Methodology and Recommendations on development of Mixed Reality applications in foreign language education for medical professionals

This document presents a comprehensive overview of the general guidelines and best practices that have been formulated for the development of effective Mixed Reality (MR) based learning applications. The primary focus is on developing a state-of-the-art methodology and recommendations (M&R) to cater specifically to Foreign Language Education in healthcare professions, ensuring the successful development of MR applications in this context. The document is broken down into two main blocks: initially we identify and select educational content suitable for conversion into MR format for Foreign Language Education (FLE) in healthcare. This task is undertaken through different tasks that include the definition of the vision of the DR FLEMP MR application, the development of user stories, the alignment of the curricula of all partners in the area of healthcare and the implementation of design thinking workshops in all partner countries.  The second component involves the development of a methodology that is based on existing design-based approaches and involves adaptation of existing design and development frameworks and allows for productive collaboration for stakeholders with different backgrounds and expertise. This document is a shorter version of the report “PR1: DR FLEMP Guidelines: Methodology and Recommendations on development of Mixed Reality applications for foreign language education for nursing in caretaking”. For the full report follow the link here.


4th Transnational Project Meeting in Utena, Lithuania

4th Transnational Project Meeting in Utena, Lithuania

The picturesque town of Utena, Lithuania played host to the fourth transnational meeting on the DR FLEMP project, convened on September 19th and 20th. Such transnational meetings have been pivotal in ensuring that all partners stay aligned and that the project moves forward effectively. This specific meeting, in particular, represented a significant juncture in the project’s timeline.

The session began with warm greetings and a comprehensive overview of the project, highlighting where we currently stand, particularly in relation to scenario development and digital prototyping. Detailed discussions centered around PR1 Research outcomes, with partners from Cyprus and Germany delivering a stellar presentation on methodology and recommendations.

Post the insightful deliberations around PR1, attention was turned to the fascinating realm of Virtual Reality (VR). The technical team laid out the concept of a demonstration tool, aimed at showcasing the myriad possibilities of VR to educators. Feedback received from partners was invaluable, ensuring that the next version of the application will be even more robust and user-centric.

Further, PR3 was also put under the spotlight, revolving around VR-supported modules for foreign language learning. The team discussed in-depth about the preparation of two VR scenarios, held a didactic conversation about their educational value, and plotted a course for their imminent completion.

On the second day, the conversation veered towards the structure of the impending course, delineating its values, objectives, and comprehensive content. The day also encompassed a Design Thinking Workshop, shedding light on the DR FLEMP Training Course structure, its didactic purposes, key elements, and relevant tasks and deadlines.

The immediate future holds more such engaging events. The 5th TPM is slated for November, followed by a Teachers Training session in December 2023. The Final TPM is expected to occur in February 2024.

Towards modelling of Mixed Reality application for language learning for healthcare – part 2

Related work

Defining Mixed Reality (MR) as a term has not seen a consistent use. In some contexts it includes both AR and VR, whilst in others, it represents the point where real and virtual elements are equally displayed for the user (Speicher et al., 2019).  According to Speicher et al. (2019), MR combines different dimensions: (a) number of environments (e.g. Virtual Reality, Augmented Reality), (b) number of users (e.g. one or many), (c) level of immersion (e.g. non immersive, partly immersive, fully immersive), (d) level of virtuality (e.g. non virtual, partly virtual, fully virtual) and (e) degree of interaction (e.g. implicit and explicit). For the purposes of this work MR is classified as combination according to Speicher et al. (2019), where distinct AR and VR parts are combined and interact with each other, but are not tightly integrated and user can switch between Augmented Reality (AR) and Virtual Reality (VR) devices as necessary.

