The XR Deep Dive training sessions have been developed collaboratively between clinicians and digital experts at Torbay and South Devon Foundation Trust (TSDFT). The sessions were designed to be delivered to teams of health care professionals across the trust in the on-site TSDFT Digital Futures Research Lab. Since the authors consider cross-fertilization of digital and clinical expertise to be paramount in the development of digital interventions that are useful and usable in practice, the sessions were designed to be co-delivered by a clinician and a digital expert.

The Deep Dive learning strategy was originally conceptualized by a global learning design company in the early 2000s and has since been widely implemented across various industries to promote learning and process development within professional teams [15]. Core to the Deep Dive methodology is integration of key stakeholders, affording them the opportunity to experiment with new concepts and brainstorm how that concept could be adapted and successfully integrated into their own unique context [15]. This approach offers an ideal solution to the challenges of XR health care training we have previously described. Therefore, we have adapted the Deep Dive methodology to develop our local training program: we first introduce participants to the concept of XR, then we demonstrate its potential within health care, and finally we allow time, space, and support for teams to explore how the concept could be developed within the context of their own health care specialty for the direct benefit of local teams and patients.

To achieve this, we grounded our Digital Deep Dive session design in Experiential Learning theory [16]. A vital component of the deep dives is to showcase examples of embedded digital technologies in health care pathways across both our own trust and more widely, thus feeding the imaginations of the participants with the possibilities within the digital health care space by promoting hands-on experience and reflection [16]. In-session digital interaction was a key design priority, with time allocated to practical demonstrations and “digital playtime” allowing participants to trial the XR technology first hand. This also aligns with active learning theories and evidence that this type of digital interaction is a key component of achieving successful technology training [17]. The Digital Futures program has a “human first” approach to all its innovations, emphasizing how digital innovation can be utilized directly to improve patient care. In the Deep Dives, we therefore focus on technology in a humanistic sense—adopting this approach accentuates the personal, emotional, and psychological needs of the person in addition to their physical health needs, stressing the importance of treating each person as a unique individual, ensuring that care is patient-centred and that the health care experience is characterized by compassion, empathy, respect, and dignity [18]. We aimed to showcase how technology can be used to connect us with and value one another as fellow human beings, and so incorporated illustration of local use cases to provide context and authenticity. This design choice aligns with the goal of uniting concept with practice, which is central to contextual teaching and learning theory [19]. The informal learning environment was designed to encourage questions and discussion throughout, thereby supporting learners to develop a deeper understanding and explore different perspectives [20]. Time was also allotted at the end of the session for a mini focus group to further promote ideas for co-design and interdisciplinary collaboration of potential digital solutions. Sessions were designed to be delivered in a small group format (<10 participants), as this has been shown to foster better group collaboration, interaction, and discussion [20]. Finally, given the importance of posttraining follow-up to provide further support and ensure ongoing development [21], we considered how we would deliver postsession support as part of our program design—signposting to digital drop-in clinics to further improve targeted digital skills and share and refine ideas for future digital innovation was therefore promoted at the end of the Deep Dive sessions.

These design principles for the XR Deep Dive session are outlined in Figure 1, encapsulating the overarching aims of the training sessions, which are summarized in Figure 2.

Following the design phase, 8 voluntary pilot sessions were held between May 2022 and May 2023. Health care professionals—including resident doctors, consultants, nurses, occupational therapists, play specialists, and physiotherapists—from departments across TSDFT were invited between May 2022 and April 2023 via email and online trust advertising platforms to attend on a voluntary basis, therefore utilizing self-selection sampling [22]. Volunteers from all of these clinical groups attended sessions, with each session hosting between 3 and 8 participants to maintain the important small group sizes. Participants were invited to complete an anonymous postsession QR feedback form in Multimedia Appendix 1; by submitting this, participants consented for their anonymized comments to be included in this service evaluation. The Squire Guideline for Service Evaluation was used as a framework [23]. Free-text responses were evaluated by 2 authors (CG and PG) using thematic analysis, which is the accepted preferred method of interpreting qualitative data [24].

