Research article
Open Access

Do innovative immersive virtual reality simulation videos have a role to play in teaching non-technical skills and increasing preparedness for clinical placements for medical students?

Sushil Pal[1], Rosalind Benson[1], Paul Duvall[1], Vidhi Taylor-Jones[1]

Institution: 1. School of Medicine, University of Liverpool
Corresponding Author: Dr Sushil Pal ([email protected])
Categories: Curriculum Planning, Educational Strategies, Technology, Simulation and Virtual Reality, Undergraduate/Graduate
Published Date: 11/08/2020


Teaching non-technical skills (NTS) is an important part of the undergraduate medical curriculum. Resource intensive high-fidelity simulation has an established role in this. We developed an innovative series of immersive virtual reality simulation videos for medical students. We found they demonstrated efficacy in teaching NTS and after viewing students felt better prepared for clinical placements.

Keywords: undergraduate; medicine; education; virtual reality; simulation


Teaching non-technical skills (NTS) is an important part of the undergraduate medical curriculum. Resource intensive high-fidelity simulation has an established role in this. We developed an innovative series of immersive virtual reality (VR) simulation videos for medical students. We found they demonstrated efficacy in teaching NTS and after viewing, students felt better prepared for clinical placements.

The GMC published a pivotal report on the UK medical graduates preparedness to practice (Monrouxe et al., 2014). They highlighted the importance of the development of non-technical skills (NTS) including leadership, situational awareness and the clinical environment, team working and clinical decision-making. They reported variability in the quality of teaching that students experience when traditional learning methods of the apprentice model and junior doctor shadowing were employed. However, the benefit of being an integral team member and the importance of familiarity with the specific working environment was recognised to beneficially facilitate the medical student’s preparedness to practice on graduation. 

The community of practice (COP) is a social learning theory embedded within many successful clinical learning environments. Learners, namely medical students initially find themselves on the edge of a COP. As they become more integral to the group and their knowledge increases they move more centrally into the COP. We can enable this transition by equipping students with skills to enhance their legitimacy within the clinical setting. This can be achieved by repeated clinical exposure but situated learning can also be replicated within the simulation setting and in doing so increase a medical student’s legitimacy to practice (Thomas, Reedy and Gill, 2014).

Using high fidelity simulation to teach NTS has noted success (Coggins et al., 2017). However, it is expensive, requiring dedicated space and large faculty of trained staff necessitating alternatives to be sought. The educational value of low fidelity simulation has been evaluated in comparison with high-fidelity simulation and has shown consistent improvement in both groups in the teaching of complex clinical and management skills (Bracq, Michinov and Jannin, 2019).

Increasingly VR technology to teach surgical techniques and clinical anatomy is used. It’s utility in the teaching of NTS has been little explored and as yet there is no comparator study with high-fidelity simulation published (Norman, Dora and Grierson, 2012).


We were interested in whether immersive 360° video simulations of clinical practice can enhance and improve the teaching of NTS and future preparedness for clinical placements following the introduction of VR video simulation to medical students at the University of Liverpool.


The Simulation Programme

In 2016-7 the initial project started as several simulation scenarios recorded using 360° cameras. New scenarios were videoed in the 2017-2018 academic year to improve the authenticity and aesthetics. The scenarios were filmed in a common clinical multi-bedded ward-based environment. Scenario learning objectives were developed based on GMC described domains focussing on NTS such as teamwork, communication and task prioritisation (Monrouxe et al., 2014).

These scenarios were integral to the development of a simulation programme for the 3rd year students, aiming to increase the students’ exposure to simulated practice through the combination of emerging technology and innovative clinical scenarios, otherwise difficult to deliver to large numbers of students. The scenarios provided a unique opportunity to exposure students to situations they rarely face such as blood transfusion errors, and to those scenarios to be experienced in authentic clinical environments with authentic clinical protagonists.

The programme consisted of one high-fidelity simulation session and three lectures based on immersive 360° videos. During the lectures, students would watch the clinical scenarios unfold. Delivered by a highly experienced simulation facilitator and clinician, the scenarios would be interrupted at key points to enable discussion about demonstration of NTS in the style of debriefing a clinical scenario.

On programme completion all students were invited to take part in an anonymous Likert scale questionnaire. Shortly after a focus group was formed which allow thematic analysis to take place from their responses. 


