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Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 228-231

Resident perspectives on communication training that utilizes immersive virtual reality

1 Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
2 Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, India
3 Division of Learning and Development, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
4 Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center; Division of Learning and Development, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA

Date of Web Publication18-Apr-2018

Correspondence Address:
Francis J Real
3333 Burnet Ave, MLC 2011, Cincinnati, OH 45229
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_9_17

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Background: Communication skills can be difficult to teach and assess in busy outpatient settings. These skills are important for effective counseling such as in cases of influenza vaccine hesitancy. It is critical to consider novel educational methods to supplement current strategies aimed at teaching relational skills. Methods: An immersive virtual reality (VR) curriculum on addressing influenza vaccine hesitancy was developed using Kern's six-step approach to curriculum design. The curriculum was meant to teach best-practice communication skills in cases of influenza vaccine hesitancy. Eligible participants included postgraduate level (PL) 2 and PL-3 pediatric residents (n = 24). Immediately following the curriculum, a survey was administered to assess residents' attitudes toward the VR curriculum and perceptions regarding the effectiveness of VR in comparison to other educational modalities. A survey was administered 1 month following the VR curriculum to assess trainee-perceived impact of the curriculum on clinical practice. Results: All eligible residents (n = 24) completed the curriculum. Ninety-two percent (n = 22) agreed or strongly agreed that VR simulations were like real-life patient encounters. Seventy-five percent (n = 18) felt that VR was equally effective to standardized patient (SP) encounters and less effective than bedside teaching (P < 0.001). At 1-month follow-up, 67% of residents (n = 16) agreed or strongly agreed that the VR experience improved how they counseled families in cases of influenza vaccine hesitancy. Discussion: An immersive VR curriculum at our institution was well-received by learners, and residents rated VR as equally effective as SP encounters. As such, immersive VR may be a promising modality for communication training.

Keywords: Communication, medical education, relational skills, virtual reality

How to cite this article:
Real FJ, DeBlasio D, Ollberding NJ, Davis D, Cruse B, Mclinden D, Klein MD. Resident perspectives on communication training that utilizes immersive virtual reality. Educ Health 2017;30:228-31

How to cite this URL:
Real FJ, DeBlasio D, Ollberding NJ, Davis D, Cruse B, Mclinden D, Klein MD. Resident perspectives on communication training that utilizes immersive virtual reality. Educ Health [serial online] 2017 [cited 2023 May 28];30:228-31. Available from:

  Background Top

Communication training, specifically relational skill training, can be difficult to implement and assess in medical education. Typical training standards include role play and standardized patient (SP) encounters.[1] However, these types of interventions can be time intensive, costly, and variable.[2] Consideration of supplemental educational strategies to teach and assess relational skills is critical to prepare learners to effectively communicate with patients and families.[3]

Emerging technologies such as immersive virtual reality (VR) may prove to be an effective adjunct to traditional educational methods used to teach communication skills. VR uses a “virtual world,” a three-dimensional (3D), computer-generated environment in which learners interact with graphical characters called avatars. VR has also been used to some extent for communication training, most notably in palliative care through the use of Second Life, an online virtual world that allows for interactions between avatars.[4] Unlike this previous VR curriculum that utilized a computer screen to deliver the educational content, our curriculum was novel in its use of a VR headset to fully immerse learners in the environment. For the purposes of this manuscript, we define curriculum as a planned educational experience on a specific subject.[5]

To evaluate the potential role for immersive VR in medical education, specifically in regards to relational skills training, we created a curriculum focused on addressing influenza vaccine hesitancy. We chose to focus our communication curriculum on influenza vaccine hesitancy as it is commonly encountered.[6] We were primarily interested in pediatric resident attitudes regarding the immersive VR experience as well as resident perceptions of how VR compared to other educational modalities. In this manuscript, we describe the process of developing a VR training curriculum utilizing Kern's six-step approach to curriculum development.[5]

  Curriculum Development Top

Step 1: Problem identification and general needs assessment

Education regarding communication skills is difficult to deliver in the busy outpatient setting; however, effective counseling is critical for patient adherence.[7] A literature review and consensus among attending physicians at the Cincinnati Children's Hospital Medical Center and Pediatric Primary Care Center (PPCC) identified several common reasons for influenza vaccine hesitancy in its population including feelings of the vaccine as ineffective or injurious. Best-practice communication skills during vaccine counseling were identified as eliciting perspective with open-ended questioning, demonstrating empathy to patient statements, and providing caregiver education without medical jargon.[8]

Step 2: Needs assessment of targeted learners

Targeted learners included postgraduate level (PL) 2 and PL-3 pediatric residents who had their continuity clinics at the PPCC. The PPCC is a large, academic clinic which provides primary care for approximately 19,000 children from birth through age 18. The majority (>85%) of the patients seen at the PPCC are publicly insured. An initial needs assessment of residents (n = 46) revealed that 70% (n = 32) felt they were unable to persuade influenza vaccine-hesitant families in most cases.