Each session was also observed by the senior author (JRL), who provided feedback on content and flow and suggested modifications. Using this feedback combined with the participant feedback, through an iterative process, the final content of the Digital Deep Dive sessions took shape.

In line with guidance provided by the Health Research Authority and compatible local Research and Development policies at TSDFT, a formal ethics application was not required for this service evaluation project. Participants were made aware through a formal statement on the feedback form that their anonymous responses may be used for evaluation purposes and may be included in future published work.

Data were collected through a series of closed questions and 5-point Likert scales. Quantitative data were collected in 2 categories: presession experience and postsession feedback.

Free-text responses were collected in 4 main areas: presession ideas and motivation, session content and delivery; session relevance and utility; and postsession development. Following thematic analysis of the responses, key themes were identified in each of these areas. These themes are presented visually in Figure 3.

Participants indicated that their presession experience of using XR technology was minimal to nonexistent. The integration of digital playtime and first-hand exposure to the technology were reported as being an overwhelming strength of the session. Participants were encouraged to reflect on these practical experiences and engage in collaborative group discussion about potential applications and developments in their own health care settings. This experiential learning is a key component of adult learning theory, where learning takes place in a context-specific cycle of experience, reflection, conceptualization, and experimentation [16]. To provide this all-important context, relevant local use cases of successful XR interventions formed the basis of the practical demonstrations, fueling participants’ imaginations of what is achievable within our own organization, thereby lifting the concept of XR integration from an abstract idea to a realistic possibility. For example, the following use cases (developed in-house) were explored (Figure 4):

This contextual relevance was another key strength in our survey results, supporting the mantra that “seeing is believing” where emerging technologies are concerned [25].

Significant cultural challenges exist to the widespread adoption of XR technologies across all industries, including feelings of apathy, distrust, confusion, and skepticism [25]. Such cultural barriers are reinforced through our survey, with more than half of respondents exhibiting negative preconceived ideas about the use of XR technology in health care across 3 themes: Patient Concerns, Technology Skepticism, and Cost and Scalability. We believe that such concerns must be addressed head-on by providing staff with the opportunity to experience the technology in action, with time and support to understand its qualities and limitations as well as openly discussing and addressing concerns [25]. After taking part in a Deep Dive session, many participants acknowledged the potential of XR technology for health care innovation and had developed an appreciation of what might be realistically achievable at a local level.

Our co-creation approach to developing digital solutions that are useful and usable in practice was fundamental to the design of the Digital Futures Deep Dive sessions and to addressing these concerns. Having access to a digital expert during the session enabled practical discussions focused on achievable digital goals. Emphasizing cross-fertilization of clinical and digital expertise allows participants to understand that our local Digital Futures Programme aims to produce co-developed, intelligently implemented, and practically driven bespoke patient-focused health care solutions [26], and that digital care transformations are taking place in a positive sphere of negotiation and meaningful dialogue with key stakeholders, rather than being forced upon them [27].

The success of our XR Deep Dive training sessions is encapsulated and demonstrated by a significant number of participants showing active postsession engagement and interest in becoming involved in the local Digital Futures Programme, bringing with them the seedlings of ideas that were sown in the initial XR Deep Dive session.

Our survey revealed that participants felt the balance and complexity of the session could be improved, with respondents requesting more hands-on time with the XR headsets and less presentation time, reinforcing that the strength of the session lies in its integration of practical digital experience. As a result of this feedback, we were able to perform a review of the session design after the first few deliveries and made some intermediate interventions, including increasing the session length from 90 to 120 minutes with more dedicated practical time, streamlining the session presentation, and simplifying the digital-focused background information. This resulted in improved feedback, with improvement comments under the themes of “Improvement of Session Balance” and “Improvement of Session Complexity” occurring far less frequently in the later pilot sessions.

