A Mixed-Methods Analysis of Facilitator Activities in Fully Immersive Virtual Reality (VR) Medical Simulation

Background: Immersive virtual reality (VR) offers healthcare simulation programs a pathway to greater flexibility and access, enabling repeatable clinical scenarios across diverse representations of patients, environments, and pathologies that may be difficult to simulate with manikins or standardized patients. As this technology is adopted more widely, institutions are working to integrate it into existing simulation workflows. This process depends on a clear understanding of how facilitation is carried out during VR simulations and what new demands it places on facilitators. Facilitation is central to simulation-based education, shaping the quality of learner engagement and outcomes. However, most facilitation practices were developed for environments that differ substantially from immersive VR. This study asked: How is immersive VR simulation currently facilitated in healthcare training environments, and how do facilitator behaviors vary across contexts, learner populations, and session structures? To address this question, we conducted a mixed-methods study using real-time behavioral observation, post-session interviews, and survey data across multiple simulation sites. By characterizing current patterns of facilitator activity, instructional strategy, and contextual variation, this study contributes foundational knowledge to support the integration of immersive VR into routine educational practice. Methods: This mixed-methods study employed a contextual inquiry framework to investigate facilitator activities while running immersive simulations on a commercially available VR clinical simulation platform. Eighteen facilitators were observed at four sites across 40 simulation sessions. Study sites represented a range of institutional contexts (academic center, hospital, military base) and resource environments (low-, medium-, and high-resource). Facilitators included simulation educators, technicians, and student learners acting in either single-facilitator or multi-facilitator scenarios, with VR simulation experience levels ranging from beginner to highly experienced. Learners participating in the simulations included students and healthcare professionals with varied clinical knowledge. Data collection followed a four-stage contextual inquiry process: 1) pre-simulation interviews; 2) live observation of simulation sessions using structured behavioral coding; 3) post-observation interviews; and 4) post-session surveys. Facilitator behavior was documented using a structured time-and-motion schema. During each simulation session, a single researcher conducted real-time behavioral coding using a predefined set of task categories. All sessions were also video- and screen-recorded to allow for retrospective review and coding refinement. The recordings were used to clarify ambiguous moments, validate task durations, and ensure completeness of the behavior log. Semi-structured interviews were conducted immediately before and after the simulation sessions. Pre-simulation interviews focused on scenario design, site-specific constraints, and facilitation intent. Post-session interviews explored facilitators’ reflections, adaptations, and explanations of in-simulation decisions. Facilitators also completed a brief survey to capture demographic data, self-assessed experience with VR, perceived challenges, and preferred facilitation strategies. Qualitative data from interviews and observation notes were analyzed thematically using Braun and Clarke’s six-phase process: familiarization, initial coding, theme generation, theme review, definition, and synthesis. Quantitative time-and-motion data were analyzed to characterize the distribution of task types, time allocation, and action frequency. Exploratory comparisons were made across contextual factors such as facilitator experience level, site type, and learner background to identify emergent patterns in facilitation strategy. Results: Data was collected for over 40 scenario simulations that ran for an average of 18 minutes per patient encounter. Facilitators engaged in a range of tasks during immersive VR simulations, with substantial variation in time allocation across sessions. Initial quantitative analysis demonstrated that facilitators spend roughly two-thirds of their time actively performing scenario facilitation tasks during VR simulations and one-third of their time on observation and cognitive processing. Core active tasks were organized into the following categories: directly managing the scenario by operating the VR software; providing verbal medical instruction to learners; offering technical support for both virtual environment navigation and hardware/software troubleshooting; engaging in contingency management by addressing unexpected, immersion-breaking events to maintain learner focus; and performing ancillary tasks such as taking notes for debriefing, interacting with non-VR learners, and recording sessions. On average, the most time-consuming tasks were conversing and performing actions as simulation characters, accounting for over 40% of the average total task time. Roughly 20% of time was spent providing educational instruction or support for interaction with the platform. Qualitative analysis revealed distinct styles of facilitation. Some facilitators delivered real-time feedback during the simulation, while others postponed all instructional input until the debriefing phase. Clinical teaching strategies varied as well, with some facilitators embedding instruction throughout the simulation and others reserving it for post-session discussions. When student learners acted as peer facilitators, they used a distinctive facilitation model that emphasized peer-to-peer learning and informal coaching. Several factors influenced the facilitation approach. Facilitator decisions were shaped by learner characteristics, such as clinical background and comfort with the technology. Logistical factors, including session time constraints and whether scenarios were novel or repeated, also played a role. In addition, the structure of the simulation itself—such as the clarity of learning objectives and the inclusion of non-VR learners—appeared to guide facilitation style and emphasis. Conclusions: This study examined current facilitation practices in immersive VR medical simulation, identifying core activities and variations in facilitation style across sites and contexts. While many tasks mirrored those in traditional high-fidelity simulation, immersive VR introduced unique operational and pedagogical considerations. Facilitation strategies in VR proved highly context-sensitive, shaped by institutional goals, learner readiness, and available resources. Rather than prescribing a fixed facilitation model, VR enables diverse approaches. This flexibility supports instructional innovation but can also result in inconsistent learner support when not guided by structured training or pedagogical intent. Facilitator adaptability appears most effective when grounded in deliberate planning. These findings offer practical implications for the simulation community. For educators, this work provides a clearer framework for understanding facilitation complexity in VR environments. For program leaders, it underscores the need for targeted facilitator training tailored to immersive modalities. As VR becomes more integrated into simulation curricula, its success depends on developing shared facilitation models that balance flexibility with consistency. By documenting current practices, this study offers a foundational step toward guidelines for VR simulation facilitation. It also highlights promising directions for future research, including the development of facilitation models specific to immersive VR, exploration of how facilitator behavior impacts learner outcomes, and the design of tools that support real-time instructional decision-making. Notably, the emergence of student-led facilitation suggests a scalable peer-assisted learning model that merits further study. Longitudinal research could investigate how facilitation evolves with institutional experience, while intervention studies might assess the effects of structured facilitator training on simulation quality and learner outcomes.