Table 4 What would make virtual patient learning tools more likely to be adopted to teach CR

These are the lessons learnt from this study, which can be seen as additional to having a solid evidence-base of effectiveness and acceptability of learning tools using virtual patients

a) Introducing learning innovations using virtual patients is more likely when CR has been explicitly taught already because both student and tutors have a language to express what they are doing, and therefore learning can be recognized and measured

b) Opportunistic implementation of online learning innovations using virtual patients to address limited face-to-face teaching capacity can build local support for virtual patients and may reduce institutional barriers to formally approving curriculum changes

c) Training and sharing information on key features of learning tools using virtual patients can help, that emphasises:

- the position of virtual patients as complementary rather than a replacement of face-to-face teaching

- capacity for online learning approaches to involve students that are typically quiet during face-to-face teaching

- opportunities for using virtual patients in group learning situations not just individual study

- ways in which virtual patient learning tools can save or optimize tutor time

d) Adoption is more likely when evidence of effectiveness and acceptability are combined with support for dissemination, cases and scenarios that are realistic, and with adaptable resources by developers