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A review of virtual-simulation for assessing healthcare students’

clinical competency

Elisabeth Coyne, Pauline Calleja, Elizabeth Forster, Frances Lin

PII: S0260-6917(20)31473-8
DOI: https://doi.org/10.1016/j.nedt.2020.104623
Reference: YNEDT 104623

To appear in: Nurse Education Today

Received date: 30 June 2020

Revised date: 11 September 2020
Accepted date: 1 October 2020

Please cite this article as: E. Coyne, P. Calleja, E. Forster, et al., A review of virtual-
simulation for assessing healthcare students’ clinical competency, Nurse Education Today
(2020), https://doi.org/10.1016/j.nedt.2020.104623

This is a PDF file of an article that has undergone enhancements after acceptance, such
as the addition of a cover page and metadata, and formatting for readability, but it is
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version to give early visibility of the article. Please note that, during the production
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that apply to the journal pertain.

© 2020 Published by Elsevier.

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A review of virtual-simulation for assessing healthcare students’ clinical competency

Elisabeth Coyne (Corresponding author)* PhD RN RM BN MN Hons Grad Cert in Higher Education
School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Australia
Email: e.coyne@griffith.edu.au Orcid.org/0000-0001-8511-600X

Pauline Calleja PhD, MANP, GCHE, BNSC, DipManagement RN, MANC, FCENA, SFHEA, School of
Nursing, Midwifery and Social Sciences, CQUniversity; School of Nursing and Midwifery, Griffith
University, Australia. Email: p.calleja@cqu.edu.au ORCID id: 0000-0001-5674-1404

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Elizabeth Forster PhD RN BN MN Grad Cert Higher Ed SFHEA School of Nursing and Midwifery,

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Menzies Health Institute Queensland, Griffith University, Australia. Email: e.forster@griffith.edu.au
ORCID id: 0000-0002-1613-0024 -p
Frances Lin RN PhD, FACCCN, SFHEA, School of Nursing, Midwifery, and Paramedicine, University of
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the Sunshine Coast; Sunshine Coast Health Institute; School of Nursing and Midwifery, Griffith
University, Australia. Email: flin@usc.edu.au orcid.org/0000-0001-8735-5469
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Conflicts of Interest and Source of Funding

The authors have no funding conflicts of interest to disclose. The authors alone are responsible for
the content and writing of the paper.

Acknowledgements: Griffith University School of Nursing and Midwifery Scholarship of Effective

Learning and Teaching Grant 2018

Word count 4081

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Key words: virtual simulation; clinical assessment; healthcare students; integrative review

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A review of virtual-simulation for assessing healthcare students’ clinical competency

Objectives: Health professional education is transitioning to online platforms to meet

students’ need for flexibility and international access. However, there is a necessity for

authentic presentation of educational material particularly in regard to clinical skills

development. There has been major growth in the delivery of virtual simulated-based

learning and assessment to provide clinical skill acquisition in an online platform. The aim of

this review was to explore the use of virtual simulation to assess clinical competence in

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health education.

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Design: Integrative review.
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Data Sources: Peer reviewed studies published between 2008 to March 2020 were searched
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across PubMed, Embase, Cochrane Library, CINAHL Medline, Scopus, and PsycINFO
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Review methods: The Preferred Reporting Items for Systematic reviews and Meta-Analyses

was followed. Twenty-three studies, which met the inclusion criteria, were downloaded, and
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a quality appraisal and analysis was completed by the research team.

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Results: A thematic analysis identified four themes; pedagogy differences across disciplines,
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debriefing to enhance learning, preparing healthcare professionals in a safe and cost-effective

environment, and managing challenges of virtual simulation. Debriefing with students within

the online environment enabled students to share experience and reflect on choices for a

deeper learning experience.

Conclusions: Virtual simulation can prepare students for the clinical environment by

providing safe practice within complex clinical situations. Challenges related to managing

and debriefing students must be overcome to ensure best student learning outcomes. Virtual

simulation is a feasible strategy to assess students’ clinical competency and support their
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learning in both medical and nursing programs, however simulation should be authentic and

incorporate reflection.

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Highlights

 Simulations used in medical training programs were often task focused, whilst in

nursing programs the focus was developing critical thinking

 Online student debriefing is an important part of the learning process in virtual

simulation

 Complex clinical situations can be presented in a virtual world to enable students to

learn clinical reasoning in a safe environment

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Key words: virtual simulation; clinical assessment; healthcare students; online education,
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integrative review
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Background

Ensuring client safety is one of the highest priorities for healthcare organisations, especially

for clients with complex clinical conditions (Australian Commission on Safety and Quality in

Health Care, 2018; World Health Organization, 2019). The level of education and clinical

competency of all health professionals is a key factor in improving client outcomes, for

nurses, as the largest part of the health workforce this is particularly related to complex

decisions and delegation of care (Conley, 2019; Gardner et al., 2016). The concept of clinical

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competency has been defined as the healthcare professional’s ability to conduct a

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comprehensive assessment, develop and implement a care plan, and evaluate the outcomes

for their clients (Australian Health Practitioner Regulation Agency, 2019; Benner et al.,
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2009). However, opportunity for advanced face-to-face clinical training and assessment of
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clinical skills is often constrained by clinical educator time and resources.
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Within the context of postgraduate healthcare courses, traditional approaches focused on

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theory-based programs with limited hands-on experience, as postgraduate students are often

working clinically and therefore are able to apply theory into the practice environment
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(Anderson et al., 2019; Schneidereith & Daniels, 2019). Clinical health assessment is often
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related to the student’s clinical environment, which then provides clinical learning

opportunities and also completes assessment of the students’ clinical competence within their

workplace. An issue with this process is the variation and the interpretation of a reasonable

clinical standard for students to be assessed against. The increase in blended learning

education has enabled healthcare programs to use high-fidelity simulation as a teaching tool

to develop students’ clinical reasoning and decision-making (Henderson et al., 2016).

