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Understanding the value of inclusive education and its implementation: A review of the literature

• Published: 07 September 2020
• Volume 49 , pages 135–152, ( 2020 )

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• Anthoula Kefallinou 1 ,
• Simoni Symeonidou 1 , 2 &
• Cor J. W. Meijer 1  

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European countries are increasingly committed to human rights and inclusive education. However, persistent educational and social inequalities indicate uneven implementation of inclusive education. This article reviews scholarly evidence on inclusion and its implementation, to show how inclusive education helps ensure both quality education and later social inclusion. Structurally, the article first establishes a conceptual framework for inclusive education, next evaluates previous research methodologies, and then reviews the academic and social benefits of inclusion. The fourth section identifies successful implementation strategies. The article concludes with suggestions on bridging the gap between inclusive education research, policy, and practice.

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Kefallinou, A., Symeonidou, S. & Meijer, C.J.W. Understanding the value of inclusive education and its implementation: A review of the literature. Prospects 49 , 135–152 (2020). https://doi.org/10.1007/s11125-020-09500-2

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Review of Literature: Inclusive Education 

This brief review of relevant literature on inclusive education forms a component of the larger Inclusive School Communities Project: Final Evaluation Report delivered by the Research in Inclusive and Specialised Education (RISE) team to JFA Purple Orange in October, 2020. 

Suggested citation for full evaluation report: 

Jarvis, J. M., McMillan, J. M., Bissaker, K., Carson, K. L., Davidson, J., & Walker, P. M. (2020).  Inclusive School Communities Project: Final Evaluation Report. Research in Inclusive and Specialised Education (RISE), Flinders University. 

https://sites.flinders.edu.au/rise  

Introduction 

Inclusive education has featured prominently in worldwide educational discourse and reform efforts over the past 30 years (Berlach & Chambers, 2011; Forlin, 2006). Inclusive schools are critical to providing a strong foundation for young people with disabilities to access, participate in and contribute to their communities and lead fulfilling lives (Hehir et al., 2016). Schools also represent a key condition for the development of thriving, inclusive communities for all citizens. Yet, as reflected in submissions to the current Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability, and consistent with recent South Australian reports (Parliament of South Australia, 2017; Walker, 2017), many students living with disability (and their families) continue to report negative experiences of education. While progress has been made, traditional educational structures and practices often run counter to inclusive goals (Slee, 2013), and inconsistencies occur between theory and policy and the implementation of inclusive principles and practices in schools (Carrington & Elkins, 2002; Graham & Spandagou, 2011). In addition, both preservice and practicing teachers consistently report feeling underprepared to teach students with disabilities and special educational needs (Jarvis, 2019; OECD, 2019). 

Despite legislation and policy imperatives related to inclusive education, there remains a lack of consensus in the field about the definition of inclusion and associated models of inclusive practice (Ainscow & Sandill, 2010; Kinsella, 2020). Multiple conceptualisations of inclusion and theoretical approaches to fostering inclusion in schools may contribute to confusion and uncertainty for educators and policymakers. With schools facing growing accountability and teachers expected to educate an increasingly diverse student population (Anderson & Boyle, 2015), it is vital that the concept of inclusive education is demystified for practitioners. Against this backdrop, initiatives such as the Inclusive School Communities (ISC) project that aim to deepen understandings of inclusion and increase the capacity of school communities to provide an inclusive education, are particularly important. 

Inclusive Education 

Inclusive education is based on a philosophy that stems from principles of social justice, and is primarily concerned with mitigating educational inequalities, exclusion, and discrimination (Anderson & Boyle, 2015; Booth, 2012; Waitoller & Artiles, 2013). Although inclusion was originally concerned with ‘disability’ and ‘special educational needs’ (Ainscow et al., 2006; Van Mieghem et al., 2020), the term has evolved to embody valuing diversity among all students, regardless of their circumstances (e.g., Carter & Abawi, 2018; Thomas, 2013). Among interpretations of inclusion, common themes include fairness, equality, respect, diversity, participation, community, leadership, commitment, shared vision, and collaboration (Booth, 2012; McMaster, 2015). The United Nations Convention on the Rights of Persons with Disabilities (CRPD), to which Australia is a signatory, defines inclusive education as:  

. . . a process of systemic reform embodying changes and modifications in content, teaching methods, approaches, structures and strategies in education to overcome barriers with a vision serving to provide all students of the relevant age range with an equitable and participatory learning experience and environment that best corresponds to their requirements and preferences. (United Nations, 2016, para 11)

Consistent with this definition, inclusive education now generally refers to the process of addressing the learning needs of all students, through ensuring participation, achievement growth, and a sense of belonging, enabling all students to reach their full potential (Anderson & Boyle, 2015; Booth, 2012; Stegemann & Jaciw, 2018). Inclusion is concerned with identifying and removing potential barriers to presence (attendance, access), meaningful participation, growth from an individual starting point, and feelings of connectedness and belonging for all students and community members, with a focus on those at particular risk of marginalisation or exclusion (Ainscow et al., 2006; Forlin et al., 2013). 

Critically, the view of inclusion described above moves beyond considerations of the physical placement of a student in a particular setting or grouping configuration. That is, while physical access to a mainstream school environment is essential to maintain the rights of students living with disabilities to access education “on the same basis” as their peers (consistent with legislation and human rights principles), it is not sufficient to ensure inclusion. Rather, inclusion can be considered a multi-faceted approach involving processes, practices, policies and cultures at all levels of a school and system (Booth & Ainscow, 2011). Inclusive education is responsive to each child and promotes flexibility, rather than expecting the child to change in order to ‘fit’ rigid schooling structures. The latter approach reflects integration, and inclusion is also inconsistent with segregation, in which children with disabilities are routinely educated separately from others. 

Considerable research has focused on the implementation of inclusive school processes, practices and cultures that are sustainable over time. Although a number of frameworks to achieve sustainable inclusive practice have been proposed, key elements are consistent across approaches and well supported by research (Booth & Ainscow 2011; Azorín & Ainscow, 2020). These interconnected elements are summarised in Figure 1 and considered fundamental to the process of achieving whole-school (and systemic) cultural change towards more inclusive ways of working. Of particular relevance to the Inclusive School Communities project are the concepts of a whole school approach, leadership, school values and culture, building staff capacity, and multi-tiered models of inclusive practice. 

