Outside in: A Protocol for Qualitative Study of the Implementation of Immersive Technology in Dementia Care

Abstract

Older adults living in hospitals and long-term care (LTC) settings often lack opportunities for meaningful social engagement and interaction with the outside world, particularly due to mobility disabilities and frailty. Immersive virtual reality (VR) technologies have shown potential to overcome these barriers by virtually connecting individuals with nature, familiar environments, and cultural experiences, thereby promoting well-being and social engagement. However, existing research primarily utilizes head-mounted displays (HMDs) and involves healthy community-dwelling participants, limiting relevance for people living with dementia in care settings such as hospitals and LTC. This qualitative study protocol outlines the use of a non-HMD immersive technology tailored for people living with dementia in hospital and LTC settings. Employing wall projections and motion sensors, the intervention is specifically designed for accessibility among people living with dementia in hospitals and LTC environments. Guided by the Collaborative Action Research (CAR) approach, the study comprises three phases: Plan, Implement, and Evaluate. Focus groups, interviews, and ethnographic observations will be conducted to collect data. Thematic analysis will identify key themes related to feasibility, acceptability, and user experiences. Findings will inform the equitable design and implementation of future immersive technologies in dementia care settings.

Background

Dementia significantly impacts the quality of life for older adults, their families, and caregivers, placing increasing demands on healthcare systems globally and specifically within Canada. By 2050, it is estimated that approximately 1.75 million people will be living with dementia, representing about 4.3% of the total population (Alzheimer Society of Canada, 2022). Currently, nearly 200,000 Canadians live in long-term care (LTC), with approximately 50% aged 85 or older (Canadian Institute for Health Information, 2024). In parallel, health system demands are expected to increase, with direct dementia-related care costs projected to reach CAD 18.2 billion by 2031 (Manuel et al., 2016). Dementia can influence a person’s physical and mental well-being, and it also impacts family members and caregivers in significant ways, including declining cognitive function, emotional distress, social isolation, and reduced opportunities for meaningful interaction (Goto et al., 2023; Rosdinom et al., 2013). While many individuals living with dementia experience physical mobility limitations, sensory impairments, and cognitive changes that can make social participation more difficult, especially in institutional settings such as hospitals and LTC facilities, they still retain the capacity to engage in joyful, meaningful interactions when provided with appropriate support. Therefore, innovative and inclusive solutions that reduce these barriers and promote quality of life are urgently needed.

Immersive virtual reality (VR) technology has emerged as a promising tool to enhance emotional well-being, cognitive engagement, and social interaction among older adults. VR refers to computer-generated environments that use visual, auditory, or other sensory stimuli to enable users to experience a sense of presence and participation in virtual spaces (Makransky & Petersen, 2021; Radianti et al., 2020). VR has been increasingly used to support the well-being of older adults (Healy et al., 2022), including those living with dementia, and has demonstrated positive outcomes for both care recipients and their caregivers in terms of cognitive, emotional, and relational benefits (Hung, Ma, et al., 2025; Yen & Chiu, 2021). A recent intervention study conducted among institutionalized older adults with mild dementia found that an 8-week VR-based reminiscence therapy significantly improved participants’ temporal orientation and enhanced their levels of positive thinking compared to baseline (Tominari et al., 2021). Research has shown that a 5-week cognitive training program utilizing VR technology in a supermarket scenario resulted in significant improvements in overall cognitive functioning among older adults with mild cognitive impairment (MCI), accompanied by reductions in perceived stress and depressive symptoms (Zhu et al., 2022). Additionally, individuals living with dementia have shown a positive acceptance of VR technology, particularly when it is designed appropriately (Flynn et al., 2022). An in-depth interview study involving people with Alzheimer’s disease (AD) who underwent a 5-week VR intervention revealed positive effects across three key themes: enjoyment, novel experience, and reminiscence (Kim et al., 2023).

