Measuring Stress and Perceptions for a Virtual Reality–Based Pericardiocentesis Procedure Simulation for Medical Training: Usability Study

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Background: Virtual reality (VR) is increasingly used in medical education, providing immersive environments for training in high-risk procedures such as pericardiocentesis. This lifesaving procedure requires technical precision and induces cognitive and physiological stress. Evaluating both usability and stress responses in a VR-based pericardiocentesis simulation is essential. Heart rate variability (HRV) serves as an objective stress marker, while prior VR experience may influence usability and stress perception. objectives: This study aimed to assess the usability of a VR-based pericardiocentesis simulation, examine the relationship between usability perceptions and physiological stress (HRV), and determine the impact of prior VR experience on usability scores and stress responses. Methods: A total of 119 final-year medical students participated in a VR pericardiocentesis simulation. Usability was evaluated using the System Usability Scale (SUS), the Post-Study System Usability Questionnaire, the Presence Questionnaire, and the Simulator Sickness Questionnaire. Physiological stress was assessed through HRV parameters, including the root-mean-square of successive differences (rMSSDs), percentage of differences greater than 50 ms (PNN50), low-frequency to high-frequency ratio, and nonlinear HRV indices (SD1/SD2 ratio, Poincaré area). Statistical analyses included descriptive statistics, Spearman correlations, and Mann-Whitney U tests to explore relationships between usability, stress, and prior VR experience. Results: The VR simulation received a mean SUS score of 75.00 (SD 6.41; 95% CI 73.42-76.58), exceeding the general usability threshold of 68 (P=.002). The mean Post-Study System Usability Questionnaire score of 2.92 (SD 1.83; 95% CI 2.55-3.29) indicated moderate satisfaction, while the mean Presence Questionnaire score of 109.46 (SD 9.12; 95% CI 107.88-111.04) reflected strong immersion. Simulator sickness symptoms were mild (mean Simulator Sickness Questionnaire score 12.43, SD 15.41; 95% CI 9.28-15.58), although novice users reported significantly higher nausea levels (P=.02). Physiological stress analysis revealed a mean rMSSD of 281.27 (SD 98.99; 95% CI 259.45-303.09) ms and PNN50 of 56.85% (SD 19.70%; 95% CI 52.23%-61.47%), indicating moderate autonomic balance. A significant negative correlation was observed between HRV parameters (rMSSD and PNN50) and simulator sickness (P=.04; Spearman ρ=-0.23), suggesting that higher physiological stress was associated with increased simulator sickness symptoms. Prior VR experience was linked to higher usability scores (SUS +5.2; 95% CI 3.12-7.28; P=.03) and lower simulator sickness symptoms (P=.02) but did not significantly affect HRV markers. Conclusions: VR-based simulations for high-risk medical procedures are effective training tools with high usability (SUS=75) and strong immersion. Simulator sickness correlated with physiological stress, emphasizing the need for design refinements to improve user comfort. Prior VR experience improved usability and reduced simulator sickness but did not significantly impact HRV markers. Future research should refine VR interfaces to balance immersion with minimized cognitive and physical discomfort.

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