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Advancing virtual patient simulations through design research and interPLAY: part II—integration and field test

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In Part I of this two-part series, we examined the design and development of NERVE: A virtual patient simulation created to give medical students standardized experiences in interviewing, examining, and diagnosing virtual patients with cranial nerve disorders. We illustrated key design features and discussed how design-based research studies improved the total learning experience, including the virtual patient (VP) simulations and the instructional features incorporated with the simulations. In Part II, we examine the efficacy of NERVE and the strategy used to integrate the system into the medical school curriculum by field-testing it with 119 s-year medical students, and measuring students’ use, reactions, learning, and transfer. We report findings and reflect on lessons learned from the field-test to posit recommendations for improvement and guide the future research and development of virtual patient simulations.

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  • Ahmed, M., Sevdalis, N., Paige, J., Paragi-Gururaja, R., Nestel, D., & Arora, S. (2012). Association for Surgical Education: Identifying best practice guidelines for debriefing in surgery: a tri-continental study. The American Journal of Surgery, 203, 523–529.

    Article  Google Scholar 

  • Barrows, H. S. (1985). How to design a problem based curriculum for the preclinical years. New York: Springer.

    Google Scholar 

  • Berman, N., Fall, L., Smith, S., Levine, D. A., Maloney, C. G., Potts, M., et al. (2009). Integration strategies for using virtual patients in clinical clerkships. Academic Medicine, 84(7), 943–949.

    Article  Google Scholar 

  • Botezatu, M., Hult, H., Kassaye Tessma, M., & Fors, U. G. (2010). As time goes by: Stakeholder opinions on the implementation and use of a virtual patient simulation system. Medical Teacher, 32(11), e509–e516.

    Article  Google Scholar 

  • Cendan, J., & Lok, B. (2012). The use of virtual patients in medical school curricula. Advances in Physiology Education, 36(1), 48–53.

    Article  Google Scholar 

  • Clark, R. E. (2004). Design Document for a Guided Experiential Learning Course. Submitted to satisfy contract DAAD 19-99-D-0046-0004 from TRADOC to the Institute for Creative Technologies and the Rossier School of Education, University of Southern California.

  • Consorti, F., Mancuso, R., Nocioni, M., & Piccolo, A. (2012). Efficacy of virtual patients in medical education: A meta-analysis of randomized studies. Computers & Education, 59(3), 1001–1008.

    Article  Google Scholar 

  • Cook, D. A. (2014). How much evidence does it take? A cumulative meta-analysis of outcomes of simulation-based education. Medical Education, 48(8), 750–760.

    Article  Google Scholar 

  • Cook, D. A., Erwin, P. J., & Triola, M. M. (2010). Computerized virtual patients in health professions education: A systematic review and meta-analysis. Academic Medicine, 85, 1589–1602.

    Article  Google Scholar 

  • Cook, D. A., & Triola, M. M. (2009). Virtual patients: a critical literature review and proposed next steps. Medical Education, 43(4), 303–311.

    Article  Google Scholar 

  • Dewey, J. (1938). Logic: The theory of inquiry. New York: Holt, Rinehart and Winston.

    Google Scholar 

  • Edelbring, S. (2010). A three-fold framework for relating to innovations and technology in education: learning from, with and about technology. In A. Bromage, L. Clouder, J. Thistlethwaite, & F. Gordon (Eds.), Interprofessional E-learning and collaborative work: Practices and technologies (pp. 23–33). Hershey: IGI Global.

    Chapter  Google Scholar 

  • Edelbring, S., Broström, O., Henriksson, P., Vassiliou, D., Spaak, J., Dahlgren, L. O., & Zary, N. (2012). Integrating virtual patients into courses: follow-up seminars and perceived benefit. Medical Education, 46(4), 417–425.

    Article  Google Scholar 

  • Edelbring, S., Dastmalchi, M., Hult, H., Lundberg, I. E., & Dahlgren, L. O. (2011). Experiencing virtual patients in clinical learning: a phenomenological study. Advances in Health Sciences Education, 16(3), 331–345.

    Article  Google Scholar 

  • Fischer, M., Hege, I., Hörnlein, A., Puppe, F., Tönshoff, B., & Huwendiek, S. (2007). Virtual patients in medical education: a comparison of various strategies for curricular integration. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen, 102(10), 648–653.

    Article  Google Scholar 

  • Haag, M., Singer, R., Bauch, M., Heid, J., Hess, F., & Leven, F. (2007). Challenges and perspectives of computer-assisted instruction in medical education. Lessons learned from seven years of experience with the CAMPUS system. Methods of Information in Medicine, 46(1), 67.

    Google Scholar 

  • Halan, S., Rossen, B., Cendan, J., & Lok, B. (2010). High score! - motivation strategies for user participation in virtual human development. Intelligent Virtual, 9783642158919, 482. doi:10.1007/978-3-642-15892-6_52.

    Article  Google Scholar 

  • Hirumi, A., Johnson, T. & Reyes, R. J. (2015). Field-testing Strategies to Improve the Integration of Virtual Patient Simulations into Medical School Curriculum. Concurrent session presented the annual Association for Educational Communication and Technology conference, Indianapolis, IN. November 4–6.

