Our study was guided by the design thinking methodology to ensure the co-created VIP in LTC prioritizes the needs, desires and challenges of the end-users (i.e., residents, family members, and staff) (Roberts et al., 2016). Design thinking methodology offers a systematic and collaborative approach to foster innovative and team-generated solutions that guides our research team to effectively engage residents, family members, and staff from the beginning of the study (Lorusso et al., 2021; Pepping et al., 2023). All participants are part of the co-design team. The design thinking process is constantly evolving and has a variety of models (Lorusso et al., 2021). Our study followed the design thinking process proposed by Stanford University’s Hasso Plattner Institute of Design (2010). The five stages include (1) empathize (the desires of our end-users and potential outcomes), (2) define (what are the potential challenges and concerns), (3) ideate (brainstorm solutions and activities in the virtual immersive programs), (4) prototype (rapid prototyping of the solution and potential activities), and (5) test (test the prototype and activities) (see Figure 1). The design process is iterative. This paper will focus on the first and second stages—empathize and define.

Participants were recruited by convenience sampling (Stratton, 2021). For resident participants, they were recruited based on the inclusion criteria: (1) residents living in the long-term care home of the study and (2) the ability to speak and express themselves. Family caregiver participants were recruited if (1) they are the family member of a resident staying at the long-term care home of the study and (2) they can speak, read and understand English. For staff participants, they were recruited if they were (1) regular or casual frontline staff working at the long-term care home of our study, (2) working in a discipline that provides direct care to residents or manages residents’ care (e.g., nurses, recreation staff, decision makers, or care aides) and (3) able to speak, read and understand English. The participants were excluded if they have (1) severe visual or auditory impairment, or (2) are sensitive to motion sickness and have a history of seizures or epilepsy. The frontline staff members (e.g., the recreation staff member and director of care) helped identify potential participants, including residents, family members and staff members at the long-term care site. The principal investigator, LH, followed up with the family member with phone calls to introduce them to the research and confirm recruitment. The research team project coordinator and trainee, JW, followed up with the residents and staff members in person to introduce them to the research and confirm recruitment.

Data collection was conducted in one LTC home in an urban area of Metro Vancouver, British Columbia, Canada. The care home is a not-for-profit care home with 230 beds, with the average age of residents being 85 years old. Sixty percent of the residents are living with mild to severe dementia, and about half of the residents are in wheelchairs.

For the empathize and define stages, two focus groups and six individual interviews were conducted from November 2023 to January 2024. After reflecting on the group dynamics in the first focus group, our team decided to conduct separate interviews with staff to ensure opportunities for all partners to share their insights, as well as to accommodate their work schedules. The first focus group was done in November 2023 and involved eight residents, six family members and three staff members. The second focus group involved participants who rejoined from the first focus group, which consisted of six residents and four family members. The second focus group along with six staff interviews were done in January 2024. Each focus group lasted for 60 min. Two residents and family members did not attend the second focus group because they were unwell or had other scheduling conflicts.

At the beginning of the interviews and focus groups, JW explained the project and what VIP was. We define VIP as fully immersive headsets and semi-immersive projections to accommodate for populations in LTC who may experience discomfort with headsets. After explaining what VIP was, participants would have the opportunity to try the virtual reality headsets and watch a one-minute video of their choice among three videos prepared by our research team, including a visit to a local food market in Vancouver, a visit to a Chinese restaurant and a trail walk in Vancouver. The headsets used were Oculus 2 headsets (see Figure 2). In the interviews and focus groups, we followed a semi-structured interview guide with the following questions:

All interview and focus group audio recordings were transcribed verbatim.

Ethical approval for this study was obtained from the University of British Columbia Research Ethics Board (Ethics ID: H23-01481). We implemented a process for ongoing consent and assent as per best practice (Diaz et al., 2025). All participants provided written informed consent. We obtained consent from the resident’s substitute decision-maker and assent from the resident themselves. Crucially, we treated this initial consent as a starting point. We continuously monitored for verbal and non-verbal signs of assent (e.g., nodding, smiling, active participation) and dissent (e.g., verbal refusal, turning away, pushing the headset away, expressing discomfort) throughout the data collection session. Participants were explicitly informed that they could pause or withdraw at any time without any consequence to their care. Participants also provided verbal consent for audio recordings and photo taking. If the participant showed disinterest or declined participation, their decision was honored without any attempt to persuade or coerce them into the interviews of focus groups. Fieldnotes were taken if the interview was consented to, but audiotaping was declined. Verbal consent was obtained for the pictures used in the paper. All identifying information in the pictures included in the paper was blurred. Pseudonyms are used in this paper to protect the anonymity of the participants and the care homes.