Inclusion as a Whole School Approach 

Adopting a whole of school approach to inclusive education is fundamental to ensure efficacy and sustainability (Read et al., 2015). The process of developing inclusive schools is complex and multi-faceted, requiring time, commitment, ongoing reflection, and sustained effort. For inclusion to truly take root in schools, changes must be made from the inside out; a strong foundation must be built from inclusive school values, committed leadership, and shared vision amongst staff to support whole school structural reforms to policy, pedagogy, and practice (Ekins & Grimes, 2009). Whilst challenging, “it is necessary to unsettle default modes of operation” in schools (Johnston & Hayes, 2007, p.376), as inclusive education requires new, more efficient and effective ways of supporting student participation and achievement. This is made possible by implementing flexible, planned whole school support structures, such  as multi-tiered systems of support (MTSS), where teachers work collaboratively with specialist staff to identify, monitor, and support students requiring varying levels and types of intervention at different times, and for different purposes (Sailor, 2017; Witzel & Clarke, 2015). This contrasts to the more traditional, ‘categorical’ and segregated approach of general educators referring identified students with additional needs to special educators, to devise and administer further education in isolation from the regular classroom (Sailor, 2017). 

Figure 1. Interconnected elements in sustainable inclusive education, derived from research.

Even at the classroom level, inclusive planning and teaching practices must be supported by school policies, practices, and culture in order to be sustainable (Sailor, 2017). Barriers to inclusive classroom practice can include lack of effective professional learning and support for teachers; teachers’ lack of willingness to include students with particular needs; attitudes that are inconsistent with inclusive practices; teacher education that fails to address concerns about inclusion; and, a lack of accountability for the implementation of inclusive teaching practices (Forlin & Chambers, 2011; Forlin et al., 2008; van Kraayenoord et al., 2014). Addressing each of these relies on targeted, coordinated support. The complexity of embedding inclusive practices such as differentiated instruction or Universal Design for Learning (UDL) into classroom work is often underestimated, and these practices have the greatest chance of becoming embedded when they are reinforced by a shared vision and collaborative effort (McMaster, 2013; Sailor, 2015; Tomlinson & Murphy, 2017). 

Sustainable, whole school change cannot be achieved via focus on a single element of inclusion in isolation, as components do not function in isolation. Rather, the core elements of inclusion including leadership, school culture, building staff capacity, and inclusive practices are parts of an interdependent system. Hence, key elements of inclusion must be considered collectively and accounted for in advanced planning to ensure they function harmoniously and are integrated into the developing inclusive fabric of the school (Alborno & Gaad, 2014). 

Leadership for Inclusion 

The importance of leadership for determining the success of school reforms or changes to practice is well established in the literature (McMaster & Elliot, 2014; Poon-McBrayer & Wong, 2013). Becoming a more inclusive school often requires significant shifts in school values, culture, practices, and organisational systems; thus, leadership is critical to ensuring sustainable inclusive change in schools (Ainscow & Sandill, 2010; McMaster, 2015; Poon-McBrayer & Wong, 2013). School leaders are highly influential figures whose values, beliefs, and actions directly affect the culture of the school, expectations of staff, and school operations (Slater, 2012; Wong & Cheung, 2009). It is critical that school leaders are committed to embodying inclusive principles, establishing and modelling a standard of behaviour that promotes the development of inclusion within the school community. 

Organisational change on the scale often required for inclusion requires leadership across multiple levels (Jarvis et al., 2016; Tomlinson et al., 2008). It is likely to be most effective when facilitated through models of distributed leadership across roles and levels within a school, and when the case for change is underpinned by a broader, shared vision specifically related to student outcomes (Harris, 2013). Research has established the relationship between distributed leadership practices and the implementation of effective, inclusive school practices (Miškolci et al., 2016; Mullick et al., 2013; Robinson et al., 2008; Sharp et al., 2020). Leaders should consider utilising inclusive styles of management, replacing hierarchical structures with leadership teams (Ainscow & Sandill, 2010; McMaster, 2015). Effective school leadership enables shared responsibility, vision, and consistency within the school community, which is vital for the successful implementation of inclusion (Poon- McBrayer & Wong, 2013). 

Fostering Inclusive School Cultures 

Developing an inclusive school culture is a fundamental component of developing sustainable inclusion in schools (Dyson et al., 2004; McMaster, 2013). The culture of a school is made up of the shared values, attitudes, and beliefs of the school community (Booth, 2012). Transitioning to a truly inclusive culture requires close attention to attitudes and general support of the inclusive values being adopted, particularly by staff, but also by students and the broader school community (Dyson et al., 2004; Forlin & Chambers, 2011). 

A whole school approach to inclusion prompts a school to reflect on and embrace values based on inclusive principles, such as equality, diversity, and respect. This process cannot be imposed, but should be a collaborative exercise with school leaders and staff, to ensure any pedagogical philosophies or practices based on outdated ideas or past assumptions are not operating by default (Johnston & Hayes, 2007; Schein, 2004). Evaluating and redefining existing school values also requires professional learning, to facilitate a collective reconceptualisation of inclusion specific to the unique context of the school; the meaning, aims, and expectations of inclusion must be clarified for the school community, to encourage a shared understanding, vision, and responsibility for supporting the inclusive changes unfolding within the school (Horrocks et al., 2008; Symes & Humphrey, 2011). Finally, it is vital that school policies and practices are regularly revised, to ensure that they reinforce the inclusive values and culture of the school; otherwise, they can act as a potential barrier to the development of sustainable whole school inclusion (Dybvik, 2004; McMaster, 2013). 

