Journal of Medical Systems (2020) 44 : 94

https://doi.org/10.1007/s10916-020-01550-5

EDUCATION & TRAINING

VR4Health: Personalized teaching and learning anatomy using VR

M. Fairén1 · J. Moyés1 · E. Insa2

Received: 6 January 2020 / Accepted: 18 February 2020 / Published online: 19 March 2020
© The Author(s) 2020

Abstract
Virtual Reality (VR) is being integrated into many different areas of our lives, from industrial engineering to video-games,
and also including teaching and education. We have several examples where VR has been used to engage students and
facilitate their 3D spatial understanding, but can VR help also teachers? What are the benefits teachers can obtain on using
VR applications? In this paper we present an application (VR4Health) designed to allow students to directly inspect 3D
models of several human organs by using Virtual Reality systems. The application is designed to be used in an HMD device
autonomously as a self-learning tool and also reports information to teachers in order that he/she becomes aware of what the
students do and can redirect his/her work to the concrete necessities of the student. We evaluate both the students’ and the
teachers’ perception by doing an experiment and asking them to fill-in a questionnaire at the end of the experiment.

Keywords Virtual reality · Self-learning · Health sciences · Nursing

Introduction allows the teacher to monitor and guide the learning process
of the student.
Teaching human anatomy by using only 2D images has Self-learning is the way of learning that is equipping
been always complicated. Advanced technologies have been people with relevant skills for their daily activities.
the clue to clarify all the 3D anatomy structures by using Although this requires lots of discipline, it has some proven
directly 3D models to interact with (www.visiblebody.com; advantages:
www.anatomylearning.com). This is even more useful when
the student can use Virtual Reality (VR) systems to explore – Developing problem solving skills
and see what the teacher has explained in class. – Stress-free learning process
Following the good experience we had with an anatomy – Learning experience becomes more meaningful
teaching activity carried out with nursing students in – Learning is led by curiosity
Campus Docent Sant Joan de Déu [5], we now present a – Choose your mode of learning
new application, VR4Health, to be a self-learning tool that
By allowing VR4Health to be also a teaching facilitator
tool we want to avoid some problems when student is
This article is part of the Topical Collection on Education & completely alone in self-learning:
Training
– The complete freedom of the student to learn, because
 E. Insa this requires much discipline and auto-control.
[email protected]
– The missing guidance and help from teacher to student,
M. Fairén that is required by many students (see results in
[email protected] Section “Evaluation and results”).
J. Moyés The paper is structured as follows: Section “Related
[email protected] work” reviews some related work, Section “VR4Health, the
project” explains the VR4Health project, Section “Experiment
1 ViRVIG Group, Universitat Politècnica de Catalunya, design” describes the experiment for the user study whose
Barcelona, Spain results are exposed in Section “Evaluation and results”, and
2 GIEES Group, Campus Docent Sant Joan de Déu-Fundació finally we conclude in Section “Conclusions”.
privada, Barcelona, Spain
94 Page 2 of 11 Journal of Medical Systems (2020) 44 : 94