We conducted reflexive thematic analysis and followed the six phases to analyze the data collected from the interviews and focus groups (Braun and Clarke, 2021) to identify expectations, positive outcomes, and concerns of a VIP in LTC. (1) Two research assistants (MV and AS) familiarized themselves with the transcripts by reading and re-reading them. (2) MV and AS identified meaningful data segments and generated initial codes. (3) MV and AS shared initial codes and generated initial themes. (4) The research team, including the research assistants, the supervising researcher, LH and the other team members, reviewed and discussed the preliminary themes. (5) The research team refined and finalized our themes. (6) MV and AS drafted the findings. See Table 1 for examples of coding.

The research was led by Principal Investigator LH, an experienced researcher in the field of aging and technology, who provided overall supervision and methodological guidance. We included members with diverse expertise in our research team. There were patient and family partners with lived experience of dementia, and researchers and trainees from diverse disciplines of nursing, science, arts, biomedical engineering, occupational therapy, and computer science.

To enhance the credibility of our study, we engaged one person living with dementia not residing in LTC and two family partners with lived experiences at every stage of the research. They were involved in interview question development during monthly research meetings on Zoom, data collection sessions, and data analysis meetings over a period of 3 months on Zoom to ensure our work was relevant to the topic and ethical. Second, as a research team, the research assistants involved in the data collection sessions wrote research journals after each interview and focus group to reflect on the data collection process, practising reflexivity on how the sessions were carried out, the challenges and our individual assumptions stemming from our diverse social backgrounds. During the team meetings, the research team would discuss and challenge each other’s assumptions. To enhance the rigour and clarity of our qualitative reporting, we used the COREQ checklist to guide reporting of our study procedures and findings. See Appendix I for the COREQ checklist.

Appreciating the potential of VIPs to recreate specific experiences, residents had expressed the desire to be immersed in activities that they enjoyed, as well as given the opportunity to partake in these activities that they may no longer be able to do as a result of physical or cognitive limitations, or residency in LTC. The inclusion of familiar faces in the videos was also an essential factor in making the VIP experience more interactive and engaging.

A key expectation of an appropriate VIP is to ensure that content is tailored to residents’ unique preferences, experiences, and backgrounds as stated by one staff member, “I think [a VIP should] be individualized to the residents with their past and history.” For example, Ivan, a resident who had previously played hockey and enjoyed watching hockey games shared that being able to see a program on an enlarged screen, where it seemed that they were a player in the hockey game in real time, excited him:

For residents who previously engaged in sports and continue to especially enjoy sports, VIP can provide residents the experience of being players in sports games.

Other residents also communicated that they wanted content that enabled artistic appreciation by showcasing performances with music and dancing. A resident, Rosie, expressed, “I like dancing… [I want to see] tap dancing, ballet dancing, all kinds of dancing… a lot of figure dancing would interest me.” Some residents stated that cheerful music and dancing from an era relevant to them could actively engage and encourage other residents to dance along when seeing individuals in the VIP dancing. There were residents who preferred to see videos of day-to-day activities that they used to frequently participate in. For example, Robert shared how he enjoyed driving because it was an important aspect of his life. He thus expressed that he would like to drive again using the VIP:

This example further demonstrates how VIPs that are well-tailored according to the preferences of residents could potentially provide a sense of autonomy as well as foster personal meaning and engagement for residents in LTC settings.

Furthermore, residents shared how VIP content would be more engaging if individuals being shown in the programs were familiar and relevant to them, such as the residents themselves, other residents, or their loved ones. A resident, Paulina, shared that the videos would be boring without displaying familiar faces:

Participants emphasized that delivery was equally important in shaping a meaningful experience. Many residents noted that while passive watching was enjoyable, the impact of VIP would be significantly enhanced if it incorporated active physical elements. One resident, Sally, explained, “We need to be moving, not sitting.” This suggests that VIPs could be designed to encourage movements and support residents in staying both physically active and cognitively engaged. Another resident also appreciated an alternate viewing option of having projections on a wall or larger screen, enabling VIPs to be more inclusive for residents who may struggle to use head-mounted devices. One resident, Charlie shared, “[The video would] be great in a big square [screen]. If you could get it that way, then you can see it a little bit more.”

