Designing virtual natural environments for older adults in residential care facilities

1.1 Concepts and features in VR technology

Today, virtual environments (VE) are commonly created with the help of real time 3D graphics, i.e., computer game technology, or with 360-degree video footage that has been captured with an omnidirectional camera. Presence is a central concept in the VR theory, and describes a viewer’s perceptual illusion of “being there” [16]. Viewing VEs through immersive technology such a head mounted display (HMD) provides a higher sense of presence compared to viewing VEs by using non-immersive technology such as a single TV or computer screen [16, 17, 18]. Another key element helping to create the feeling of presence is the sense of agency, which can be defined as the viewer’s sense that they are the one causing an action [19] by, e.g., actively deciding what to look at and do, rather than passively watching a predetermined set of events. Thus, interactive VR has the potential to provide a higher sense of presence than non-interactive VR (for in-depth discussion about immersive VR see [20]).

1.2 Previous use of VR in therapeutics

Previous studies have suggested that use of VR may, in certain conditions, be an effective and safe alternative method of treating and preventing both mental and physiological health problems [15]. Interventions including use of VR technology in medical care has for example, been tested in rehabilitation of neurological disorders and stroke [21], in cognitive rehabilitation, addressing gait and cognitive deficits after brain injury [22, 23]; and in treatment of psychiatric disorders such as post-traumatic stress disorder, anxiety disorders, phobias and pain management [23, 24]. Research also cautiously encourage the use of VR technology in treatment of certain health problems frequenting among the elderly population. For example, a systematic review concluded that VR games can have positive effects on balance and fear of falling in community-dwelling older adults [25]. Another study indicated an increased positive attitude towards the use of immersive (HMD-based) VR technology, without any associated cybersickness by older adults after first use [26].

Thus, according to previous findings, it is possible that exposure to natural environments through immersive VR is a feasible way to overcome difficulties with accessing in-vivo natural environments among the elderly. The use of VNEs has been suggested as a means to increase mental well-being in older adults who experience reduced mobility [15, 14].

However, before the use of VNEs can be considered by residents of a care facility, they first need to acquire a certain level of knowledge about what VR is. Since VR essentially is a medium that speaks to the senses, it must be sensed to be understood. And just as any other experience, VR is perceived differently among different individuals [27]. Therefore, the experience of VR, cannot be fully conveyed through words or other media and must be obtained first-hand to be understood. Currently, more immersive HMDs such as the HTC Vive, compared to less immersive ones such as the Oculus Go, may appear bulky, uncomfortable and intrusive and may therefore deter from future use in individuals with cautious disposition. Furthermore, using highly immersive VR may be perceived as quite intense, potentially overwhelming at first experience. Thus, it is possible that frail individuals that tire easily, may find such experiences off-putting from future use. Using a less immersive HMD at first introduction of VR for older adults at residential care facilities, may therefore be preferable.

1.3 Use of VR natural environments in the elderly population

There are several previous examples of studies that have involved viewings of natural environments by VR technology for various therapeutic purposes including: improving muscle strength and balance [28]; improving cognitive function [28, 29]; reducing anxiety and agitation [30], and improving engagement, apathy, and mood states [31] in people with dementia; and improving motivation to exercise and mental wellbeing [32]. A recent study explored the acceptability of VNEs for people with memory loss at memory cafes [33]. Some of these studies have involved activities like kayaking [28], bicycling [29, 32], or interacting with objects present in the VE through hand and arm movements [31]. However, a rather small number of the previous studies have regarded the potential therapeutic effects of exposure to natural environments. Furthermore, in the majority of the above mentioned studies the VR technology used is non-HMD and single screen-based [28, 30, 31], and/or non-interactive [28, 30].

An exception from this trend is, however, the study published by Bruun-Pedersen et al. [32], which investigated the potential of increasing motivation to exercise in residents of elderly care facilities, by exposing them to virtual bike rides in VNEs. Bruun-Pedersen et al. based the design of their VNEs on a combination of knowledge derived from previous non-VR-related sources reviewing restorative aspects of natural environments and experiences from tourism and recreational design, as well as from VR-specific sources including examples from the areas of urban design and urban planning in VR, and spatial recognition for navigation in VNEs.

