Diminishing restrictive practices in psychiatric wards via virtual reality training: Old wine in a new bottle?

Abstract

This editorial examines the application of virtual reality (VR) training to mitigate restrictive practices (RPs) within psychiatric facilities. RPs include physical restraints, seclusion, and chemical restraints, used to ensure patient safety but with varying usage rates across regions. In recent years, there has been a growing focus on the adverse effects of RPs on both healthcare workers and patients, leading to calls for its reduction. Previous research has shown the efficiency of VR training in RP reduction. This editorial will analyze the limitations of VR training in prior research aimed at reducing RP, emphasizing that the essence of RPs is a medical safety issue, calling for careful differentiation of the causes of RPs, and avoiding the use of AR technology as a "new bottle" for "old wine" to improve the quality and reproducibility of future research in this field.

Key Words: Virtual reality; Virtual reality training; Restrictive practices; Questions; In-patient; Psychiatric wards

Core Tip: There has been an increasing clamor for reducing restrictive practices (RPs), alongside a surge in practical explorations to address this issue. This editorial comments on an article published in the World Journal of Psychiatry, which explored the application of virtual reality (VR) training as a strategy to reduce RPs within psychiatric wards. This editorial emphasizes the need to focus on the underlying issues of medical safety associated with RPs, discusses the strengths and limitations of VR training, and advocates for the differentiation of RPs based on their causes while also cautioning against overcorrection in the clinical practices of reducing RPs.

INTRODUCTION

Restrictive practices (RPs) encompass a range of medical interventions intended to ensure medical safety and prevent self-harm or the potential for harm to others by patients, which include physical restraints, seclusion, and chemical restraints[1]. The utilization of RP exhibits substantial variations across different regions and healthcare institutions, with reported usage rates differing by more than a hundredfold among various countries[2-4]. Such variations are attributed to disparities in the definitions and subjective interpretations of RPs and individual healthcare providers' values, professional levels, experience, cultural nuances, and the specific health policies of different regions[5]. In recent years, there has been a growing focus on RP's adverse physical and psychological impacts on healthcare staff and patients[6,7]. Consequently, there has been an increasing clamor for the reduction of RP, along with a surge in practical explorations within the field to address this challenge.

We are interested in an article published in the World Journal of Psychiatry, which explored the application of virtual reality (VR) training as a strategy to reduce RPs within psychiatric wards, offering a fresh approach to bolstering patient care and staff training[8]. Drawing on the valuable insights from the study in question, we are committed to delving deeper into the challenges and doubts associated with applying VR training to reduce RPs in psychiatric wards. This editorial aims to provide a nuanced perspective on this topic, contributing to the ongoing discourse on diminishing RPs.

REASSESSING THE UNDERLYING CAUSES

Reference citation analysis (RCA, https://www.referencecitationanalysis.com/) is a unique artificial intelligence (AI) system for evaluating citations in biomedical literature. RCA was used to analyze previous studies on RPs up to August 2024.

Before exploring the current challenges and potential solutions for reducing RPs, it is imperative to comprehend the rationale behind their clinical implementation. RPs are pervasive across medical practices due to their effectiveness in safeguarding patients from self-harm or harm to others, ensuring ward security, and mitigating conflicts and acts of violence within medical institutions[1]. At their essence, RPs are about safeguarding medical safety. However, it is evident that the factors influencing medical safety are intricate and cannot be resolved solely by training healthcare professionals[9,10]. Furthermore, it is a misconception to view the safety of healthcare workers as being in direct conflict with patient safety. From this perspective, any strategy that seeks to reduce the safety requirements of healthcare providers or patients to decrease RPs is misguided and counterproductive[11].

Concurrently, we cannot overlook that, despite calls from various nations and scholars to reduce RPs, their frequent use in real-world scenarios remains a cause for concern[12]. This situation necessitates a reevaluation of the issues within the realm of medical safety, encompassing the safety of both healthcare providers and patients. Taking the quality of medical care in psychiatric wards as an example, concerns about reduced medical quality and safety stem from human resources, technical expertise, ethical dilemmas, management levels, healthcare systems, or economic support[13,14]. Furthermore, there is a lack of viable alternatives to RPs and research and consensus on determining the least restrictive options that patients perceive[15-17]. Without addressing these fundamental issues, innovations in training methods may provide only temporary solutions or potentially lead to further complications in the future, including the widespread investment of already strained healthcare funds in areas with low cost-effectiveness. Such complications may exacerbate the economic burden in the public health sector and further diminish the quality of care, leading to increased medical inequities and safety concerns[18].

POTENTIAL AND LIMITATIONS OF VR TRAINING

As an engaging and immersive educational tool, VR training has received acknowledgment for its potential to facilitate learning without actual safety risks. VR technology can potentially enhance patient safety by allowing staff to practice crisis intervention techniques, communication strategies, and de-escalation methods in a safe and repeatable setting[19]. A recent study compared the incidence of violent incidents and the use of restrictive measures on the wards in the 12 wk preceding the introduction of VR with the first 12 wk following its adoption. It revealed that during the VR relaxation training phase, the frequency of violent incidents and the application of RPs were halved[20]. Meanwhile, some studies have also found that VR training may not outperform traditional face-to-face methods in specific complex medical procedure training, and there are issues with low knowledge retention rates among employees after 4 wk of training in non-medical fields[21,22]. Other limitations of VR training include its inapplicability to individuals with motion sickness or those unaccustomed to VR environments, the necessity for additional training on VR technology, the inability to fully replicate the complexity and unpredictability of real-world medical issues, and ethical concerns, such as the simulation of distressing scenarios or the potential for desensitization to certain aspects of care[23,24].