  • Hirumi, A., Kleinsmith, A., Johnsen, K., Kubovec, S., Eakins, M., Bogert, K., et al. (2016). Advancing virtual patient simulations through design research and interplay: Part I: Design and development. Educational Technology Research and Development,. doi:10.1007/s11423-016-9429-6.

    Google Scholar 

  • Huwendiek, S., & De Leng, B. A. (2010). Virtual patient design and curricular integration evaluation toolkit. Medical Education, 44(5), 519.

    Article  Google Scholar 

  • Huwendiek, S., Duncker, C., Reichert, F., De Leng, B. A., Dolmans, D., van der Vleuten, C. P., & Tönshoff, B. (2013). Learner preferences regarding integrating, sequencing and aligning virtual patients with other activities in the undergraduate medical curriculum: A focus group study. Medical Teacher, 35(11), 920–929.

    Article  Google Scholar 

  • Huwendiek, S., Reichert, F., Bosse, H. M., De Leng, B. A., van der Vleuten, C. P., Haag, M., & Tönshoff, B. (2009). Design principles for virtual patients: a focus group study among students. Medical Education, 43(6), 580–588.

    Article  Google Scholar 

  • Issenberg, S. B., McGaghie, W. C., Petrusa, E., Gordon, D. L., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10–28.

    Article  Google Scholar 

  • Keller, J. M. (1987). Development and use of the ARCS model of instructional design. Journal of Instructional Development, 10(3), 2–10.

    Article  Google Scholar 

  • Keller, J. M. (2010). Motivation design for learning and performance: The ARCS model approach. New York: Springer.

    Book  Google Scholar 

  • Kirkpatrick, D. L. (1994). Evaluating training programs: The four levels. San Francisco: Berrett Koehler Publishers.

    Google Scholar 

  • Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs: Prentice-Hall Inc.

    Google Scholar 

  • Levett-Jones, T., & Lapkin, S. (2014). The effectiveness of debriefing in simulation-based learning for health professionals: A systematic review (Protocol). JBI Database of Systematic Reviews and Implementation Reports, 9, S81–S96.

    Google Scholar 

  • Lindsey, L., & Berger, N. (2009). Experiential approach to instruction. In C. Reigeluth & A. Carr-Chellman (Eds.), Instructional-design theories and models (Vol. 3, pp. 117–142)., Building a common knowledge based New York: Routledge.

    Google Scholar 

  • Maran, N. J., & Glavin, R. J. (2003). Low-to high-fidelity simulation – a continuum of medical education? Medical Education, 37(1), 22–28.

    Article  Google Scholar 

  • McGaghie, W., Issenberg, S., Cohen, E., Barsuk, J., & Wayne, D. (2011). Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine, 86(6), 706–711.

    Article  Google Scholar 

  • McGaghie, W. C., Issenberg, S. B., Petrusa, E. R., & Scalese, R. J. (2010). A critical review of simulation-based medical education research: 2003–2009. Medical Educator, 44, 50–63.

    Article  Google Scholar 

  • Paige, J. T., Arora, S., Fernandez, G., & Seymour, N. (2015). Debriefing 101: Training faculty to promote learning in simulation-based training. The American Journal of Surgery, 209(1), 126–131.

    Article  Google Scholar 

  • Pfeiffer, J. W., & Jones, J. E. (1975). Introduction to the structured experiences section. In J. E. Jones & J. W. Pfeiffer (Eds.), The 1975 annual handbook for group facilitators. La Jolla: University Associates.

    Google Scholar 

  • Salem-Schatz, S., Ordin, D., & Mittman, B. (2010). Guide to the after action review v1.1. Accessed 27 September 2014 from

  • Schank, R. C., Berman, T. R., & Macpherson, K. A. (1999). Learning by doing. In C. M. Reigeluth (Ed.), Instructional design theories and models: A new paradigm of instructional theory (pp. 161–179). Hillsdale: Lawrence Erlbaum Associates.

    Google Scholar 

  • Stapleton, C., & Hirumi, A. (2011). Interplay instructional strategy: Learning by engaging interactive entertainment conventions. In M. Shaughnessy & S. Fulgham (Eds.), Pedagogical models: The discipline of online teaching (pp. 183–211). Hauppauge: Nova Science Publishers Inc.

    Google Scholar 

  • Stapleton, C., & Hirumi, A. (2014). Designing InterPLAY learning landscapes to evoke emotions, spark the imagination, and promote creative problem solving. In A. Hirumi (Ed.), Grounded designs for online and hybrid learning: Practical guidelines for educators and instructional designers (pp. 159–190). Eugene: International Society for Technology in Education.

    Google Scholar 

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Research reported in this paper was supported by the National Institutes of Health (NIH) under award number 1R01LM010813-01.

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Correspondence to Atsusi Hirumi.

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Hirumi, A., Johnson, T., Reyes, R.J. et al. Advancing virtual patient simulations through design research and interPLAY: part II—integration and field test. Education Tech Research Dev 64, 1301–1335 (2016).

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