Healthcare students, particularly students in postgraduate programs want online courses for

access and flexibility, the problem however, is how to facilitate teaching and assessing

clinical competencies in an online environment.

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Online education

University curriculum has a significance reliance on innovative ways (such as blended

learning) to deliver information and communicate with students (Coyne, Rands, et al., 2018).

Students use technological devices every day and expect flexible education opportunities,

which enable them to be immersed in the learning environment (Barak, 2018). An online

learning approach for healthcare programs enables a student-centered approach. This

approach addresses the desire for time and location flexibility and extends the reach of

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educational opportunities by enabling student engagement despite geographical location. In

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remote locations, or for international students studying in their own countries, learning via an

online platform enables equitable study opportunities (Hardenberg et al., 2019). Online
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learning improves access for students, and provides an ability to teach a substantial number
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of students while optimizing costs for the educational institution (Haerling, 2018). Despite
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many benefits of online education, there are also disadvantages, particularly related to clinical

competency assessment (Duff et al., 2016). Clinical competency assessment, which has been
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traditionally conducted in a face-to-face environment, becomes a challenge within online

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programs. Thus, more innovative approaches need to be explored to assess students’ clinical

skill competency in the online environment.

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Virtual Simulation

Virtual simulation uses interactive technology providing a realistic clinical situation in a

virtual world where students can engage in decision making with realistic changes within the

situation as the simulation unfolds (LaManna et al., 2019). It can be used in both face-to-face

or online environments. A realistic learning environment prepares the student for critical

thinking in a range of different clinical situations within a safe environment (Borg Sapiano et

al., 2018) and especially for low-occurring but high-risk incidents. Within the online teaching
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platform, virtual simulation creates a realistic clinical experience with the use of videos,

avatars or games (Coyne, Frommolt, et al., 2018; Wright et al., 2018).

Simulation as a teaching tool

Within nursing and midwifery education, the development of high-fidelity simulation has

enabled a safe learning environment for students (Cobbett & Snelgrove-Clarke, 2016). A

blended learning approach in teaching clinical skills in an undergraduate nursing program has

identified positive aspects such as flexibility and student engagement (Coyne, Frommolt, et

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al., 2018; Massey et al., 2017). Online learning has also been used with medical students,

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who were provided simulation training to successfully increase task dexterity before they
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enter a real clinical setting (Huber et al., 2017; White & Siu, 2017). However, the availability

of quality research that has evaluated the effectiveness of virtual simulation, particularly to
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assess healthcare students is scarce (Duff et al., 2016). A scoping review for diagnostic
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reasoning and virtual simulation in healthcare professionals identified that virtual simulation
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was a reasonable teaching method (Duff et al., 2016). However, Duff et al. (2016) did not

focus on the effectiveness of assessing students within the online environment. The definition
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of virtual simulation used for this study is the recreation of realistic simulation in a fully
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online situation and the creation of an immersive environment for learning an activity

(Haerling, 2018; Sankaranarayanan et al., 2018). To our knowledge, there is no systematic or

integrative review in the current literature that explores virtual simulation use in online

education in the healthcare disciplines. The aim of this integrative review was to synthesise

current evidence in relation to using virtual simulation programs to assess students’ clinical

skill competency in online health education programs.

We aimed to answer the following two questions in this review:

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 What virtual simulation programs are used within online health education programs to

assess clinical competency?

 How is virtual simulation used in the assessment of clinical competence in health

education programs?

Methods

An integrative review methodology was used to enable the inclusion of published articles

with a range of research designs. The integrative review method affords a deeper

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understanding of the phenomenon of interest by including studies that utilize diverse

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methodologies and including a critical analysis of the findings. The five stages of the
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integrative review were used to provide a framework for the review process and critical
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analysis of the articles (Whittemore & Knafl, 2005). The stages include problem

identification, conducting a literature search, data evaluation, data analysis and presentation
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of the findings. The literature review protocol has been published in Prospero
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CRD42018096615.

Search strategy
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Three authors (SD, EC and PC) conducted an electronic database search [in July 2018,
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updated March 2020] of databases including PubMed, Embase, Cochrane Library, CINAHL,

Medline, Scopus, and PsycINFO. The search of databases including Medline, Scopus, and

PsycINFO yielded only duplicates, thus we did not include these results in the PRISMA

flowchart. Using a PICO framework developed by the research team and a health librarian,

the following combination of search terms were used: nurs*, health*, education*,

postgraduate*, virtual simulation, virtual reality, computer simulation, virtual patient,

VSIM*, High fidelity simulation, assessment*, clinical reasoning, competency assessment*,

problem based learning. Papers were included it they were: published between 2008- 2020
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(as the development of simulation and virtual simulation is within this period) published in

English, in a peer reviewed journal, related to education, were fully online, and included

clinical competency assessment. Exclusion criteria included: not related to healthcare

professionals, or only used virtual simulation in a face-to-face environment.