Building Teachers’ Capacity for Inclusive Practice 

Building the knowledge and capacity of teachers and other school staff is crucial to developing sustainable inclusion in schools. The evolution of an inclusive school culture depends on aligning the attitudes and behaviour of staff (McMaster, 2015). Teachers must be knowledgeable about how inclusive education has progressed over time, particularly how the meaning of inclusion has changed and what it means in their school context. Understanding the concepts and values behind inclusion can help teachers appreciate its significance, prompting reflection of their own practice and how they see their students (Anderson & Boyle, 2015; Skidmore, 2004). This can allow any unhelpful assumptions or beliefs that may have been unconsciously informing their teaching practice, particularly in relation to students living with disability, to be challenged and revised (Ashby, 2012; Ashton & Arlington, 2019). 

While attention to attitudes, values, and broad understandings is fundamental, the goals of inclusion will only be achieved when principles are consistently enacted in daily classroom practice. At the classroom level, inclusion relies on teachers’ willingness and capacity to apply evidence-informed inclusive practices, such as Universal Design for Learning (UDL) and Differentiated Instruction (Van Mieghem et al., 2020). UDL is a planning framework for learning activities designed to maximise curriculum accessibility for all students by offering multiple opportunities for engagement, representation, and action and expression (CAST, 2018; Sailor, 2015). Differentiated Instruction (DI) is a holistic framework of interdependent principles and practices that enables teachers to design learning experiences to address variation in students’ readiness, interests and learning preferences (Tomlinson, 2014). UDL is primarily focused on inclusive task design, although the model has been expanded in recent years to include greater attention to pedagogy. Differentiation encompasses elements of planning (clear, concept-based learning objectives; formative  assessment to inform proactive decision-making for diverse students), teaching (strategies to differentiate by readiness, interest and learning preference; ensuring respectful tasks and ‘teaching up’), and learning environment (flexible grouping, classroom management, establishing an inclusive culture) (Jarvis, 2015; Tomlinson, 2014). 

The application of UDL and DI principles and practices by skilled teachers enables diverse students to access curriculum content in multiple ways (Kozik et al., 2009; McMaster, 2013), at appropriate levels of challenge and support to ensure learning growth, and in ways that support motivation, engagement, and feelings of connection and belonging (Beecher & Sweeney, 2008; Callahan et al., 2015; van Kraayenoord, 2007; Stegemann & Jaciw, 2018). These complementary frameworks apply to all students and define general, flexible classroom practices that also reduce the need for individualised adjustments for students with identified disabilities and specialised learning needs. However, in inclusive classrooms, teachers must also develop the knowledge and skills to make and implement reasonable adjustments and accommodations that enable students with identified disabilities and more complex needs to engage with curriculum and assessment ‘on the same basis’ as their peers, as defined within the Disability Standards for Education (Davies et al., 2016). 

While inclusive teaching and classroom practices are non-negotiable, the challenge for some teachers to master the necessary skills and achieve the significant shift away from traditional teaching practices is often underestimated (Dixon et al., 2014; Tomlinson & Murphy, 2015). It is well-documented that teachers often find it difficult to apprehend both the conceptual and practical tools of DI and to embed differentiated practices into their daily work (Dack, 2019), particularly when they are not adequately resourced or supported to do so (Black-Hawkins & Florian, 2012; Brigandi et al., 2019; Fuchs et al., 2010; Mills et al, 2014). Perhaps related to teachers’ perceived lack of competence and confidence, the past 5-10 years have seen an enormous increase in the employment of teacher aides to work alongside students with disabilities in mainstream classrooms, despite limited evidence for its effectiveness and often in the context of inadequate planning and oversight (e.g., Sharma & Salend, 2016). 

Engagement in targeted professional learning (PL) is fundamental to supporting the shift towards inclusive teaching. Yet, traditional approaches to PL have been criticised for a lack of systematic evaluation and inadequate adherence to principles of effectiveness (Avalos, 2011; Merchie et al., 2018). Research on effective professional learning for teachers has established common principles and practices that are associated with changes in practice, and these also align with teachers’ stated preferences (Walker et al., 2018). These include: 

• professional learning is embedded in teachers’ own work contexts, and requires teachers to engage with content that is highly relevant to their daily practice, and closely linked to student learning (Desimone, 2009; Easton, 2008; Spencer, 2016; Van den Bergh et al., 2014); 
• professional learning enables teachers to learn together with colleagues, such as in communities of practice (Gore et al., 2017; Voelkel & Chrispeels, 2017); 
• professional learning activities are supported by robust school leadership and linked to broader school values and goals (Carpenter, 2015; Frankling et al., 2017; Sharp et al., 2020; Tomlinson et al., 2008; Whitworth & Chiu, 2015); 
• professional learning is provided over extended periods, is led by facilitators with expert knowledge, and includes timely follow up activities such as mentoring and coaching to embed changes in practice (Desimone & Pak, 2017; Grierson & Woloshyn, 2013; Tomlinson & Murphy, 2015). 

Multi-tiered Approaches to Whole School Inclusive Practice 

Multi-tiered system of supports (MTSS) is an overarching term for a whole school inclusive framework that can be used to structure the flexible, timely distribution of resources to support students depending on their level of need (Sailor, 2017). As reflected in the generic depiction of MTSS in Figure 2, models generally utilise three tiers of intervention and teaching, where the intensity of the support is increased with each level or tier (McLeskey et al, 2014; Witzel & Clarke, 2015). Tier 1 includes core differentiated instruction and universal, evidence-based strategies for support that all students in the class receive. Tier 2 provides additional, targeted support to certain students for a specified purpose and period of time, usually in a small group format, while Tier 3 represents the most intensive and individualised support (Webster, 2016). The MTSS approach requires assessing all students regularly to assist in the early identification of needs requiring additional support, to enable prompt delivery of targeted interventions (McLeskey et al., 2014). MTSS is concerned with supporting the holistic development of students, by targeting their academic progress, behaviour, and socio-emotional well- being (McMillan & Jarvis, 2017). 