The effectiveness of VR training depends on the quality of the simulated environments and the system's ability to provide realistic and engaging training experiences[25,26]. However, previous studies' lack of detailed information regarding VR training content, specific training programs, and quality control raises concerns about its efficacy and replicability in reducing RPs[8]. Moreover, the VR training simulations are relatively short, as indicated in the previous study, with each simulation lasting approximately 5 min[8]. Meanwhile, the long-term efficacy of VR training in reducing RPs remains unestablished. Consequently, it is also essential to investigate whether extended VR training sessions differ significantly from the current shorter duration regarding their long-term impact. Furthermore, ensuring a sustained effect of VR training requires its seamless integration into standard psychiatric care protocols. It involves developing standardized VR training programs, establishing best practices, and continuously evaluating VR training's effectiveness in real-world clinical scenarios. In addition, VR training requires expensive hardware, such as VR headsets, and continually updated software, which may increase the cost and complexity of training and exacerbate the financial strain on the healthcare industry, especially in the current poor economic environment worldwide.

More importantly, future research should concentrate more on the content and design of personalized training programs rather than just adopting an expensive new technology to repackage existing training content. After all, VR is just a medium, and the medium itself cannot guarantee that the costly VR procedure is suitable for all kinds of training and produces more optimal results than the existing training methods[27]. From this angle, for the previous study aiming to improve "self-efficacy, anxiety, burnout, discrimination, and empathy" through VR training to reduce RPs[8], we are concerned that VR may only be an expensive new bottle for old wine, as the effectiveness of VR training may not so much depend on the VR "bottle" itself, but on the quality of the "wine" inside, where VR training plays a role in enhancing the experience. This understanding is easily overlooked in the constant flow of new technologies. Taking the interactivity of VR as an example, while VR's interactivity enables immediate feedback and strategic adjustments, which are crucial for the complexity and dynamism of psychiatric care, the effectiveness of VR training ultimately depends on the pre-designed quality and diversity of the training modules. Therefore, merely transferring conventional, video-based training content into a VR shell should be avoided.

DIMINISHING RPs IN PSYCHIATRIC WARDS

The reduction of RPs can be broadly achieved by reducing their incidence and shortening the duration of its employment. Effective methods encompass staff training, risk evaluation, management enhancement, and alterations to laws and regulations[28,29]. Additionally, digitalized mental health services and training initiatives have more recently been acknowledged as promising approaches[8,14]. VR technology significantly improves the customization of psychiatric staff training programs. A notable study has demonstrated that interactive VR (IVR)-based training in psychiatry represents an enticing and practical alternative to traditional face-to-face instruction, showcasing considerable promise for the field. IVR enables trainees to become fully immersed in simulations while maintaining control over their learning experience, including the ability to dictate the direction of their inquiries[30]. In the intricate clinical milieu of psychiatric units, a critical yet often overlooked aspect before addressing the reduction of RPs is the necessity to examine the specific causes of which RPs occur within a particular healthcare setting during a given period. These causes may include subjective decisions by inadequately trained staff, urgent interventions following an acute violent act after thorough risk assessments, or the resort to RPs due to a lack of de-escalation or alternative approaches. Blending RPs stemming from various sources for intervention effectiveness statistics may lack scientific rigor and the ability to be replicated in real-world scenarios. Moreover, a secure treatment environment is an essential need for every patient in a psychiatric ward, and it is imperative to avoid a swing from an extreme over-reliance on RPs to the opposite extreme of diminishing RPs altogether, which could result in an overcorrection.

This understanding can guide the development of targeted interventions that are more likely to be effective and replicable across different settings. For example, if RPs result from healthcare providers' overreaction to certain behaviors, interventions could concentrate on improving alternative techniques and communication skills through training. If RPs stem from inadequate staffing or resource allocation, strategies could be designed to enhance staffing levels and resource management[31].

When integrating new technological approaches, such as digital mental health care and VR technology, into training methods, it is essential to consider how they will complement and integrate with traditional training modalities and other emerging technologies. A potential limitation of psychiatric VR training, its focus on short-term outcomes, underscores the need for ongoing observation of the long-term effectiveness and sustainability of VR training programs[8,32]. Incorporating AI for adaptive learning and collecting longitudinal data can be particularly beneficial[33]. By leveraging AI for adaptive learning, VR training can become more personalized and responsive to individual trainees' needs, potentially enhancing its long-term impact[34]. Moreover, collecting longitudinal data allows for monitoring and evaluating VR training's sustained effects over time. This data-driven approach not only aids in refining training modules but also provides a mechanism for ensuring VR technology's ongoing relevance and efficacy in psychiatric care. By integrating VR training with AI and longitudinal data collection, healthcare managers and staff can better understand and enhance the long-term impact of VR training in reducing RPs, thereby improving the overall quality of care in psychiatric settings.

CONCLUSION

Given ethical considerations, patient needs, and the ongoing refinement of healthcare management, reducing unnecessary RPs is an inevitable trend in psychiatry. Implementing VR training in psychiatric institutions to diminish RPs represents an innovative strategy with promising potential; however, it must be accompanied by ongoing evaluation and monitoring to ensure its real-world outcomes. Although the previous study has limitations, it provides valuable insights into the feasibility and potential benefits of VR training in this context. To avoid VR training merely being a "new bottle for old wine", strategies including focusing on individual patient needs, further optimizing the quality of module design within VR, and continuously exploring integrating AI for adaptive learning to enhance the long-term effectiveness of the training may all be beneficial.