While immersive VR offered promising outcomes, traditional VR applications predominantly employed head-mounted displays (HMDs), which posed significant barriers for older adults living with dementia, particularly those with physical discomfort, sensory sensitivities, or cognitive limitations. Commonly reported challenges associated with HMDs included eye strain, motion sickness, fatigue, and general discomfort (Carnegie & Rhee, 2015), thereby limiting broader adoption in care settings (Ijaz et al., 2022; Ke et al., 2025). Recent reviews have shown that, aside from HMD-based systems, most non-headset VR applications for older adults are screen-based and rely on motion-sensing platforms, which prioritize interactive exercise over immersive experiences and offer limited spatial or environmental engagement (Li et al., 2022; Yen & Chiu, 2021). Additionally, existing studies have primarily focused on healthy community-dwelling older adults, neglecting the unique needs and constraints experienced by those living in LTC or hospital settings (Chaze et al., 2022). Recognizing these critical gaps, this protocol addresses the necessity for non-head-mounted immersive technologies specifically tailored to the complex needs of older adults living with dementia in institutional settings. Non-HMD immersive environments, using wall projections, motion sensors, and portable technology setups, can significantly enhance accessibility and comfort, facilitating meaningful and inclusive engagement for older adults with varying degrees of cognitive, physical, and sensory abilities (Hung et al., 2023). By providing virtual access to natural scenes, familiar locations, cultural events, and interactive experiences, these immersive solutions may help promote emotional well-being, reduce isolation, and support social inclusion, thereby enhancing the overall quality of life and care experiences for older adults living with dementia. To support meaningful adoption in institutional care, immersive VR experiences must be tailored to the needs, preferences, and abilities of older adults. This includes attention to cultural context, functional and sensory limitations, and the physical care environment (Beidas et al., 2022). Addressing these factors is essential to ensuring equitable and person-centred use of immersive technologies in dementia care.

The development and implementation of VR technology necessitate collaborative, adaptive, and contextually informed approaches to ensure that the technology meets the diverse needs and preferences of users and is sustainably integrated into existing care routines and settings. Wong et al. (2024) identified critical facilitators to VR implementation, including perceived benefits of VR, integration of VR into workflow and routines, and collaboration with skilled VR champions. Conversely, barriers such as staff concerns about VR use, financial burden, competing priorities, inadequate infrastructure and physical spaces, excessive staff workload, and limited leadership support were also highlighted. As such, participatory approaches, such as Collaborative Action Research (CAR), have been recommended to navigate these real-world complexities (Bradbury, 2015). To address these considerations comprehensively, this study employs a CAR approach to actively engage users, including older adults, family members, healthcare providers, and industry partners, in iterative cycles of planning, implementation, and evaluation of the immersive intervention. This participatory approach not only facilitates user-driven design and implementation strategies but also supports ongoing adaptability to real-world contexts and evolving user needs, ultimately supporting meaningful adoption and sustainable integration within dementia care settings (Mann & Hung, 2019).

Aims

This CAR study aims to comprehensively explore the feasibility, acceptability, and user experiences associated with implementing a non-head-mounted immersive VR approach specifically designed to support meaningful engagement for older adults living with dementia in hospital and LTC settings. By utilizing immersive wall projections, motion sensors, and portable studio equipment, the intervention aims to enhance accessibility and comfort for individuals with cognitive and physical limitations.

Guided by key implementation outcomes outlined by Proctor et al. (2011), the objectives of this study include examining:

(1) Feasibility: Assess the practical aspects of integrating immersive VR into existing hospital and LTC care routines, including identifying logistical requirements, evaluating resource allocation, and determining the sustainability of the technology in daily operations.

(2) Acceptability: Examine the perceptions and receptivity of older adults, family members, care staff, and leadership towards immersive VR technology, exploring user satisfaction, comfort, ease of use, and perceived value.

(3) User Experiences: Capture detailed insights into the personal and emotional responses of participants engaging with immersive VR, focusing on observed behavioural and social interactions, mood changes, and the potential to alleviate feelings of isolation or boredom.

(4) Contextual Influences: Investigate environmental, cultural, and organizational factors that facilitate or hinder the successful implementation and sustained use of immersive VR, ensuring cultural relevance, inclusivity, and alignment with the unique characteristics of each care setting.

(5) Implementation Strategies: Co-develop practical and adaptive strategies to overcome barriers identified during the study, promoting collaborative decision-making with stakeholders, including frontline staff, management, family members, older adults, and industry partners.

By addressing these specific aims, this study aims to produce actionable knowledge that informs best practices for the equitable implementation and sustainable integration of immersive VR technology.

