Of 80 students that were given the option to complete the online voluntary and anonymous evaluation survey, 51 responded (64%) with a mean age of 20 (std 3.24 years, 18-33) and all responses were included in the analysis. Given the high response rate these responses are representative of the cohort. These first-year students who completed the evaluation had diverse exposures to optometry: 43 (83%) had visited an optometry practice for retail spectacle, contact lens or sunglass purchase, 39 (76%) had received eye care a patient in an optometry practice, 11 (22%) students had worked in an optometry practice and 5 (10%) had visited a university clinic. The majority of students were high school leavers (n = 32, 63%) while a quarter had completed a bachelor’s degree level qualification (n = 13, 25%). No students had studied in any other university optometry program.
The findings from thematic analysis are presented alongside the quantitative results in Tables 1 and 2 to support triangulation of qualitative insights. There were six themes and their subthemes identified from an initial 31 codes once data saturation was achieved. Quotes are reported verbatim from students in italics with clarifying insertions in square brackets and an identification number. The quantitative results are presented as a percentage of the responses.
Theme 1: enablers to cognitive experience in virtual simulation in optometry education
Students’ responses indicated that their ability to accept the virtual simulation experience as authentic was dependent on previous exposure to the context of optometry. One student said:
“I haven’t personally visited an optometry clinic yet, so I am unsure if the virtual clinic is representative or not.” (S7).
Others commented on how real-life familiarity with optometry practice supported their interpretation of the environment.
“It looks pretty similar to my experience with eye clinics, with all the equipment there.” (S2).
Theme 2: realism of the virtual simulation design
Students described the virtual simulation as operationally realistic enough to feel like work experience and that they could enter the clinic, describing a sense of immersion.
“I felt like I am in the real clinic and that enhanced my interest.” (S19).
“…despite being online it felt very real.” (S7).
This theme is further supported by quantitative responses suggesting that the level of detail in the VDCECC created an experience that represents a particular world with 80% of students agreed or strongly agreed that the virtual simulation was realistic (Table 1).
The realism of this virtual world allowed the students to feel as though they are involved in metaphysical events that really take place.
“…an indirect experience in the physical environment.” (S41).
The fact that the virtual clinic has properties similar to the working world gave students a sense of immersion and the feeling that they are working as a practitioner. Students said that they.
“… learn more about the process of seeing a patient in general.” (S12).
“… know how it feels to work with patients (and) trying to diagnose them” (S7).
All students who had previously visited a university optometry clinic agreed that the virtual clinic was an accurate representation of an optometry clinic, 88% of students with retail experience in an optometry practice, 86% who had undertaken an eye test, and 66% who had worked at an optometry practice.
Theme 3: dimensions of fidelity in virtual simulations design replicated the complexity of the optometric environment
Fidelity is defined as the degree that a simulated experience approaches reality, the believability of the users’ experience (International Association for Clinical Simulation and Learning) . The experience of a virtual simulation is constructed by multiple dimensions of fidelity. During the qualitative analysis of this study researchers identified in student responses the dimensions of fidelity that contributed to their experience of the virtual simulation that approximated optometry practice . The four key dimensions of fidelity that supported the realism of a virtual world in a metaphysical space were coded as the subthemes context, conceptual, functional and task fidelity. One example of context fidelity is illustrated in responses describing features of the physical environment that represent an optometry clinic, such as Student 7’s comment:
“It represents my idea of a clinic with the patient rooms, front desk, and displays of glasses.” (S7).
Students also experienced the replicated environment as a space in which activities that occur at an optometry practice could be performed, indicating functional fidelity was an important contribution to the realism of the simulation for some students.
“… an area for frames to be selected, just like most eye clinics...” (S41).
“… found that using this virtual eye clinic gave students a realistic perception of what it’d be like if we were to perform these tasks in real life.” (S30).
“Felt like I am in a real clinic.” (S18).
Task fidelity was also identified by students as an important aspect of the VDCECC learning environment and assessment strategy that enhanced the realism of the simulation through replicating the professional role [32, 33].
“… using this virtual eye clinic gave students a realistic perception of what it’d be like if we were to perform these tasks in real life.” (S5)
The realism of the VDCECC environment and the integrated learning and assessment activities relevant to the unit content produced a coherent experience leading to conceptual fidelity .