Related work the traditional class which is guided and dominated by

the curriculum and the evaluation tests. In this sense,
Virtual Reality has been present in the educational field the evaluation of self-learning activities need to be
for more than half a century but its adoption is not yet different from those traditional. Alternatives to conventional
extensive. The use of virtual reality learning environments examinations are required and they need allow to evaluate
(VRLEs) (see [1, 4, 15]) and the technologies related the motivation, the level of interest and the participation in
to them has grown in recent years due to their benefits communities of learning combined with techniques for the
compared to classical education, the educational and longitudinal long term evaluation (see [7]).
education opportunities they offer [17] and the ability Applied to nursing students, schools and universities
to change the social dynamics of learning environments must have the right tools to measure the self-directed
through transformed social interaction (see [2]). learning (SDL) abilities. Cheng, Kuo, Lin and Lee-
Thus, we see the use of VR in different areas of Hsieh [20], for example, developed an instrument to
the educational field, being the medical one of the most measure the SDL abilities of nursing students and test
developed. We can emphasize: a) training of medical or the validity and reliability of the instrument. On the
surgical procedures [3, 13, 14, 16, 18, 21], and b) learning other hand, technological development can be exploited to
and understanding of anatomomorphological aspects of generate tools that promote lifelong learning while attaining
difficult visualization or access [6, 22]. In both cases, the specific learning objectives. Applied to the field of VR,
aim is to improve professional competence and ultimately the development of technology and VR applications is
reduce human errors in professional practice. presented as an opportunity to cover both objectives.
Nevertheless, technology costs and logistics constitute An example of self-learning VR application is
some of the limitations of their use (see [11]) that teachers the Human Anatomy VR tool from Virtual Medicine
and education institutions have to deal with. In this sense, (http:www.medicinevirtual.com) which allows the student
what is interesting is to ask what do teachers expect to to visualize and interact in 3D with a set of human anatom-
win with the use of VR in their classes and what are their ical structures and also offers the student the possibility of
motivations [19]. doing a self-evaluation by using quizzes. This tool does not
One of the reasons why most teachers use VR, as involve the teacher in the learning and therefore does not
specified by Kavanagh et al. [11], is to increase the allow tracking of student process. It is difficult to monitor
motivation of students. In this case, they justify their the student discipline and recover the motivation when is
use, referring to factors such as constructivist pedagogy, lost.
collaboration and gamification in the design of experiences. The tool presented in this paper is also usable as a self-
Keskitalo [12] focuses the attention on the pedagogical learning tool by allowing the visualization and interaction
use of VR in education and training based on simulation. in 3D with a set of human anatomical structures but without
He shows that teachers have different conceptions about including quizzes to do a self-evaluation. Our application is
learning. They find that pedagogical models are not thought as a training tool where the teacher is able to follow
consistent or not well defined. Hence the concern to specify the learning process and to give feedback to the student. Our
and develop a pedagogical model for the use of VR. tool allows the teacher to obtain data on motivation, level of
The effectiveness of VR in learning is another topic of interest and possible problems, or at least, promotes that the
debate among teachers. Some experiences of the usage of teacher formulates these questions later to the student at the
VR for the learning of human anatomy and physiology have time of feedback.
shown that students consider VR as a useful tool and that it
can facilitate their study and comprehension. Fairén et al. [5]
and Yildrim [23] coincide in considering experience and VR4Health, the project
interaction as key elements on the learning process. Games,
for instance, are seen to be preferred in front of images or VR4Health was inspired by the anatomy teaching activity
video, due to the sense of reality that they offer and the carried out with nursing students from Campus Docent Sant
capacity to interact with the environment. Joan de Déu [5]. Students attended to a seminar in the
In self-learning the centrality of learning lies with the Barcelona VR Center (UPC) where they may experiment
individual (see [9]). In it, students should be independent with 3D models of several anatomical organs by using
and learn what they are supposed to learn meanwhile two different VR systems, a powerwall and a CAVE. Each
teachers has to guide them and provide them with abilities VR session is given to a small group of 15-20 students
and support so they can become self-directed and become divided in two subgroups and directed by two assistant
responsible adults for acquire competencies [10]. So self- teachers who adopt the role of learning facilitator while the
learning, supporting lifelong learning, is different from students are interacting with the models. This activity is
Journal of Medical Systems (2020) 44 : 94 Page 3 of 11 94

being done every course since 2014 and is really appreciated making them be the same movements into the virtual world.
by students and teachers. The application also allows the user to cut models through
Following the good reception of this activity and taking a plane in order to see slices of the model.
into account that the new HMD devices appeared in recent Apart from the labeling included in all models, each
years have an affordable price for the consumer, we decided one of them has been also improved with some other
to adapt the application to be used in an HMD device and particular visual information. In Table 1 we describe these
we extended it to be used autonomously as a self-learning characteristics for each one.
tool. VR4Health (the new application) also includes several The application includes at the moment these seven 3D
facilitator mechanisms in order that the teacher can modify anatomical models but it is completely scalable so it allows
and adapt the teaching activities to the student necessities. to add any other anatomical model or substitute one of
them. Teachers can suggest any modification of models or
The self-learning tool animations although they need to be done by a technician.