When implemented with fidelity, MTSS is an effective whole school inclusive framework as teachers, therapists, and other support staff work collaboratively to assess, monitor, and plan interventions to support students (Sailor, 2017). Student progress is frequently monitored and data are evaluated by the support team to determine whether alternative interventions are required. MTSS additionally encourages the use of evidence-based practices to be implemented across the tiers of support. Some common examples of MTSS include Response to Intervention (RTI) and Positive Behaviour Interventions and Supports (PBIS) (Webster, 2016). RTI is focused on supporting students academically, while PBIS is concerned with emphasising behavioural expectations in a positive manner, naturally supporting the social and emotional development of students. MTSS models have also been applied in whole-school mental health promotion, prevention and intervention (McMillan & Jarvis, 2017) and inclusive approaches to academic talent development for more advanced students (Jarvis, 2017). 

MTSS approaches to contemporary inclusive practice stand in contrast to traditional, categorical models whereby students were either ‘in’ or ‘out’ of special education services. The focus is on determining and responding to what students need when they need it, as opposed to focusing on a specific diagnosis or inflexible program options. In the MTSS framework, the tiers do not represent students or their placement, but the flexible suite of supports and interventions that may be provided. The implementation of MTSS approaches fundamentally reconceptualises the role of the classroom teacher, who must work collaboratively with specialist staff and other professionals to define and address individual student needs in ongoing ways, rather than relying on a specialist teacher or even a teacher aide to take responsibility for the education of students with identified special needs. While MTSS requires substantial changes to school operations (and must therefore be supported by leadership and culture in deliberate, coordinated ways), the general framework provides an organisation and structure to support the development of sustainable, contemporary inclusive schools (McLeskey et al., 2014). 

Figure 2. Multi-tiered System of Supports (MTSS) framework. 

Conclusion 

Ultimately, developing sustainable and effective inclusion in schools is a challenging but worthwhile undertaking, requiring shared vision, commitment, ongoing reflection, and patience. Changes in practice, particularly in teachers’ daily planning and pedagogy, take time and will be supported by ongoing, well designed and embedded professional learning in the context of strong leadership and an inclusive school culture. By utilising a whole school approach, key areas including leadership, school values and culture, building staff capacity, and coordinated frameworks for inclusive practice, can be considered collectively and planned for in advance.  

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Measuring Inclusive Education

ISBN : 978-1-78441-146-6 , eISBN : 978-1-78441-145-9

Publication date: 25 October 2014

This chapter reviews the international literature in order to support ongoing international development work on indicators for measuring inclusive education. Building on previous work in this area, this chapter outlines 13 themes in the international literature that should be considered in the development of a set of indicators for measuring inclusive education and has produced one extra thematic area for consideration.

• Inclusive education
• Measurement

Acknowledgements

This research has been funded by the Australian Government through the Department of Foreign Affairs and Trade’s Australian Development Research Awards Scheme (ADRAS) under an award titled ‘Developing and testing indicators for the education of children with disability in the Pacific’. The views expressed herein are those of the author(s) and not necessarily those of the Commonwealth of Australia. The Commonwealth of Australia accepts no responsibility for any loss, damage or injury resulting from reliance on any of the information or views contained in this publication.

The assistance and advice of members of the International Inclusive Teacher Education Research Forum (IITERF) is gratefully acknowledged, along with the many members of the ADRAS research team who provided documents and advice.

Loreman, T. , Forlin, C. and Sharma, U. (2014), "Measuring Indicators of Inclusive Education: A Systematic Review of the Literature", Measuring Inclusive Education ( International Perspectives on Inclusive Education, Vol. 3 ), Emerald Group Publishing Limited, Leeds, pp. 165-187. https://doi.org/10.1108/S1479-363620140000003024

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Inclusion in physical education: a review of the literature from 1995-2005

Affiliation.

• 1 Kinesiology Program, University of Virginia, Charlottesville, VA, USA. [email protected]
• PMID: 17916912
• DOI: 10.1123/apaq.24.2.103

The purpose of the review is to critically analyze English-written research articles pertaining to inclusion of students with disabilities in physical education published in professional journals both within and outside of the United States from 1995-2005. Each study included in this review had to meet seven a priori criteria. Findings of the 38 selected studies were divided into six focus areas: (a) support, (b) affects on peers without disabilities, (c) attitudes and intentions of children without disabilities, (d) social interactions, (e) ALT-PE of students with disabilities, and (f) training and attitudes of GPE teachers. Recommendations for future practice and research are embedded throughout the article.

Publication types

• Disabled Children / education*
• Interpersonal Relations
• Mainstreaming, Education / trends*
• Physical Education and Training / trends*

This paper is in the following e-collection/theme issue:

Published on 8.5.2024 in Vol 10 (2024)

The Scope of Virtual Reality Simulators in Radiology Education: Systematic Literature Review

Authors of this article:

• Shishir Shetty 1 , PhD ; 
• Supriya Bhat 2 , MDS ; 
• Saad Al Bayatti 1 , MSc ; 
• Sausan Al Kawas 1 , PhD ; 
• Wael Talaat 1 , PhD ; 
• Mohamed El-Kishawi 3 , PhD ; 
• Natheer Al Rawi 1 , PhD ; 
• Sangeetha Narasimhan 1 , PhD ; 
• Hiba Al-Daghestani 1 , MSc ; 
• Medhini Madi 4 , MDS ; 
• Raghavendra Shetty 5 , PhD

1 Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, , Sharjah, , United Arab Emirates

2 Department of Oral Medicine and Radiology, AB Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), , Mangalore, , India

3 Department of Preventive and Restorative Dentistry, College of Dental Medicine, University of Sharjah, , Sharjah, , United Arab Emirates

4 Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, , Manipal, , India

5 Department of Clinical Sciences, College of Dentistry, Ajman University, , Ajman, , United Arab Emirates

Corresponding Author:

Supriya Bhat, MDS

Background: In recent years, virtual reality (VR) has gained significant importance in medical education. Radiology education also has seen the induction of VR technology. However, there is no comprehensive review in this specific area. This review aims to fill this knowledge gap.

Objective: This systematic literature review aims to explore the scope of VR use in radiology education.