Methods for data extraction

EndNote Online© (version X9) was used to manage the search and screening process. Two

authors followed a stepped screening process. Title and abstract screening identified 127

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studies for full-text review of which 23 studies met the inclusion criteria (see Figure 1

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Literature searches, screening and selection of studies). The review process was designed and
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adapted with reference to the Preferred Reporting Items for Systematic reviews and Meta-

Analyses (PRISMA) statement (Liberati et al., 2009). A data extraction form was developed
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to extract data from the included studies. The items included in the data extraction form
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included the following headings: author (year, country), methods (sample including
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discipline), simulation focus, clinical competency, measures and findings.

Data evaluation
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Quality assessment was completed by the team using the Mixed Methods Appraisal Tool
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(MMAT) – Version 2018 (Hong et al., 2018). This appraisal tool allows a framework for

critical appraisal on mixed methodological studies, the rating provides sensitivity to the

quality of the study (Pluye & Hong, 2014). The final studies were rated independently by two

researchers [EC, PC] and differences were discussed. The whole team reviewed the process

and resolved any differences. The rating of the studies was not used to exclude them as they

all had potential to contribute to the findings (Hong et al., 2018).

Data analysis
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A critical analysis of the studies was completed using a table to present the data. Qualitative

themes were identified within each study using an inductive approach and then compared

across the data set. The themes were discussed across the research team and reviewed and

refined for connection with the research questions (Pluye & Hong, 2014). The research

questions ensured a focused analysis of the studies to meet the aim of the review.

Results

The 23 studies included this review were published between 2014 and 2020. Thirteen studies

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were conducted in United States. In Australia, Canada, and Singapore there were two studies

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conducted. There was one study each from Germany, Portugal, Malta and India.
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There were seven randomized controlled trials (RCT), six with sample mean of 59, one with
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sample of 229 (Shah et al., 2018). Seven quasi-experimental studies, sample size ranged from
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10 (Sankaranarayanan et al., 2018) to 489 (Bogossian et al., 2015). Seven descriptive

quantitative studies with a mean sample size of 159, and two qualitative studies were also
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included. The discipline focus of the studies were maternity care, critical care and general

nursing procedures for nursing and surgical procedure along with pediatric care and general
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knowledge for the medical profession. The reported mean age of participants in the studies
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was between 22 to 30 years.

The quality assessment of the included studies using the MMAT found that Menzel et al.

(2014) did not have comparable data for a randomized controlled trial and Cobbett and

Snelgrove-Clarke (2016) did not have clear randomization and blinded assessors in their

randomized controlled trials. The qualitative study Carman et al. (2017) did not have clarity

in presentation of data collection and interpretation of findings which detracted from the

usability of the data (Hong et al., 2018).

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Virtual simulation programs

The virtual simulation programs developed for the nursing discipline focused on developing

skills of critical thinking related to nursing procedures; maternal assessment (Agrawal et al.,

2016; Cobbett & Snelgrove-Clarke, 2016), adult client assessment (Carman et al., 2017;

Dubovsky et al., 2017; Padilha et al., 2018; Wright et al., 2018), pediatric life support

(Lehmann et al., 2015), management of hypoglycemia (Hudson et al., 2015), management of

chronic obstructive pulmonary disease (Haerling, 2018), sudden client deterioration

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(Bogossian et al., 2015; Borg Sapiano et al., 2018; Cooper et al., 2015; Liaw et al., 2014;

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Liaw et al., 2015), and communication skills (Foronda et al., 2014; Kron et al., 2017; Menzel

et al., 2014; Verkuyl et al., 2017). The medical simulations meanwhile were developed for
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supporting medical students and clinicians to familiarize them with medical procedures;
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carpal tunnel release (Amer et al., 2017), neuroanatomy (Stepan et al., 2017) and complex
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situations; operating theatre fires (Sankaranarayanan et al., 2018), pediatric assessment (Shah

et al., 2018), diagnostic assessment (Willis et al., 2016), before going into the real clinical
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environment.
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Virtual simulation within the selected studies was mainly web-based simulation over a set
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time-period to develop skills, except for one mobile app (Amer et al., 2017). There were four

main simulation programs used FIRST2ACT WEBTM (Bogossian et al., 2015; Borg Sapiano

et al., 2018; Cooper et al., 2015), Laerdal and Wolters Kluwer Health from Lippincott

(Cobbett & Snelgrove-Clarke, 2016; Haerling, 2018; Wright et al., 2018), CliniSpace

(Dubovsky et al., 2017; Foronda et al., 2014) and Second life (Hudson et al., 2015; Menzel et

al., 2014). The other studies had developed their own campus-based simulation program to

meet their specific needs. The simulation programs were based on three styles of simulation;

patient actor simulation, manikin actor simulation and avatar based simulation. See Table 2

Explanation of simulation programs

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Assessment of clinical competence

Pre and post simulation tests were used to measure knowledge increase, performance change

and satisfaction of the simulation. See Table 1 for summary of results. The quantitative

studies all reported knowledge and competence increases however they were measured on a

range of tools related to the focus of the simulation. All survey results are presented in

percentages within the summary table to enable comparison. The surveys used across the

quantitative studies also measured demographic data, motivation, satisfaction and self-

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confidence. Reliability or validity of the tools used to measure knowledge were

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acknowledged or reported in these studies (Bogossian et al., 2015; Borg Sapiano et al., 2018;

Cobbett & Snelgrove-Clarke, 2016; Cooper et al., 2015; Liaw et al., 2014; Liaw et al., 2015;
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Menzel et al., 2014; Padilha et al., 2018). Several of the studies completed power calculations
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to identify sample size required for statistical significance and reached that sample size
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(Haerling, 2018; Lehmann et al., 2015; Menzel et al., 2014; Sankaranarayanan et al., 2018).