101 students responded to the questionnaire, of which 89% had attended all lectures and 82% had attended their high fidelity simulation session. 

In all NTS domains assessed, students reported greater understanding of the clinical decision making process (79%), task prioritisation and delegation (69%) and the clinical environment (69%). 71% of students reported feeling better prepared for clinical placement as a result of the programme, stating in part increased confidence in the clinical environment (59%).  

Thematic analysis following a focus group interview showed strong concordance of the described themes. Students reported benefiting from the immersive environment of the simulation programme describing the ‘safe space’ for their first exposure to the clinical scenarios as helpful. They found observing the scenarios enabled them to feel they could imitate some of the behaviours displayed by the doctors in the scenes using terms like ‘role modelling’. They found the deconstructive/debriefing elements to the programme meant they developed a more critical approach to their learning following ward placement (see extract 1). These findings are consistent with improving a student’s sense of legitimate peripheral participation.

Extract 1: Focus group comments

‘I learned that you should be critical as well, in your own practice and in other peoples’ practice… you have a tendency…in clinical placement to just watch the ward round and not really take it…overwhelmed by it…. So, I think that’s helped me see placement in a different way, I don’t just take everything on face value for granted… I’m actually think, oh, the doctor’s doing this… maybe he’s stressed, things like that…' 


The immersive 360° videos can also be viewed by utilising emerging video hosting software enabling a more individualised experience for students. The school has partnered with a start-up company called Virti™ to host these videos. Through the creation of interactive layers over the videos, student can interact with the content in a unique way on their smartphones, choosing to watch them in both VR and non-VR formats. As the scenario progresses, questions and information boxes appear in the form of annotated layers of text on the screen which the student can choose to interact with as part of their learning experience. Multiple packages can be created from the same scene depending on what the specific learning objectives are.

Next we will embed the scenarios within complete learning packages including links to algorithms and guidelines used in the scenarios. The school also aims to provide VR headsets compatible with most smartphone devices. Further scenarios will be created that look at more diverse clinical environments including general practice, paediatrics and mental health.


Our research has shown that the development of our unique simulation programme using both VR video simulation alongside traditional high-fidelity simulation has clear educational value in the teaching of NTS, translating into the medical student feeling better prepared for clinical placement. 

Take Home Messages

  • Teaching non-technical skills (NTS) is an important part of undergraduate medical curriculum. It is an important part of increasing medical students preparedness for clinical placement.
  • High fidelity simulation is resource intensive which consequently limits its accessibility.
  • A programme of combined virtual reality video simulation alongside high fidelity simulation offers a novel and effective approach to teaching non-technical skills also enabling the student to access the material outside of the educational setting.

Notes On Contributors

Dr Sushil Pal - Former Clinical Medical Education Fellow at the University of Liverpool and now a Core Anaesthetics Trainee in the Mersey region. 

Dr Rosalind Benson - Honorary Clinical Medical Education Fellow at the University of Liverpool and a Rheumatology/General Internal Medicine Specialist Trainee in the Mersey region. ORCID:

Mr Paul Duvall - Former Director of Technology Enhanced Learning at the University of Liverpool.

Dr Vidhi Taylor-Jones - Director of Simulation at the University of Liverpool and Consultant Anaesthetist at Aintree University NHS Foundation Trust.




Bracq, M.S., Michinov, E. and Jannin, P. (2019) ‘Virtual Reality Simulation in Nontechnical Skills Training for Healthcare Professionals: A Systematic Review’, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 14(3), pp. 188–194,

Coggins, A., Desai, M., Nguyen, K. and Moore, N. (2017) ‘Early acquisition of non-technical skills using a blended approach to simulation-based medical education’, Advances in Simulation, 2(1), p. 12,

Monrouxe, L., Bullock, A., Cole, J., Gormley, G., et al. (2014) ‘UK Medical Graduates Preparedness for Practice: Final Report to the GMC.’ General Medical Council. Available at: (Accessed: 9 June 2020).