“The simulation gave us more direction and a sense of importance into what was being taught in that week.” (S4)
Theme 4: virtual simulation as an enabler for learning and assessment in optometry education
Exploring the role of virtual simulation researchers found it to be an enabler for learning and assessment.
“In general, I enjoyed how we got to put the content to use in a practical situation, which further developed my knowledge.” (S33)
“… provided greater motivation as the learning felt more engaged than rote learning facts.” (S14)
In comparison to other learning activities the unit employed the virtual simulation promoted active learning for the students.
“The virtual simulation is different because it’s not just someone talking at me for an hour. It forces me to actively engage with content.” (S5)
“… it allows a different perspective where responses can be more considered and less rushed than with an in-person setting.” (S44)
There was evidence that students perceived the value of the virtual simulation as a learning and assessment environment that allowed safe experimentation.
“… think it was a good way to experiment and test the waters without much consequence for any mistakes. It gave [students] more confidence to see how different things would work out…” (S25)
The quantitative responses also demonstrate students’ perception of the virtual simulation as enabled learning through offering another form of teaching and assessment that is relevant and motivated them to seek out more learning. In Table 1 most students agreed or strongly agreed that the virtual simulation was relevant (93%), and increased their motivation to learn unit content (87%) and to research material beyond that provided (77%). After visiting the VDCECC 83% would prefer virtual simulation over a regular lecture in their future studies (Table 1). In terms of their motivation for learning 86% agreed with the statement that the virtual simulated training and learning strategy delivered in the unit motivated them to learn the unit’s content and 76% agreed that it motivated them to learn beyond the material provided in lectures and other teaching activities in the unit. Most students (93%) felt that the virtual simulation increased their motivation to become an optometrist.
Theme 5: a place to develop cognitive and affective skills
In the quantitative data students strongly rated the VDCECC as a place to develop core competency skills for becoming an optometrist as shown in Table 2. They appreciated that the simulation was scaffolded to the appropriate level to begin learning these skills.
Qualitative analysis of open responses gave further understanding that the virtual simulation itself was regarded as a place to develop core conative and affective skills.
“To me, virtual simulation is simply a good way to introduce first year students to the clinical reasoning that will be expected of them in the future.” (S14)
When asked what they learnt through the virtual simulation experience, students identified that the virtual simulation experience developed their research skills, clinical reasoning as well as skills involved in interacting with patients.
“I began developing patient communication skills and further developed my research and collaboration skills.” (S44)
“Recognising and diagnosing issues using different diagnoses and other methods.” (S31)
There were also reflections indicating the simulation supported students to develop their mindset of patient-centred care.
“Having to consider the patient when helping and communicating to them.” (S43)
“It will greatly improve the way we communicate with patients and positively affect our ability to make decisions.” (S37)
All students expressed that their preference to learn using the virtual simulation in the future. Compared with traditional teaching and learning activities 40% of students preferred virtual simulation, 43% appreciated both modalities, 13% were unsure and 4% preferred traditional learning activities.
Theme 6: application of learning in the virtual simulation developed an appreciation of future roles and professional identity
Students embraced the opportunity to simulate being a professional in the virtual simulation and enact the role of an optometrist by applying the learning from the unit.
“I put myself in the shoes of an actual Optometrist.” (S30)
“Having to review the information given by the patient and create a list of the differential diagnoses was very helpful to apply my knowledge to an actual clinical scenario, as well subsequently evaluating the results of the eye examination.” (S34)
Students indicated that the virtual simulation promoted the development of their professional identity.
“It assisted [first year students] to understand the challenges behind the profession and there are more things than just diagnos[ing] pathology.” (S25)
“… a hint of how it feels like to work in a real world with patients.” (S15)
“… an opportunity to examine the principles behind optometry practice and get the sense of being an optometrist.” (S28)
“helped [students] understand that the role of an optometrist extends beyond just caring for the patient’s vision - it involves making sure their overall health and wellbeing is good and properly managed.” (S29)
In fact, the majority of students reported a positive effect on their professional identify after participating in the virtual simulation, as shown in Table 2. Participation in the simulation increased their confidence for when they next encounter a patient (86%) and their understanding of how they will behave as an optometrist (82%).