See Table 1 for study characteristics and findings of included studies.

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Overall the results from the reviewed studies indicated that the virtual simulation program
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undertaken enhanced students’ knowledge, confidence and virtual clinical performance

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relevant to the clinical skills taught. With simulation, students had an opportunity to practice

clinical skills repeatedly and accumulate the experience of the complex scenario before going

into the real clinical situation.

Themes

There were four main themes identified within the studies related to virtual simulation and its

integration into student learning: pedagogy differences across disciplines, debriefing strategy

to enhance learning, preparing healthcare professionals in a safe and cost-effective

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environment, and managing challenges of virtual simulation. See Table 3. Themes from

literature synthesis

Pedagogy differences across disciplines

The development of the simulation related to the task or attribute the student was required to

learn. The medical student simulations had a focus on teaching the skills related to a task and

the knowledge around that task. Medical discipline simulations also focused on embedding

knowledge and skills in clinical decision making (Shah et al., 2018; Stepan et al., 2017;

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Willis et al., 2016). In contrast, for nursing simulation programs the focus was on preparation

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for practice, critical thinking and situational awareness related to a task or client group.
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Within nursing focused studies, the simulation scenarios were about challenging or complex

situations and working as an individual or team to develop good decision making, working
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through mistakes and to be able to prioritize care (Dubovsky et al., 2017; Hudson et al., 2015;
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Willis et al., 2016).

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Debriefing strategy to enhance learning

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One of the themes across all the studies was the need for interaction, reflection and debriefing

to enhance the learning associated with virtual simulation. This enabled the students to either
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work together or when prompted by the instructor, develop a deeper learning from the

simulation. Debriefing post-simulation provided opportunities to highlight and learn from

mistakes and uncover deeper critical analysis of the situation (Cooper et al., 2015; Willis et

al., 2016). One of the gaps identified within this concept was that very few virtual simulations

provided any ability for teamwork-related skills to be developed. In contrast, the gaming

simulations and interactive simulations provided an ability for students and instructors to

interact within the simulation environment (Carman et al., 2017; Dubovsky et al., 2017; Kron

et al., 2017; Willis et al., 2016). In the small number studies that contained interactive
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programs, these provided realistic interaction possibilities in a safe environment. The

preparedness of the instructor and student enhanced the student’s learning after the virtual

simulation but was an added burden for the instructor who had to learn and develop

competence in using virtual simulation as a learning tool (Menzel et al., 2014; Verkuyl et al.,

2017).

Preparing healthcare professionals in a safe and cost-effective environment

The main benefit of virtual simulation was the ability for repetition and safe practice in a

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realistic environment. Ease of use and engagement was another benefit and the age of

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participants was an influencing factor related to this, with the mean age of participants across
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the studies being below 30 years. The older the age of the student the lower students’

perceived usability of the simulation (Hudson et al., 2015). Simulation education for
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instructors ensured the instructors could move around the simulation with ease and assist
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students (Kron et al., 2017; Wright et al., 2018). The use of virtual simulation enabled
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repeated practice, changes in levels of difficulty and scenarios, which increased student

learning and engagement (Borg Sapiano et al., 2018; Kron et al., 2017; Verkuyl et al., 2018).
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Virtual simulations that could be tailored to the learner and aim of the teaching session, or for
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assessment of skills for various year level groups were more positively rated and useful

(Agrawal et al., 2016; Bogossian et al., 2015; Lehmann et al., 2015).

The analysis of the studies highlighted that the development of virtual simulation was cost

effective, and once developed could be used repeatedly and changed according to student

need (Borg Sapiano et al., 2018). Several studies noted increased feasibility of virtual

simulation compared with face-to-face simulation (Cobbett & Snelgrove-Clarke, 2016;

Cooper et al., 2015; Dubovsky et al., 2017; Haerling, 2018; Willis et al., 2016).
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In the medical studies, virtual simulation enabled a safe learning environment to practice

tasks prior to client engagement, particularly surgery and high acuity tasks (Amer et al.,

2017; Sankaranarayanan et al., 2018; White & Siu, 2017). The development of critical

thinking in complex clients via virtual simulation was present in the nursing studies,

particularly in relation to triage and health assessment (Bogossian et al., 2015; Borg Sapiano

et al., 2018; Cooper et al., 2015; Dubovsky et al., 2017).

Managing challenges of virtual simulation

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Virtual simulation is only as good as the technology and this was noted as a limitation for

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both students and instructors (Carman et al., 2017; Foronda et al., 2014). The technological
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support needed to be accessible and consistent over time (Carman et al., 2017; Cobbett &

Snelgrove-Clarke, 2016). In some of the studies, the complexity of using virtual simulation
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highlighted the need for instructor support particularly in the first stages of development and
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use which was seen as a limitation (Foronda et al., 2014; Menzel et al., 2014). Several studies
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identified the need for teacher and student debrief after virtual simulation, these studies

incorporated debrief online and was either written or verbal (Carman et al., 2017; Cooper et
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al., 2015; Wright et al., 2018).

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Another concept identified was, who was benefiting from the virtual simulation, the learner

or the organization (Cobbett & Snelgrove-Clarke, 2016). Virtual simulation is often

employed to enable student preparedness to compliment teaching particularly if face-to-face

simulation was not suitable or feasible (Cooper et al., 2015; Foronda et al., 2014;

Sankaranarayanan et al., 2018).

