Research Article: Virtual patients designed for training against medical error: Exploring the impact of decision-making on learner motivation

Date Published: April 23, 2019

Publisher: Public Library of Science

Author(s): Luke A. Woodham, Jonathan Round, Terese Stenfors, Aleksandra Bujacz, Klas Karlgren, Trupti Jivram, Viktor Riklefs, Ella Poulton, Terry Poulton, Christophe Leroyer.


Medical error is a significant cause of patient harms in clinical practice, but education and training are recognised as having a key role in minimising their incidence. The use of virtual patient (VP) activities targeting training in medical error allows learners to practice patient management in a safe environment. The inclusion of branched decision-making elements in the activities has the potential to drive additional generative cognitive processing and improved learning outcomes, but the increased cognitive load on learning risks negatively affecting learner motivation. The aim of this study is to better understand the impact that the inclusion of decision-making and inducing errors within the VP activities has on learner motivation.

Using a repeated study design, over a period of six weeks we provided undergraduate medical students at six institutions in three countries with a series of six VPs written around errors in paediatric practice. Participants were divided into two groups and received either linearly structured VPs or ones that incorporated branched decision-making elements. Having completed all the VPs, each participant was asked to complete a survey designed to assess their motivation and learning strategies.

Our analysis showed that in general, there was no significant difference in learner motivation between those receiving the linear VPs and those who received branched decision-making VPs. The same results were generally reflected across all six institutions.

The findings demonstrated that the inclusion of decision-making elements did not make a significant difference to undergraduate medical students’ motivation, perceived self-efficacy or adopted learning strategies. The length of the intervention was sufficient for learners to overcome any increased cognitive load associated with branched decision-making elements being included in VPs. Further work is required to establish any immediate impact within periods shorter than the length of our study or upon achieved learning outcomes.

Partial Text

This study took place as part of the TAME (Training Against Medical Error) project, which aims to explore the use of VPs incorporating branched decision-making elements for developing awareness of medical error amongst undergraduate medical students [42]. The 3-year project, funded by the European Commission Erasmus+ programme, began in October 2015. The project partnership includes partners from 10 academic institutions across Europe and Central/South-East Asia.

In total, across all institutions, 346 out of a possible 384 students completed the survey instrument, giving a response rate of 90.10%. Response rates at the different institutions varied between 81.25% and 100%, with the number of students who declined to participate and complete the survey at each site varying between 0 and 12. The average age of respondents varied between 21.00 years old and 23.75 years old. All students were at the same stage of training, enrolled in the paediatric block which took place in the clinical years of undergraduate medical training. In general, there were a considerably higher number of female participants at each institution, but this was approximately equally reflected in both arms of the study and was also true in all institutions. The breakdown of participant numbers at each site, along with descriptive statistics for age broken down by gender, is shown in Table 2. The full dataset of responses can be found in S1 Dataset.

The results showed that, with a few exceptions at specific institutions, the type of VP did not make a significant difference to learner motivation. This demonstrates that those learner groups who received VPs with branched decision-making elements, which afforded the ability to make decisions and to subsequently be responsible for errors made, did not suffer any significant negative impact upon their learning motivation or perceived self-efficacy relating to the areas covered by the cases by the end of the six week period in which the cases were delivered. The generalisability of the study is addressed by using a repeated study design; by demonstrating a similar effect at multiple institutions we have shown that the findings are generalisable beyond the context of a specific institution.