The benefits of Mixed Reality in education

Applications for Mixed Reality (MR) have seen a rise in popularity in recent years in a variety of fields including education and medicine (Barba & Marroquin, 2017). Extended realities such as MR, VR and AR can offer learning methods that would not be available otherwise, allowing for a more hands-on, immersive, and active learning approach to teaching and learning (Allcoat et al., 2021). We chose MR over other digital tools or media such as web or video content due to its affordance to provide in-situ interactions for enabling real-like communication in healthcare contexts. MR environments have the ability to promote learning by giving students the advantages of engaging users with interactive content (Yannier et al., 2015). By providing intuitive interactions with data in our living spaces and with our friends, MR frees us from experiences that are limited to screens (Bray & Zeller, 2018). The combination of the physical and digital worlds, enable fluid and natural 3D interactions between people, machines, and the environment.  Beyond displays, mixed reality applications now also include spatial mapping and anchors for environmental understanding, hand, eye, and speech input tracking, sound in space, both physical and virtual spaces’ positions and locations as well as collaboration on 3D assets (Bray & Zeller, 2018). MR is a suitable and safe learning technology that has the potential to enable new approaches to teaching. The advantages, such as increased engagement and positive emotions, indicate that MR would be beneficial as supplement to traditional learning methods (Allcoat et al., 2021).

Past studies have also demonstrated enhanced learning rates and skills improvement as a result of the induced sense of immersion and presence in such a ‘risk-free’ mixed environments. In addition, extra cues in the form of visual or auditory feedback can facilitate learning of the task and allow simulating the task in a flexible way to adapt it to users’ needs and training goals (Carver & Lamb, 2020; Zheng et al., 2022). Considering these advantages of MR, our work is focused on designing an educational application for the healthcare professionals with a clear orientation toward the final outcomes of the learning experience.

Mixed Reality and Language Learning

Mixed reality has the potential to improve language learning by offering a more immersive, fun, and tailored learning experience that can aid students acquire new language skills faster (Zhang et al., 2023; Hsu et al., 2023). MR-enhanced language learning can be implemented under different theoretical frameworks such as game-based learning theory, cognitive theories of multimedia learning, sociocultural theory, collaborative learning theory, constructivist theory, and embodied learning theory  (Zhang et al., 2023).  Incorporating Mixed Reality (MR) into language learning entails multiple advantages such as increased autonomy, improved communication and collaboration, reduced risk for learners, rich input, opportunities for practice, support communication and collaboration, improved student-centeredness, authentic language use and increased enjoyment (Chen & Tsai, 2009; Zhang et al., 2023; Hsu et al., 2023).

Popular VR, AR and MR simulators for language learning (e.g. “Do you speak Holo?” in Torelli et al., 2020; Virtual Medicine, 2023; EduVenture VR – Apps on Google Play, 2023; Second Life – Virtual Worlds; Virtual Reality, VR, Avatars, and Free 3D Chat, 2023; Google Expeditions, n.d.; OpenSimulator, 2022; Mondly AR, 2019 etc.) have gained popularity in recent decades and have been integrated into self-paced, blended and face to face language courses (Lin et al., 2015; Parmaxi, 2020; Torelli et al., 2020; Statti & Torres, 2020; Zhang & Zou, 2022). Additional simulators for language learning for specific purposes in the context of healthcare (e.g. Ein Tag Deutsch in Der Pflege, 2017) provide real-life practice for learners to improve the necessary cognitive, affective, and psychomotor skills, however the majority of them have limited content focusing mostly on virtual simulations of healtchare equipment and protocol training rather than language learning and/or communication. Moreover, there are various simulators available for healthcare professionals but do not aim to support language learning (e.g. Sharecare VR, 2023; Osso VR, 2023; Oxford Medical Simulation, 2023). For example, Oxford Medical Simulation (Oxford Medical Simulation, 2023) is a VR nursing simulation which despite promoting communication between healthcare professionals, it does not aim at supporting language learning.


