Instructional design of virtual patients in dental education through a 4C/ID lens: a narrative review

Although VPs have been applied in various medical and dental education programmes, it remains uncertain whether their design was based on specific instructional design (ID) principles, and therefore, how to improve on them. In this study, we evaluated the extent to which ID principles have played a role in the development of VPs for clinical skills training purposes in dental education. First, as frame of reference we mapped key ID principles identified in VPs and medical simulations on the widely used four-component instructional design (4C/ID) model. Next, a literature search was conducted using Libsearch, a single search tool accessing databases such as MEDLINE, PubMed, Embase, CINAHL, ERIC, PsycInfo and Scopus. Following the PRISMA framework for systematic reviews, we selected 21 studies that used screen-based VP simulations for undergraduate dental students. The data analysis consisted of a review of each study analysing the key instructional design features connected to the components of the 4C/ID model. Overall, the results indicate that a structured approach to the design and implementation of VPs likely will have a positive effect on their use. While some ID-principles are shared such as the importance of clinical task variation to improving the transfer of learning. Others, however, such as the choice of learning mode or the use of cognitive feedback are ambiguous. Given its impact on students' ability to establish effective cognitive schemas and the option to compare and study designs we recommend a more rigorous approach such as 4C/ID for the design of VPs.