Approximately one-quarter of respondents talked about connectivity issues when asked whether they experienced technology difficulties during the session. Resolution of connectivity issues subsequently became a theme for improvement. Such connectivity issues are unfortunately widespread in the NHS—a survey found that 58% of NHS staff had experienced Wi-Fi blind spots in their trust buildings, and two-thirds agreed that digital innovations in their team had been abandoned due to poor connectivity [26]. This is a limitation of NHS infrastructure and is not within the abilities of this paper’s authors to change. However, we recognize—like 98% of NHS staff—that Wi-Fi infrastructure and mobile connectivity are crucial to the future delivery of innovative health care [26] and will therefore continue to play our part in campaigning for improved connectivity as part of our local Digital Futures initiative.

The Digital Futures Lab is on-site in our NHS trust, and it is bespoke and evolving. It was built to develop and support the digital literacy of all health care staff in our trust. Our evaluation found that most participants came to our training session with no or little knowledge about the use of XR technologies in a health care context or local XR development projects. As expected, most participants had never heard of our new local Digital Futures Programme and were not aware of the investment and facilities available within our own organization recently. Without awareness of the opportunities available, clinical teams simply cannot drive digital innovation. This aligns with the findings of a 2023 survey that lack of digital knowledge and skills within health care teams was considered by three-quarters of surveyed NHS workers to be a significant barrier to innovation [26]. Furthermore, this emphasizes the Topol recognition that a culture of NHS digital innovation can only be achieved when coupled with a learning culture that supports frontline staff to explore new technologies and the opportunities they present for patient care [1].

An integral component to building such a culture is having a cohort of learners who are motivated to explore the opportunities presented by advancing digital technologies. An appetite to explore and embrace digital advancements to transform patient care has been identified among health care workers on a national scale [26]. Similarly, many participants in our survey acknowledged the upcoming digital age of the NHS, recognized digital technology as a tool for innovation, and cited their curiosity to learn about such innovation opportunities as motivation for seeking digital training.

Overall, in our local health care workforce, there exists a knowledge gap regarding XR potential and current local opportunities coupled with a strong desire to rectify this, indicating a clear need for the XR Deep Dive training session we have created. After taking part in our session, all respondents reported an increased awareness of local digital innovation and most felt inspired to get involved in future digital projects themselves, highlighting that our sessions have been successful in meeting their aims.

Feedback from pilot sessions has supported the need for our new XR Deep Dive training sessions and has informed the refinement of the original session design as part of a quality improvement cycle. Intermediate interventions to address initial concerns regarding session balance and overcomplexity have already been successfully implemented, and there remains scope for further improvement. For example, future directions of the XR Deep Dive training program may involve a tiered approach to cater for participants of different starting abilities and experiences, potentially incorporating “beginner,” “intermediate,” and “advanced” training sessions, which can be accessed either in isolation or as a progressive series. Future evaluation of such an expansion of the training program would offer further insights into how we can successfully fulfill the NHS Long Term Workforce Plan of upskilling and training staff in our NHS trust to maximize digital technologies to improve health care delivery for the benefit of patients locally [3]. Future research will also inform us about the different technology behaviors of individuals and help us develop insights on how behavior change can be encouraged.

Digital transformation, and XR health care technologies in particular, are rapidly evolving and driving change. Maturation of hardware and software means content is becoming more sophisticated, user friendly, and seamlessly integrated into the real world [25]. Training programs—such as the one we have developed—will therefore also be required to evolve. Regular periodic reviews of the session content must be scheduled with updates as required, to ensure the training does not become outdated and irrelevant. Further, as use of technology in our local trust increases, the use cases demonstrated in the XR Deep Dive training sessions must also be reviewed to ensure they remain current and engaging. Showcasing use cases tailored to the participants’ own context will become easier as more local health care specialties adopt XR innovation.

