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1 Introduction

The implementation and use of technology is not a new phenomenon in higher education, as the use of technology creates new possibilities and challenges involving pedagogical thinking and planning [1]. Since learning using digital technology can provide a wider variation within education, as well as training for a professional career, society in general increasingly implements and adopts new technology [1, 2]. The use of technology can enhance interest among students and provide them with better conditions to understand complex information and phenomena [1].

The quality of healthcare and patient safety is prioritized within the healthcare system, and evidence-based health education is important when it comes to ensuring quality of care and patient safety [3]. Clinical practice is in a state of continuous change and has led to increasing demands in terms of student competencies and clinical skills. Higher education plays an important role in knowledge translation and in strengthening the competencies and clinical skills of students [4]. In higher education, the implementation of technology has enhanced the possibilities to teach students more complex concepts in a more efficient manner and with greater variation and visualization [5]. An example of a complex subject is the teaching and learning of anatomy. Anatomy is considered an essential science within medicine and healthcare education, and anatomical knowledge is important for developing skills and becoming a competent practitioner [5,6,7,8].

Anatomy is a visual and three-dimensional (3D) science, traditionally taught in higher education through two-dimensional presentations (pictures) in books and classroom teaching. A recognized visualization technology for exploring and experiencing 3D is virtual reality (VR). Numerous systematic reviews state that technology such as VR can enhance motivation for learning and preserve knowledge and in-depth learning [9,10,11,12,13]. This chapter provides a general introduction to different aspects of VR and its potential relevance for increasing the quality of anatomy teaching and learning in higher education. We also provide practical insights into the development and implementation of VR-based teaching and learning of anatomy on the bachelor and master’s levels in a Norwegian setting.

2 Virtual Reality: The “Whats” and “Whys”

VR is defined as “a technology which allows a user to interact with a computer-simulated environment, be it a real or imagined one” [14] and is increasingly presented as a feasible interface to promote salient, motivational, and safe environments for virtual learning [15, 16]. However, the definition of VR varies significantly in scientific literature and covers a wide range of technologies. In short, it varies from the classic, non-immersive desktop system (PC, Mac®, PlayStation®) with or without added motion tracking (Nintendo Wii® and Microsoft Kinect®) to immersive CAVE systems (multiple large projected surfaces) and head-mounted display (HMD) systems (HTC Vive® and Oculus Rift®) [17] (Fig. 1). CAVE systems have become more common due to technological advances and a desire to prioritize such systems [17]. However, our focus in this chapter is on the use of head-mounted display (HMD) systems. With HMDs, the user is immersed in the virtual environment by wearing goggles with screens for both eyes. The goggles utilize sensors that give the software exact information on the user’s position and movement. Head-mounted display (HMD) systems have an additional advantage over less immersive VR technologies in that they give students the possibility to physically move around in the environment and interact with, explore, and move objects from different angles.

Fig. 1
An illustration of 3 human figures. It depicts a man in a CAVE system, a man sitting in front of a desktop, and a man with a head-mounted display.

Examples of three different types of virtual reality systems: desktop, CAVE, and head-mounted display. (Illustration: Lauritz Valved)

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Immersion relates to how effectively the computer-simulated environment replaces the perception of the real world, making the student perceive the environment through sensorimotor contingencies [18], meaning that the student’s learning is shaped by stimuli and actions within the virtual environment. In this setting, it is of relevance to note the difference between 360-photo and video-based virtual experiences and computer-generated VR environments (virtual environments, VE). A photo or video captured by a 360-degree camera can be viewed in a head-mounted display (HMD) system and enables the student to visually explore the surroundings. However, this exploration is limited to the point in space in which the camera is positioned at the time of capture and the timeline of events and interactions is predefined. A virtual environment is based on 3D models, and the head-mounted display (HMD) system’s position and movements are translated into the virtual environment, thus enabling the student to move around in this environment, viewing the surroundings from all positions and angles. In a VE, the timeline of events and interactions is not necessarily predefined, as the 3D models can be generated for continuous interaction.

