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Learn more: PMC Disclaimer | PMC Copyright Notice Innov Aging . 2026 Mar 15;10(5):igag021. doi: 10.1093/geroni/igag021 Search in PMC Search in PubMed View in NLM Catalog Add to search Implementing virtual reality training for person-centered communication in dementia care: a longitudinal qualitative study Marie Y Savundranayagam Marie Y Savundranayagam , PhD 1 School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada 2 Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada Find articles by Marie Y Savundranayagam 1, 2, ✉ , Annette Schumann Annette Schumann , PhD 3 School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada 4 Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada Find articles by Annette Schumann 3, 4 , Grace Norris Grace Norris , MSc 5 Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada Find articles by Grace Norris 5 , Jennifer L Campos Jennifer L Campos , PhD 6 KITE Research Institute, University Health Network, Toronto, Ontario, Canada 7 Department of Psychology, University of Toronto, Toronto, Ontario, Canada Find articles by Jennifer L Campos 6, 7 , Joseph B Orange Joseph B Orange , PhD 8 School of Communication Sciences and Disorders, Faculty of Health Sciences, Western University, London, Ontario, Canada 9 Canadian Centre for Activity and Aging, Faculty of Health Sciences, Western University, London, Ontario, Canada Find articles by Joseph B Orange 8, 9 Editor: Jennifer R Turner Author information Article notes Copyright and License information 1 School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada 2 Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada 3 School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada 4 Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada 5 Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada 6 KITE Research Institute, University Health Network, Toronto, Ontario, Canada 7 Department of Psychology, University of Toronto, Toronto, Ontario, Canada 8 School of Communication Sciences and Disorders, Faculty of Health Sciences, Western University, London, Ontario, Canada 9 Canadian Centre for Activity and Aging, Faculty of Health Sciences, Western University, London, Ontario, Canada ✉ Address correspondence to: Marie Y. Savundranayagam, PhD. E-mail: [email protected] Roles Jennifer R Turner : PhD , Decision Editor Received 2025 Aug 18; Accepted 2026 Feb 18; Collection date 2026. © The Author(s) 2026. Published by Oxford University Press on behalf of the Gerontological Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact [email protected]. PMC Copyright notice PMCID: PMC13076933 PMID: 41988142 Abstract Background and Objectives Be EPIC-VR, developed to improve dementia care by teaching person-centered communication skills through virtual reality (VR) simulation training, integrates conversational artificial intelligence and structured feedback. Although VR training offers unique immersive learning experiences, implementing it to train care providers in long-term and home care settings remains challenging. This study aimed to examine factors influencing the implementation of Be EPIC-VR. Methods This longitudinal qualitative study was guided by the Consolidated Framework for Implementation Research. Eight managers from 4 care organizations participated in semi-structured interviews pre-implementation, 2 weeks post-implementation, and 5 months post-implementation. Data were analyzed using the framework method. Results Three themes emerged across time points: (1) a strong perceived need for dementia-specific person-centered communication training, indicating an urgency for change; (2) Be EPIC-VR’s alignment with organizational values around person-centered and learning-centered care fostered engagement and sustained commitment; and (3) openness to VR training increased over time as managers observed implementation-relevant signals of feasibility and fit. Initial concerns about technology, staffing, and workflow integration diminished through experience and facilitator support. Managers developed tailored strategies such as phased rollouts, peer champions, and timing training to mesh with operational needs. Discussion and Implications Successful implementation and early sustainment planning required aligning Be EPIC-VR with organizational goals and workforce priorities. Experiencing Be EPIC-VR helped ease managers’ concerns about staffing, technology, and compatibility with workflows and organizational values. Findings highlight the value of longitudinal qualitative inquiry and working collaboratively with managers to inform integration of VR-based training in dementia care. Keywords: Dementia care, Virtual reality, Intervention, Implementation, Consolidated Framework for Implementation Research Innovation and Translational Significance: This study examined factors influencing the implementation of Be EPIC-VR in long-term care and home care. Be EPIC-VR uses conversational artificial intelligence to help staff build person-centered communication with immediate feedback. Using the Consolidated Framework for Implementation Research, we interviewed managers in 4 organizations before, after, and 5 months later. They reported an urgent need for dementia-specific communication training, strong cultural fit, and increasing acceptability as signals of feasibility and relative advantage; key barriers were backfilling and workflow. Strategies such as protected time, small cohorts, peer champions, educator support, and online delivery offer guidance for integrating VR-based training. Introduction Virtual reality (VR) provides immersive simulations that enhance learning and skill retention in healthcare training. 1 , 2 In dementia care, VR-based interventions can foster empathy and staff confidence, and provide safe practice opportunities, 3–7 largely through first-person perspective-taking. 8 However, most VR interventions remain passive and do not develop active communication skills. 3–5 , 9 Be EPIC-VR addresses this gap by combining empathy-building with active skills practice and structured feedback to strengthen person-centered communication and responses to responsive behaviors. Modules use speech recognition and conversational artificial intelligence to enable interactions with culturally diverse avatars, with feedback from avatar responses, in-simulation cues, peers, and facilitators. 10 Personal support workers (PSWs) provide most hands-on care and communication support for people living with dementia across long-term care (LTC) and home care, with limited training in person-centered communication. 11 Despite evidence of effectiveness, VR uptake in LTC is constrained by limited paid time for training, insufficient managerial support to integrate VR into workflows, and competing operational priorities. 8 Technology acceptance models, 12 , 13 explain individual willingness to adopt technology but are less suited to understanding how complex interventions are introduced, embedded, and adapted within organizations. 