Bringing Simulation to Life: The Benefits of Virtual Reality in Healthcare Simulation

Virtual reality simulation immerses learners in a low-cost reality based clinical environment.

When first thinking about how patient carecould be improved through more effective healthcare training, the team atOxford Medical Simulation (OMS) started with the problem: clinicians killpeople.

Nursing student at the University of Northampton trying out the OMS virtual reality platfrom. Image credit: OMS/University of Northampton Nursing.

Medical error is the third leading cause ofdeath in hospitals, second only to heart disease and cancer1.  The reasons behind it are complex. Cliniciansare burned out, dealing with unprecedented pressures and not having enough timeto see patients effectively. Combine this with the natural uncertainty ofclinical 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 istraining. The same pressures that put clinicians under pressure in the clinicalworld are taking time away from training, and training budgets are easy to cutas financial pressures bite. However, to improve patient care, training shouldbe seen as a focus rather than an expendable luxury, as not only does itimprove clinical performance but has a significant impact on workplacesatisfaction 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.

Immersive

Oxford Medical Simulation began exploringother methods of delivering the benefits of physical simulation in a scalable,accessible manner. The one technology that has the power to immerseparticipants in fully interactive, immersive environments that feels real, isvirtual reality (VR).

Virtual reality simulation has been growingrapidly in recent years. The value of immersive VR has been confirmed both incomparison to screen-based learning2, and compared to physicalsimulation, where it has been found to be at least as effective in terms ofeducational outcomes, while being more cost effective3.

So, if VR sim can be cheaper and moreeffective 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 thelearning objectives and let the simulation technology follow. For example. VRis not the best way to teach abdominal palpation; in-situ simulationnecessitates the real environment and the subtleties of breaking bad news arebest 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 immersionsimulation and deliberate practice at scale in an objective, standardised way,without need for faculty, VR is perfect. This is particularly true when thefocus 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 institutionsto build learning packages around the scenarios.

Medical student at Oxford University sampling an OMS virtual reality medical emergency scenario. Image credit: OMS/OxSTaR.

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 invirtually simulated environments. Oxford found that its students were onlygetting access to physical simulation sessions once or twice in an academicyear and needed a way to widen this accessibility and provide flexibility inthe delivery of simulation to fit students’ busy schedules.

Rosie Warren, Centre Manager at OxSTaRcommented: “As a world-leading institution, it is important for us to remain atthe forefront of changes in the types of learning opportunities we offer ourstudents. Embedding virtual reality simulation into what we do has enabled usto give a far greater number of learners access to simulation in a shorterspace of time. It’s encouraging to see how quickly our students have adoptedthe technology and I’m excited to see how they progress clinically as they useit more and more. Simulation is a vital part of medical education and studentsjust don’t get to do it enough. The OMS platform allows learners to entersimulation as often as they like to transfer their knowledge to practice.”

Implementing VR simulation to empowerblended learning has proven to be popular with the students at Oxford. Studentsusing the OMS platform recognise its capacity to increase their confidence andcompetence 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’sseat, of making the decisions and then following through with the managementbecause as a medical student, you do a lot of standing around watching peopledo things and you tell yourself that you would make those decisions but it’snice to actually practice making the decisions. I think it will give me moreconfidence to make those decisions in real life.”

Training doctors in a way that boosts theirconfidence is crucial. 2018 reports suggested that only 43% of junior doctorsacross the UK continued on to further training after their first two years ofpractice on the wards. With so many newly-qualified clinicians leaving theprofession shortly after medical school - it has never been more relevant toaddress the likelihood that established training methods are not appropriatelyequipping students for the realities of working in the modern day healthcaresystem.

Nursing student at the University of Northampton with feedback from their OMS virtual reality simulation. Image credit: OMS/University of Northampton Nursing.

Flexibility

Practically, training needs to fit withlearners’ modern working patterns. The OMS system is totally flexible to usebut also simple to implement and manage. Requiring only a compatible laptop andvirtual reality kit, the system is portable, space saving and cost efficient.The system has been designed to enable users to step into the virtualsimulation seamlessly and from anywhere.

This is particularly useful forinstitutions with multiple sites, enabling them to open up simulation to widergroups 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 facultypresent, as all of the feedback is standardised and based on best practice andinstitutional requirements.

In the UK, OMS is used across the NationalHealth Service (NHS), with the NHS England diabetes team using the OMS systemto optimize training to improve the quality of care of diabetic patients.

Recognizing that people with Type 1diabetes are at a higher risk of developing diabetic ketoacidosis andhypoglycemia when in hospitals than in the community, NHS England is using OMSto improve clinical recognition and treatment of such events.

Dr Jack Pottle, founder and MedicalDirector of OMS noted that this application of the technology forms a vitalpart of his vision behind the company: “When I was in training we’d learn onthe wards using the age-old method of ‘see one, do one, teach one’. I had neverpracticed managing a diabetic emergency until I had to do it in real life. Youwouldn’t expect a pilot to fly a plane full of passengers without havingpracticed first. Why do we think that’s acceptable for doctors and nurses?”

The diabetes-specific use case illustrateshow VR simulation can be woven into the healthcare ecosystem to improve patientcare and is reflective of the NHS commitment to innovation and embracingtechnologies.

Dr. Partha Kar, NHS England ClinicalDirector of Diabetes is fully supportive of VR training and embracing of newmethods of improving patient care: “Training doctors using virtual reality isanother example of modernising the NHS to help improve care for patients withdiabetes.”

At the University of Northampton, nursingstudents are using the OMS system in a virtual ward that has been set upspecifically to offer open access to simulation.

Integrating this virtual technology withinthe context of the wider skills lab offers a clear example of how thistechnology complements existing structures.

The University of Northampton explained thedecision to roll out the OMS system for nursing students, “Since nursing is acomplex and challenging profession which encompasses a range of skillsincluding people skills, soft skills and clinical skills, we needed to be ableto train future nurses in a balanced way that caters to each of these skillsets.

Technological developments are allowing usto do this in a safe and supportive learning environment, focusing on immediatefeedback and the opportunity to repeat the scenarios and improve over time.

The OMS system allows us to integratetheory into practice in a really meaningful manner, allowing progressionthroughout their academic career.”

In exploring these different uses of theOMS system across Oxford University, NHS England and the University ofNorthampton the application of virtual reality technology is clear and marks anexciting 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 Pottleis co-founder and medical director of Oxford Medical Simulation - a virtualreality medical training company. A practicing physician, NHS clinicalentrepreneur and medical simulation instructor, Jack is dedicated to improvingpatient safety by enhancing clinical training. He founded OMS to deliver thistraining in a fully-immersive, scalable and cost-efficient manner. Prior toworking in virtual reality Jack successfully led an online medical educationcompany and has worked across four continents, including in patient-centrededucation in South Africa. He has degrees in psychology and medicine fromOxford University.

References

1 Mackery, M A; “Medical error—the thirdleading cause of death in the US”. BMJ (2016)

2 Gutierrez, F; “The effect of degree ofimmersion upon learning performance in virtual reality simulations for medicaleducation.” (2007)

3 Haerling, K A; “Cost-Utility Analysis of Virtual and Mannequin-Based Simulation.” (2018)

Originally published in  Issue 3, 2019 of MT Magazine.