Discussion
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Virtual simulation prepares healthcare professionals to perform clinical skills and work

confidently in a clinical environment, especially in emergency and complex situations. This

integrative review has identified several gaps in the existing literature including lack of

multidisciplinary studies in relation to patient deterioration, rigorous strategies to support

deep learning, for example, structured debriefing and reflection, and the need for

opportunistic synchronous interaction within the virtual simulation. The included studies

showed limited reporting of validity and reliability of evaluation measures and this highlights

the need for the development of reliable tools to assess clinical competency in virtual

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simulations.

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This integrative review aimed to explore virtual simulation as an assessment method for
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healthcare professionals’ education. The reviewed studies originated from eight different
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countries, indicating global interest in virtual simulation teaching programs. Through our
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strategy of identification, evaluation, summary, and thematic grouping of the 23 studies, we

were able to identify four underlying themes: pedagogy differences across disciplines,
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debriefing strategy to enhance learning, preparing healthcare professionals in a safe and cost-
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effective environment and managing challenges of virtual simulation. Based on the review of

literature, a virtual simulation program was found to be a feasible strategy to assess students’
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clinical competency and support their learning in both medical and nursing programs.

The studies included in this review provide evidence that virtual simulation not only

enhanced students’ knowledge, confidence and virtual clinical performance, but also

communication, critical thinking and clinical decision-making (Agrawal et al., 2016;

Bogossian et al., 2015; Borg Sapiano et al., 2018; Hudson et al., 2015; Lehmann et al., 2015).

Virtual simulation supports students and healthcare workers to practice in a realistic and risk-

free environment, as well as enhance the flexibility and autonomous learning (Cobbett &

Snelgrove-Clarke, 2016; Liaw et al., 2015; Sankaranarayanan et al., 2018). Where

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programming allowed, the content of virtual simulation can be changed related to the levels

of difficulty and clinical needs, providing realistic scenarios to support student development

of lifelong learning (Borg Sapiano et al., 2018; Kron et al., 2017; Verkuyl et al., 2018). The

reviewed virtual simulation studies were mainly web-based using high-fidelity programs,

which allowed students repeated use. The students could enter into the real-world scenarios

and answer questions to direct client care (Liaw et al., 2015; Wright et al., 2018).

Clinical resources and opportunities for practice are often limited within a university setting

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(O'Brien et al., 2019). Virtual simulation programs are highly accepted by students because

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they liked the aspects including; being interactive, stimulating and enjoyable for learning

(Borg Sapiano et al., 2018; Carman et al., 2017). Virtual simulation was easy to access for
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both students and instructors and provided flexible and repeated practice. Timely feedback
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used within the simulation enabled the student to extend their knowledge and build their
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confidence (Verkuyl et al., 2017). Debriefing is an important aspect to consider when using

virtual simulation to enable a deeper student engagement in the learning opportunities

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(Lapum et al., 2019; Verkuyl et al., 2020). The use of self-debrief and online group
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debriefing provides students with an opportunity to ask questions and develop understanding

into clinical reasoning used during the simulation (Verkuyl et al., 2020). Online tests,
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performance scores or self-assessment evaluated the students’ knowledge, performance and

satisfaction (Agrawal et al., 2016). Clinical performance was often measured by self-

reflection.

There was a difference in the purpose of simulation programs used across disciplines in the

included studies. In nursing programs, the objectives for virtual simulation were focused on

competency training (such as managing hypoglycaemic clients) through using complex

clinical scenarios that required situational awareness and critical thinking. Whereas in the

medical programs, simulations focused on the practice of tasks and knowledge

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understanding. Overall, virtual simulation was found to be able to create a safe clinical

situation and engage the learner to enhance their clinical skills (Cobbett & Snelgrove-Clarke,

2016) regardless of the overarching aims.

Building virtual simulation programs can be expensive and time-consuming, and this was

identified as challenging when developing virtual simulation models however over time the

virtual simulation teaching opportunity is cost effective (Sankaranarayanan et al., 2018).

Virtual simulation also needs high-speed internet connection for smooth delivery. Instructors

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must have updated technical skills and enough time to teach students how to learn and engage

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in the simulation (Menzel et al., 2014).
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The strength of evidence for using virtual simulation as a teaching program is undermined by

methodological limitations within the research. The included randomized controlled trials had
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small sample sizes (Cobbett & Snelgrove-Clarke, 2016; Lehmann et al., 2015; Liaw et al.,
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2014; Menzel et al., 2014) and other studies had a lack of a comparison groups and
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randomization method, which challenges the analysis if the sample provided a positive

tendency to engage in simulation. The mean age of participants was below 30, which
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suggests that samples were mainly of students who already engaged with higher-level
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technology. This leads to questions about whether virtual simulation would be useful to

enhance clinical preparedness in mature aged students (Barak, 2018), although with the

advent of high-technology health environments this is perhaps not too concerning (Jedwab et

al., 2019) and could be seen as another way of preparing health practitioners for real practice

environments. The motivational [fun factor] and functional experience [side effects such as

visual disturbance] were found to be influencing factors of user acceptability rather than age

or gender in research by Bracq et al. (2019). This aligns with the Unified Theory of

Acceptance and Use of Technology model, which identifies aspects such as expectation of

the simulation, social influence, resources and motivation (Venkatesh et al., 2012).
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In an era where the preparation of healthcare professionals increasingly requires inter-

professional learning, virtual simulation needs to evolve to include more interdisciplinary

interaction among participants. The importance of teamwork and interdisciplinary

communication training using virtual simulation is particularly important in the context of

deteriorating client scenarios where human factors are recognized as being critical to

successful outcomes (Bursiek et al., 2017). When contemporary gaming platforms can foster

multiple user synchronous interaction, the technology has the potential to enable an inter-

professional approach to learning within this medium.