14 , 15 Conversely, the Consolidated Framework for Implementation Research (CFIR) 16 is a structured approach to examining implementation determinants across 5 domains: outer setting, inner setting, innovation, characteristics of individuals, and implementation process. Organizational context shapes adoption and sustainment, reflecting outer setting external pressures (eg, policy and funding) and internal setting features such as culture, structure, and capacity for learning 16 Prior work shows that alignment between innovation and organizational mission supports engagement and credibility. 17 , 18 Individual perceptions, planning processes, and innovation features (eg, adaptability and relative advantage) further influence fit with organizational workflows and priorities. In LTC and home care settings, managers, often regulated clinicians, hold authority over whether and how workforce training innovations are implemented. They oversee PSWs, coordinate education and onboarding, allocate staffing and training resources, and integrate new initiatives into existing workflows. Consequently, they strongly influence organizational readiness, feasibility, and early sustainability of training interventions. The goal of implementing VR training is not the technology itself, but its potential to support sustainable training infrastructure, strengthen staff communication practices, and enhance care experiences for people living with dementia. Given the complexity of implementing a unique VR training program, we used a longitudinal design to examine how determinants of implementing Be EPIC-VR evolved across pre-, post-, and follow-up phases. The present study aimed to investigate factors influencing the successful implementation of Be EPIC-VR from the perspective of managers in LTC and home care settings. Although PSWs are often supervised by regulated staff such as nurses or team leads, managers hold organizational authority over workforce training decisions, including approval, resourcing, and integration of new interventions into workflows. Using CFIR as a guiding framework, we focused on the perspectives of managers with decision-making authority to support staff participation and foster organizational conditions that promote person-centered communication practices. Methods Study design We conducted a longitudinal qualitative study (pre-, post-, 5-month follow-up; Table 1 ). Table 1. Overview of study phases, measures, and timeline. Phase Measure Timeline 1 Pre-implementation interviews 1-2 weeks before Be EPIC-VR 2 Be EPIC-VR training with 8 managers 2 sessions over 2 weeks Post-implementation interviews 1-2 weeks after Be EPIC-VR 3 Be EPIC-VR training with 8 PSWs (2 per organization) 2 sessions over 2 weeks Follow-up interviews 1-2 months after PSW Be EPIC-VR training Open in a new tab Abbreviation: PSW = personal support worker. Participants Eight managers from 3 LTC settings and 1 home care agency in London, Ontario, Canada, participated. Eligible participants were managers aged 18 years or older who oversaw direct care staff in an LTC or home care setting and could participate in English-language interviews. Although LTC often involves individuals with higher care complexity, home-dwelling individuals may also have moderate-to-advanced dementia where aging in place is prioritized; care needs can overlap across settings. 19 , 20 Table 2 includes demographic and occupational characteristics. Participants held roles, including directors/associate directors of care, clinical and nursing managers, and staff development/education coordinators. Ethics approval was obtained from Western University’s Research Ethics Board (REB# 121543). All participants provided written consent. Table 2. Descriptive characteristics of managers. Variable N % Mean ( SD ) Age (years) 46.38 (11.2) Gender Female 7 87.5 Male 1 12.5 Race Black 1 12.5 Latin American 1 12.5 South Asian 1 12.5 White 5 62.5 Educational degree College 5 62.5 University bachelor’s degree 3 37.5 General work experience in care settings (years) Long-term care 8 19.75 (15.2) Home care 8 2.0 (3.4) Work experience providing care for person living with dementia (years) 8 12.54 (13.6) Work experience in managerial position (years) 8 6.33 (6.9) Current employment (years) 8 6.3 (6.9) Open in a new tab Abbreviations: N = sample size; SD = standard deviation. We used purposive sampling to recruit managers with organizational responsibility for workforce training and implementation decisions involving PSWs. Organizations were eligible if they had expressed interest in Be EPIC-VR during proposal development, via letters of support or direct contact with the research team. Consistent with CFIR, 16 , 21 managers were selected because they approve training, allocate staffing/training resources, and support implementation and sustainment within workflows. Although many participants held nursing credentials and supervisory responsibilities, inclusion was based on organizational decision authority rather than frontline task supervision. Organizational interest was treated as contextual, rather than as a marker of effectiveness or representativeness. The target population comprised LTC and home care settings that were positioned to consider or implement workforce training innovations, and managers with decision authority over training and implementation. We recruited more than one manager per organization to capture role-complementary perspectives (eg, operational and training leadership) and to support within-site triangulation; this design prioritized analytic depth within organizations over breadth across sites. Intervention Be EPIC-VR is delivered remotely in small groups over 2 sessions, 1 week apart ( Figure 1 ), following a 1-hour onboarding to VR. Session 1 (6 hours) includes Modules 1-2; Session 2 (5 hours) includes Modules 3-4. Modules 1 and 4 are pre- and post-assessments, including online surveys and a VR simulation, that assess person-centered communication. Modules 2 and 3 combine brief e-learning, small-group VR practice, and facilitated discussion focused on person-centered communication during daily care and on recognizing and responding to responsive behaviors and delirium. Figure 1. Open in a new tab Overview of the Be EPIC-VR training program. Procedure Semi-structured, 1-hour interviews were conducted with each manager at 3 intervals: pre-implementation (Phase 1), post-implementation after managers completed training (Phase 2), and follow-up after PSW training (Phase 3). Interviews were audio-recorded, transcribed verbatim (see online supplementary material section for interview guides), and guided by CFIR 16 across phases to assess anticipated determinants, early impressions, and process-related factors such as planning and engagement. Data interpretation We used the Framework Method’s 5 iterative stages to guide our analysis across all 3 phases: familiarization, identifying a thematic framework, indexing, charting, and mapping/interpretation. 