Methods: A literature search was carried out using PubMed, Scopus, ScienceDirect, and Google Scholar for articles relating to the use of VR in radiology education, published from database inception to September 1, 2023. The identified articles were then subjected to a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)–defined study selection process.

Results: The database search identified 2503 nonduplicate articles. After PRISMA screening, 17 were included in the review for analysis, of which 3 (18%) were randomized controlled trials, 7 (41%) were randomized experimental trials, and 7 (41%) were cross-sectional studies. Of the 10 randomized trials, 3 (30%) had a low risk of bias, 5 (50%) showed some concerns, and 2 (20%) had a high risk of bias. Among the 7 cross-sectional studies, 2 (29%) scored “good” in the overall quality and the remaining 5 (71%) scored “fair.” VR was found to be significantly more effective than traditional methods of teaching in improving the radiographic and radiologic skills of students. The use of VR systems was found to improve the students’ skills in overall proficiency, patient positioning, equipment knowledge, equipment handling, and radiographic techniques. Student feedback was also reported in the included studies. The students generally provided positive feedback about the utility, ease of use, and satisfaction of VR systems, as well as their perceived positive impact on skill and knowledge acquisition.

Conclusions: The evidence from this review shows that the use of VR had significant benefit for students in various aspects of radiology education. However, the variable nature of the studies included in the review reduces the scope for a comprehensive recommendation of VR use in radiology education.

Introduction

The use of technology in education helps students achieve improved acquisition of professional knowledge and practical skills [ 1 - 3 ]. Virtual reality (VR) is a modern technology that simulates experience by producing 3D interactive situations and presenting objects in a virtual world with spatial dimensions [ 4 , 5 ]. VR technology can be classified as nonimmersive or immersive [ 6 ]. In a nonimmersive VR, the simulated 3D environment is experienced through a computer monitor [ 6 ]. On the other hand, an immersive VR provides a sense of presence in a computer-generated environment, created by producing realistic sights, sounds, and other sensations that replicate a user’s physical presence in a virtual environment [ 6 , 7 ]. Using VR technology, a person can look about the artificial world, navigate around in it, and interact with simulated objects or items [ 5 , 8 ]. Due to the broad nature of VR technology, it has many applications, some of which are in the field of medicine [ 9 , 10 ].

The use of VR in medicine started in the 1990s when medical researchers were trying to create 3D models of patients’ internal organs [ 11 - 13 ]. Since then, VR use in the field of medicine and general health care has increased substantially to cover many areas including medical education. Radiology education has also come to see the use of VR technology in the recent past [ 14 ]. The use of VR in radiology education enables students to practice radiography in a virtual environment, which is radiation free [ 15 ]. Additionally, the use of VR enables effective and repeatable training. This allows trainees to recognize and correct errors as they occur [ 16 , 17 ]. The aim of this review is to explore the scope of VR in radiology education.

This systematic review has been performed using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines [ 18 ] [ Checklist 1 ]).

Information Sources and Study Selection

The bibliographic databases used were PubMed, Scopus, ScienceDirect, and Google Scholar. A systematic literature search was conducted for articles published from database inception to September 1, 2023. Topic keywords were used to generate search strings. The search strings that were used are provided in Table 1 . Only the first 10 pages of Google Scholar results were exported. The identified studies were then subjected to a study selection process. The search string for ScienceDirect was shorter because the database only allows a maximum of 8 Boolean operators, hence the sting had to be shortened. The search in PubMed was limited to the title and abstract. The searches in Scopus and ScienceDirect were limited to title, abstract, and keywords.

Inclusion and Exclusion Criteria

Original research articles written in the English language were included in the review. Studies conducted on medical, dental, and allied health sciences students (undergraduate and postgraduate) from any part of the world were included in the review. Studies exploring the use of VR learning in radiology education were included.

Narrative reviews, scoping reviews, systematic reviews, meta-analyses, editorials, and commentaries were excluded. Studies that did not align with the required study objective were excluded.

Method of Quality Assessment

Randomized controlled trials (RCTs) and randomized experimental studies were appraised using the RoB 2 tool from the Cochrane Collaboration [ 19 ]. A visualization of the risk-of-bias assessment was done using the web-based robvis tool [ 20 ]. Cross-sectional studies were appraised using the appraisal checklist for analytical cross-sectional studies from the Joanna Briggs Institute [ 21 ].

Data Extraction

Each article included in the review was summarized in a table, including basic study characteristics. The extracted attributes were study author(s), publication year, study design, type and number of participants, type of radiology education under study, and the outcome being assessed. The extracted data are provided in Table 2 .

a RCT: randomized controlled trial.

b CT: computed tomography.

Search Results

The database search identified a total of 2877 studies; 374 (13%) studies were from PubMed, 2169 (75.4%) were from Scopus, 234 (8.1%) were from ScienceDirect, and 100 (3.5%) were from Google Scholar. Before the screening procedure, 37 duplicates were removed. During title and abstract screening, 2808 articles were excluded since they did not align with the eligibility criteria. The remaining 32 articles were then subjected to a full-text review, and 15 were excluded for reasons provided in Figure 1 , which shows the study selection process [ 38 ]. At the end of the process, 17 studies were found eligible for inclusion in the review.

Characteristics of Included Studies

Among the 17 studies, 3 (18%) RCTs, 7 (41%) randomized experimental trials, and 7 (41%) cross-sectional studies were included. The studies encompassed various aspects of radiology education, including dental radiology [ 28 , 29 ], diagnostic radiology [ 22 , 24 ], and interventional radiology [ 25 , 31 ].

Results of Quality Assessment

Among the 7 cross-sectional studies, 2 (29%) scored “good” in overall quality and the remaining 5 (71%) scored “fair.” The results for the quality appraisal of cross-sectional studies are shown in Table 3 . Studies were appraised using the checklist for analytical cross-sectional studies from the Joanna Briggs Institute [ 21 ].