In the Faculty of Health and Social Science at the Western University of Applied Science (HVL), we have implemented head-mounted display (HMD)-based VR in the teaching and learning of anatomy, making it possible for our students to enter a synthetic anatomical environment. We use commercially available VR software, including over 4500 anatomical structures, where the students can interact with (dissect) all of them, starting from a full-body structure or predefined substructures [19].

3 Anatomy Teaching and Learning in Higher Education

To construct knowledge about anatomical structures and how different bones, muscles, nerves, etc. are located and relate to one another is something students of both medicine and nursing have claimed to be difficult or challenging [1]. Traditionally, the teaching of anatomical knowledge within our health science programs has been introduced to students through lectures and two-dimensional pictures from books. Both primary studies and systematic reviews report that students experience learning anatomy as difficult and challenging [5,6,7,8]. The most prominent challenge to learning anatomy among students is to identify anatomical structures and understand the spatial relations between the different structures [6]. The ability to understand and perceive spatial dimensions and understand how human structures relate to one another is difficult to learn using two-dimensional resources, while anatomical structures are three-dimensional [13]. Actual anatomical knowledge and spatial anatomy knowledge has been shown to increase using three-dimensional methods instead of two-dimensional [13].

Learning concepts argue that learners must play a significant role in the educational process, presented as collaborative learning, meaning that students become more active and responsible for their own learning and achieving their learning goals when collaborating with peers [1, 20]. An important prerequisite in small-group collaboration is the sharing of knowledge and expertise and student ability to explain their reasoning to one another and to themselves. Promoting such cognitive restructuring of knowledge, interaction, and positive relationship within the group is essential [21,22,23]. Working together also contributes to developing social competencies through problem-solving and instant feedback, in addition to preparing students for a professional career, as collaboration is an essential core competency for achieving quality of healthcare [24, 25].

4 VR as Part of Anatomy Learning in Higher Education: A Practical Insight

Systematic reviews report that the use of VR has a positive impact on student ability to understand spatial and structural anatomy [3] and may be an effective resource to enhance the student’s level of anatomy knowledge [5]. Another important advantage of using VR in anatomy teaching is the possibility to create a realistic learning environment that enhances student motivation and situated learning [4]. An additional reason to implement VR into the teaching of anatomy is to potentially achieve a transition from teacher-centered and passive learning (lectures) to an interactive, student-centered and exploratory learning, i.e., collaborative learning.

Since 2018, the Faculty of Health and Social Sciences at the Western Norway University of Applied Sciences (HVL) has been developing and implementing VR in anatomy teaching and learning within the bachelor’s program in radiography and the master’s program in midwifery. The strategic goals of the faculty are to implement and enhance the use of different learning activities, combined with technological tools, in order to enhance the ability to provide tailored and flexible education [26]. By using digital tools and a more collaborative approach within teaching, our primary goals are to enhance the learning outcomes among students, increase student motivation for learning, and, consequently, enhance the quality of the teaching.

The implementation of VR within anatomy learning and teaching was a progressive process that started with a pilot using the commercially available software 3D Organon VR [19] among first-year radiography students. The students tested the equipment in small groups of three to four students, by which one student used the head-mounted display (HMD) systems to enter the virtual environment and the other students participated by observing the VE on the desktop display. Each piloting session lasted for 60 min and concluded with a questionnaire evaluating the experience of learning anatomy in VR, the use of the software equipment, and their opinions on VR as a possible learning resource in learning anatomy as part of radiography studies. We also collected data through participant observations and dialogue.