VIPs were expected by staff, family members, and residents to provide the ability to experience both novel and familiar worlds, enabling a sense of connection both to self and others. Staff believed that VIPs could allow residents to reconnect with their previous communities and neighbourhoods, providing a brief sense of ‘home’ while at the care home. One staff member, Tom expressed that the VIP could provide individuals unable to leave their rooms the opportunity to explore what is outside the care home:

Staff suggested that residents would be able to experience a sense of self-connection when reminiscing on their past. Another staff member, Anna commented how residents can move beyond local experiences and travel to other parts of the world, “People come from wherever [such as] Italy, and you can take them on a trip to Italy, and they do not have to leave the facility.”

Similar to staff, residents also echoed the sentiment of exploring what is outside the care home as a positive outcome expected of the VIPs. One resident, Peter shared how he expected the VIP to be a medium in which he could see parts of the world and community that he never had the chance to see: “I feel like to see a lot of the world because I’ll never see it… Get to see some places like me for never seen them… Like that Chinese restaurant. I’ve never seen it.” Furthermore, staff and family members imagined VIPs as an opportunity to provide residents novel experiences, such as extreme sports and travelling to different countries, that they might not be able to try in reality due to physical age-related limitations:

One family member, Biraj, echoed travelling as a beneficial experience for residents: “One of the things would be travel, showing different countries and different cultures would be really fascinating with a lot of color.” This example further displays that travelling to new parts of the world allows residents to potentially feel more connected to others and themselves as they learn about different cultures, including their own.

VIPs were expected to foster social connection and support overall wellbeing among residents. The program was also imagined as a practical behavioural support tool for staff within LTC by providing distraction, comfort and positive stimulation, managing agitation, and easing transitions during difficult routines.

Participants proposed that VIPs should not be designed as solitary experiences provided in headsets only, but include opportunities for dialogue, storytelling, and collective reflection to enable social connection through mediums such as an immersive projection. One staff member, George, highlighted the potential of shared reminiscence among residents with common experiences or backgrounds. George described how the residents could experience VIP together through an immersive projection:

A family member, Kim, also mentioned the creation of a shared space through a communal approach when using the projector: “Having a space for them [residents] to go to and have a projector on the wall is great, and usually there will be more than one person there and other residents.” Residents also shared how they expected VIPs to support social connections with other residents beyond verbal communications, similar to how residents had expressed motivation to dance when seeing dancing figures on the VIP. A resident, Tonya expressed a preference for singing along with other people in front of the VIP rather than by herself: “I like to sing with other people. I’m not a singer, but if everybody sings, I’m happy with it.”

In addition to fostering interpersonal bonds between residents, a VIP with communal delivery through projection can create an atmosphere of engagement among other relationships. A staff member, Sarah stated that the VIP could allow intergenerational interaction between residents, family and friends, or community members: “There can be an involvement [of the residents] with the younger generation. They [the younger generation] know more about VIP. This friend or younger family member who is visiting them [the residents] can explain [VIP] to our residents, and this is a way of discussing things.” With the VIP, residents and younger individuals could have conversations together. Residents might feel connected to younger generations while enabling younger generations to understand older people through interactions. Nonetheless, staff noted that communal formats might not always be beneficial, depending on whether the residents had formed close relationships with one another. One staff member, Yoojung, reflected, “For social interaction…although there would be some [residents that] would prefer to do it [the VIP program] on their own.”

Besides social engagement, staff consistently described VIPs as a promising means of supporting behaviour management in LTC environments. Behavioural responses are defined as actions, words, or gestures made by an individual with dementia in responding to negatively perceived stimuli in the environment and can be presented as aggression, restlessness, and paranoia (Alzheimer Society of Canada, 2019). When working with residents with behavioural responses, VIPs were viewed as unique tools for redirection. Staff also suggested the use of VIPs prior to behavioural escalation or during unexpected episodes of agitation, demonstrating that they envisioned the programs as both a preventive and responsive tool. One staff member, Kayla explained how VIPs were expected to provide calming effects for residents who frequently experienced agitation or distress:

Staff also suggested how VIP could support their care such as bathing, which could be distressing for some residents living with dementia. As one staff member Zach, reflected: “Bathing is a very difficult one for residents and then you can help them [using the VIP] be in a place that wasn’t so scary.” By immersing residents in calming or enjoyable environments, VIP was expected to reduce resistance, agitation, and fear during these care activities, ultimately making them less stressful for both residents and care staff.