22 Although CFIR informed our interview guides and initial analytic orientation, we began with open coding to capture participants’ own language and remain open to unanticipated ideas. This reflects prior applications of the Framework Method and CFIR-guided studies, which advise starting with open coding even when guided by an a priori framework. 21 , 23 , 24 During familiarization, 2 researchers independently reviewed 2 pre-implementation transcripts, reading them in full, listening to audio recordings, and began open coding by noting initial impressions, strong or divergent perspectives, key ideas, and recurring topics. From these initial codes, we developed a provisional thematic framework that integrated deductive CFIR constructs with inductive themes emerging from the data. We applied this draft framework to 2 additional transcripts, holding team meetings to compare coding, refine definitions, collapse or split themes, and reorder categories until we achieved consensus on a stable analytic structure. Coding decisions were documented in analytic memos to ensure transparency and guide iterative refinement. We then indexed all transcripts from Phases 1 to 3 using both CFIR-informed and inductive codes. Data saturation was reached by the fifth transcript in Phase 1, the third transcript in Phase 2, and the second transcript in Phase 3, with no new CFIR constructs or inductive codes emerging beyond these points. We summarized the indexed data in a matrix with cases as rows and CFIR domains and themes as columns, populating each cell with concise summaries of participant comments and illustrative quotations. This charting step provided a visual overview that allowed us to compare themes across timepoints and care settings and to track how facilitators and barriers evolved. Finally, in full-team workshops, we revisited earlier analytic decisions, verified the coherence of each theme/subtheme across the data set, and used the longitudinal design to assess if interpretations held across time and settings. Final themes were supported by exemplar quotations to enhance credibility. Results Three main themes persisted across timepoints: (1) the need for dementia-specific person-centered communication training, (2) alignment with organizational cultures, and (3) an openness and ability to adapt to VR-based training. Each theme included subthemes that shifted from inner setting pre-implementation to innovation post-implementation. All subthemes were confirmed at the follow-up timepoint, along with one new subtheme related to CFIR’s process domain. Figure 2 summarizes CFIR mapping, and Table 3 includes exemplar quotations. Figure 2. Open in a new tab Longitudinal shifts in implementation determinants across CFIR domains. Table 3. Exemplar quotation of managers from each subtheme within the 3 main themes, including pre- and post-implementation, and 5-month follow-up. Theme Subtheme Exemplar quotation Need for dementia-specific person-centered communication training 1.1 Gaps in training content and access (pre-implementation) “In LTC, you know the staffing ratio. So, what happens with the PSWs…they are all always task oriented. They are never person-centered… if they would learn more about how they can effectively communicate…that’s the best thing that could happen to LTC.” (M101, LTC) 1.2 Maintain a skilled workforce (pre-implementation) “We have a client-centered business here…in order to be client-centered, our employees have to know what they’re doing and be comfortable with all kinds of scenarios. So, I really think that this will enhance what we’ve already been doing.” (M201, Home Care) 1.3 Be EPIC-VR addresses training needs of new staff (post-implementation) “When we are hiring the new PSWs, they come with zero knowledge… there’s no other initiative out there…other than Be EPIC which could do it.” (M101, LTC) 1.4 Improved communication to address responsive behaviors (post-implementation) “Be EPIC is something which is going to teach everyone how you can communicate with the resident… and how to de-escalate the triggers before it becomes a responsive behavior.” (M101, LTC) (follow-up) “She was able to guide resident’s emotions towards the needs… she said it was a wonderful feeling when she did that.” (M101, LTC) Alignment with organizational culture 2.1 Prioritizing staff well-being and training (pre-implementation) “Our main thing is to make sure that they’re safe and that caregivers are safe… that’s the main thing for us.” (M201, Home Care) 2.2 Commitment to person-centered, culturally responsive care (pre-implementation) “I like the focus, that it’s person centered. We’re about relationship-centered care… it builds on our strategic plan and our values.” (M301, LTC) 2.3 Recognized benefits for PSWs’ well-being (post-implementation) “I feel like that’s just going to bring a better life for both residents and the staff.” (M101, LTC) 2.4 Enhancing person-centered and inclusive care practices (post-implementation) “Be EPIC will teach you how to enter their world and speak their language… that will bring a huge change in resident care.” (M101, LTC) Openness and adaptation to VR training 3.1 Unclear impact on resource requirements (pre-implementation) “As long as we are able to backfill and have staff on the floor… that would be the only challenge.” (M301, LTC) 3.2 Concerns about less tech-savvy staff (pre-implementation) “I don’t know that a lot of caregivers will have had experience with it… some of our older caregivers might struggle.” (M201, Home Care) 3.3 Fit with workflows (pre-implementation) “That [the remote delivery] is always a bonus for me…Our learning will not be disrupted because of outbreaks… those pieces are important to us. Continuity.” (M302, LTC) 3.4 Adaptable delivery eased resource strain (post-implementation) “It is much easier for me to move 2 or 3 staff from the floor than having to move 12 people, right? Or 9 people or 10 people.” (M103-LTC) 3.5 Facilitator support improved comfort with VR (post-implementation) “You helped with my fears and that anxiety… if I can do it, anybody can do it.” (M301, LTC) 3.6 Tailoring implementation strategies (follow-up) “I think starting small and then seeing how it works… that’s the way to go.” (M301, LTC) Open in a new tab Abbreviations: LTC = long-term care home; PSW = personal support worker. The results are presented chronologically within each theme, beginning with pre-implementation findings and followed by post-implementation and follow-up observations. Theme 1: need for dementia-specific training Managers identified gaps in dementia-specific training that compromised staff preparedness and the quality of care prior to implementation. Post-implementation, they confirmed that Be EPIC-VR addressed the identified needs. Gaps in training content and access—inner setting domain: tension for change Managers described a persistent tension for change driven by 2 interrelated barriers: deficits in the content of person-centered communication training and limited access to training. Person-centered communication, especially when addressing responsive behaviors, was