In the present study we used a different approach to Bruun-Pedersen et al. by involving the end-users in the process to design the VNE. We based our approach on the following arguments. VR provides a perceptual but not cognitive illusion of being in an different reality [16], i.e., it feels real, but the users are aware that it is an illusion. Therefore, when a user perceives an artifact in VR, the VR medium itself is likely to be on the user’s mind; for example, the artifact may be viewed in light of the VR system’s capability to produce an illusion of it. Thus, the VR medium is an essential part of the context in which the artifact is perceived. Since a user’s perceived meaning of an artifact is dependent on the context in which it resides [27], and VR by definition is fundamentally different from actual reality, a user’s perceived meaning of natural environments in a VR context is likely to be essentially different to the same user’s perceived meaning of real natural environments. Therefore, knowledge of restorative natural environments such as the works by Kaplan [34] or Bengtsson and Grahn [35] may not be valid for, and/or transferrable to, VNEs. Furthermore, inspired by Krippendorff and Butter [27], we do not believe one can design VNEs with inherent meanings. Users find their own meanings in artifacts through using them and communicating about them with others. Thus, a designer of VNEs can only, based on their understanding of the users’ perceptions, attempt to provide the means for users to find meaning in VNEs. Therefore, in order to design VNEs that are meaningful for users, we believe it is necessary to invite the participation of users into the design process.

1.4 VR Island

In accordance with above presented reasoning, authors of the present study have previously carried out the first iteration of a design process in which elderly users participated (Lundstedt R, Persson J, Håkansson C, Frennert S, Wallergård M, unpublished data). By observing the participants’ actions while using a VNE prototype, and by listening to their articulated thoughts, suggestions and preferences, we acquired an understanding of their perceived meanings of the prototype, which informed our design decisions as the development proceeded. This process led to the creation of a VNE, which was named “VR Island”. VR Island is designed in a way that gives the viewer ability to freely explore, and to some extent, manipulate the environment; or, if they so choose, idly observe the scenery. Further, by including a separate TV-screen showing a third-person view of the HMD-wearing viewer’s avatar in the VNE, VR Island allows a group of by-standing residents to be somewhat co-present in the VNE and thus engage in social interaction with each other and the current viewer. According to a recent publication reviewing indoor nature interventions in the residential care setting [36], the interventions that entailed some active involvement were more likely to exert beneficial health effects than passive exposure only. Further, the authors of the review recommended that for added benefits, future indoor nature interventions should provide social stimuli such as shared/group experiences, skill development and decision making. VR Island is described further in Section 2.3.3.

Our previous work with the development of VR Island (Lundstedt R, Persson J, Håkansson C, Frennert S, Wallergård M, unpublished data) was carried out in a laboratory environment and only included elderly study participants in good condition who were able to, without assistance, transport themselves to the lab. Thus, immobile elderly individuals in frail condition were excluded from the study, which is unfortunate as this group is the one that is most likely to experience a shortage in exposure to natural environments and may thus benefit the most from a VR intervention. Also, as stated above, a user’s perceived meaning of an artifact is dependent on the context [27], e.g., laboratory environment versus residential care facility. These conditions were deemed acceptable, when the trade-off between authenticity and operability were considered, for the purpose of producing a prototype to serve as a starting point for coming iterations. Furthermore, the resident wearing the HMD is not the only stakeholder. An artifact such as a VNE at a residential care facility is the concern of a network of different stakeholders, e.g., residents, assistants, activity workers, nurses, next of kin of residents, caretakers, administrators, purchasers, sanitary technicians and property managers. Stakeholders form and coordinate, in communication with each other, their meanings of an artifact based on their individual perspectives [27]. Therefore, the purpose of the present study was to acquire an understanding of how residents and staff at a residential care facility may use and experience different virtual natural environments, and thus aid the design of virtual natural environments.

2.1 Participants

We contacted an administration for elderly care facilities in a southern Swedish municipality. This particular municipality was chosen because of the relatively diverse socioeconomic background among its population. The administration expressed interest to participate in the study and conveyed contact with one of their residential care facilities with a suitable residential profile.