Development of the DRFLEMP MR application for Healthcare

The involvement of dedicated stakeholders is considered important towards the design and development of an application that is expected to support the language learning experience of professionals in the healthcare sector (Howard et al., 2021). With this in mind, we collaborated with multimedia specialists, instructional designers, healthcare instructors, language instructors and students over a period of 10 months to gather a deep understanding of the needs and the perspectives of the perspective users. By incorporating the ADDIE model, we emphasized on a systematic and iterative process for creating effective learning experiences. The ADDIE acronym represents the five key stages of the model, that is Analysis, Design, Development, Implementation, and Evaluation. We commenced the MR application with the Analysis phase. This involved working collaboratively with multimedia specialists, instructional designers, healthcare instructors, language instructors and students to identify learning needs, goals, and objectives for the DRFLEMP MR application. Moving on to the Design phase, we implemented Design Thinking workshops with our key stakeholders and developed specific learning objectives aligned with the identified learning outcomes. Additionally, we crafted evaluation strategies to assess the learners’ skills effectively. With the learning objectives and evaluation strategies in place, we progressed to the Development phase. During this stage, again through Design Thinking workshops we designed the instruction in the form of Modularised Units. These modules were carefully structured to include guided activities, practice session, enabling learners to practice language in a meaningful and organised context. Finally, the mudularised units that derived from the Design Thinking Workshops were Evaluated and feedback received from learners and instructors informed revisions and refinements of the MR application. The resulting learning activities effectively fulfilled the derived learning outcomes, as depicted in Figure 2. Throughout the process, we followed an iterative approach, continuously refining and improving the system design and development of the modularized units for the DR FLEMP Healthcare application to ensure an optimal language learning experience.

Table 1. Development of the DRFLEMP MR application for Healthcare

 Analysis: Market Research, Survey and Discussions with Key Stakeholders

In the analysis phase, AR, VR and MR platforms were analyzed through systematic literature review and survey with consideration given to technological features, sustainability as well as technological and pedagogical opportunities. With the increased use of AR, VR and MR applications, various applications are currently available. This provided the team with concrete examples of the existing MR applications, as well as their strengths and weaknesses.  These technologies have been observed to enhance students’ creative thinking efficacy (Y. J. Lin & Wang, 2021) and facilitate the advancement of language proficiency and communication skills among students (Jehma, 2020). The significance of authentic contexts and lifelike settings was also highlighted (Ma, 2021; Hara et al., 2021; Taguchi, 2022). These environments provide valuable opportunities for interactive learning, which in turn promote enriched learning experiences and improved educational outcomes (X. Chen et al., 2022). The desk research analysis also highlighted the provision of instant feedback (e.g. Mondly VR, 2021; Mondly AR, 2019), the availability of content into various levels (e.g. ImmerseMe,, 2023), the accessibility from anywhere and compatibility with various devices such as mobile, desktop, VR headset (e.g. Bodyswaps, 2023), the interaction with other people online (e.g. FluentWorlds, 2023), the gamification elements (e.g. Busuu,2018), as well as some or entire free functions of the applications (e.g. Ein Tag Deutsch in Der Pflege, 2017). Some other advantages identified, include the use of authentic scenarios (Hamad & Jia, 2022) (e.g.ImmerseMe, 2023; Ein Tag Deutsch in Der Pflege, 2017), the development of communication skills (e.g. VirtualSpeech, 2021), the opportunity to practice in multiple languages (e.g. ImmerseMe, 2023;  Dynamic Languages, 2023), as well as the customizable and flexible environment (e.g. Avakin Life, 2023; UbiSim, 2023) and the provision of immersive features such as 3D models and 360 videos (e.g. 3D ORGANON, 2023; ImmerseMe, 2023; Dynamic Languages, 2023). However, it’s important to note that while there are benefits, there are also potential challenges and pitfalls associated with the application of XR technologies. Notably, common barriers encountered include technical difficulties, motion sickness (Jehma, 2020; Wu et al., 2021; Kruk, 2021) limitations in time and space  (V. Lin et al., 2022), diminished confidence and motivation levels  (Kruk, 2021), as well as heightened anxiety when engaging with XR applications (J. C. C. Chen, 2020). Adittionally, the desk research identified the paid functions or applications (Alfarsi & Yusof, 2020) (e.g. Dynamic Languages, 2023; UbiSim, 2023), the limited content availability (Hamad & Jia 2022) and only in specific languages such as English (e.g. VirtualSpeech, 2021;FluentWorlds, 2023) or specific language aspects such as vocabulary (e.g. Panolingo, 2017), limited CEFR levels offered (e.g. Ein Tag Deutsch in Der Pflege, 2017; Varvara, 2017), lack of updates (e.g. Panolingo, 2017) and availability only in specific countries or specific population (e.g. Varvara, 2017). Furthermore, some applications were found to behard to operate and maintain (Hamad & Jia, 2022)(e.g.UbiSim, 2023), used non-realistic characters (e.g. Osso VR, 2023) and require specific equipment such as standalone headsets (e.g. Virtual Medicine, 2023).