identified as a major deficit in dementia care. Managers described PSWs’ care practices as “non-person-centered,” “task-oriented,” “verbally abusive,” and “aggressive,” reflecting their perceptions of gaps in dementia-specific communication training. As one manager described: “Anything that you are going to develop that can help the staff to manage the responsive behaviors. Then it’s going to be fantastic because that’s the area everyone struggles” (M101-LTC-Pre-Implementation). These communication challenges were compounded by gaps in dementia-specific knowledge, skills, and attitudes, especially among newer PSWs with minimal exposure to experiential-based learning or experience with persons living with dementia. We’ve had quite a few fresh graduates, and I’ve noticed just over the last month some comments about dementia and delirium are maybe not as good of an understanding as they could have had in the schooling, so I think [Be EPIC-VR] would give them that opportunity to see and engage and learn how to respond more appropriately. (M302-LTC-Pre- Implementation) Although the need for dementia-specific training was acknowledged, the COVID-19 pandemic disrupted organizations’ capacities to deliver it. In-person sessions were halted, and staffing shortages left little time or flexibility for learning, despite high demand from PSWs themselves. I think the biggest challenges over COVID-19 pandemic was the lack of education for staff to attend […] Our staff are eager to learn…They’ve missed having training opportunities over the last two to three years. We haven’t had any learning like none. (M301-LTC-Pre-Implementation) Maintain a skilled PSW workforce—outer setting domain: external (performance measurement) pressure Alongside internal training disruptions, managers faced growing external expectations to demonstrate high-quality care. In LTC settings, provincial policy required the hiring of staff educators to support ongoing PSW development. We do have a staff educator in all LTC homes. So that’s something new happened after the pandemic… So, [the Ministry of LTC] found that the continuing education for the nurses or healthcare workers is important… the staff educator has been hired in each LTC home because they have found that they need that extra support to get that education out there to staff members. (M101-LTC-Pre-Implementation) In for-profit home care, training was framed as a business imperative, reflecting external pressure within the outer setting domain, where organizational survival and competitive advantage depended on the ability to deliver person-centered care. This heightened the urgency to adopt reliable and scalable training solutions like Be EPIC-VR. These findings highlight a tension for change shaped by limited access to dementia training, financial concerns, gaps in PSW communication skills, and external pressures to deliver person-centered care. After implementation, managers’ discussions shifted from contextual factors to Be EPIC-VR’s relative advantage. They described how Be EPIC-VR addressed training gaps identified earlier in the 2 subthemes listed below. Be EPIC-VR addressed training needs of new staff—innovation domain: relative advantage Post-implementation, managers highlighted Be EPIC-VR’s contribution to onboarding and early-career training. The program was seen as an effective solution for preparing PSWs who often entered care environments with little or no prior experience in dementia-specific communication. Managers appreciated the program’s practical focus and immersive design, which addressed foundational knowledge gaps through active learning. Compared to existing didactic or passive training, managers described Be EPIC-VR as a way for PSWs to practice communication skills, receive feedback, and build confidence in a safer and more realistic environment before applying these skills on the job. There’s really no comparison, to be honest with you. Be EPIC gives the individual a safe space to practice interactions…with real life scenarios…this gave the learner an opportunity to put things to practice without being fearful of doing something wrong. (M402-Home Care-Post-Implementation) Managers also emphasized that Be EPIC-VR filled the knowledge-to-practice gap found in other training programs. I have to discipline staff who have received {redacted} training, who never implemented it. And I had to discipline them for either being verbally abusive or aggressive towards residents. So, the actual information didn’t get out there, even though they were certified…Be EPIC is going to be successful, and people are going to prioritize it . (M101-LTC-Post-Implementation) Perceived benefits of Be EPIC-VR for new staff were reinforced during follow-up interviews. Managers emphasized the program’s use of adult learning principles, which may be particularly helpful for newcomers to Canada with different language backgrounds. Our ladies who come to us brand new, who are new to Canada, don’t have much training… Having this different training would be very helpful because it’s that reading it, seeing it, and then applying it. I think that it would be good for the people who really struggle with language. (M201-Home Care-Follow-Up) Collectively, these findings demonstrate how Be EPIC-VR filled a training gap for new hires. Its clear structure, immersive format, and staged delivery offered a distinct advantage over existing didactic programs, reinforcing its perceived relevance and usability for onboarding. Improved communication to address responsive behaviors—innovation domain: relative advantage Along with Be EPIC-VR’s value for new hires, managers expressed confidence in its potential to improve person-centered communication and staff responses to residents/clients’ needs. Immediately after completing the training themselves, managers noted that it encouraged self-reflection on how their own behaviors could influence resident/client reactions. This potential was especially apparent to managers who recognized the link between communication style and responsive behaviors: “Be EPIC is going to teach everyone how you can communicate with the resident. And how to identify the triggers. And how to de-escalate the triggers before it becomes a responsive behavior” (M101-LTC-Post-Implementation). Managers were optimistic that the training would reduce unsafe or reactive practices and help PSWs handle difficult scenarios more calmly and confidently. We have a high number of residents-to-staff incidents where the residents are physically responsive and the staff are getting punched or kicked. So, for the resident’s quality of life and their safety and the staff safety, I think Be EPIC is so important…You want to de-escalate the situation, but if you can use communication to prevent a situation altogether, then we’re farther ahead. (M301-LTC-Post-Implementation) Some also noted Be EPIC-VR’s potential to reduce the need for chemical or physical interventions. I would hope that after the training that staff would use a different