Our initial plan was to create two groups of participants, each consisting of four to six residents (group A and B). According to our exclusion criteria a person that was bedridden, suffered from severe dementia, or prone to motion sickness, was not suitable to partake. In addition, we only accepted participants that could speak and understand Swedish, had sufficient eyesight to watch television, sufficient cognitive ability to perceive the VNE and to answer questions about their experience, and were generally fit enough to be able to handle and potentially benefit from the VR experiences. In the selection of study participants, we relied on the help from the care home staff, since they were familiar with the inhabitants, their abilities and health status. The residents who were suitable to partake in the study first received brief information about the study including general information about what VR is, what participating in the study entails in practice, and potential risks of participating. Individuals who stated their interest to participate then received further information including the purpose of the study and the participants’ rights regarding confidentiality and voluntarism. Persons who remained interested in partaking were thereafter asked to sign their written informed consent.

2.2 Study procedure

In order to create a familiar and comfortable situation for the residents, we based our VR test sessions on a traditional social activity in Sweden – having coffee. In practice, this meant that we sat down, drank coffee and ate pastries together with the participants as we invited them to experience VNEs through the VR devices we had brought. At least one member of the staff partook in the sessions, assisting the residents when necessary. Each VR coffee session lasted approximately one hour during which each participant spent between 5 and 20 minutes immersed in VR, wearing an HMD.

During a two-week period in the spring of 2019, Group A participated in two VR coffee sessions per week resulting in four sessions in total (see Fig. 1). In order to achieve a, for the participants, manageable progression towards advanced VR use, we introduced VNEs in ascending order in terms of levels of immersion and interactivity (see Section 2.3). After our final session with group A, we paused the study for three weeks before performing the same sequence of sessions with group B. The reason for the break was to allow us to, based on what we had learned from the VR coffee sessions with group A, make changes to our test procedure and VNE design before the VR coffee sessions with group B began.

OPEN IN VIEWER

In addition to VR Island, we included two other VNEs to our study (see detailed descriptions below). This would later allow us to combine traits of the different VNEs that appeared to be important for a positive viewer experience in future versions of VR Island. The participants used three types of headsets each paired with their own specific audiovisual VR content. These specific content-device combinations were: a) 360 ∘ blue space videos – 360 ∘ videos of coastal environments [33], viewed on Oculus Go headsets; b) theBlu – a series of interactive under water environments rendered using real time 3D graphics (Wevr, USA), viewed on a Samsung Odyssey headset; and c) VR Island – an interactive explorable island featuring various types of natural environments rendered using real time 3D graphics, viewed on an a HTC Vive headset. With all three HMDs, a pair of brand-specific cableless handheld controllers were included for user interaction.

During the VR coffee sessions, we took notes of observations of the residents’ reactions as expressed through oral communication, and verbal and bodily expressions. We also noted our observations of the usability of the VNEs and the situation in general. After each VR coffee session, each participating resident was, separately from the group, asked a series of open-ended questions by a staff member about their experience. After the final VR session, we interviewed two of the staff members who had been the most frequently involved in the VR sessions regarding their views of the usefulness of such VR sessions at residential care facilities and their general impressions. The interview was audio-recorded and later transcribed. The staff were also asked to respond to questionnaires regarding the participating residents’ gender, age, number of years residing at the facility, and diagnose/reason for taking residence at the facility.

2.5 Analysis method

To allow for methodological triangulation [39], the unit of analysis comprised of our notes of observations, the answers to the open-ended questions by the participants, and the interview with the staff. The first author (RL) transcribed the audio recording of the interview with the staff. All documents were shared with all members of the research team. We analyzed the data through an inductive qualitative method inspired by Graneheim and Lundman [40].

We read through the above mentioned documents several times to get an understanding of the content as a whole. Using NVivo, the first author broke down the text into meaning bearing units. The units were grouped, whereon categories and subcategories (types of reactions, impressions, ideas, opinions and other expressions) emerged through reflection on their meaning. During the analysis, the authors made comparisons with the original texts and discussed the analysis. In an iterative manner, the team went back and forth several times between the first author revising the analysis in NVivo and the whole team meeting and reflecting in group until the team had reached an agreement on the analysis.