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Limitations
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A limitation of this review is the range of disciplines of the samples, which made comparison

of the benefits of virtual simulation difficult. Additionally, the different virtual simulation
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programs and teaching methods were not compared due to small numbers using each specific
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simulation program. The randomized controlled trials had small sample sizes and used non
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validated surveys and few reported reliability, which is a limitation for enacting

recommendations from our analysis.

ur

Recommendations
Jo

Virtual simulation is useful for teaching and assessing clinical competency however a

specific focus for or intent of the simulation outcomes should be clear. When using virtual

simulation for assessment it is important to ensure the instructor is competent with the

technology and the technology is reliable. A debriefing plan and facilitation within an

asynchronous virtual environment ensures a deeper learning process and students felt

comfortable within this simulated environment. Future high-level research is required to

explore the student benefits and barriers to learning within a virtual environment as more

teaching moves online.

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Conclusion

Virtual simulation has been of global interest to health educational organisations. It can

prepare students for the clinical environment by providing safe practice environment. Virtual

simulation has been found to be a feasible strategy to assess students’ clinical competency

and support their learning in both medical and nursing programs, however simulation should

be authentic and incorporate reflection. There is a lack of multidisciplinary approach in

virtual simulation programs reported in literature. In addition, the mean age of the student

of
population in included studies were below 30, indicating a need to research its use in older

ro
learners. Challenges related to managing and debriefing students must be overcome to ensure

best student learning outcomes.

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Figure 1 Literature searches, screening and selection of studies

Table 1 Study characteristics and findings of included studies (n=23)

Author, Year, Methods Simulation Clinical Measureme Main MMAT

Country sample Focus competency nts findings
program
Agrawal et al., Quasi- CEED Maternal 72 hour VS training 100
2016 Experimental technology neonatal standardized blended with
India Nursing/midwif health training traditional
ery students assessment package classroom
Pre n=83 Post Pre OSCA learning
n=92 28% (95% enhanced
CI, 19.9– knowledge

of
22.6) and skills of
Post OCSA students.
82% (95%

ro
CI, 60.3–
63.7)
Amer et al., Quasi- TouchSurge Carpal tunnel Mobile App Students 100s
2017 Experimental ry Mobile
-p
release Post-test utilizing VS
USA Medical application surgery knowledge training
students Average performed
re
Control n=50 grade better on a
Intervention n = Control standardized
50 75.6% SD test
lP

9% examining
App 89.3% the steps of a
SD 6% carpal tunnel
release than
na

those using a
traditional
teaching
ur

modality.
Bogossian et al., Quasi- FIRST2AC Sudden client Post-test The web- 80
2015 Experimental T WEBTM deterioration knowledge based e-
Jo

Australia Nursing Cardiac, Mean 62 - simulation

students respiratory, 76% SD 30% program
N=489 shock Self- effectively
evaluation of enhanced
competence knowledge,
virtual
clinical
performance,
and self-
assessed
knowledge,
skills,
confidence,
and
competence
in final-year
nursing
students.
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Borg Sapiano et Quasi- FIRST2AC Sudden client Pre-test VS was 100

al., 2018, Experimental T WEBTM deterioration knowledge effective to
Malta Nursing Cardiac, Mean 61% improve pre-
students respiratory, SD 16% registration
N=166 shock Post-test nursing
Mean 69% student’s
SD 16% knowledge,
had easy
access and
repeatability.
Carman et al., Quantitative iSimulate Client data Mandatory VS allowed 20
2017, Descriptive Physical virtual live Lacked
USA Registered assessment simulations interaction clarity of
nurse techniques online between data
N=23 Identifies training students and presentati
interventions Performance faculty. on
required evaluation Opportunity

of
80% of to practice
student teams assessment
performed and

ro
key decision-
behaviours in making in
-p the emergency
simulations and high-risk
situations.
VS offered
re
opportunity
to practice in
nonthreateni
lP

ng
environment,
feedback on
their skills,
na

and time
improve
their
confidence.
ur

Cobbett et al., RCT vSim Pre- Maternal Minimal 60

2016, Nursing developed eclampsia newborn difference in
Canada students by Laerdal assessment scenario knowledge
Jo

Face to face and Wolters Group B F2F and self-

n=28 Kluwer Streptococcu knowledge confidence
Virtual Health from s Mean 68% between
simulation n=27 Lippincott SD 11% face-to-face
or virtual
VCS clinical
knowledge simulation.
Mean 64% Cost
SD 15% effectiveness
and risk/
benefits for
students
considered
before
developing
VS. Higher
student
anxiety
existed in
virtual
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simulation.

