Immersive virtual reality (VR) has exciting potential as a training tool, providing opportunities for more independent learning, easier access and repeatability, and fewer cost implications 
. But more evidence is needed regarding its utilization in teaching clinical decision-making, in particular, understanding where it fits with relation to simulation suites using high-fidelity manikins (SimS). To date, there appears to be only one other study that has investigated this question, but the comparative effects of the teaching modalities were potentially blurred as SimS was undertaken in groups compared with VR in single-player scenarios 
Use mixed methods to analyse the differences in confidence and competence in clinical decision-making between medical students trained using either VR or SimS scenarios; and the perceived value and experience of VR compared with SimS.
Simulation activity outline:
To teach students through participating individually in acute medical scenarios (sepsis-based) in the VR and SimS environments. Volunteers were given time to familiarize themselves with each environment beforehand, and the scenarios and debriefing were replicated in each setting (content and timing) as much as possible.
In April 2021, nine medical students (in their first clinical year) volunteered to take part in the pilot and were randomly allocated to experience either SimS or VR first, in a simulation centre attached to a university hospital. Each session ran as follows, with paper questionnaires used to collect data:
1.Baseline confidence and competence questionnaires;2.Lecture on the topic (sepsis);3.Familiarization followed by scenarios and debrief (Group A – VR, Group B – SimS);4.Follow-up competence and confidence questionnaires;5.Familiarization followed by scenarios and debrief (Group A – SimS, Group B – VR);6.Comparison and general feedback questionnaires.Data were transcribed into Excel® for analysis. This was a proof-of-concept pilot for a larger study that has ethical approval (MS IDREC Reference: R76053/RE001).
Both the VR and the SimS groups increased their confidence (VR 3.75%, SimS 4.2%) and competence (VR 10.73%, SimS 11.44%) in relation to clinical decision-making. Overwhelmingly, 89% of the students wanted to undertake the VR training before SimS, although 66% preferred SimS overall to VR. Participants described VR training as feeling safer, less pressured and allowing them to consolidate prior learning. This subsequently increased their confidence to tackle SimS training, which felt more stressful, challenging and true-to-life, with the added bonus that more could then potentially be gained from SimS. Each modality was felt to increase the students’ confidence in clinical decision-making, while adding different aspects to the learning experience.
Implications for practice:
This pilot indicates that a larger study would give more information on the best utilization of VR in medical student training. The data suggest VR training is a good introduction to and complements SimS training. Additionally, the increases in confidence and competence it induces make it an independently valuable tool, suggesting it could be a viable alternative where SimS is unavailable, e.g. due to lack of funds or a pandemic, where face-to-face educational opportunities may be limited.