3.1 Emotional reactions

The participating residents expressed emotions during the VR coffee sessions: a) spontaneously, while immersed in a VNE wearing the HMD; b) in conversion with other study participants, staff and researchers while standing by, observing others exploring VNEs; and c) in interviews after sessions. In addition, some expressions of emotional reactions by participating residents were noted by staff in between sessions, and were reported to us regularly. The number of observed emotional reactions was the highest for theBlu, slightly lower for VR Island and noticeably lower for the 360 ∘ videos.

3.2 Expressions of interest

During the VR coffee sessions, residents showed both positive and negative interest in VNEs. The number of observations of positive expressions of interest outweighed the negative ones. Positive expressions of interest include comments by participants where it is unclear whether these were actually connected to using the VNEs or if they were uttered in regard to something else, e.g., interest to participate in the VR coffee sessions for the sake of the social interaction, or general curiosity about VR technology. However, the majority of positive expressions of interest were clearly associated to the interest of using the VNEs, or even interest in viewing specific content in the VNEs.

3.3 Usability matters

During the VR coffee sessions and the interview with the staff, we made several observations of usability matters. Some regarded the comfort of the HMDs where the Oculus Go HMD was considered flexible and smooth, being cable-less and lightweight. Also, there were observations of the HTC Vive HMD being experienced as heavy, slightly painful on the face and/or unstable, sliding down.

3.4 Perceived usefulness

Based on the staff’s observations of positive development cases among the participants during the study, including reduced need for on-demand medication, they projected that VNEs could be useful for reducing anxiety. Further, the staff reasoned that VNEs may reduce the use of on-demand medication, and thus both increase health in residents and reduce costs of residential care. In addition, they speculated that VR could help patients with neurological conditions, sorrow, fear of death and/or worry for survivors to temporarily escape from their troubles through occupying their thoughts with something else. Other uses of VNEs projected by the staff was as a complementary alternative for residents who cannot go outside as much as they would like, and that VR may incite residents to engage in physical activity, e.g., through virtual apple picking.

3.5 Progression

Some participants appeared to increasingly enjoy the VNEs as a result of repeated attendance of VR coffee sessions. Also, as the study proceeded, individual residents progressed in various ways relating to their VNE use. For example, we observed how residents’ reactions to things they had previously been startled by, e.g., close encounters with marine animals, became calmer. Further, some residents became more skilled in steering and using the handheld controller while in VR Island.

3.6 Social interaction

In the beginning of the study, though most participants expressed themselves and commented what they saw while being in the VNEs, there was very little social interaction between the residents. However, in the later sessions social interactions became increasingly more common and all study participants in the room watched the spectator view screen attentively and commented and discussed what they saw. Both the by-standing residents (BSR) and the HMD wearing resident (HWR) as well as the assistant (A) were involved in conversation.

Example:

Further, when asked the question “How did it feel to be in the group?” in the post-session interviews, answers described positive feelings, e.g., fun, good, comfortable, nice and cozy. There were also more neutral answers such as “Nothing special” and “Okay”.

3.7 Mid study changes

We adjusted the VR Island prototype, according to the feedback while the study was ongoing. The following changes were made:

4.1 Interest

Our observations of the participants’ expressions of interest suggest that there was a genuine interest to use VNEs among the participants – that it was not merely something else, surrounding the use of VNEs that drove their interest. Negative reactions and expressions of disinterest, which also occurred, may suggest that VNEs does not suit everyone. Possible explanations may be a lack in modalities – failure to provide sensations such as air movement, temperature and smell, i.e., fresh air; and a lack in diversity – failure to meet individual residents’ preferences in content. It is possible that due to such shortcomings, the VNEs failed to provide the means for individual participants to acquire a meaningful experience. However, based on participants’ apparent increased interest, skills and enjoyment after acquiring extended experience of using VNEs, we hypothesize that it may take longer than we had originally anticipated to get used to VR and that VNEs may be more beneficial for individual residents after getting used to the experience of VR.