Among the 10 randomized trials, 3 (30%) had a low risk of bias, 5 (50%) showed some concerns, and 2 (20%) had a high risk of bias. These results are shown in Table 4 . RCTs were appraised using the RoB 2 tool from the Cochrane Collaboration [ 19 ]. A risk-of-bias graph ( Figure 2 ) and a risk-of-bias summary ( Figure 3 ) are also provided.

a Item 1: were the criteria for inclusion in the sample clearly defined?

b Item 2: were the study subjects and the setting described in detail?

c Item 3: was the exposure measured in a valid and reliable way?

d Item 4: were objective, standard criteria used for measurement of the condition?

e Item 5: were confounding factors identified?

f Item 6: were strategies to deal with confounding factors stated?

g Item 7: were the outcomes measured in a valid and reliable way?

h Item 8: was appropriate statistical analysis used?

i N/A: not assessable.

a D1: risk of bias arising from the randomization process.

b D2: risk of bias due to deviations from the intended interventions (effect of assignment to intervention).

c D3: risk of bias due to missing outcome data.

d D4: risk of bias in measurement of the outcome.

e D5: risk of bias in selection of the reported result.

Type of VR Hardware and Software Used in the Studies

The studies used a wide range of VR software and hardware. Some of the studies used 3D simulation software packages displayed on 2D desktop computers [ 22 , 24 , 25 , 36 ], whereas others used headsets for an immersive VR environment [ 15 , 23 , 26 , 35 , 37 ]. The most used VR teaching software were the CETSOL VR Clinic software [ 33 , 35 ], Virtual Medical Coaching VR software [ 15 , 30 , 32 ], Projection VR (Shaderware) software [ 36 ], SieVRt VR system (Luxsonic Technologies) [ 37 ], medical imaging training immersive environment software [ 23 ], VR CT Sim software [ 25 ], VitaSim ApS software [ 26 ], VR X-Ray (Skilitics and Virtual Medical Coaching) software [ 27 ], and radiation dosimetry VR software (Virtual Medical Coaching Ltd) [ 31 ].

Effect of VR Teaching on Skill Acquisition

Ahlqvist et al [ 22 ] looked at how virtual simulation can be used as an effective tool to teach quality assessment of radiographic images. They also compared how it faired in comparison to traditional teaching. The study reported a statistically significant improvement in proficiency from before training to after training. Additionally, the study reported that the proficiency score improvement for the VR-trained students was higher than that for the students trained using conventional method.

In the study conducted by Sapkaroski et al [ 34 ], students in the VR group demonstrated significantly better patient positioning skills compared to those in the conventional role-play group. The positioning parameters that were assessed were digit separation and palm flatness (the VR group scored 11% better), central ray positioning onto the third metacarpophalangeal joint (the VR group scored 23% better), and a control position projection of an oblique hand. The results for the control position projection indicated no significant difference in positioning between the 2 groups [ 34 ].

Bridge et al [ 23 ] also performed a performance comparison between students trained by VR and traditional methods. They assessed skills about patient positioning, equipment positioning, and time taken to complete a performative role-play. Students in the VR group performed better than those in the control group, with 91% of them receiving an overall score of above average (>3). The difference in mean group performance was statistically significant ( P =.0366). Similarly, Gunn et al [ 24 ] reported improved and higher role-play skill scores for students trained using VR software simulation compared to those trained on traditional laboratory simulation. The mean role-play score for the VR group was 30.67 and that for the control group was 28.8 [ 24 ].

Another study reported that students trained using VR performed significantly better (ranked as “very good” or “excellent”) than the control group (conventional learning) in skills such as patient positioning, selecting exposure factors, centering and collimating the x-ray beam, placing the anatomical marker, appraisal of image quality, equipment positioning, and procedure explanation to the patient [ 30 ]. Another recently conducted study found that the VR-taught group achieved better test duration and fewer errors in moving equipment and positioning a patient. There was no significant difference in the frequency of errors in the radiographic exposure setting such as source-to-image distance between the VR and the physical simulation groups [ 32 ].

Nilsson et al [ 28 ] developed a test to evaluate the student’s ability to interpret 3D information in radiographs using parallax. This test was applied to students before and after training. There was a significantly larger ( P <.01) pre-post intervention mean score for the VR group (3.11 to 4.18) compared to the control group (3.24 to 3.72). A subgroup analysis was also performed, and students with low visuospatial ability in the VR group had a significantly higher improvement in the proficiency test compared to those in the control group. The same authors conducted another follow-up study to test skill retention [ 29 ]. Net skill improvement was calculated as the difference in test scores after 8 months. The results from the proficiency test showed that the ability to interpret spatial relations in radiographs 8 months after the completion of VR training was significantly better than before VR training. The students who trained conventionally showed almost the same positive trend in improvement. The group difference was smaller and not statistically significant. This meant that, 8 months after training, the VR group and the traditionally trained group had the same skill level [ 29 ].

Among the included studies, only 1 reported that the VR group had lower performance in proficiency tests and radiographic skill tests, compared to a conventionally trained group. The study, conducted in 2022, showed that the proficiency of the VR group was significantly lower than that of the conventional technique group in performing lateral elbow and posterior-anterior chest radiography [ 27 ]. An itemized rubric evaluation used in the study revealed that the VR group also had lower performance in most of the radiographic skills, such as locating and centering of the x-ray beam, side marker placement, positioning the x-ray image detector, patient interaction, and process control and safety [ 27 ]. The study concluded that VR simulation can be less effective than real-world training in radiographic techniques, which requires palpation and patient interaction. These results may be different from those of other studies due to different outcome evaluation methods and since they used head-mounted display VR coaching, whereas the other studies, except O’Connor et al [ 15 ], used VR on a PC monitor.

All of the studies except Kato et al [ 27 ] agreed that VR use was more effective for students in developing radiographic and radiologic skills. Despite this general agreement, there were slight in-study variations in learning outcomes, which made some of the studies look at factors that may influence skill and knowledge acquisition during VR use. In studies such as Bridge et al [ 23 ], it was noted that the arrangement of equipment had the greatest influence on the overall score. After performing a multivariable analysis, Gunn et al [ 24 ] reported that there was no effect of age, gender, and gaming skills or activity on the outcome of VR learning. In the study by Shanahan [ 36 ], a few students (19/84, 23%) had previously used VR simulation software. This had no bearing on the learning outcomes. Another observation in the same study was that student age was found to significantly affected the student’s confidence about skill acquisition after VR training [ 36 ].