Norman, G., Dore, K. and Grierson, L. (2012) ‘The minimal relationship between simulation fidelity and transfer of learning: Simulation fidelity’, Medical Education, 46(7), pp. 636–647,

Thomas, L., Reedy, G. and Gill, E. (2014) ‘0216 Becoming A Doctor: How Simulated Practice Can Legitimise Medical Students’ Participation In Clinical Practice’, BMJ Simulation and Technology Enhanced Learning, 1(Suppl 1), p. A80,




There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (

Ethics Statement

Ethics approval was granted by the University of Liverpool Ethics Committee - Project ID 2618.

External Funding

This article has not had any External Funding


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Ken Masters - (07/11/2020) Panel Member Icon
The paper deals with immersive virtual reality simulation videos in teaching non-technical skills and increasing preparedness for clinical placements to medical students.

While the research appears to have been useful, the paper does need a great deal of work. So much so that it is difficult to assess the value of the research itself.

I would recommend a Version 2 of the paper, in which the authors address these issues:

• The Abstract is far too short and uninformative. It should be properly structured in the same format of the paper, and then give the most important results and findings.

• The first paragraph of the Introduction is a repeat of the Abstract, and should be removed.

• “It’s utility in the teaching of NTS has been little explored and as yet there is no comparator study with high-fidelity simulation published (Norman, Dora and Grierson, 2012).” This statement should be re-phrased, as it implies that the Norman et al. reference supports the statement that “and as yet there is no comparator study with high-fidelity simulation published”. If this was the case in 2012, it might not necessarily true 8 years later. In addition, it would be safer if the authors wrote that they could not find such a study (as such a study may have been published, but the authors missed it in their search).

• There is an error in the Norman et al. reference (The words “Simulation fidelity” have erroneously been added to the title).

• In the Methods, far more information is required about:
o The technical information about the construction of the videos (including partnering with Virti, costs (in both time and money)) should be given in the Methods (not the Discussion). In fact, most of the Discussion’s first paragraph should go into the Methods.
o Given that Virti appears to be a private company, their involvement needs to be explicitly described (what does “partnered” in this study refer to?)
o The students, their stage of study (not just “3rd-year”), previous exposure to similar technologies, etc.
o The survey: how many questions, how delivered (if online, details, not just “online”). It would be best to supply a copy of the questionnaire.
o Focus group: How conducted, by whom, how many participants, how long. It would be best to supply a copy of the initial questions.
o Theming: process of theming, including software (if any) used.
o Data storage and anonymisation.

• In the Results, again, far more information is required:
o Student demographics of both the survey and the focus group.
o Raw numbers and percentages (even though the total was 101, it’s best to stay with the convention).
o Any correlations between the variables, especially demographics and answers to questions, groups (e.g. lectures and session) and the answers to the questions, and statistically significant differences.
o Focus group: The data from the focus group should be given properly in themes, with each theme supported by 1-2 quotations.

• The Discussion, unfortunately, is lacking. Once the first paragraph has been moved to the Methods (where it should be), the Discussion consists only of looking forward. There is no discussion of the results, relating them back to the literature, no Limitations, etc.

• There are quite a few language and punctuation errors in the paper. Sometimes, they are minor irritations, but sometimes, they interfere with the meaning. I would strongly recommend that the authors perform another careful proof-read of the paper.

So, while the research appears interesting, I feel that the authors have missed a golden opportunity to write it up as a strong and coherent research paper. I look forward to reading Version 2 in which these issues are addressed.

Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

P Ravi Shankar - (26/08/2020) Panel Member Icon
This is an interesting article about implementing a mixed educational program utilizing a high-fidelity simulation and virtual reality sessions. Virtual reality can play an increasingly important role in medical education. The cost of VR hardware is decreasing and as the authors mention VR can be accessed through smartphones and VR glasses.
One of the issues to be addressed in a revised version is to provide a greater description of what was done during the intervention, what was measured, how it was measured and what was found. Readers can benefit from greater details about what was addressed during the high-fidelity simulation and the topics addressed during the virtual reality (VR) sessions. How were the VR sessions conducted in the classroom? More details about the questionnaire and how the focus groups were conducted and how the data was analyzed will be helpful. How many focus groups were conducted? What were the themes which emerged? Greater details about the company called ‘Virti’ and which topics will be addressed and more information about the videos will be of interest.
Carol Quinn - (25/08/2020)
important contribution in recognising medical students are on the edge of a community of practice and utilisation of technology to enhance learning. Clear outcomes with appropriate measurement. Practical implications identified.