VR4Health is designed to be used in an HMD device. This Teacher helping mechanisms

implies a necessary isolation of the user because he/she
is completely immersed into the VR world and does not The student can inspect all the structures he/she wants and at
have any contact to the real world around him/her. The the same time the application is registering what the student
application is directed to an individual use in order to be is doing during his/her inspection in order to help the teacher
a self-learning tool that the student can use everywhere. In to facilitate the learning flow.
this sense, the different virtual models shown in VR4Health The information the application registers is: What
are completely labeled with all parts and sub-parts easily structures the student inspected, How long the student
identifiable by the student (see Fig. 1). These labels dedicated to each structure and How many times each label
were decided taking into account the student necessities into each structure has been required.
identified by teachers. The VR application has also visual With all this information captured by the application
and sound feedback in order that the user knows that he is during the students inspection, the teacher can evaluate
interacting with it. It also includes multi-language capacity different aspects about the student’s learning:
(at the moment 3 languages available: Catalan, Spanish and
English) that allows to easily configure any other language – What structures inspected: With this information the
by only writing the correct names into a configuring file. teacher knows what the student is visualizing and can
The application starts with a virtual world that visualizes, direct him/her to a more guided session if needed. This
onto a 3D wall, a menu showing all the possible anatomical information is also useful to know at any time what
structures to visit. In this step, the user can select which each student has worked through and the teacher can
structure to visit and the virtual world changes to become ask about it.
the chosen anatomical structure which is scaled to be – Time dedicated to each structure: This gives infor-
big enough to be visited and inspected in detail by the mation about the time each student devotes to each
user. For this inspection we use VR implicit interaction by structure and whether there is any structure that has not
recognizing the movements of the users in the real world and been seen or has not been seen with enough time. The
Fig. 1 Example of two labeled
models: a Heart. b Brain
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Table 1 Description of models and their animations

Heart Colored arrows indicating the direction and kind of blood. Animated
(by 3dregenerator) blue or red pills flowing through it. Vertical section view.
Eye (by Alef itd) Animation separating the layers showing all the different parts.
Ear (by Imagework) Colored different sections. Animation simulating sound into the ear.
Circulatory system Visualization of arteries and veins. Semitransparent view of skin and
(by dugongmodels) bones.
Digestive system Adding liver, pancreas and gallbladder. Animation showing the
(by 3d moliere and Activepoly) exocrine and endocrine secretion and the pancreatic circulation.
Lungs Animation and a zoomed vision of an alveol. Colored blue and red
(by scyrus) arrows simulating blood. Animation simulating the air into the lungs.
Brain Possible division in colored parts. Show separately ventricular system,
(by leo3Dmodels) basal ganglia and nervous system.

time devoted to the learning of each structure is impor- advantages teachers can have by using the information that
tant for the teacher because it encourages him to ask the application gets from the student’s participation.
himself why and to ask the student the reason (greater
difficulty in learning, greater interest...). Sample and participants
– How many times each label has been required: The
option knowing how many times the student needed to The participants in the experiment was established with 6
see a label with the name of the structure of substructure teachers of human anatomy and 18 students enrolled in
gives to the teacher idea of the previous knowledge subjects of anatomy and human physiology. The students
of the student. The excess of consultancy or the never were from two different degrees in health sciences, both
consultancy of a label can alert to the teacher and taught at the same institution and where the contents of
push him/her to ask to the student for the reason (no human anatomy are contemplated in both cases in the first
motivation, lack of study, ...). year of training.
The inclusion criteria of students was to be enrolled in
All this information stored by the application can give the subject of human anatomy. As criteria of exclusion,
also an overall view to the teacher in order to know whether those students repeating the subject or having completed an
the student needs a bit more help on this learning or not, or education with human anatomy contents.
if there is any structure shown in the application that should The inclusion criteria of teachers was to teach human
be better explained in some sense. anatomy at the Campus Docent Sant Joan de Déu.
The experiment was done between December 2018
Experiment design and February 2019. First contact with the participants
was made in December. The rest of the participants
The experiment was designed to analyze the goodness were achieved through the snowball strategy. Once the
and/or difficulties found by the students in the use of the researcher came into contact with the future participant, he
VR4Health project for the autonomous learning and the checked the eligibility to participate and the information and

