
The implementation and education phase included:

• planning for installation of Immersive VERT systems within educational institutions and the installation of Seminar VERT systems in radiotherapy and oncology departments;
• training in use of the systems;
• incorporation of VERT experience within academic and clinical components of pre-registration radiotherapy programmes; and
• gathering information for dissemination and continued development based on user experience.

2.4.2 Evaluation and Research
The impact of VERT was assessed from the perspective of students, academic staff and clinical radiographers to address the Project outcomes. Review of associated literature and informal data gathered through communication during the Project informed and enhanced the overall evaluation strategy which comprised both quantitative and qualitative elements including:

• questionnaires and tests to assess the impact of VERT on the development of student skills, confidence and performance;
• collection and interpretation of data in relation to the impact of VERT on recruitment and retention;
• reports compiled by educational institutions and clinical departments; and
• a final evaluation survey distributed at the end of the Project.