Students’ Perception of VR Uses for Learning

The findings from the study by Gunn et al [ 25 ] revealed that 68% of students agreed or strongly agreed that VR simulation was significantly helpful in learning about computed tomography (CT) scanning. In another study by Jensen et al [ 26 ], 90% of the students strongly agreed that VR simulators could contribute to learning radiography, with 90% reporting that the x-ray equipment in the VR simulation was realistic. In the study by Wu et al [ 37 ], most of the students (55.6%) agreed or somewhat agreed that VR use was useful in radiology education. Similarly, 83% of the students in Shanahan’s [ 36 ] study regarded VR learning with an ease of use. In the same study, students also reported that one of the major benefits of VR learning include using the simulation to repeat activities until being satisfied with the results (95% of respondents). Students also stated that VR enabled them to quickly see images and understand if changes needed to be made (94%) [ 36 ]. In the study by Gunn et al [ 25 ], 75% of medical imaging students agreed on the ease of use and software enjoyment in VR simulated learning. In the same study, 57% of the students reported a positive perceived usefulness of VR. Most respondents (80%) in the study by Rainford et al [ 31 ] favored the in-person VR experience over web-based VR. Similarly, 58% of the respondents in the study conducted by O’Connor et al [ 15 ] reported enjoying learning using VR simulation. In the study by Wu et al [ 37 ], 83.3% of students agreed or strongly agreed that they enjoyed using VR for learning. Similarly, the studies by Rainford et al [ 31 ] and O’Connor et al [ 15 ] reported student recommendation of 87% and 94%, respectively, for VR as a learning tool.

Students’ Perceived Skill and Knowledge Acquisition

In the study by Bridge et al [ 23 ], students who trained using VR reported an increase in perceived skill acquisition and high levels of satisfaction. The study authors attributed this feedback to the availability of “gold standards” that showed correct positioning techniques, as well as instant feedback provided by the VR simulators. Gunn et al [ 25 ] examined students’ confidence in performing a CT scan in a real clinical environment after using VR simulations as a learning tool. The study reported an increase (from before to after training) in the students’ perceived confidence in performing diagnostic CT scans. Similarly, the study by Jensen et al [ 26 ] reported that the use of VR had influenced students’ self-perceived readiness to perform wrist x-ray radiographs. The study, however, found no significant difference in pre- and posttraining (perceived preparedness) scores. The pre- and posttraining scores were 75 (95% CI 54-96) and 77 (95% CI 59-95), respectively. The study by O’Connor et al [ 15 ] looked at the effect of VR on perceived skill adoption. Most of the students in the study reported high levels of perceived knowledge acquisition in the areas of beam collimation, anatomical marker placement, centering of the x-ray tube, image evaluation, anatomical knowledge, patient positioning, and exposure parameter selection to their VR practice. However, most students felt that VR did not contribute to their knowledge of patient dose tracking and radiation safety [ 15 ]. In the study by Rainford et al [ 31 ], 73% of radiography and medical students felt that VR learning increased their confidence across all relevant learning outcomes. The biggest increase in confidence level was regarding their understanding of radiation safety matters [ 31 ]. Sapkaroski et al [ 33 ] performed a self-perception test to see how students viewed their clinical and technical skills after using VR for learning. In their study, students reported a perceived improvement in their hand and patient positioning skills. Their study also compared 2 software, CETSOL VR Clinic and Shaderware. The cohort who used CETSOL VR Clinic had higher scores on perceived improvement [ 33 ]. Sapkaroski et al [ 35 ] compared the student’s perception scores on the educational enhancement of their radiographic hand positioning skills, after VR or clinical role-play scenario training. Although the VR group scored higher, there was no significant difference between the scores for the 2 groups [ 35 ]. In the study by Shanahan [ 36 ], when the perception of skill development was evaluated, most of the students reported that the simulation positively developed their technical (78%), radiographic image evaluation (85%), problem-solving (85%), and self-evaluation (88%) abilities. However, in the study by Kato et al [ 27 ], there was no difference in the perceived acquisition of knowledge among students using traditional teaching and VR-based teaching.

Principal Findings

The results presented in this review reveal strong evidence for the effectiveness of VR teaching in radiology education, particularly in the context of skill acquisition and development [ 22 , 24 , 27 , 30 , 32 , 34 ].

In this review, quality appraisal of the cross-sectional studies revealed that the strategies for deal with confounding factors was one of the factors directly affecting the reliability of the results. Similarly, the appraisal of the randomized trials revealed that the bias arising due to missing outcome data was one of the factors directly affecting the reliability of the results.

All the studies found that VR-based teaching had a positive impact on various areas of radiographic and radiologic skill development. In comparison to the traditional way of teaching, only 1 study by Kato et al [ 27 ] reported VR teaching as inferior to traditional teaching. The studies consistently reported better improvements in proficiency, patient positioning outcomes, equipment handling, and radiographic techniques among students trained using VR. According to Nilsson et al [ 29 ], O’Connor et al [ 15 ], and Wu et al [ 37 ], the improvements were due to the immersive and interactive nature of VR simulations, which allowed learners to engage with radiological scenarios in a dynamic and hands-on manner. The studies also revealed that VR learning has the ability to easily and effectively introduce students to new skills. It was also found that existing skills could be improved, mainly through simulation feedback that happens in real time during training [ 22 , 24 , 28 , 30 , 36 ].