Table 2 Questions for categories 1 and 2

Category 1. Ease of use:

Q1.1 The use of a Head Mounted Display (HMD) has been comfortable?
Q1.2 The use of the VIVE hand controller has been easy?
Q1.3 The navigation through the structures menu has been intuitive?

Category 2. Self-learning usage:

Q2.1 By using VR, do you understand better the anatomical structures?
Q2.2 By using VR, do you understand better the relative position of the different structures in the body?
Q2.3 By using VR, have you been more motivated than using traditional study?
Q2.4 The anatomical models you have inspect in VR4Health are a good support material for the human anatomy course?
Q2.5 Would you use VR4Health as a support material for your classes?
Journal of Medical Systems (2020) 44 : 94 Page 5 of 11 94

Table 3 Questions for category 3

Category 3. Teacher helping usage:

Q3.1 - How do you prefer to use VR4Health? (2 max. answers ordered)
1) Individually with teacher support online
2) Individually without teacher support online
3) In group of students with teacher support online
4) In group of students without teacher support online
5) Individually with teacher support presentially
6) In group of students with teacher support presentially

Q3.2 - With respect to the time of use, do you prefer an open time (no limit) or having a time limit proposed by the teacher? Why?
1) Without limits
2) With limits
3) Both options

Q3.3 - Do you prefer a predefined and guided inspection through the anatomical structure or do you prefer the student freely deciding it?
1) Defined
2) Free
3) Mixed

Q3.4 - Do you find useful that the teacher receive information about the inspection the student has done through the anatomical structures
(what structures visited, how long for each one, etc...) in order to know the learning necessities of the student?
Q3.5 - Do you find useful that teachers give feedback to the student from the data analysis of the information obtained through the application?
Q3.6 - How do you think this feedback should be given to the student? (2 max. answers ordered)
1) Through e-mail
2) Through the application
3) Through moodle or a similar teaching application
4) Presentially
5) Through Skype or facetime
6) Individually
7) Collectively

Q3.7 - When do you think feedback should be done? (2 max. answers ordered)
1) During the use of the application
2) Immediately after using the application
3) During the same day of using the application (24h)
4) During the week of using the application
5) While implementing the course (semester)
6) Other:

confidentiality document was delivered to him. With the During the test no feedback was given to the participant
help of a technician the test was conducted individually and in order not to condition the action of the participant. The
had a maximum duration of one hour. participant had total freedom of decision over which models

Table 4 Results of questions in Category (1) (Q1.1, Q1.2 and Q1.3)

Q1.1 Students Teachers Q1.2 Students Teachers Q1.3 Students Teachers

4 1 (5.6%) 4 1 (5.6%) 1 (16.7%) 4

5 9 (50%) 3 (50%) 5 4 (22.2%) 5 6 (33.3%) 3 (50%)
6 8 (44.4%) 3 (50%) 6 13 (72.2%) 5 (83.3%) 6 12 (66.7%) 3 (50%)
94 Page 6 of 11 Journal of Medical Systems (2020) 44 : 94