As the training program grows, we must ensure its sustainability. This will involve the recruitment of local “clinical digital champions”—as identified in Topol [1]—to deliver peer-to-peer training, sharing their knowledge and unique experiences. Recruitment and training of digital experts must also be maintained—and increased proportionately—at the trust level. Ongoing funding must be secured in line with the program growth, which will require a funding strategy as part of the wider Digital Futures Programme in our trust. A robust and sustainable follow-up support model must be established to bridge the gap between this initial training session and adopting XR solutions in the clinical environment. Sparking the imagination of what is possible in the realm of local XR health care technology is trivial if participants do not subsequently have access to the technical support and expertise required to conduct trials within their own clinical spaces. We have already begun to tentatively explore a model of “Digital Clinics” for this purpose, but data from our survey emphasize how follow-up support must be focused, context-specific, and clearly signposted. Refining a sustainable follow-up model that meets these criteria is the next step in the development of this training program.

Finally, digital health care transformation is certainly not without its ethical challenges, including concerns around access, consent, inclusivity, privacy, and dignity [1,28]. As digital innovation training evolves, it must incorporate these ethical discussions and continue to tackle cultural barriers. Encouraging honest and open dialogue will be key to finding workable local solutions to ethical challenges and ensuring a true co-design culture is adopted. Our survey highlights staff concerns that XR technology will remove the personal aspect from patient-clinician relationships, thereby dehumanizing care. This concern is also recognized in the Topol review. Our local Digital Futures goal aligns with that of Topol: to focus on how digital technologies can enhance, rather than retract from, our human interactions. We are proud that our local digital projects prioritize the humanistic aspects of care and have built our training to showcase this. As digital innovation and the associated awareness training evolves, we must not lose sight of our core values.

This paper explores a small, single-center pilot of a new local training intervention. Its findings are intended to inform future directions in our own trust and may not be generalizable to a wider context.

First, given the voluntary, self-selection sampling used to recruit participants to the Deep Dive pilot sessions, it is likely that our survey suffers from selection bias, capturing the views of staff who were already motivated to undertake the training in the first place. Given that a significant number of survey respondents talked about a prior interest in technology and a curiosity to explore new digital opportunities further as a reason to sign up to the pilot sessions, it is likely that our data do not capture the cohort of staff in our trust who are true digital skeptics. To obtain a wider spectrum of opinions, for future iterations of this pilot, we should aim to recruit staff members who do not have prior motivation for engaging in digital training sessions. This will provide insights into how we can effectively engage digital-skeptic staff to engage in the technology advancements being implemented both in our local trust and nationally within the health service.

Second, feedback was collected via an online feedback form accessed via a QR code at the end of the session. Not all session participants completed the feedback (60% response rate), possibly owing to the fact there was no physical form and they never got around to submitting it online. Concerns around nonresponse bias must therefore be considered when interpreting our findings. Obtaining feedback online is an established challenge [29]. To ensure a more complete representation of participant views in future, it may be preferable to supplement a feedback form with a recorded feedback focus group at the end of future sessions.

Having identified a gap in real-world working models of health care workforce XR awareness and development training, we have designed and implemented XR Deep Dive training sessions for health care staff. This was one of the principle aims of our Digital Futures Programme. These sessions provide contextually relevant XR technology awareness training and are the first step in working toward the goal of nurturing digitally literate health care workforces who have the knowledge and skills to embrace transformative technology in the improvement of patient care, as per Topol [1]. Our session design draws on Experiential, Active, and Contextual Learning theories by showcasing local use cases of the technology in practice, prioritizing hands-on digital playtime and emphasizing the vital cross-fertilization of clinical and digital expertise in the co-creation of digital solutions that are useful and usable in practice. Data from the pilot sessions suggest that we have created a training session that is engaging as well as relevant and useful to future clinical practice. The results from this paper will help to inform future directions for developing digital awareness training in our trust.