4.2 Usability matters

In order to counter the difficulties participants had using the handheld controller while exploring VR Island (see Section 3.3.1), an alternative controller could be designed with a single easy-to-push button. Thus, the user would no longer risk choosing the incorrect button. In addition, the controller could be designed to accommodate for impaired fine motor function, e.g., for a grip action. Regarding the difficulties the members of the staff experienced while turning a wheelchair with one hand occupied by a controller (see Section 3.3.3), possible solutions may include to design an easy-to-revolve platform that a wheelchair can be easily rolled up onto, and/or to redesign the controller so it can be fitted onto a wheelchair handle.

As previously stated, in the case of a resident using an Oculus Go, an assistant is fully relying on the viewer’s reports of any error since the assistant cannot see what the resident sees (see Section 3.3.4). Concerningly, first-time users, who do not know what to expect, may accept the compromised content and may not raise any complaints; or, they may be unable to communicate for other reasons. Not only may the then ongoing experience be negatively impacted, but the onboarding of the resident to future VR experiences may also be compromised, which may lead to missed opportunities for the resident.

On certain occasions when participants had been present in a VNE for a while and wanted to finish, they had to ask us how to exit VR. “How do I come back, to reality?” It made us realize that we had not devised a method for the residents to exit VR by their own power or initiative. Routinely, the HMD was mounted and removed by an assistant. Therefore, though the residents may be physically capable of removing the HMD, they may not be inclined to do so on their own accord. This may also be difficult to do by yourself. Further, viewers may be so immersed that they temporarily forget that they are wearing the HMD. Therefore, participating residents were generally left to call upon someone on the outside to help them exit VR. But we had not established the concept of exiting VR with the participants and therefore they may have lacked the tools to communicate their intent to do so. In essence, it is necessary to device some sort of easily accessible return path from VR, be it through established verbal communication protocol, or through the user interface, or both.

4.3 Gradual progression

Gradual progression appears to be instrumental for the residents’ beneficial use of VNEs. Our introduction progressed slowly and stage-wise. On their first VR coffee session, participating residents were able to get a basic understanding of what VR entails through a first-hand experience, using a less immersive/intrusive HMD. It being their first encounter with VR, the choice of such an HMD may have helped the onboarding process. Furthermore, the benefits of using VNEs seem to increase as the residents become more experienced. The progression itself, in the form of learning, skill development and acquiring experience, is likely to be a beneficial factor in the VNE use [36] since lifelong learning has been suggested to promote psychological wellbeing in older adults [41, 42].

4.4 Diversity in VNEs

The expressions of fascination/mind-blowing realization and joy were more frequent when people were viewing theBlu than when using VR Island. This was not so surprising since we found theBlu to be somewhat reminiscent of theme park rides, which are designed to invoke such feelings. In theBlu, the viewer does not need to use their own initiative, but is instead served close encounters with various awe-inspiring marine species, which amounts to a rather spectacular show. The emotional responses of the study participants to theBlu were interpreted as highly positive.

During the VR Island sessions, we observed that while some residents were eager explorers, some preferred to remain in one place, passively observing the scenery with mostly nothing happening. Therefore, future VNEs should provide the content to accommodate both for active exploration (with possibilities of imaginative discovery) and passive observation, accommodating for various levels of intensity on a scale from “nothing happens” or “find interest in the little things” type of content to mind-blowing. Further, we argue that VNEs should accommodate for individual preferences for various types of content such as different types of natural environments.

4.5 User-friendliness versus authenticity

The slightly lower number of emotions expressed by the participants while exposed to the VR Island environment compared to theBlu can be explained with the lower intensity, and more contemplative, inward directed influence by VR Island. As VR Island is interactive, it requires a certain degree of concentration and involvement. The users of VR Island must seek out their own thrills, which are admittedly milder than what is provided by theBlu, but is also truer to an authentic nature experience typical for Northern Europe where nature is not “user friendly”, but rather unpredictable and elusive, e.g., you cannot spot an elk on demand. While walking in real nature, encounters with wild mammals are rare and therefore valuable – something to write home about. Contrarily, theBlu brings immediate gratification through a maximized and compressed spectacular show. The viewer does not have to do anything and is being served awe-inspiring content at a constant rate. Thus, it is reasonable to expect that theBlu will generate more emotional reactions over a shorter time period.