to inspect, what to visualize in them and how much time helping usage. The questionnaire had 8 closed questions
to devote to them based on their interests, concerns of in which the student had to indicate the degree of
knowledge or exploration. agreement or disagreement with a score of 1 to 6 (1 =
At the end of the test a questionnaire was delivered to completely disagree, 6 completely agree). It has also 7
the participant and we previously explained the purpose and open questions in order to value the preferences on the
length of the questionnaire as well as the authorship. teacher helping (category 3).
– Application data, which includes data on measure the
Ethical considerations time each user spent in any structure and data on how
many times the substructure label has been visited or
Given the nature of the study, it was not necessary required. This information is captured automatically by
to approve the ethics committee. Information document the application for the teacher helping mechanism (see
and informed consent were signed before testing the Section “Teacher helping mechanisms”) and it is also
application. Participants were reinformed on anonymity and giving us results about which structures are more visited
confidentiality as well as warned that no personal data by the users.
would be collected, the data was stored in a safe place.
Participants were informed about the benefits and possible Questionnaire
damages and that the withdrawal of the project would not
affect their attention, relationship or their grades in the case Questions asked to the user organized in the 3 categories are
of students. presented in Tables 2 and 3.

Validity and reliability Results from questionnaire

The written questionnaire was specifically developed for the (1) Ease of use:
presented experiment by the researchers, taking into account The answers to the 3 questions in this category are
the previous knowledge, skills and abilities of the students. all in the range [4:6] so Table 4 are only showing those
Once the draft questionnaire was finished, it was reviewed 3 values.
by a nurse with experience in the design of learning spaces From the answers we can say the users felt
and the nursing curriculum and two technologists, an expert comfortables with the VR system proposed and also
in programming VR applications and systems and the other with the user interface that they found very intuitive.
expert in research in VR. (2) Self-learning usage:
To obtain consistency of the questionnaire it was In this category we can say that the general opinion
reviewed by 3 students of the first year, with 4 questions that of students and teachers is that the use of VR helps on
were modified following the suggestions of the students. the understanding of the 3D shapes of the anatomical
structures and also on the relative position each one
has into the human body (see Table 5).
Evaluation and results The users also consider that using VR is more
motivating and they would use the application as a
The evaluation is composed by two different parts: support material for the human anatomy course.
(3) Teacher helping usage:
– The questionnaire, which includes data on 3 categories: In the third category we have grouped the 7
(1) Ease of use, (2) Self-learning usage and (3) Teacher questions in 3 groups: How to use the application,

Table 5 Results of questions in Category (2)

Q2.1 Students Teachers Q2.2 Students Teachers Q2.3 Students Teachers

4 2 (11.1%) 4 4 1 (5.6%)
5 1 (5.6%) 5 6 (33.3%) 1 (16.7%) 5 3 (16.7%) 1 (16.7%)
6 15 (83.3%) 6 (100%) 6 12 (66.7%) 5 (83.3%) 6 14 (77.8%) 5 (83.3%)

Q2.4 Students Teachers Q2.5 Students Teachers

4 4
5 2 (11.1%) 5 3 (16.7%)
6 16 (88.9%) 6 (100%) 6 15 (83.3%) 6 (100%)
Journal of Medical Systems (2020) 44 : 94 Page 7 of 11 94

Table 6 Results of questions Q3.4 and Q3.5

Q3.4 Students Teachers Q3.5 Students Teachers

Yes 16 (88.9%) 6 (100%) Yes 16 (88.9%) 6 (100%)

No 2 (11.1%) No 2 (11.1%)

Obtaining feedback and How and when to obtain with the teacher present in order to obtain
feedback. support presentially. Teachers, however, prefer
group sessions but giving either presentially or
– How to use the application: on-line support.
From the answers given to questions Q3.1, Students also prefer to have unlimited time to
Q3.2 and Q3.3 (Fig. 2) we can say the students use the application, while teachers prefer to force
prefer to use the application individually and a limited time of usage.