Discussions within the key stakeholders including 5 multimedia experts, 1 healthcare instructor and 8 language instructors raised awareness of the needs and challenges of the DR FLEMP application, as well as its vision. At this stage, we also developed user personas to represent exemplary users of the DR FLEMP MR application, allowing the design team to develop a deeper understanding of the target users, their needs, preferences, and behaviors. Moreover, the discussions with key stakeholders brought forward the features and functionalities they considered important for the DR FLEMP MR application which were grouped according to common themes and were prioritisd following the MoSCoW prioritisation technique in order to  reach a hierarchy of features. This phase concluded with a survey to healthcare instructors, healthcare professionals, language instructors and healthcare students to inform the design team regarding the learning needs, goals, and objectives of the DRFLEMP MR application. Having concluded this phase, the collected recommendations and needs we reached a consensus on the vision of the DR FLEMP MR application.

Towards modelling of Mixed Reality application for language learning for healthcare – part 1


The labor market situation in the area of nursing and caretaking is very tight already. In the future, the need for skilled healthcare workers will increase even further due to demographic change. New skills including language learning are required for healthcare workers in order to keep pace with the changing healthcare landscape, overcome language barriers and ensure that they provide the best possible care to their patients. Healthcare workers must be able to communicate with patients in their native language or at least have a basic understanding of the language. To address this challenge, we present a Mixed Reality (MR)-based language learning system aimed at supporting linguistic competence and communication in healthcare simulations. This paper describes the process for modeling a Mixed Reality application for language learning for medical purposes. We applied the analysis, design, development, implementation, and evaluation (ADDIE) approach to design a VR healthcare simulator in the form of modularised units. Using prototype, we conducted a user study with 7 novices to test the system’s usability. Our findings show (1) effectiveness of the system in transferring skills to real-world health-care environments and, (2) realistic learning experience to users. Using the solution, we envision inexperienced healthcare workers to achieve language competencies faster and be better prepared to enter actual work environments.

 Keywords: Virtual reality, Virtual Reality simulators, Virtual Reality language learning, Language learning


Recently the healthcare sector in Europe and beyond has reported a substantial deficit in healthcare provision and an increasing need for skilled healthcare workers. In the future, the need for skilled healthcare workers will increase even further due to demographic change. Data provided by the World Health Organization (WHO, 2022) indicate that within the European region, the doctor density, that refers to the number of active healthcare workers divided by the population, varies from 17.3 per 10 000 people in Tajikistan and 17.5 in Kyrgyzstan, to 88.7 in Monaco. Western Europe had the highest doctor density (45.5). Nurse density varies significantly by country, from 27.0 in Turkey to 183.7 in Switzerland and 202.7 in Monaco. Countries in the European Region with the lowest densities are those in the western Asia subregion (48.2), followed by those in central Asia (48.9), southern Europe (61.7), and eastern Europe (65.3). Data indicate the increasing demand for community-based care that requires a healthcare workforce with the right composition of professionals and skills (WHO, 2022). A potential solution to the deficit in healthcare is to attract more workers from other EU countries or even from non-EU countries, who must possess the necessary minimum qualifications as well as professional language abilities. Language barriers in the medical field cause miscommunication between the patient and the medical staff, which lowers both parties’ satisfaction and reduces both the quality of healthcare delivery and patient safety (Al Shamsi et al., 2020). Healthcare workers must be able to communicate with patients in their native language or at least have a basic understanding of the language (Olimpia et al., 2021). The importance of language learning for healthcare professionals lies in the fact that it allows them to communicate effectively with patients from diverse cultural and linguistic backgrounds (Bonder et al., 2001). It is imperative that healthcare practitioners have cultural competence in order to recognize and address cultural values, beliefs, and practices when intervening in treatment, which is likely to result in more successful outcomes (Bonder et al., 2001). Moreover, language barriers can lead to misunderstandings and errors in medical care, which can have serious consequences for patients (Waters et al., 2023). Healthcare students and professionals need to practice the language in assimilated healthcare context. The high-costs of placement constraints on the environment restrict access to real-life healthcare facilities, and therefore they cannot overcome the need for language competence of healthcare professionals today. Therefore there arises a necessity to introduce more interactive learning courses and training to enable contextualised and situated language communication for healthcare practitioners.