Collaborative Action Research Approach

This study is guided by CAR, a participatory approach that emphasizes cycles of reflection, action, and learning in real-world contexts (Bradbury, 2015). CAR is particularly suited for complex healthcare settings where collaboration and adaptability are essential. It supports the meaningful involvement of staff, people living with dementia, family members, and collaborators in shaping interventions to ensure contextually relevant and responsive care. In line with CAR principles, the study involves ongoing cycles of reflection, action, and evaluation. These iterative cycles facilitate continuous learning and real-time adaptations, ensuring the immersive technology intervention remains contextually relevant, acceptable, and responsive to user feedback. These cycles will be used to explore the feasibility and acceptability of a non-head-mounted immersive experience in hospital and long-term care environments. Through ongoing dialogue and shared decision-making, participants will help identify practical barriers to implementation, such as physical space limitations, sensory preferences, and staffing constraints. The process will also facilitate the co-development of strategies to overcome these challenges, for example, by adjusting session timing, refining facilitation approaches, or modifying the technical setup to fit the care context better. By embedding learning and adaptation into each phase, this approach will support the development of practical, user-informed implementation that can be scaled and sustained in real-world settings.

Theoretical Grounding

The Consolidated Framework for Implementation Research (CFIR) provides the theoretical foundation for this study, guiding the exploration and understanding of key contextual factors influencing technology implementation in healthcare settings (CFIR Research Team, 2023). CFIR offers a comprehensive, evidence-based framework consisting of five major domains: intervention characteristics, outer setting, inner setting, characteristics of individuals involved, and the implementation process. By applying CFIR, this study systematically examines facilitators and barriers across these domains, helping to identify essential factors that influence the successful implementation and sustainability of immersive VR interventions within dementia care settings. This theoretical approach ensures a rigorous and structured analysis of contextual influences, enabling the development of targeted strategies that can enhance the feasibility, acceptability, and adoption of non-HMD immersive technology.

Methods

We will follow the Standards for Reporting Qualitative Research (SRQR) to guide the design, conduct, and reporting of this study (O’Brien et al., 2014).

As noted above, this study will consist of three phases: Plan, Implement, and Evaluate. A descriptive qualitative design within a CAR framework will be employed to guide the study. Qualitative methods are well-suited for exploring how technologies are experienced in context, capturing emotional, relational, and practical insights that cannot be measured through standardized tools alone (MacDonald, 2012; Oranga & Matere, 2023). This approach aligns closely with the study’s goal of exploring how immersive technology can be meaningfully integrated into dementia care through three iterative phases. The research team will be actively involved in the implementation process across two distinct institutional sites, enabling contextual comparison while co-developing solutions with care providers, older adults, family members, and organizational leaders. In keeping with the CAR framework, participants will be engaged throughout the study design and implementation. Insights gathered during Phase 1 will inform the setup of the intervention in Phase 2, and findings from Phase 3 will shape future iterations of the practice.

The immersive VR system used in this study is a portable, projection-based monoscopic 3D setup that enables 360-degree visual immersion without the need for head-mounted displays. The projections will be displayed directly on walls or within a semi-enclosed, portable room that creates an immersive environment. Participants will interact with the virtual scenes using wearable motion sensors placed on their wrists, allowing natural and intuitive engagement. This non-intrusive and flexible setup will be particularly suitable for older adults with cognitive and physical limitations, offering a comfortable and accessible alternative to headset-based VR.

Phase 1: Plan

This phase will focus on collaboratively identifying the needs, expectations, and anticipated challenges of participants before implementation. Focus groups will be conducted with staff members and operational leaders at one hospital unit and one LTC facility to identify expectations, perceived opportunities, and anticipated barriers. These discussions will help shape how the immersive experience is introduced and adapted to fit local routines and environments.

Phase 2: Implement

This phase will involve introducing and adapting the immersive VR system in real-world care settings to assess feasibility in practice. Participant observations and informal, conversational interviews will be used to document real-time interactions, adaptations, and challenges that arise during the immersive experience. Attention will be paid to verbal and nonverbal cues, participant engagement, environmental conditions, and team dynamics. This phase aims to understand feasibility and identify practical strategies to support successful delivery.