Step 3: Goals and objectives

The overarching goal for the curriculum was that PL-2 and PL-3 pediatric residents would demonstrate the knowledge and skills necessary to effectively counsel families who express influenza vaccine hesitancy. Our objectives stated that by the end of the curriculum, residents would [1] recognize common reasons for influenza vaccine hesitancy and [2] demonstrate best-practice communication strategies for counseling.

Step 4: Educational strategies

To demonstrate achievement of communication skills for vaccine counseling, we used immersive VR to simulate patient encounters [Figure 1]. Such a curriculum required collaboration between general pediatricians and simulation developers with expertise in virtual design. A virtual clinic was created to replicate an actual clinic room in the PPCC [Figure 2]. Four avatars were designed based on common caregiver demographics. Each avatar could assume four different body positions to suggest the emotions of anger, disinterest, neutrality, and interest. Audio recordings were created to provide a variety of dialog for the resident-avatar interaction, and avatar facial expressions and mouth movements were synchronized with speech. The Oculus Rift,[9] a lightweight head-mounted display that shows 3D graphics, was used to deliver the educational content [Figure 1].
Figure 1: The curriculum utilized a virtual-reality headset to completely immerse participants in the clinical space. (a) An example view inside the headset. (b) The virtual room was designed in all dimensions so that a participant might look in any direction and see clinic space

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Figure 2: Real patient room (a) and virtual patient room (b)

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The VR curriculum consisted of three vaccine hesitancy scenarios. During each simulated encounter, the resident counseled an influenza vaccine-hesitant caregiver through verbal dialog. In order for the resident to succeed (vaccination accepted), the resident had to demonstrate the best-practice communication skills previously described: (1) open-ended questioning, (2) demonstrating empathy, and (3) providing education without medical jargon. The caregiver avatar's verbal and nonverbal responses to the resident's counseling were driven by a single facilitator. Each scenario utilized a flow sheet to standardize the experience. Following the scenarios, the facilitator provided the resident with feedback about his/her use of best-practice communication skills.

Step 5: Implementation

A total of 24 PL-2 and PL-3 categorical pediatric residents completed the VR curriculum. It was completed individually at a single time. On average, it took 15 min to complete the 3 scenarios.

Step 6: Evaluation and feedback

Immediately following the VR curriculum, residents completed a survey assessing attitudes toward the VR experience. Residents were asked to express their agreement on a 5-point Likert scale (from strongly disagree to strongly agree) regarding the similarity of the VR scenarios to real-life patient experiences. In addition, residents were asked to briefly describe the VR experience. Their written comments were reviewed by three authors (FR, ND, and MK) to identify codes with a subsequent content analysis to identify frequencies. One month following the VR curriculum, residents were asked to express their agreement on a Likert scale regarding the impact of the VR curriculum on their ability to successfully counsel families with influenza vaccine hesitancy. Descriptive statistics for these outcomes were reported.

Immediately following the curriculum, residents were also asked to rate how VR's effectiveness compared to other common educational strategies (e.g., reading, traditional didactic teaching, online learning, SP encounters, high fidelity mannequins, and bedside teaching) on a scale of less, equally or more effective. Residents were asked to compare effectiveness only for educational strategies in which they had previous experience. Differences in participant attitudes toward effectiveness were tested by a multinomial exact test for equal proportions. This survey also included questions related to demographic information such as race, age, gender, and career interest.

The Institutional Review Board approved this study. Consent was obtained from residents before participation. Surveys were reviewed and piloted for clarity and content before use.

