The influence of a novel simulated learning environment upon student clinical subjective refraction performance: A pilot study

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Optometry students are taught the process of subjective refraction through lectures and laboratory-based practicals before progressing to supervised clinical practice. Simulated leaning environments (SLEs) form part of an emerging technology used in a range of health disciplines; however, there is limited evidence regarding the effectiveness of clinical simulators as educational tools.


Forty optometry students (20 fourth year and 20 fifth year) were assessed twice by a qualified optometrist (two examinations separated by four to eight weeks), while completing a monocular non-cycloplegic subjective refraction on the same patient with an unknown refractive error, simulated using contact lenses. Half of the students were granted access to an online simulated learning environment, The Brien Holden Vision Institute (BHVI) Virtual Refractor, and the remaining students formed a control group. The primary outcome measures at each visit were; accuracy of the clinical refraction compared to a qualified optometrist and relative to the Optometry Council of Australia and New Zealand (OCANZ) subjective refraction examination criteria. Secondary measures of interest included descriptors of student SLE engagement, student self-reported confidence levels and correlations between performance in the simulated and real-world clinical environment.


Eighty per cent of students in the intervention group interacted with the simulated learning environment (for an average of 100 minutes); however, there was no correlation between measures of student engagement with the BHVI Virtual Refractor and speed or accuracy of clinical subjective refractions. Fifth year students were typically more confident and refracted more accurately and more quickly than fourth year students. A year group by experimental group interaction (p = 0.03) was observed for accuracy of the spherical component of refraction and post hoc analysis revealed that less experienced students exhibited greater gains in clinical accuracy following exposure to the SLE intervention.


Short-term exposure to a SLE can positively influence clinical subjective refraction outcomes for less experienced optometry students and may be of benefit in increasing the skills of novice refractionists to levels appropriate for commencing supervised clinical interactions.

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