The data indicated that the students found the VR session to be stimulating and motivational for learning. We also experienced that the discussions and collaboration within the small groups increased during the session, and the students reported a discovery of anatomical structures and coherence that they had not achieved with the two-dimensional learning resources. Data from the pilot project provided valuable knowledge about how the students experienced the VR environment. The students reported that they preferred specific tasks and guidelines to achieve learning in the virtual environment. They reported that they felt uncertain and less independent if they were left in the VE without any instructions or goals for the session. We used this feedback to develop a thematic exercise booklet that guides the students through relevant structures, including group discussion exercises, facilitating the students in using anatomical terminology orally and with positive responses from the pilot students. We experienced that both the students and teachers need to be familiar with the technology in order to enhance the potential of the technology and, consequently, the learning of anatomy.

As a result of the positive feedback and experiences from the pilot project, the faculty established the SimArena VR Lab in our simulation and training center on campus, including a total of seven HMD setups. Since then, we have established two approaches to using VR in anatomy learning and teaching in higher education: VR-based anatomy as an integrated learning resource and VR-based medical simulation.

4.1 VR-Based Anatomy as an Integrated Learning Resource

Within the bachelor’s program in radiography, VR-based anatomy teaching is used as one of several digital learning resources parallel to mobile apps that utilize artificial reality (AR) models, video-based lectures, and the video recordings of fellow students. VR serves as a supplement to classroom teaching and books but has not replaced these learning resources. This pedagogical strategy is based on the theory that learning is constructed when students work with peers to generate their own knowledge and are motivated by various learning strategies [27].

Implementing VR into the bachelor’s program requires both didactical and pedagogical thinking and planning, and we used the didactical relation model that emphasizes the relationship between content, learning objectives, settings, learning activity, learning conditions, and assessment [28]. In a well-planned and developed course, there is good coherence and consistency between the six different factors in this model.

The curriculum plan focuses on the essential knowledge, skills, and general competencies students are expected to achieve by the end of the program [29], while the learning objectives (LO) in higher education are based on a predefined structure of knowledge, skills, and general competence. In implementing VR, we had to consider the students’ learning outcomes both during and at the end of the anatomical course. To achieve this, we have differentiated the teaching of anatomy into various topics, such as the skeletal system, nervous system, and gastrointestinal system, and organized the anatomy learning in the virtual environment into different topics. The students are taught anatomy following the structure of the anatomical syllabus reading list, creating a familiar environment for the students.

Each topic is presented in a similar way and includes a classroom lecture, independent working, and assignments. The topic lecture is given at the beginning of a new topic and is used to outline the most relevant learning outcomes for the upcoming topic, followed by a walk-through of available and relevant tools for independent working. Assignment hours are scheduled 1 week after the topic lecture. The assignments focus primarily on “general competences,” entailing group assignments of practical relevance in which the students must express professional anatomical knowledge of the subject, both in writing and orally. These assignments are carried out within the virtual environment in order to enhance student knowledge and understanding of spatial anatomical structures.

By differentiating the anatomy into different topics, we can enhance student understanding of spatial anatomy by tailoring the different teaching technologies to the content. In the past, we had experienced that students struggled with the content and understanding of the relationship between the different anatomical structures, but during the assignment sessions in VR, the students are more active, collaborate more, and use more precise anatomical language in their discussions. We have also experienced that the role of the teacher has transitioned from lecturer to facilitator.

We decided to implement the VR in the radiography course in relation to each student’s different assignments on each topic, and the students’ tasks and guidelines were entered into the virtual environment based on the pilot findings. Each radiography class has around 30 students, and all students are given 60–120 min to complete their assignments and tasks in VR. Considerable time is spent in VR, but the student evaluations and positive experiences in relation to knowledge and skills are the main reason to continue using VR in this setting. Alternatively, VR could be made available as a separate teaching tool for students, but our experience shows that students are not very familiar with the VR environment, and it is essential to be present, facilitate the discussions, and support the practical tasks in order for the VR-based approach to be of value in the learning of anatomy.