approach. They’d use their skills and knowledge and interact with the resident in a different way, so…I would hope that we would see a reduction in responsive behaviors…and hopefully maybe even see a gradual reduction in antipsychotic medication because they’ve used like non-pharm strategies too. (M301-LTC-Post-Implementation) At the 5-month follow-up, managers provided concrete examples of how Be EPIC-VR led to improvements in staff communication and resident care. They observed that PSWs were more confident, attentive, and proactive in addressing responsive behaviors, leading to safer and more person-centered care. She was able to listen and observe the need of the resident at that moment. Rather than going “Mr. Smith, let’s go get dressed,” and “let’s go,” she offered a choice. She was able to direct the resident on what she would like to do, even though resident had a little bit of struggle to get there, but she was able to guide resident’s emotions towards the needs. She said it was a wonderful feeling when she did that. (M101-LTC-Follow-Up) Managers reported that the training helped staff interpret resident/clients’ non-verbal cues and respond earlier to distress, preventing escalation: “I definitely think it teaches the individual to pay more attention to nonverbal cues, and the environment, which is something that I think a lot of us need to pay more attention to and be aware of” (M402-Home Care-Follow-Up). These accounts reflect managers’ observations and interpretations of staff practices following training, rather than independently measured changes in PSW behavior. Together, post- and follow-up interviews indicate that managers perceived Be EPIC-VR as offering relative advantage and increasing compatibility with workforce needs, and reinforced their confidence in continued implementation. These outcomes reinforce existing organizational values and show how the training aligned with organizational culture. Theme 2: intervention alignment with organizational culture Before implementation, managers emphasized the importance of organizational values that support PSWs, ensure resident/client safety, and provide culturally responsive care. These values reflected a culture of both learning- and recipient-centeredness within the inner setting. Following implementation, managers described how Be EPIC-VR reinforced these values through observed improvements in staff well-being, communication, and inclusive care practices. These findings illustrate how the innovation aligned with and helped to operationalize existing organizational priorities. Prioritization of staff well-being and training—inner setting domain: culture—learning-centeredness Learning-centeredness refers to an inner setting culture valuing safety, continuous improvement, and evidence-based practice. 16 Prior to implementation, all managers prioritized PSWs’ safety and well-being, especially those in home care whose staff are alone with clients. Managers also valued ongoing dementia-specific training at all career stages, especially programs that recognize each resident/client’s uniqueness and the need for individualized care. Learning is always a good opportunity. You can never really say “I have encountered all the situations with all people with dementia”…it could be people that we have worked with for 15 years but still this one time they’ve gone to someone who’s completely different, who has taken them by surprise. I think that learning always improve us to a greater extent in giving that care and understanding. (M202-Home Care-Pre-Implementation) Commitment to person-centered, culturally responsive care—inner setting domain: culture—recipient-centeredness Recipient-centeredness, referring to shared values and norms about caring for and supporting residents/clients, was central to the organization’s culture. 16 All managers described their organizational values as focused on meeting the needs of their residents/clients. A core principle in person-centered care is understanding, acknowledging, and incorporating an individual’s history, values, and background into care. 25 Managers emphasized that building trusting relationships requires understanding residents’ diverse identities. Training and education were viewed as essential for supporting culturally responsive, person-centered care given the diversity of their residents/clients. “I believe that it’s the training that enables you to see what the situation is, to see how to redirect a client, different clients with different backgrounds” (M202-LTC-Pre-Implementation). This commitment included recognizing and respecting residents’ cultural practices, religious observances, and personal preferences in daily routines. We need to know that individual as they are and how they would be in their community and respect their rights and their choices that they would respect in their community. So, absolutely, we need to be able to adjust a routine to allow a prayer moment… we really need to know who we are supporting, and that’s resident-centered, resident relationship building process that we have here. (M302-LTC-Pre-Implementation) Following implementation, managers confirmed Be EPIC-VR aligns with the organizational culture of both learning- and recipient-centeredness as outlined in the following. Recognized benefits for PSWs’ well-being and performance—inner setting domain: culture—learning-centeredness After the Be EPIC-VR training, managers reported PSWs felt more competent, confident, and satisfied with their roles. …we do have a high population of residents with dementia. So that puts an impact on staff when they don’t know how to manage the behaviors, and they always are quite stressed out…So I feel like once we know how to bridge the gap of knowledge and make their life better by treating or caring for the residents differently, I feel like that’s just going to bring a better life for both residents and the staff. (M101-LTC-Post-Implementation) Managers also observed increased staff confidence and emotional capacity when applying communication techniques in daily care routines. One (PSW) shared that the training helped her with a resident who’s very resistive with morning care, and the way that she speaks to this resident, she’s used the tips in the training, and she’s much more successful. And the resident is much more agreeable and comes with her, and she’s able to get the care done a lot easier because of what she’s learned and how she’s changed how her approach and how she communicates with that person. (M301-LTC-Follow-up) Finally, managers appreciated the safe learning space of the virtual environment for staff, especially for practicing how to respond to responsive behaviors. Be EPIC is an amazing and safe way to train staff how to respond to responsive behaviors in a safe manner. They’re protected…Whereas, if you have to do that in the moment with a real-life scenario, you could run into difficulties . (M402-LTC-Post-Implementation) Enhancing person-centered and inclusive care practices—inner setting domain: culture—recipient-centeredness Across phases, managers confirmed that Be EPIC-VR aligned with their organizational values of inclusive, person-centered care by equipping PSWs to better interpret resident/client needs, communicate empathetically, and adapt care to diverse backgrounds. Our main goal, we’re always client centered…It really fits hand in hand with your philosophy, your training. (M201-Home Care-Post-Implementation) Managers valued the opportunity for staff to practice person-centered communication with culturally diverse avatars, noting that immersive practice can increase comfort and competence in navigating complex care interactions and foster safer, more responsive dementia care. “Even if they would practice five minutes a day with the resident, what we are learning in Be EPIC, that will bring a huge change in resident care” (M101-LTC-Post-Implementation). Be EPIC-VR’s diversity-integrated design supported safer care by promoting empathy, cultural humility, and a deeper understanding of residents/clients’ backgrounds. At follow-up, managers reported that Be EPIC-VR reinforced culturally responsive, person-centered care, helping staff uphold dignity and autonomy by respecting each person’s identity, history, and choices. We want to make sure that even if they meet their friends, their friends are not thinking, “you have dementia, and you can’t look after yourself well.” I feel like that part mostly resonates with what we do… to maintain their dignity, to give them the respect that they deserve, to give them a chance to make a choice and respect their culture, their history, or where they come from. (M202-Home Care-Follow-Up) Managers anticipated that Be EPIC-VR would contribute to a broader cultural shift within their organizations, elevating care quality. They anticipated that Be EPIC-VR would help PSWs use more person-centered communication, especially to address responsive behaviors and improve the quality of care. So, with Be EPIC…it’s going to bring lots of changes, and that’s going to change the culture, the way that they discuss things with residents are to pause and prioritize their needs, or to even closely observe what is their behaviors. And what is the reason or try to redirect them with a different question. So, I feel like all those little things that would make residents’ life better or the care better on that with the main focus of Be EPIC. (M101-LTC-Post-Implementation) These observations reinforced Be EPIC-VR’s alignment with organizational priorities on staff safety and development, and values of fostering a culture of responsive person-centered care. Theme 3: openness and adaptation to VR training The final theme was managers’ openness to using and adapting to VR for training within their organizations. Early concerns included unclear resource requirements, challenges for less tech-savvy staff, and the need for compatibility with workflows. Be EPIC-VR’s adaptable delivery, including small group sessions and flexible scheduling, along with facilitator support and on-site assistance, helped ease concerns about resource strain and staff readiness following implementation. Moreover, managers recognized the training’s relative advantage over existing training that used passive and didactic approaches and began planning for sustainable implementation. Unclear impact on resource requirements—inner setting domain: available resources Managers discussed available resources, a key CFIR construct encompassing funding, space, materials, and staffing needed to support implementation. Although they initially needed more information about the resources required to implement Be EPIC-VR, they confirmed that their organizational infrastructure could support training. This included access to individual training spaces and Wi-Fi-connected laptops with cameras. “We would be setting them [PSWs] up in the office, so they access the right amount of [internet] power and [computer] equipment” (M201-Home Care-Pre-Implementation). However, backfilling during an ongoing staffing shortage was the major barrier: “As long as we are able to backfill and head staff on the floor to make them free for training, that would be the only challenge” (M301-LTC-Pre-Implementation). Additionally, managers inquired about training-related expenses. These included clarity on all costs, such as training and shift coverage compensation, meals, and transportation. It’s going to be the cost of the training…is it going to include lunch? Then other trainings we do pay for where they’re coming, and we are paying them by the hour for that [transportation]. (M202-Home Care-Pre-Implementation) Concern about less tech-savvy staff—inner setting domain: culture—learning-centeredness Prior to implementation, PSW’s comfort with VR was a common concern among managers, also reflecting their own limited experience with VR technology. A few noted that their organizations had VR headsets as recreational tools for LTC residents, but PSWs had little to no experience using them. Consequently, some managers were concerned that VR could be intimidating for staff unfamiliar with advanced technology: “I don’t know that a lot of caregivers will have had experience with it [VR]…some of our older caregivers might struggle a bit with the technology” (M201-Home Care-Pre-Implementation). They also anticipated that less tech-savvy staff would need additional support: “We do have some more mature PSWs that aren’t great with technology and need a little bit more cueing and direction” (M103-LTC-Pre-implementation). Fit with workflows—inner setting domain: compatibility Compatibility of Be EPIC-VR with existing workflows is an important CFIR construct when assessing implementation. Managers emphasized that Be EPIC-VR’s remote delivery appeared compatible with their existing training workflows and systems, which had expanded significantly during the COVID-19 pandemic. They anticipated that offering the program virtually would align with staff familiarity with online learning and help maintain continuity of training during operational disruptions. That [the remote delivery] is always a bonus for me. So if we’re in an outbreak in this home area…we wouldn’t allow you to come to the home. Our learning will not be disrupted because of outbreaks because of financial strategies. Those pieces are important to us. Continuity. (M302-LTC-Pre-implementation) Across post-implementation intervals, managers confirmed the adaptability and advantage of Be EPIC-VR to address resource concerns and began strategizing implementation plans. Be EPIC-VR’s adaptable delivery eased resource strain—innovation domain: innovation adaptability The remote, small-group delivery of Be EPIC-VR helped address early concerns about staffing, scheduling, and infrastructure. Managers appreciated that Be EPIC-VR’s flexibility minimized disruptions to care routines and enabled staff participation even amidst workforce constraints. Managers also emphasized how Be EPIC-VR’s online format fits with existing infrastructure and staff expectations shaped