4.6 Active involvement and decision making

Although some usability issues need to be resolved, it is evident from presented findings that elderly study participants were in general able to be actively involved and exercise decision making by deciding where to go and what to do in VR Island, either under their own steam or through assistance. In cases when the study participant needed assistance with steering, it appeared to be easier for the staff members than for the researchers to help residents convey their agency. It is likely that the staff’s knowledge of the residents, and the relationships of trust they may have developed [43], helps the staff’s ability to interpret the resident’s emotions and wishes. Further, residents may be more comfortable with giving instructions and making demands to a person they know than to a previously unknown individual.

4.7 The spectator view

Experiencing indoor nature in group and during shared activities may promote the wellbeing of elderly more than individual indoor nature activities [36]. The spectator view seemed to make it possible for the residents to be social with each other within the context of the VNE. Being co-present in the VNE may promote the perception of a shared experience even further, allowing residents to reminisce together later, about their adventures in the VNE. Comments uttered by the by-standing study participants, while watching their fellow resident’s avatar in the virtual environment, indicate that the spectators were able to, in some sense, follow along on the experience of the immersed viewer. However, with the spectator’s screen being non-immersive, the by-standing residents probably did not feel as if they were present in the VNE. Further, no visual representation of any other resident existed inside the VNE for the HMD-wearing resident to notice. Thus, even though there was some social interaction between them and the rest of the group, the HMD wearing resident was most likely getting the experience of being the only one present in the VNE.

4.8 Possible pathways from VNE use to improved mental wellbeing

During our study we saw indications of VNE use being able to improve the mood of care home residents, at least in the short term. Previous literature has suggested that VNEs may potentially have a beneficial effect on mental well-being in older adults [14, 15]. Our observations are in agreement with the previous literature, and thus allow us to speculate about potential positive health effect of a similar but more long-term intervention. However, further research is needed to examine whether VNE use can lead to improved mental well-being.

As a resident first begins to use VNEs, they may get a sense of having discovered a whole new world inside the HMD. The experience may arouse curiosity and an interest to explore such new worlds and the possibilities they may bring. Driven by this curiosity, the individual may develop new skills and experiences through their continued use of VNEs. Acquiring new skills and experiences may instill a sense of accomplishment and pride; also, gaining new interests and goals may bring a sense of added meaning in life. As the resident is present in the VNEs, they may get both contemplative and mind-blowing experiences, which may instill a sense of wonder, potentially broadening their perspectives. Such experiences may allow a troubled person, perhaps stuck on obsessing on their problems, to see beyond themselves and their troubles; or at least, temporarily take a break from them. Further, the ability to freely explore the environment may provide a sense of regained freedom and control to a person who otherwise experience reduced mobility. Experiences in VNEs may become memories that may reside in the resident’s thoughts, potentially enriching their inner life and shared in social interaction with others.

4.9 Risks

There is a risk that VNEs are used as a replacement for providing real outdoor excursions for residents, e.g., in order to save resources. Or, that residents experience them as such. Therefore, it is important that it is understood by all the stakeholders involved that VNEs do not replace spending time in nature, but should rather be regarded as a complement.

4.10 Limitations of the study

Due to the limited time of the study we cannot see how extended use affects the stakeholders’ meanings of the VNEs. Further, it is possible that other factors than VNE use lie behind some of the effects we saw, e.g.: something different happening – a break from the usual activities; attention – researchers are interested in them; or the social interaction during the sessions, unrelated to the VNEs. Also, there is a risk that the selection process favored those with positive attitudes towards trying new technologies such as VR, and that it may have affected the results. Further, since we did not measure effects on the residents’ well-being, the results serve mostly as guidance for future development and study where well-being may be measured.

4.11 Future research

In order to see how VNE use affect mental wellbeing and on-demand medication use in older adults at residential care facilities, longitudinal interventions where both physiological and psychological effects are measured is needed. Further, this study has exposed several new challenges/questions:

•

How does one introduce VR in a way that enables residents to acquire an authentic understanding of what VR is without inducing a too intense experience and at the same time not understating the capabilities of VR?