  Results Top

All residents (n = 24) completed the VR curriculum in November 2015. Participants were primarily Caucasian, aged 25–29, female and interested in pursuing a subspecialty fellowship following residency. Ninety-two percent (n = 22) agreed or strongly agreed that the interaction was similar to real-life experiences. Analysis of comments revealed that participants most often described the experience as realistic (n = 10), engaging (n = 8), and immersive (n = 5) where n indicates the number of quotes related to that particular code. One month following the curriculum, 67% (n = 16) agreed or strongly agreed that the VR experience improved how they counseled families in cases of influenza vaccine hesitancy.

In terms of perceived effectiveness of VR in comparison to other educational strategies, participants reported VR as more effective than reading, online learning and didactic presentations (P < 0.001). Residents reported that VR was equally effective to SP encounters and less effective than bedside teaching (P < 0.001) [Figure 3].
Figure 3: Learner perceptions of how virtual reality compared to other common educational methods. Residents' Perceptions of Immersive Virtual Reality

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  Discussion Top

An immersive VR simulation experience was created, implemented, and evaluated through a thoughtful approach to curriculum development and harnessing of individual team member's expertise. The vast majority of residents considered VR simulations to be similar to real-life patient encounters, and at 1-month follow-up, most residents reported that the VR curriculum had improved their ability to counsel families.

Most participants found the VR modality to be a more effective educational strategy than reading, didactic lectures, and online learning and equally effective to SP encounters. Despite positive feedback regarding the VR curriculum, residents expressed preference for bedside teaching over VR, a preference which has been well established in the literature.[10] Although bedside teaching should remain a fundamental component of training, supplemental approaches to bedside education are critical as increased patient turnover and duty hour restrictions limit opportunities for learning at the bedside. Immersive VR experiences such the curriculum described here may prove promising as a complement to current bedside teaching.

Effective communication is a crucial skill to teach learners in medicine. Poor communication is a frequent source of patient/caregiver dissatisfaction and nonadherence.[6] Immersive VR is advantageous for communication training. VR allows for failure in a safe setting. In addition, avatar-mediated training can provide a uniform experience for learners with the capacity to measure performance. The potential for immersive VR in medical education is substantial especially as a strategy to appeal to young learners given their familiarity with technology. We anticipate further exploration of how VR might best be implemented to enhance medical training beyond even communication training.

This study had multiple limitations. It was piloted at a single site resulting in a small sample size limiting generalizability. It was a one-time educational experience. In addition, resident self-perceptions of communication were assessed rather than direct observation of skills. Future studies regarding VR as a potential adjunct to bedside teaching are warranted including an analysis of VR to SP encounters that compares costs and outcomes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lane C, Rollnick S. The use of simulated patients and role-play in communication skills training: A review of the literature to August 2005. Patient Educ Couns 2007;67:13-20.  Back to cited text no. 1
Cleland JA, Abe K, Rethans JJ. The use of simulated patients in medical education: AMEE Guide No 42. Med Teach 2009;31:477-86.  Back to cited text no. 2
Magen E, DeLisser HM. Best practices in relational skills training for medical trainees and providers: An essential element of addressing adverse childhood experiences and promoting resilience. Acad Pediatr 2017;17:S102-7.  Back to cited text no. 3
Hamilton G, Ortega R, Hochstetler V, Pierson K, Lin P, Lowes S, et al. Teaching communication skills to hospice teams: Comparing the effectiveness of a communication skills laboratory with in-person, second life, and phone role-playing. Am J Hosp Palliat Care 2014;31:611-8.  Back to cited text no. 4
Kern DE, Thomas PA, Hughes MT. Curriculum Development for Medical Education: A Six-Step Approach. 2nd ed. Baltimore, MD: Johns Hopkins University Press; 2009.  Back to cited text no. 5
Poehling KA, Edwards KM, Griffin MR, Szilagyi PG, Staat MA, Iwane MK, et al. The burden of influenza in young children, 2004-2009. Pediatrics 2013;131:207-16.  Back to cited text no. 6
Riekert KA, Borrelli B, Bilderback A, Rand CS. The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Educ Couns 2011;82:117-22.  Back to cited text no. 7
Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G, et al. Communicating with parents about vaccination: A framework for health professionals. BMC Pediatr 2012;12:154.  Back to cited text no. 8
Oculus. Available from: https://www. [Last accessed on 2016 Aug 08].  Back to cited text no. 9
Peters M, Ten Cate O. Bedside teaching in medical education: A literature review. Perspect Med Educ 2014;3:76-88.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]

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