Virtual reality simulation immerses learners in a low-cost reality based clinical environment.
When first thinking about how patient care could be improved through more effective healthcare training, the team at Oxford Medical Simulation (OMS) started with the problem: clinicians kill people.
Medical error is the third leading cause of death in hospitals, second only to heart disease and cancer1. The reasons behind it are complex. Clinicians are burned out, dealing with unprecedented pressures and not having enough time to see patients effectively. Combine this with the natural uncertainty of clinical medicine and the lack of support from the systems in which they work, this becomes a recipe for disaster.
However, fundamental to all of this is training. The same pressures that put clinicians under pressure in the clinical world are taking time away from training, and training budgets are easy to cut as financial pressures bite. However, to improve patient care, training should be seen as a focus rather than an expendable luxury, as not only does it improve clinical performance but has a significant impact on workplace satisfaction and staff retention.
The optimal method of clinical training is simulation – where the learner is placed in an immersive and engaging environment in which to practice as if in real life. Simulation is effective and has proven benefits on clinical performance and subsequent patient care. However, physical simulation is expensive, time and space consuming. It is only available in larger centres and needs to be led by faculty, meaning it cannot be scaled to deliver flexible training when needed by clinicians.
Oxford Medical Simulation began exploring other methods of delivering the benefits of physical simulation in a scalable, accessible manner. The one technology that has the power to immerse participants in fully interactive, immersive environments that feels real, is virtual reality (VR).
Virtual reality simulation has been growing rapidly in recent years. The value of immersive VR has been confirmed both in comparison to screen-based learning2, and compared to physical simulation, where it has been found to be at least as effective in terms of educational outcomes, while being more cost effective3.
So, if VR sim can be cheaper and more effective than physical sim, does this spell the death of mannikins? No. Simulation is a technique, not a technology, so the key is to focus on the learning objectives and let the simulation technology follow. For example. VR is not the best way to teach abdominal palpation; in-situ simulation necessitates the real environment and the subtleties of breaking bad news are best taught through expert standardised patients.
So while VR should not be seen as a panacea, is it perfect for a large part of simulation. To delivering full immersion simulation and deliberate practice at scale in an objective, standardised way, without need for faculty, VR is perfect. This is particularly true when the focus is on decision-making, critical thinking and clinical reasoning.
That is what Oxford Medical Simulation does. Learners see patients in virtual reality and do what they would do in real life - history, examinations, investigations, interpretation of results, diagnosis and treatment, all the while interacting with their virtual team. The patient, vitals, labs and clinical team adapt depending on learner actions and – thanks to in-built artificial intelligence – respond as they would in real life.
As in physical simulation, once the scenario is completed, the learner receives a debrief – either guided by the system or by faculty – and feedback on what they have done during the simulation. This data is made available to both the learner and the institution through the in-built analytics system. Learners can use the data to track progress, link to learning portfolios and identify areas for further improvement. Institutions use it to help identify struggling students in order to offer further opportunities for learning and practice.
The entire system is customizable to allow institutions to build learning packages around the scenarios.
Creation of Experiences
The team behind Oxford Medical Simulation – comprised of clinicians, medical educators and technology and game developers – has focused on creating experiences that feel completely real – from hospital environments to clinically accurate behaviours to the amount patients sweat as their temperature increases. This all-encompassing sensory experience creates a deep cognitive and emotional connection to a scenario which brings about true experiential learning.
At the OxSTaR Centre at Oxford University, medical students have been using the OMS technology to support theoretical, classroom-based learning with the practical application of that knowledge in virtually simulated environments. Oxford found that its students were only getting access to physical simulation sessions once or twice in an academic year and needed a way to widen this accessibility and provide flexibility in the delivery of simulation to fit students’ busy schedules.
Rosie Warren, Centre Manager at OxSTaR commented: “As a world-leading institution, it is important for us to remain at the forefront of changes in the types of learning opportunities we offer our students. Embedding virtual reality simulation into what we do has enabled us to give a far greater number of learners access to simulation in a shorter space of time. It’s encouraging to see how quickly our students have adopted the technology and I’m excited to see how they progress clinically as they use it more and more. Simulation is a vital part of medical education and students just don’t get to do it enough. The OMS platform allows learners to enter simulation as often as they like to transfer their knowledge to practice.”
Implementing VR simulation to empower blended learning has proven to be popular with the students at Oxford. Students using the OMS platform recognise its capacity to increase their confidence and competence in applying their learning to practice in the clinical environment.