A typical assignment for our radiography students is to be handed a 2D image and to familiarize themselves and discuss topographic anatomy in order to understand how the structures are projected on the body. During these group discussions, students are required to engage orally. In the beginning of the semester, before students and facilitators have become better acquainted, we have noticed that the students who use the HMDs initiate discussions, while their fellow students often remain silent. The students report that they are unsure about their medical nomenclature pronunciation and are afraid to reveal their limitations to other students. The awareness of being observed may potentially limit them, as many of our students are straight out of secondary school, where they are used to being evaluated during oral discussions. Because of this, we must establish a safe and positive learning environment at the beginning of each semester to help the students view the teachers as facilitators, not evaluators.

To establish a safe learning environment, the students must work under the same learning conditions. We therefore invest considerable time and resources into familiarizing the students with the technology used in the virtual environment. When there are substantial discrepancies in the mastery levels of the technology in a group of students, we have experienced that students with fewer technical skills withdraw from the learning activities and tasks and become passive and highly dependent on the presence of a teacher. It is therefore important to set aside enough time for relatively basic tasks at the start of each course, making sure that all students master the learning conditions before progressing to more advanced topics.

Students generally demonstrate their knowledge and general competencies in anatomy by means of a written exam. After implementing VR into the anatomy lectures, we have altered the exam so that the students can also demonstrate their skills. The exam now consists of a written part and a video submission in which the students present their knowledge and skills in an oral presentation. By combining different assessment methods, the students can demonstrate in-depth knowledge rather than only memorizing structures and anatomical definitions.

The implementation of VR into the bachelor’s program in radiography has provided valuable knowledge and experiences for the further development and implementation of VR in other programs within our faculty. The midwifery program has worked together closely with the radiography program, learning from their experiences and having the opportunity to further develop the use of VR in higher education. The exchange of knowledge between the different educational programs has led to a different use of VR in education.

4.2 VR-Based Medical Simulation in Midwifery

Within the master’s program in midwifery, we have established a VR-based medical simulation session focusing on the relationship between the female pelvis, fetus, and uterine muscle. As with other medical and healthcare programs, midwives and midwifery students require in-depth knowledge of anatomy, especially the female pelvic anatomy and fetus. A midwife must have the right competencies to facilitate normal processes in pregnancy, birth, and postnatal care, with anatomical knowledge being one of many cornerstones for developing these clinical skills and competencies [30]. Encouraging the physiological processes of intrapartum care requires a significant understanding of the interaction between the female pelvis, uterine contractions, and the fetus. To learn these skills, midwifery students need opportunities for concrete, contextually meaningful learning situations where they could improve their clinical reasoning, critical thinking, and problem-solving skills and, through these learning strategies, increase their knowledge [31].

To stimulate knowledge and understanding of the female pelvis in accordance with fetal rotation through the birth canal, we have found VR to be an appropriate learning method. By using this tool, we can demonstrate the relationship between the female pelvis, fetus, and uterine muscle in a combination that is not possible in the traditional classroom sessions. The use of HDMs enables students to follow the rotation of the fetus through the birth canal simply by adopting the fetal perspective looking down from the pelvic brim and into the pelvic cavity. The 3D effect has become essential to the teaching by replacing as many sense impressions as possible with virtual impressions and creating the illusion of being actual present in the female pelvis as a fetus. The task given to students is a laboring woman, and during the VR session, the midwifery students follow the woman and fetus through the different stages of labor. Working together in pairs, the students discuss and explore anatomical structures, use correct anatomical terms, and reflect on which procedures to initiate to promote a physiological birth. The teaching is implemented as a discussion and critical thinking among peers, demonstrating which bones, muscles, nerves, blood vessels, and structures are included in the female pelvis. Once these elements are identified, the students demonstrate how the leading part of the fetus positions itself in relation to the actual female anatomical structure or bone. During the entire session, the teacher serves as a facilitator of knowledge by participating and engaging in the discussions.