In this work we address this gap by leveraging one of the emerging technologies that entail the potential to accelerate the development and improvement of the learning competences. Mixed reality  (MR) along with the integrated speech recognition applications supported by Artificial Intelligence (AI) allows a learner to engage with interactive digital enhancements – individually or in a group – in real or digital worlds simulating a typical working environment and standard situations of the healthcare profession. Virtual highly valuable didactic environments comprehend an important number of learning-related strategies and realities, provides freedom in the development process and several valuable and applicable features for foreign language education (Peixoto et al., 2021). We applied the analysis, design, development, implementation, and evaluation (ADDIE) approach (Colpaert, 2006; Caws, 2013) to design a MR healthcare simulator in the form of modularised units. Following the ADDIE model, our process began with the analysis phase, where we collaborated with language and healthcare experts to identify the desired learning outcomes. Next, we proceeded with the design phase, focusing on identifying assessment strategies that aligned with the desired performance. Finally, in the development phase, we designed the learning activities to meet the established goals. As a part of the learning content, we provide a MR platform that accommodates realistic healthcare scenarios, incorporates instant audiovisual feedback and enables students’ active participation and collaboration.  Through MR, the system can transfer healthcare conditions into a MR platform for addressing the communication needs (both receptive and productive) and eventually the transition to a real healthcare workplace. We implemented a training module in the form of prototype comprising one unit and conducted a user study with 7x healthcare students, 5 language instructors and 1 healthcare instructor to evaluate the usability of the MR system, and demonstrate the user engagement of the system to transfer skills into the real-world environment. Through the findings from the study, we want to answer the following research question:

What pedagogical and technological factors/aspects to consider while designing healthcare simulations for language learning and guided activities for healthcare professionals in a MR platform 

Thus, the contributions are as follows:

  • A learning design rationale developed using the ADDIE approach in learning sciences and through discussion with healthcare and language learning experts that shows what to consider while designing an effective language training system for language learning for healthcare professionals;
  • A design framework encompassing structured learning modules to achieve language competence at A2 and B1 Common European Framework of Reference for Languages (CEFR) levels; and
  • The user study and evaluation results to validate the system’s usability using a minimum viable prototype, to evaluate the performance of the proposed alternative in MR towards the development of language learning skills for healthcare professionals

We envision that this work provides insights to the Computer-Assisted Language Learning (CALL) and Human Computer Interaction (HCI) community to better understand how to leverage MR systems in healthcare training processes.

We are going to DDD’23!

We are going to DDD’23!

DR FLEMP team is pleased to announce our participation in the Digital Demo Day 2023. The DDD23, hosted by @digihub_de, is Germany’s largest B2B startup expo and conference. On August 17th, over 4,500 visitors including corporations, SMEs, investors, and startups will gather in Düsseldorf for matchmaking opportunities.
During the #DDD23, we will showcase our innovative VR product for foreign language education, which have been carefully developed in collaboration with our partners from across Europe. Together, we are driving advancements in education throughout Europe.

We invite you to visit our booth at the #DigitalDemoDay on August 17th in Düsseldorf. As our special guest, you can enjoy a 30% ticket discount by using the code DDBOOST.

For more information, please visit
We look forward to meeting you at the event!