One concern shared by staff and family members about having VIPs in LTC was the transition between virtual and actual reality, which entailed difficulty taking breaks from the VIP and feelings of sensory overload for residents.

Staff demonstrated concern over residents enjoying the VIP to an extent where it became disruptive in necessary daily routines and care administered by staff, such as meals and medication administration. A staff member, Adrien vocalized the concern that residents might refuse to stop watching the VIP: “If it were to cause them [residents] to be upset [when the staff] interrupt [them using VIP] for when they need care or medications, residents may say “no, no just leave me alone,” that could be a problem.”

Another concern expressed by staff was the potential of VIPs in causing disorientation and sensory overload for residents. Given the immersive visual and audio effects of these programs, some residents might feel overwhelmed. One staff member, Sam stated,

A family member, Ella also echoed this concern that residents may experience difficulties adapting their sense of proprioception in actual reality after taking off the VIP headsets. She mentioned, “My only concern is if it [the VIP] makes the person dizzy, or if they have balance issues, depending on what you are looking at, it [the VIP] can make you feel dizzy.” Staff and family members expected the VIPs to consider measures to address the challenges related to transitioning residents from the virtual immersive program to actual reality due to disturbances in care routines, being overwhelmed by the immersiveness, and having feelings of disorientation.

Staff believed that technical barriers would reduce the applicability of the VIPs. Staff positioned themselves as an integral part of the VIP experience, even while not being immersed in it directly. The usability of the program was not framed as a resident-only issue, but as a shared process where staff competency directly shaped residents’ engagement. Staff considered their technical ability to navigate the equipment a determining factor of how smooth and enjoyable the experience would be for residents. Several staff members reflected on their own learning curve of their previous experience using VIP headsets, noting that it was not always intuitive to operate the system or to set it up efficiently for resident use. A staff member, Victoria stated,

Some staff voiced concerns that even with their support, VIPs would remain inaccessible to some residents, such as individuals with advanced dementia. As one staff participant, Palak described,

Staff further highlighted their doubts on engaging residents who might not fully understand what they were seeing or the VIP technology. For example, residents might not realize that the content being viewed was not physically present or accessible. Even if residents understand, they may be unable to communicate that they understand and want to participate, leading staff members to perceive themselves as needed mediators when using VIPs with residents and compromising the autonomy of residents. A staff member, Evan, explained, “It’s very hard to teach somebody [the residents] and say to them, “We’ll go over here [a spot in the VIP] and go there [another spot in the VIP],” but you are not in [the VIP experience].” With VIPs offered through headsets particularly, the need to guide residents through a sensory world that staff could not simultaneously inhabit intensified staff concerns about using VIP with residents living with dementia. The gap between what staff could see and what residents were experiencing created a significant barrier to participation.

With respect to expected positive outcomes and desires of a VIP, participants have reported their desire for VIPs to have personalized content and interactions, enable exploration outside LTC, and support for care and communal experiences. The anticipated concerns of a VIP include over-engagement and immersion, and challenges in technological literacy hindering access for residents and staff engagement. Reflecting on the expectations and concerns of end-users in LTC, our team suggests practical tips for care homes or future research studies continuing to the ideate, prototype, and testing stages in co-designing similar VIPs using the following recommendations.

IMAGINE:

Our paper includes diverse voices from residents with dementia that are often socially marginalized, as well as perspectives of family members and staff which are typically not included in research studies geared towards programs for residents in LTC. We engaged patient and family partners who provided their lived experiences in our research process, including the data analysis phase. However, our data was collected from a small participant sample size from one LTC home in British Columbia, Canada, which may not be representative of the broader Canadian population, as well as individuals in rural and remote regions within or outside Canada. Valuable insights from other residents, family members, and staff may have been accordingly missed. There is also a lack of cultural representation among participants due to the residents’ demographics in the two LTC homes we worked with. We may have missed insights specific to other cultural groups.