4.3 Pedagogical Strategy During the Simulation

Experience with digital resources and learning within a virtual environment varies among students of higher education, and they need to learn how to use the VR equipment at the same time as they are learning with it. It is therefore important to provide a model of learning in which students can explore the head-mounted display (HMD) systems and learn anatomy at the same time. Taking this into account, we created the sessions in the virtual reality room as a step-by-step learning experience for the midwifery students. Before entering the VR laboratory the first time, they are shown videos with the same anatomical structures as they will encounter in the virtual environment, so they can prepare and test their knowledge through multiple-choice and drag-and-drop assignments. In addition, we give them written instructions on how to use the digital tools, so they are familiar with the rules of VR before entering the learning environment. By using a scaffolding model constructing the teaching in VR, we gradually build on the student’s previous experience. A structured learning scaffold offers essential support and development to participants at each stage as they acquire expertise in digital learning. Scaffolding often refers to the temporary support provided for the completion of a task that learners otherwise might not be able to complete [32].

During the first session in the VR room, the students are given a set of tasks aimed at familiarizing them with the VR environment and navigating the HDMs: how to put the goggles on properly, adjust the vision, and navigate the virtual environment using self-movement and the controller. These are the basic skills and knowledge required to participate in the future learning of anatomy. During this session, the students are assigned tasks related to the use of the HDMs that entail solving simple tasks linked to topographic anatomy. The tasks are also connected to the learning materials (videos and quizzes) given before entering the VR room. In introducing them to the virtual world by gradually building their skills and competencies, we have experienced that student quickly manage to construct knowledge and understanding in anatomy using VR. The students’ immediate feedback after their first session is illustrated in a word cloud (Fig. 2).

Fig. 2
An illustration depicts a group of words. It includes interactive, entertaining, good learning situation, easier to imagine, and many more.

Student experiences from attending VR session (translated from Norwegian to English)

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Following the initial introduction to the VR room, the next time the students attend the anatomy lecture and enter the VR room, they are familiar with the equipment and can focus on a more advanced anatomy assignment, thereby enhancing their knowledge and skills. The students are assigned a task involving a laboring woman at the start of labor. During this stage of the task, the students must find the pelvic structures and name the bones of the female pelvis, defining the pelvic inlet and border of the true and false pelvis. To understand the relationship between the female pelvic and fetus, the students must define the position that the head of the fetus would normally take in the female pelvis. This discussion provides valuable knowledge and understanding of the transverse, oblique, and anteroposterior position. The students also discover the meaning of the pelvic brim or inlet and that the pelvis is a cavity with an outlet because they can look down into the pelvis. The possibility to examine the anatomical structures from different angles gives the students the opportunity to take both the fetal perspective and midwife’s perspective in relation to the pelvic inlet and outlet, gaining increased anatomical understanding. In addition to discussing and reflecting over the positioning of the fetal head, they also reflect on the flexion of the head to achieve the smallest possible diameter to pass the pelvic inlet and enter the pelvic cavity. This discussion provides the students with an in-depth understanding of how the fetus rotates and negotiates itself down the birth canal.

After accomplishing the task about the female pelvis and fetal position, the students are given further information on the progression of labor based on the woman’s contractions. The students then discuss the uterine muscle and physiology of how this muscle influences the rotation of the fetus and which observations and actions support progression in normal labor. In the VR software, the students add the muscle layer to the pelvic bones, with special focus on the levator ani muscles, urogenital and anal triangle regions, and the internal and external sphincter muscles. In collaboration with fellow students, they identify the muscles included in the levator ani and discuss the rotation of the fetal head entering the levator ani muscles. This discussion enables the students to understand the rotation of the fetal head from a transverse to an oblique position and ending with an anteroposterior position in the pelvic outlet with the help of the uterus muscle and levator ani. Through the visualization of the rotation, the students become more familiar with the topographic anatomy and how to navigate using the correct anatomical terms of anterior, posterior, deep, superficial, inferior, and superior, medial, and lateral. In addition to an understanding of the fetal rotation, the students rotate the pelvis and lift the pelvis, so that the anatomical structures can be studied from different angles. This possibility in the VR software gives the students a better understanding of the different layers of the muscles and increases their understanding of the concept of deep and superficial muscle layers. The students also discover how levator ani relates to the urogenital and anal triangle and the closeness of levator ani to the internal and external sphincter muscle. Using virtual reality and the possibility to observe the pelvic muscles from different angles helps the students understand the three-dimensional structures of the pelvic muscles. The ability to take both the fetal and midwife’s perspective during the laboring process increases the students understanding of interventions to promote physiological labor and interventions to reduce perineal trauma. By incorporating different subjects related to the promotion of physiological labor and clinical examples into the discussion of anatomy, we have experienced increased understanding among the students. The clinical examples, combined with other anatomy-related topics from the midwifery program, seem to increase the understanding of why knowledge about anatomy is important to becoming a competent practitioner. Studies have shown that combining relevant clinical examples with complex subjects increases knowledge and understanding, in addition to enhancing student awareness of why the subject is relevant to learn [33].