Phase 3: Evaluate

This phase will seek to understand how participants experience the intervention and identify factors that influence implementation outcomes. Post-intervention focus groups will be conducted to assess how participants, older adults, families, staff, and collaborators experienced the immersive environment. Guided by the Consolidated Framework for Implementation Research (CFIR), discussions will explore what supported or hindered implementation, the acceptability of the intervention, and how it can be improved or scaled for broader use.

Sample and Recruitment

Participants will be recruited from two settings: a hospital unit and a LTC home. A total of approximately 50 participants will be involved, including care staff, older adults, and family members. In qualitative research, it is often difficult to confirm the exact sample size in advance (Koh et al., 2021). Based on the feasibility and sample sizes reported in previous studies involving the implementation of technology in dementia care (Nyumba et al., 2018; Vasileiou et al., 2018), we plan to recruit approximately 10 staff members, 10 older adults, and five family members per site. Eligibility criteria for older adult participants include a diagnosis of dementia, the ability to provide informed consent or assent, the capability to participate in light seated activities (e.g., watching, interacting, or moving arms), and the ability to communicate in English. Staff members (e.g., nurses, care aides, and recreation staff) will be eligible if they provide direct care to older adults and are willing to provide informed consent. Family members of older adults will be eligible if they can communicate in English, provide informed consent, and are willing to participate in interviews or focus groups. To ensure safety and accessibility, individuals with significant visual or hearing impairments that would prevent them from engaging meaningfully with the immersive environment will be excluded from participation.

Convenience sampling will be employed for practical and timely recruitment. Recruitment posters describing the study’s purpose and schedule will be placed in visible areas of each site and shared with care teams. An internal coordinator (staff champion) at each site will assist with identifying eligible participants and facilitating introductions to the research team. In both settings, the coordinator will approach potential participants, explain the study, and collect contact information from those interested. Researchers will then meet with participants to explain study details, confirm eligibility, and obtain written informed consent and assent.

Data Collection

The study’s data collection will follow structured methods closely aligned with the CAR approach, enabling iterative reflection, action, and adaptation throughout the research phases. See Table 1 for detailed methods across three phases to ensure a comprehensive and nuanced exploration of participants’ experiences, implementation processes, and practical insights related to the immersive VR intervention.

Table 1.

Overview of Data Collection by Phase

Phase	Key activities	Participants	Data types	Purpose
Phase 1	Staff focus group to gather baseline insights and inform the implementation plan	Staff	Audio-recorded focus group; transcript; thematic analysis	Inform implementation plan and identify initial expectations and concerns
Phase 2	Weekly immersive sessions with older adults, ethnographic observation, conversational interviews, weekly staff huddles	Older adults, staff	Observation notes, field notes, informal interviews, and huddle reflections	Explore feasibility, acceptability, and staff/user experience during implementation
Phase 3	Post-intervention focus groups with staff; semi-structured interviews with older adults and family dyads	Staff, older adults, and family members	Audio-recorded focus groups and interviews; transcript; thematic analysis	Evaluate barriers, facilitators, and contextual factors using the CFIR framework

In Phase 1, a 60-min in-person focus group will be conducted with staff at each site in a private meeting room or quiet activity space designated by the facility. Participants will be invited to share their views on organizational readiness, potential risks, and resource needs to support implementation. Guiding questions will include: What needs or impacts do you anticipate from using this technology? What challenges do you foresee? What would help support a successful rollout? The discussion will be audio-recorded, transcribed verbatim, and analyzed thematically using NVivo 15 software to generate insights into the planning process, site-specific priorities, and logistical considerations.

During the implementation phase, qualitative ethnographic methods will be employed to capture real-time data on participants’ interactions with the immersive VR technology. Older adult participants will engage in weekly 20-min immersive sessions in familiar, accessible communal spaces (e.g., activity rooms or lounges). These sessions will involve interactive, culturally relevant experiences (e.g., virtual tours, nature exploration, seated exercises such as virtual Tai Chi or dragon boat rowing). Researchers will conduct ethnographic observations and take field notes during or immediately following sessions to capture participants’ verbal and non-verbal cues, participant engagement, interaction dynamics, and environmental conditions. Additionally, brief conversational interviews will be held with participants immediately following immersive sessions to gather immediate feedback, emotional responses, and suggestions for improvement. Staff will participate in weekly reflective huddles, lasting 15–20 minutes, in nursing stations. These structured opportunities will provide a forum for discussing real-time observations, challenges, adaptations, and insights. These informal group check-ins will support continuous reflection and adaptation by providing a safe and supportive environment to discuss what is working well, what needs improvement, and what could be adjusted. To support uptake, brief visual instruction cards, reminders, and training videos will be made available on-site. The discussions and actions will be documented as field notes to support continuous implementation refinements and enhance participant engagement.