Cooper et al., Mixed FIRST2AC Sudden client Pre-test No 100

2015, Australia Methods, T WEBTM deterioration knowledge difference
Multi-center Cardiac, 70% SD 13% between
Nursing respiratory, Post-test face-to-face
students shock performance simulation
N=100 79% SD 13% and Web-
Pre- and post- based
intervention simulation to
design without enhance
a control group knowledge
and skills.
Debriefing a

of
key
component
of

ro
simulation.
Dubovsky, et Quantitative CliniSpace Triage and Orientation, Computerize 100
al., 2017, Descriptive assessment
-p testing, d simulation
USA Registered of clients in debriefing of ED triage
nurses emergency phases provided
N=10 Performance opportunities
re
evaluation for disaster
Time to scenario
complete practice. The
lP

task 7:44 ± VS
2:18 min environment
(range 1:45– needed a
13:48 min) broader
na

range of
themes that
included
verbal
ur

communicati
on between
virtual
Jo

patients and
subjects and
interactions
of multiple
subjects.
Foronda, et al., Qualitative CliniSpace Recognise Communicati VS was 100
2014, longitudinal client data on Skills effective in
USA Nursing Perform CliniSpace teaching
students ISBAR ISBAR communicati
N=8 Rating Sheet on using
across two ISBAR as a
simulations communicati
One 34% SD on model.
17%
Two 82% SD
9%
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Haerling, 2018, Quasi- vSim Chronic Pre-test VS activity 100

USA experimental developed obstructive knowledge was more
Nursing by Laerdal pulmonary Mean 70% cost-
students and Wolters disease SD 14% effective
Virtual group Kluwer assessment Post-test compared
n=37 Health from knowledge with
Mannequin- Lippincott Mean 81% mannequin-
based n=44 SD 15% based
Student simulation
satisfaction activity.
and self
confidence
Hudson, et al., Quasi- Second Life Assessment 30mins VS offered 100
2015, experimental and simulation opportunities
USA Registered management System for practice
Nurses of Usability to increase
N= 12 hypoglycaem Scale (10- clinical

of
ia item decision-
questionnaire making
) effectiveness

ro
Post in a clinical
Situational environment.
-p Awareness
Score 86%
SD 8%
re
Kron, et al., Mixed Methods MPathic- Communicati Virtual Interactive 100
2017 Medical VR on skills simulation learning
USA students training score using VS
lP

VR n=210 VR mean was effective

Online module 81% SD 20% in training
n=211 Online advanced
module 75% communicati
na

SD 20% on skills and

Self- in enabling
reflection knowledge
transfer.
ur

Liaw, et al., RCT e-RAPIDS Assessment, 2-hour No 100

2014 Nursing management, training difference
Singapore students reporting of either fully between
Jo

Experimental client automated virtual

group n=31 deterioration virtual patient
Control group patient simulation
n=30 simulation or and
facilitator-led mannequin-
mannequin- based
based simulation.
simulation Virtual
training patient
Pre-test VS simulation
60% SD 9% provided
Control 54% opportunity
12% for repeated
Post-test VS practice and
68% SD 11% was cost
Control 61% effective.
SD 14%
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Liaw, et al., RCT Web-based Assessment, 3 hours of VS enabled 100

2015 Nursing simulation management, Web-based cost
Singapore students developed reporting of simulation effective
Experimental by Smith client Pre-test VS teaching,
group n=35 and Ragan deterioration 62% SD 11% provided
Control group Control no ease of
n=32 VS 64% 13% access
Post-test VS including
86% SD 14% repeatability
Control 66% for achieving
SD 13% long-term
retention of
clinical
competency.
Lehmann, et al., RCT CAMPUS- Paediatric Virtual VS 100
2015, Medical Software Basic Life simulation improved
Germany students Support Control outcomes for

of
Experimental Performance handouts clinical
group n=30 Pre-test VS preparedness
Control group 49% SD 20% for complex

ro
n=27 Control 68% skills
15% compared
-p Post-test VS with a
89% SD 9% standard
Control 84% approach.
SD 11% Motivation
re
for repeated
access was
higher in
lP

virtual
learning.
Menzel, et al., RCT Second Life Communicati 2.5-hour No 100
2014, Nursing on simulation difference
na

USA students delivered between VS

Experimental three times and online
group n=33 over a 1-year self-study.
Control group period or Faculty had
ur

n=18 online self- difficulty in

study navigating
Attitude the virtual
Jo

toward environment.
Poverty
Scale pre
post-test
Padilha, et al., Quantitative Body General Post-test VS provided 100
2017, descriptive InteractTM clinical Technology opportunity
Portugal cross-sectional assessment Acceptance for clinical
Nursing Model preparedness
students (TAM) . Students
N=426 Determinants with no
of the clinical
perceived experience
ease of use. reported ease
of use, and
usefulness in
preparation
for clinical.
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Sankaranarayan Quantitative VEST-OR Sequence for Operating VS 100

an , et al., 2018, Non- fire room fire compared to
USA randomized emergency scenario hands-on
Medical staff Pre-test VS training was
Simulation 50% IQR 3 relatively
n=10 Control 55% inexpensive
Control n=10 IQR 2 and effective
Post-test VS mode for
85% IQR 1 complex
Control 90% prevention
IQR 2 and
management
scenarios.
VS was cost
effective and
enabled
repeated

of
training.
Shah, et al., RCT Web-based Assessment Pre post No 100
2018, Medical staff curriculum and score significant

ro
USA Experimental Articulate management increase VS differences
n=112 Storyline 2 of children 20.9% found in pre
Control n=117 with medical
-p Control or post
complexity 15.5% performance
for the
device-
re
related
emergency
virtual
lP

simulation.
Low fidelity
VS enabled
opportunities
na

for learning
communicati
on
Students
ur

preferred
VS.
Stepan, et al., RCT Oculus Rift Neuroanatom 10 minutes Immersive 100
Jo

2017, Medical staff system y quiz virtual reality VR

USA Experimental study of educational
group n=33 Neuroanatom tools created
Control group y a more
n=33 Pre-test 61% positive
SD 21% learner
Control 60% experience
20% and
Post-test enhanced
76% SD 14% student
Control 75% motivation.
SD 16% However,
Instructional the
Materials technology
Motivation was equally
Survey as effective
[IMMS] as the
traditional
textbooks in
teaching
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neuroanatom
y.