Having understood the bones and muscles of the female pelvis, the students are then asked to add the nerves involved in the birth canal. The students can then visualize how the nerve branches are linked to the pelvic muscles. The students discuss the level on which an epidural would be placed and identify the nerves that could be affected by an epidural anesthesia. The picture of the nerve branches across the levator ani helps the students understand the value of an upright position of the laboring woman. In addition, they discuss the significance of nutrition and fluid during labor, as the muscles play an important role in promoting physiological labor. During this part of the task, the students are asked to find an important anatomical landmark—spina ischia and the related nervus pudendus. The students discuss how to perform a vaginal examination and give pudendal anesthetics to block the pudendal nerve. Thanks to the spatial abilities of VR, they identify the spina ischia on both sides of the pelvic cavity and understand how to navigate in an actual situation to find both spina and the nerve connected to spina. Examining spina from both a superior and inferior position, the students discover that during a vaginal examination, they must enter the vagina posteriorly and laterally to identify spina ischia. This is something that is difficult to spot in 2D pictures from books or during a classroom lecture. After identifying spina ischia, the fetal position and station in the pelvic cavity are discussed and the rotation from a transverse to oblique position exposed to the students. Again, combining both the female pelvic and fetal position in the cavity enhances student understanding of the cardinal movements of labor.

The final step of the collaborative task in the VR room is the actual delivery of the fetal head and body. The students visualize the rotation from a transverse to anteroposterior position of the fetal head. During the task, the student with the VR goggles focuses on the fetal perspective down the birth canal, enabling the student to understand that the pelvis is spatial, with an inlet, cavity, and outlet. By navigating this cavity, the student can see how the different bones, muscles, and nerves relate to one another and how these different anatomical structures work as a whole. They discuss and reflect on different interventions to promote normal labor and, through the learning of anatomy, discover how different interventions are significant in relation to an understanding of the anatomy and physiology of the fetus and female pelvis. During the teaching session, the students work together in small groups. This is an intentional pedagogical approach. We have also recognized that anatomy is complex learning, demanding reflection through discussion and explanation. To secure the quality of the interaction and in-depth learning within the small groups, the students pair up with fellow students they already know. The teacher acts as a facilitator in the VR room, participating in the discussions and communication of knowledge. The students have reported that small-group activities create a safe environment for knowledge sharing and working with peers is more helpful than working alone due to the complexity of the subject matter. The students experience an increased understanding when interacting simultaneously in the VR room, creating a sense of togetherness. The students have also reported that the presence and availability of the teacher as a discussion partner rather than knowledge transmitter facilitates knowledge exchange within the group.

5 Summary

This chapter provide two examples of the integration of virtual reality into the teaching and learning of anatomy among students. Both approaches require a systematic utilization of student learning outcomes in the planning of anatomy lectures. The technology is tailored to the learning outcomes so that the students will gain knowledge and skills that prepare them for their future profession and clinical practice. By focusing on student learning in combination with learning activities and collaboration, the technology helps students gain understanding and knowledge.