The improvement of skills after VR training have been noted in different domains, including patient positioning, equipment positioning, equipment knowledge, assessment of radiographic image quality, and patient interaction. Improvement was also observed in other skills such as as central ray positioning, source-to-image distance, image receptor placement, and side marker placement [ 22 , 24 , 30 , 32 , 34 ]. Two studies, Nilsson et al [ 28 ] and Nilsson et al [ 29 ], looked at how VR affected the students’ ability to interpret 3D information in radiographs using parallax. They both reported a positive effect. Nilsson et al [ 29 ] also gave insights into the long-term benefits of VR training in radiology. Eight months after training, the control (traditionally taught) group in Nilsson et al [ 29 ] showed a slight increase in skills, but the VR-trained group still maintained a significantly higher skill level. This finding shows the enduring impact of VR-based education on skill acquisition in radiology. Although most studies supported the effectiveness of VR in radiology education, 1 study reported contrasting results [ 27 ]. VR-trained students were found to perform worse than traditionally trained students in conducting lateral elbow and posterior-anterior chest radiography in Kato et al [ 27 ]. This difference in results was, according to the authors, attributed to the use of a different rubric evaluation method and the use of a head-mounted display–based immersive VR system, which was not used in other studies. These 2 reasons may be the reason for the variation in study findings.

A wide range of VR software with different functions were used in the studies. In addition to acquiring radiographic images, the CETSOL VR Clinic software facilitated students to interact with their learning environment [ 33 , 35 ]. Students using the Virtual Medical Coaching VR software performed imaging exercise on a virtual patient with VR headsets and hand controllers [ 15 , 30 , 32 ]. The SieVRt VR system displayed Digital Imaging and Communications in Medicine format images in a virtual environment, thus facilitating teaching [ 37 ]. The medical imaging training immersive environment simulation software provided automated feedback to the learners including a rerun of procedures, thus highlighting procedural errors [ 23 ]. The VR CT Sim software allowed the student virtually to perform the complete CT workflow [ 25 ]. Students could manipulate patient positioning and get feedback from the VitaSim ApS software [ 26 ]. The VR X-Ray software allowed students to manipulate radiographic equipment and patient’s position with a high level of immersive experience [ 27 ]. Radiation dosimetry VR software facilitated virtual movement of the staff and equipment to radiation-free areas, thus optimizing radiation protection [ 31 ].

The included studies also looked at factors that could influence skill acquisition when VR is used in radiology education. Bridge et al [ 23 ], Gunn et al [ 24 ], Kato et al [ 27 ], and Shanahan [ 36 ] investigated factors such as age, gender, prior gaming experience, and familiarity with VR technology. However, these factors were shown to have no significant effect on VR learning outcomes. This shows that VR education can equally accommodate a wide range of learners, regardless of experience or existing attributes.

Across several studies, positive feedback emerged regarding the utility, ease of use, enjoyment, and perceived impact on skill and knowledge acquisition. The included studies consistently reported positive perceptions of VR use among students [ 25 , 26 , 37 ]. Gunn et al [ 25 ] reported that a significant proportion of medical imaging and radiation therapy students found the use of VR simulation to be significantly helpful in learning about CT scanning. Similarly, Jensen et al [ 26 ] and Wu et al [ 37 ] reported that a majority of students agreed on the usefulness of VR in radiology education. Another aspect that received positive feedback was the ease of use. Students liked the ability to repeat tasks until they were satisfied with the results and the ability to quickly visualize radiographs to determine the need for revisions [ 36 ]. Rainford et al [ 31 ] and O’Connor and Rainford [ 30 ] found that most students would recommend VR as a learning tool to other students.

Several studies investigated student’s perceptions of skill and knowledge acquisition when using VR for radiology education. Bridge et al [ 15 ] and O’Connor et al [ 23 ] discovered an increase in students’ perceived acquisition of radiographic skills. Gunn et al [ 25 ] reported an increase in students’ perceived confidence to perform CT scans after learning using VR simulations. According to Rainford et al [ 31 ], a large percentage of radiography and medical students felt that VR learning boosted their confidence across all relevant learning outcomes, with the highest levels of confidence recorded in radiation safety. Sapkaroski et al [ 33 ] discovered that after using VR for learning, students experienced an improvement in their hand and patient placement skills. In summary, the positive feedback from the students shows that VR use in radiology education is a useful, engaging, and effective teaching tool. This perceived acquisition of skills is backed by the results from the proficiency tests.

The VR modalities used in some of the studies allowed remote assistance from an external agent (teacher), as the VR training is conducted in front of a screen while being part of a team, with the teacher making constant corrections and indications [ 22 , 24 , 27 ]. However, researchers are looking into VR systems with artificial intelligence–supported tutoring, which includes the assessment of learners, generation of learning content, and automated feedback [ 39 ].

Findings from the included studies show that VR-based teaching offers substantial benefits in various aspects of radiographic and radiologic skill development. The studies consistently reported that students educated using VR systems improved significantly in overall proficiency, patient positioning, equipment knowledge, equipment handling, and radiographic techniques. However, the variable nature of the studies included in the review reduces the scope for a comprehensive recommendation of VR use in radiology education. A key contributing factor to relatively better learning outcomes was the immersive and interactive nature of VR systems, which provided real-time feedback and dynamic learning experiences to students. Factors such as age, gender, gaming experience, and familiarity with VR systems did not significantly influence learning outcomes. This shows that VR can be used for diverse groups of students when teaching radiology. Students generally provided positive feedback about the utility, ease of use, and satisfaction of VR, as well as its perceived impact on skill and knowledge acquisition. These students’ reports show the value of VR as an important, interesting, and effective tool in radiology education.

Conflicts of Interest

None declared.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

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Abbreviations

Edited by A Hasan Sapci, Taiane de Azevedo Cardoso; submitted 23.09.23; peer-reviewed by FernandezHerrero Jorge, Stacey Kassutto; final revised version received 01.02.24; accepted 31.03.24; published 08.05.24.

© Shishir Shetty, Supriya Bhat, Saad Al Bayatti, Sausan Al Kawas, Wael Talaat, Mohamed El-Kishawi, Natheer Al Rawi, Sangeetha Narasimhan, Hiba Al-Daghestani, Medhini Madi, Raghavendra Shetty. Originally published in JMIR Medical Education (https://mededu.jmir.org), 8.5.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Education, is properly cited. The complete bibliographic information, a link to the original publication on https://mededu.jmir.org/ , as well as this copyright and license information must be included.