Verkuyl, et al., Qualitative Ryerson Communicati Virtual Virtual 100

2017, focus groups on gaming gaming
Canada Nursing simulation simulation
students online can provide
N=20 Community experiential
home visit learning
Post opportunities
interview that promote
engagement
and allow
learners to
acquire and

of
apply new
knowledge
while

ro
practicing
skills in a
safe and
-p realistic
environment.
Willis, et al., Quantitative ACR select Diagnostic Education VS provided 100
re
2016, Descriptive assessment simulation opportunities
USA Pre- and post- portal for specific
intervention utilizing choices
lP

Medical integrated related to

students clinical treatment.
N=34 decision VS could be
support customized
na

Pre post-test across

knowledge continuum
increase 8.45 of medical
- 8.94 SD 2.3 education.
ur

p 0.46
Wright, et al., Quantitative vSim Assessment, Surgical and VS increased 100
2018, descriptive developed management medical student
Jo

USA Nursing by Laerdal and scenarios confidence

students and Wolters evaluation of Post-test when
N=103 Kluwer care knowledge working
Health from control 55% with real
Lippincott simulation patients. VS
59% allowed
intervention repeatability
simulation and students
58% noted it was
Student easy to use
Evaluation and helped
vSim them learn
from
mistakes.
Clear
instructions
needed for
instructors.
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Virtual Simulation VS Virtual reality VR Face to face F2F Virtual clinical simulation VCS
Random control trial RCT

of
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lP
na
ur
Jo
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Table 2 Explanation of simulation programs

Simulation program name Type of simulation

CEED technology Cisco’s Education Enabled Development Technology case-based

learning, filmed patient actor simulations, demonstrations, practice,
and feedback.

TouchSurgery Online modules, video of surgery with pictures and questions

of
prompts

FIRST2ACT WEBTM Videos of patient actors allowing virtual performance of clinical

ro
skills, inclusion of choices

iSimulate
-p
Videos of patient actor simulated case study

vSim Laerdal Videos of high fidelity simulation with Laerdal manikin

re
CliniSpace Avatar based virtual reality platform with choices
lP

Second Life Avatar based scenarios with virtual choices

MPathic-VR Modelling Professionalism and Teaching Humanistic

na

Communication in Virtual Reality: avatars which interact with

choices
ur

e-RAPIDS Interactive multimedia simulation with virtual choices using avatars

Web-based simulation Smith Interactive multimedia web based simulation, including avatar
Jo

and Ragan based video with virtual choices

CAMPUS software Videos of simulation with manikins and questions

Body InteractTM Avatar based scenarios with virtual choices

VEST-OR Video based avatars with choices

Articulate Storyline Audio voice-over narration, avatar, and a custom navigation bar

Oculus Rift system 3D reconstructed computer modelling and interactive simulation

Ryerson Videos of patient actor simulation with choices and informaiton

ACR select Web based multimedia with photos and videos

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Table 3. Themes from literature synthesis

Themes Data Empirical sources

Pedagogy Hands on simulation was (Amer et al., 2017; Lehmann et al.,

differences across superior to traditional teaching 2015; Stepan et al., 2017; Willis et al.,
disciplines methods for preparing medical 2016)
students

Simulation programs may (Bogossian et al., 2015; Hudson et al.,

improving learner performance 2015)

of
and enhance patient outcomes

Evaluate learners’ ability to

ro
(Borg Sapiano et al., 2018; Carman et
prioritize triage patients
-p al., 2017; Cobbett & Snelgrove-Clarke,
according to standard principles 2016; Dubovsky et al., 2017)
re
and procedures
lP

Debriefing Differences existed in the (Cooper et al., 2015; Shah et al., 2018;
strategy to participants’ evaluation of the Verkuyl et al., 2017; Wright et al.,
na

enhance learning programs and their satisfaction 2018)

levels. Face-to-face approach was
ur

positively regarded when it came

to the benefits of working in a
Jo

team and debriefing

Preparing Participants found VSIM for
healthcare Nursing to be realistic and
professionals in a fostered critical thinking which
safe and cost- was helpful in preparing for
effective clinical practice. Virtual reality
environment simulation engaged the students
by providing real-life patient
experiences for students to
practice in a risk-free
(Agrawal et al., 2016; Borg Sapiano et
al., 2018; Carman et al., 2017; Cobbett
& Snelgrove-Clarke, 2016; Foronda et
al., 2014; Haerling, 2018; Hudson et al.,
2015; Kron et al., 2017; Liaw et al.,
2014; Liaw et al., 2015; Padilha et al.,
2018; Sankaranarayanan et al., 2018;
Wright et al., 2018)
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environment

Managing Clear instructions for staff (Menzel et al., 2014; Wright et al.,
challenges of required 2018)
virtual
simulation.

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Highlights

 Simulations used in medical training programs were often task focused, whilst in

nursing programs the focus was developing critical thinking

 Online student debriefing is an important part of the learning process in virtual

simulation

 Complex clinical situations can be presented in a virtual world to enable students to

learn clinical reasoning in a safe environment

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Figure 1