Fig. 2 Answers to questions: a Q3.1. b Q3.2. c Q3.3

94 Page 8 of 11 Journal of Medical Systems (2020) 44 : 94

Fig. 3 Answers to questions: a Q3.6. b Q3.7

Both students and teachers prefer to use the feedback to the student and help him/her with the
application freely instead of a guided use or, at material inspected (see Table 6).
maximum, be guided only in a part of the usage. – How and when to obtain feedback:
– Obtaining feedback: With respect to the question of how to obtain
Both, students and teachers, agree on the this feedback (Q3.6), both students and teachers
importance of getting information from the consider it should be given presentially and
application in order that the teacher can give individually (see Fig. 3a). Surprisingly, some

Fig. 4 Time spent by the user in each structure. Green bars: total time spent in the structure. Yellow bars: time with respect to the number of
substructures
Journal of Medical Systems (2020) 44 : 94 Page 9 of 11 94

Table 7 Number of labels existing in each anatomical structure among the different anatomical structures. However they
have some differences regarding on how to use the
Structure Tag names
application.
Eye 20 A first difference is that being a tool designed to favor
Circulatory 112 self-learning, students prefer the presence of the teacher
Brain 59 to obtain support in the learning process and in a face-
Lungs 63 to-face way in front to other options (virtuality, mailing,
Digestive 30 teleconferencing, etc.). This suggests that students prefer a
Heart 14 mixed training program and a tool that promotes blended-
Ear 16 learning instead of self-learning. This result coincides with
the study of ECAR [8].
A second difference is that students prefer to use the
teachers also prefer the possibility of giving application individually while the teachers prefer it in a
feedback through the application or other teaching group manner. This is attributed to the students desire of
application (like moodle) but these are not options autonomy and centrality in the learning while the professors
preferred by the students (only one student on each prioritize the collaborative learning by the benefits of
option 1, 2 or 3). sharing knowledge and experience, although respecting the
Students prefer to get the feedback during the individuality and the centrality at the time of providing
use of the application (Q3.7 in Fig. 3b) while feedback. In spite of the divergence of preferences, the
teachers clearly opt to give it immediately after the tool responds to the wishes of both groups at once, giving
use of the application and none of them choose to full student leadership in their learning and needs, and
do it during the use of it (option 1). providing individual student information to the teacher so
that he can build the feedback and ask the student about his
Results from application data (usage results) commitment and behavior during the training time.
The last difference encountered refers to the moment of
Following the information obtained for the teacher helping giving feedback, students prefer to have feedback already
usage we can also study the time each user has spent in any during the use of the application while teachers prefer to
of the anatomical structures available in the application (see do it immediately at the end of the student’s session. Since
Fig. 4). the application is directed to self-learning the requirement
From this data we can see that taking into account coming from the students is not possible. In case of other
the total time spent in a structure (green bars in Fig. 4) learning methodologies the students appreciations should be
the Circulatory system has been the most inspected. taken into account.
But this total time is not fair because the number of The experiment has also shown that technological
labeled substructures existing in any anatomical structure development in VR allowed the design and development
is different, so we should take into account the time spent of a tool that fits in the learning paradigms promoted to
with respect to the amount of substructures existing in the the present (self-learning and blended learning), but it must
anatomical organ (see Table 7). Taking this measure into be pointed out the existence of certain limitations that may
account (yellow bars in the figure) we can observe the affect the results. The first is that not all participants took
Heart is the most inspected organ so we can say the most the pilot test on the same day. The existence of an anatomy
interesting for the users (both, students and teachers). exam next to one of the days of testing may have introduced
By being asked about what part of the application they modifications regarding the time of visualization of certain
found more interesting, users said they appreciate a lot the models and the access to some labels by the participants
animations offered into the different anatomical structures, of that day. The second is that the students participating
like blood flowing inside the heart, air coming into the lungs in the experiment come from two different degrees but no
or the movement of the different parts in the ear system results have been compared and the different methodology
when it simulates sound coming in. used in each degree to teach and learn anatomy may have
conditioned the student’s motivation during the use of the
application.
Conclusions We can conclude that VR4Health is a tool that is
perceived by users as an easy-to-use tool for self-learning
The results presented show that for students and teachers of human anatomy and physiology and that covers the need
VR4Health is a self-learning tool that facilitates the for learning support manifested so for students as well as for
understanding regarding the volume and the relationship teachers. In addition, the tool facilitates the change in the
94 Page 10 of 11 Journal of Medical Systems (2020) 44 : 94

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