by post-COVID learning environments: “We do a lot of online learning. Staff really appreciate online learning…so it’s very familiar and user-friendly” (M402-LTC-Follow-Up). Be EPIC-VR’s facilitator support and on-site staff educators improved comfort with VR—innovation domain: innovation relative advantage Managers felt more comfortable with VR technology after completing the training because of the orientation module, the practice, and facilitator support: “What was great was that our pre-session where you got me comfortable with it and the controllers. That was very helpful, because I was really nervous that ‘Oh my gosh, am I going to be able to do this?’” (M301-LTC-Post-Implementation). Additionally, LTC home managers noted that staff educators, who were hired through pandemic-related ministry funding, could play a key role in helping staff set up devices and navigate the technology, especially those less comfortable with its use. Tailoring implementation strategies for Be EPIC-VR—process: planning and tailoring By the follow-up period, after observing the impact of Be EPIC-VR on trained PSWs over 1-2 months, managers described a range of strategies for tailoring Be EPIC-VR implementation to fit their organizational contexts. These local adaptations reflected early-stage planning and execution efforts to overcome constraints such as staffing shortages, scheduling pressures, and the need to build internal momentum. Across sites, managers used 3 main strategies: identifying optimal implementation periods, piloting small group delivery, and using peer-led champion models to support scale-up. To avoid conflicts with peak operational demands, managers recommended planning training delivery during slower times of the year when there were fewer competing priorities, such as accreditation processes or mandatory annual training. They were mindful that holidays and vacations made certain periods especially challenging. There are quieter times of the year…October is the Be EPIC month when people come in. We need to figure out the best way to implement it and try to get as many people in as possible to do it, and see what our availability here for offices. (M202–Home Care-Post-Implementation) Some managers envisioned using Be EPIC-VR for onboarding: “having the opportunity to implement that [Be EPIC-VR] into our onboarding process is a great” (M402-LTC, Follow-Up), and as role-specific refreshers: “We can train every single person and then just do the refreshers or expansion on courses…that would be amazing” (M302-LTC-Follow-Up). Furthermore, managers described the value of launching Be EPIC-VR with small cohorts to test workflows, scheduling logistics, and technology capacity before expanding access. Additionally, they highlighted the benefits of identifying peer champions, staff who completed the training and could informally promote it among colleagues: “I think it’s a great idea to get Be EPIC champions if we could have one on every unit like 5 that would be ideal” (M301-LTC-Follow-Up). Peer endorsement from respected staff accelerated engagement: “Word of mouth has already gone out… two very vibrant and one very quiet, but confident young lady. They’re all very well respected in the facility, so the word of mouth has gone out, and it’s very, very supportive” (M402-LTC-Follow-Up). Enthusiasm for VR also facilitated participation: “I sent out an email blast… saying we were going to become part of a new training program… and I received probably within the first 10 minutes… 20 plus emails saying that they were interested” (M402-LTC-Follow-Up). Together, these follow-up insights for Theme 3 illustrate how implementation planning evolved over time. Although initial concerns focused on feasibility and logistics, managers began to identify internally driven solutions, including phased rollouts, strategic recruitment, and peer engagement, that could enhance Be EPIC-VR’s scalability and sustainability over time. Discussion and implications The current study explored factors influencing Be EPIC-VR’s implementation from the perspectives of decision-makers. Across 3 timepoints, managers described an urgent need for dementia-specific person-centered communication training, cultural alignment as a facilitator, and increased openness to VR through experience. The pre-implementation findings on gaps in experiential, dementia-specific staff training confirm and extend prior research. Many VR dementia training interventions used passive observation to foster empathy, 3 , 5 , 26 whereas fewer included engagement beyond observation or active skill development. 6 , 27 The urgency for person-centered communication training reported in our study reflects CFIR’s construct of tension for change, 16 consistent with findings that external regulatory mandates and internal frustration with inadequate training can drive readiness for new interventions. 28 Managers in our study emphasized the need for training that builds person-centered communication skills and equips staff to use person-centered approaches to address responsive behaviors. At post-implementation, managers valued Be EPIC-VR’s active practice element, which enhanced perceptions of its relevance and relative advantage over existing training. At follow-up, managers’ accounts of changes in PSW communication supported continued implementation. These perceptions informed implementation decisions rather than serving as independently measured outcomes of effectiveness. Findings also show that Be EPIC-VR’s alignment with organizational culture functioned as a facilitator of initial engagement and a sustaining influence over time. Pre-implementation, managers emphasized that alignment with person-centered care and learning-centered values was critical for early buy-in, consistent with prior research indicating that cultural congruence enhances credibility and openness to innovations. 17 , 28 Post-implementation, managers stated that Be EPIC-VR’s focus on experiential learning and practice reinforced these values, ultimately supporting person-centered care for residents/clients and staff well-being. 10 This progression from anticipated fit before implementation to confirmed alignment afterward illustrates how cultural congruence moved from an initial facilitator to a sustaining influence over time. These findings are consistent with CFIR’s mission alignment as a key driver of implementation. 16 , 17 Importantly, the study’s longitudinal design captured this dynamic process of cultural fit, showing how alignment encourages engagement and sustainment. In this study, perceived benefits functioned as implementation-relevant signals that reduced uncertainty about feasibility and fit. In the pre-implementation phase, managers expressed feasibility concerns about technology, staffing constraints, and workflow integration, reflecting barriers widely documented in previous evaluations of VR and game-based dementia education interventions. 