One fifth year medical student commented: “I think it’s really good to get the experience of being put in the driver’s seat, of making the decisions and then following through with the management because as a medical student, you do a lot of standing around watching people do things and you tell yourself that you would make those decisions but it’s nice to actually practice making the decisions. I think it will give me more confidence to make those decisions in real life.”
Training doctors in a way that boosts their confidence is crucial. 2018 reports suggested that only 43% of junior doctors across the UK continued on to further training after their first two years of practice on the wards. With so many newly-qualified clinicians leaving the profession shortly after medical school - it has never been more relevant to address the likelihood that established training methods are not appropriately equipping students for the realities of working in the modern day healthcare system.
Practically, training needs to fit with learners’ modern working patterns. The OMS system is totally flexible to use but also simple to implement and manage. Requiring only a compatible laptop and virtual reality kit, the system is portable, space saving and cost efficient. The system has been designed to enable users to step into the virtual simulation seamlessly and from anywhere.
This is particularly useful for institutions with multiple sites, enabling them to open up simulation to wider groups of students by simply transporting the kit to where they need it. Similarly, the system increases efficiencies for time-poor faculty members. Students can run through the virtual simulation with or without faculty present, as all of the feedback is standardised and based on best practice and institutional requirements.
In the UK, OMS is used across the National Health Service (NHS), with the NHS England diabetes team using the OMS system to optimize training to improve the quality of care of diabetic patients.
Recognizing that people with Type 1 diabetes are at a higher risk of developing diabetic ketoacidosis and hypoglycemia when in hospitals than in the community, NHS England is using OMS to improve clinical recognition and treatment of such events.
Dr Jack Pottle, founder and Medical Director of OMS noted that this application of the technology forms a vital part of his vision behind the company: “When I was in training we’d learn on the wards using the age-old method of ‘see one, do one, teach one’. I had never practiced managing a diabetic emergency until I had to do it in real life. You wouldn’t expect a pilot to fly a plane full of passengers without having practiced first. Why do we think that’s acceptable for doctors and nurses?”
The diabetes-specific use case illustrates how VR simulation can be woven into the healthcare ecosystem to improve patient care and is reflective of the NHS commitment to innovation and embracing technologies.
Dr. Partha Kar, NHS England Clinical Director of Diabetes is fully supportive of VR training and embracing of new methods of improving patient care: “Training doctors using virtual reality is another example of modernising the NHS to help improve care for patients with diabetes.”
At the University of Northampton, nursing students are using the OMS system in a virtual ward that has been set up specifically to offer open access to simulation.
Integrating this virtual technology within the context of the wider skills lab offers a clear example of how this technology complements existing structures.
The University of Northampton explained the decision to roll out the OMS system for nursing students, “Since nursing is a complex and challenging profession which encompasses a range of skills including people skills, soft skills and clinical skills, we needed to be able to train future nurses in a balanced way that caters to each of these skill sets.
Technological developments are allowing us to do this in a safe and supportive learning environment, focusing on immediate feedback and the opportunity to repeat the scenarios and improve over time.
The OMS system allows us to integrate theory into practice in a really meaningful manner, allowing progression throughout their academic career.”
In exploring these different uses of the OMS system across Oxford University, NHS England and the University of Northampton the application of virtual reality technology is clear and marks an exciting change in how we can train healthcare professionals.
The implications for the wider healthcare system are even more important. Making simulation more accessible allows the healthcare professional of the future to be more confident, well practiced and sharper in their clinical reasoning, ultimately leading to improved patient care and saved lives.
About the Author
Jack Pottle is co-founder and medical director of Oxford Medical Simulation - a virtual reality medical training company. A practicing physician, NHS clinical entrepreneur and medical simulation instructor, Jack is dedicated to improving patient safety by enhancing clinical training. He founded OMS to deliver this training in a fully-immersive, scalable and cost-efficient manner. Prior to working in virtual reality Jack successfully led an online medical education company and has worked across four continents, including in patient-centred education in South Africa. He has degrees in psychology and medicine from Oxford University.
1 Mackery, M A; “Medical error—the third leading cause of death in the US”. BMJ (2016)
2 Gutierrez, F; “The effect of degree of immersion upon learning performance in virtual reality simulations for medical education.” (2007)
3 Haerling, K A; “Cost-Utility Analysis of Virtual and Mannequin-Based Simulation.” (2018)
Originally published in Issue 3, 2019 of MT Magazine.