The evaluation phase will involve post-intervention focus groups and interviews to assess feasibility, acceptability, and identify barriers and facilitators to implementation. Staff focus groups, lasting approximately 60 minutes, will explore experiences and insights using CFIR domains, such as organizational culture, leadership engagement, and intervention adaptability. Specific topics include perceived benefits, implementation challenges, and sustainability considerations. Questions include: What impacts did you observe? What made the implementation easier or harder? What tools or resources supported the process? Semi-structured interviews will also be conducted with older adults and family members. These sessions will take place in private or semi-private spaces that are convenient for participants and will last approximately 20–30 minutes. Where appropriate, dyadic interviews with older adults and family members may be arranged. Interviews will explore experiences of the immersive technology, perceived value, and any observed changes in well-being or interaction. All interviews and focus groups will be audio-recorded, transcribed verbatim, and analyzed to generate practical and actionable findings that inform broader implementation.

Data Analysis

Data analysis will follow a structured and iterative process, guided by the Consolidated Framework for Implementation Research (CFIR) and the reflexive thematic analysis method (Braun & Clarke, 2021; Braun et al., 2023). This comprehensive approach will ensure an in-depth exploration of participant perspectives, experiences, and contextual factors that influence the feasibility, acceptability, and implementation of immersive VR interventions in dementia care.

The research team will begin with step 1, familiarization, by thoroughly reviewing and immersing themselves in the data. During this process, the team will repeatedly read through interview transcripts, ethnographic field notes, and reflective memos. This initial step will facilitate a deep understanding of the dataset, highlighting preliminary patterns and insights. In step 2, two independent researchers will perform detailed coding of the qualitative data, supported by NVivo 15 software. A preliminary coding framework will be developed, incorporating both deductive elements from the CFIR domains (e.g., intervention characteristics, inner setting, implementation processes) and inductive elements emerging directly from the participant data. Regular team discussions will ensure alignment, clarify coding discrepancies, and refine codes for consistency.

In step 3, theme development, coded data will be organized into meaningful themes and subthemes, capturing essential patterns, relationships, and insights relevant to the study’s objectives. Themes will reflect participants’ experiences, implementation dynamics, environmental contexts, and practical considerations, providing comprehensive insights into the use of immersive VR in dementia care. In step 4, the research team will undergo critical discussion about the identified themes to assess coherence and relevance across participant groups (e.g., staff champions and patient partners). This collaborative evaluation process will ensure that themes are coherent, distinct, and meaningfully connected to the study’s objectives and research questions. Feedback from users, including staff champions and patient partners, will be sought to validate and enhance the accuracy and relevance of the themes. In step 5, researchers will finalize themes by clearly defining and naming them, ensuring clarity, precision, and direct alignment with the research objectives. Each theme will be illustrated with representative quotes and detailed examples to ensure transparency and clarity. In the final step 6, findings will be synthesized and presented, focusing on generating practical, actionable knowledge for implementation in real-world settings. Researchers will collaboratively draft comprehensive narratives that articulate clear implications for practice, policy, and future research. Regular team reflection and validation will enhance the credibility, relevance, and applicability of reported findings. Throughout the process, analytic memos will be used to document reflections, decisions, and uncertainties. Field notes and informal observations will be coded thematically and compared with interview and focus group data to enhance analytic depth. As part of our participatory approach, emerging findings will be shared with staff champions and patient partners to validate interpretations and support transparency.

Ethical Considerations

This study was approved by the University of British Columbia’s Research Ethics Board (H25-01351). Informed consent will be obtained from all participants, with assent procedures used for older adults living with dementia. Participation is voluntary, and individuals may withdraw at any time. To protect confidentiality, pseudonyms and unique ID codes will be used, and all data will be securely stored and accessible only to the research team.