5 , 8 , 9 These barriers highlight the importance of strategies such as facilitator support and onboarding to build confidence in the innovation. As managers gained experience with Be EPIC-VR, they increasingly described the training as adaptable to existing workflows and relevant to organizational priorities. These experiences align with findings that staff confidence and acceptance can grow through iterative use and that immersive training can shift perceptions of feasibility when paired with supportive learning environments. 4 , 6 The 5-month follow-up findings revealed that planning and tailoring strategies to sustain Be EPIC-VR evolved as managers gained experience with Be EPIC-VR. For example, proactively timing training to avoid accreditation cycles and holidays showed how managers anticipated and reduced barriers. Managers’ recommendations to pilot small cohorts before scaling up reflect other findings that phased rollouts help address uncertainty about VR technology and logistics. 8 Although prior studies have emphasized trialability as a factor in building confidence, 3 , 6 our findings extend this by showing that piloting with PSWs also helped managers create locally relevant solutions for resource challenges such as space and scheduling. Managers’ intention to use respected staff as informal champions supports the observation that peer endorsement strengthens cultural fit. 17 Together, these examples illustrate CFIR’s emphasis on adaptive implementation, 16 where readiness grows through continuous adjustment and engagement. The evolution from initial uncertainty to active tailoring underscores that this adaptive approach may be especially valuable when introducing VR-based training in care environments with competing demands and limited resources. This study was limited by including managers from a few organizations within a single region, which may affect the transferability of findings to settings with different regulatory requirements, technological resources, or workforce dynamics. Additionally, participants may have been innovation-oriented, introducing potential positive bias. We recruited more than one manager per organization to capture complementary perspectives within the same context and support within-site triangulation, prioritizing analytic depth over breadth. Although this supported within-site triangulation and a richer understanding of implementation processes, it may limit the extent to which findings capture variation across organizational philosophies, sizes, and staffing models. Despite these limitations, strengths include its longitudinal design using the CFIR framework, which captured how perceptions of feasibility, alignment, and value evolved over time. To our knowledge, this is the first VR dementia care training study to apply CFIR longitudinally, offering a theory-informed lens for understanding factors that influence implementation. By engaging decision-makers with direct responsibility for planning and implementation and mapping their evolving experiences to CFIR domains, the study generated insights into how strategies such as piloting, flexible scheduling, and peer-led promotion emerged to address local constraints. These findings add to evidence that VR dementia training requires not only technical readiness but also sustained organizational engagement and a willingness to adapt approaches over time. Future research should explore how Be EPIC-VR can be scaled and sustained across diverse care settings, including assisted living or acute care. Although this project is part of a larger study on Be EPIC-VR’s development, effectiveness, and implementation, future research is needed to assess how organizational commitment, staffing stability, and funding influence sustainability. It should also evaluate whether the training translates into measurable improvements in person-centered communication in practice, as well as broader outcomes relevant to LTC and home care performance, such as staff retention, reductions in responsive behaviors, and other quality-of-care indicators. The findings highlight that implementing innovative VR dementia training is not simply a matter of technological readiness. Across phases, determinants of initial uptake (eg, tension for change, culture/mission alignment, available resources) interacted with emerging determinants of continued use (eg, perceived relative advantage and locally tailored sustainment strategies). Successful implementation relies on perceived urgency and needs, alignment with organizational culture, and iterative, context-sensitive strategies to address feasibility and sustainability. Supplementary Material igag021_Supplementary_Data igag021_supplementary_data.docx (22.5KB, docx) Acknowledgments The authors thank members of the Be EPIC Advisory Board: the late Roger Marple, Mario Gregoria, Bob Joworski, Lisa Poole, Madelaine Currelly, Michelle Collins, Karen Johnson, Lisa Maynard, Polly McClinton, Tanya Pol, Vicki Schmall, Krista Schneider, Lisa Wauchope, and Mary Wellman. The authors also thank the following research team members who were involved in testing the early versions of the simulations of Be EPIC-VR: George Philip and Allison Chen. Contributor Information Marie Y Savundranayagam, School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada; Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada. Annette Schumann, School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada; Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada. Grace Norris, Sam Katz Community Health and Aging Research Unit, Faculty of Health Sciences, Western University, London, Ontario, Canada. Jennifer L Campos, KITE Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Psychology, University of Toronto, Toronto, Ontario, Canada. Joseph B Orange, School of Communication Sciences and Disorders, Faculty of Health Sciences, Western University, London, Ontario, Canada; Canadian Centre for Activity and Aging, Faculty of Health Sciences, Western University, London, Ontario, Canada. Supplementary material Supplementary material is available at Innovation in Aging online. Funding This work was supported by funding from the Alzheimer Society of Canada [23-17 to M.Y.S., J.B.O., and J.L.C.] and Future Skills Centre [to M.Y.S., J.B.O., and J.L.C.]. Conflicts of interest The authors declared no potential conflicts of interest for the research, authorship, and/or publication of this article. Data availability Application for accessing data can be sent to: [email protected] . The study was not preregistered. References 1. Mäkinen H, Haavisto E, Havola S, Koivisto JM. User experiences of virtual reality technologies for healthcare in learning: an integrative review. Behav Inf Technol. 2022;41:1-17. 10.1080/0144929X.2020.1788162 [ DOI ] [ Google Scholar ] 2. Philip G, Savundranayagam MY. Applications of virtual reality and its effectiveness in healthcare training: a scoping review. Health and Technology. 2025;15:217-–229.. 10.1007/s12553-024-00936-6 [ DOI ] [ Google Scholar ] 3. Ball S, Bluteau P, Clouder DL, Adefila A, Graham S. 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