Rigour

To ensure the rigour of this qualitative study, we will follow the eight criteria for excellent qualitative research outlined by Tracy et al. (2010): a worthy topic, rich rigour, sincerity, credibility, resonance, significant contribution, ethics, and meaningful coherence. This study addresses a timely and relevant issue by exploring inclusive immersive technologies to support engagement and well-being for people living with dementia in hospital and LTC settings. Rich rigour will be achieved through diverse sampling, iterative team-based analysis, and the application of theoretical frameworks (CFIR). Sincerity will be maintained through reflexive memoing and team discussions that surface assumptions and positionality. Our interdisciplinary team, including staff champions, researchers, and patient partners, will enhance the study’s credibility and depth. We aim to produce findings that resonate with individuals living and working in care environments and will share emerging results with participants and community collaborators. The study will make a significant contribution to dementia care and implementation science by co-producing practical strategies for integrating technology. Ethical considerations will guide all phases of the research, with a focus on relational and cultural sensitivity. Finally, coherence will be ensured by aligning the research question, participatory methodology, and implementation goals throughout the study.

As a female researcher with a background in psychology, I recognize that my identity and training influence how I approach the research and interpret the data. To support reflexivity, I will maintain a research journal, write post-interview reflections, and record my assumptions before data collection. These practices will help make my positionality transparent and support thoughtful engagement with participants and data.

Discussion

This study contributes to a growing shift in dementia care research that prioritizes accessibility, inclusion, and responsiveness to real-world care contexts. Rather than simply replicating existing models of immersive technology that rely on head-mounted displays, our approach critically examines how technology can be adapted to support collective engagement, reduce implementation burdens, and enhance participation among people living with dementia who often face systemic exclusion from innovation. A non-HMD immersive system that enables shared engagement without extensive preparation may better align with the workflow of care teams. For example, the ability to run group-based sessions in a common area without the need for individualized equipment can reduce staff burden and increase opportunities for spontaneous use. Understanding how frontline staff perceive these practical aspects is essential for determining the real-world sustainability of immersive interventions in hospital and LTC contexts.

A key strength of this study is its focus on the contextual realities of hospital and LTC environments. Implementation in these settings is shaped by structural challenges, such as staffing constraints, physical infrastructure limitations, and workflow complexity, that often prevent sustained use of new technologies. Recent studies have reported that staff face challenges such as limited time, staffing shortages, high turnover, and competing clinical demands (Havaei et al., 2025; Rai, 2010), which can make it difficult to implement technology effectively. Based on a pan-Canadian study, structural support and partnerships among academics, industry, and practice are necessary for the successful implementation of technology in LTC (Hung, Wong, et al., 2025). Our non-HMD approach offers a model for embedded, low-barrier engagement that can be aligned with shared routines and group activities. However, technological feasibility is not sufficient on its own. Building trust, aligning with cultural values, and addressing power imbalances between decision-makers and users are crucial for successful implementation.

Our application of the CAR framework emphasizes the value of co-creation in addressing these challenges. It recognizes that solutions must be negotiated in the context with the people who live and work in these settings. Moreover, by including diverse groups, such as people living with dementia, healthcare providers, caregivers, and operational leaders, we aim to surface hidden tensions and identify adaptations that improve fit and usability. This participatory approach not only supports ethical engagement but also serves as a strategic method for enhancing uptake, reducing resistance, and fostering shared ownership.

Qualitative methods play a vital role in this effort, offering insight into the subtle emotional, social, and sensory dimensions of immersive experiences. These dimensions are often underrepresented in evaluations of digital health interventions. Our methodology allows for iterative learning and responsiveness, enabling the intervention to evolve in real-time in collaboration with participants. This is particularly important in dementia care, where needs and capacities may fluctuate.

Findings from this study will help address a persistent gap in implementation literature: how to design for equity and adaptability, not just efficacy. By critically examining the assumptions underlying existing VR models and prioritizing user experience, we contribute to a broader re-evaluation of how innovation is developed and evaluated in geriatric care. Our work responds to calls for more context-sensitive, co-designed, and ethically grounded technology implementation strategies. Results will be disseminated through open-access channels, policy briefs, and partnership networks to inform both practice and policy in dementia innovation.