Visual Enhanced Mental Simulation: low cost, high effectiveness

Visual Enhanced Mental Simulation (VEMS) is an innovative, low-cost form of mental simulation that combines thinking aloud and visual aids to train cognitive, social, and relational skills. Easy to implement and adaptable online, it improves decision-making, communication, and team coordination. Recent literature shows that, even with simple materials, it can offer profound and transformative learning experiences.

Healthcare simulation technologies are becoming increasingly sophisticated: hyper-realistic mannequins, immersive environments, and virtual reality allow training in complex scenarios with a very high level of engagement. However, the costs of these solutions are not always sustainable for all organizations, where funding remains a sore point.

Yet there are simple, low-cost, and easily reproducible methodologies that can spread the culture of simulation and reflection without straining budgets. One of these is Visual Enhanced Mental Simulation (VEMS).

What is VEMS and how does it work?

VEMS is a combination of mental simulation and thinking aloud, enriched by the use of visual aids. It was first described by Alinier and colleagues and is proposed as a tool for training Non-Technical Skills (NTS) in low-fidelity scenarios.

The educational basis of this approach lies in the well-documented benefits of mental rehearsal and think-aloud, two strategies that promote the exploration of cognitive processes and awareness of one’s own decisions. As Dogan and colleagues explain in the International Journal of Healthcare Simulation:

“It differs from simple mental simulation, which takes place exclusively in the minds of the participants, because here they are asked to collectively verbalize their thoughts and actions, including the adjustment of equipment and communication with the patient.”

The rationale is therefore to promote clinical reasoning within the team by making the participants’ mental processes explicit, allowing them to train, above all, their decision-making and effective communication skills. The visual component also helps the imagination and allows for an overview of the scene.

From a practical point of view, few ingredients are needed to organize a scenario: a table, a whiteboard, laminated images of the patient and equipment, a couple of expert facilitators, and a team willing to get involved. The process is reminiscent of a board game: participants discuss, reason aloud, place visual aids on the paper patient, while facilitators update vital signs and add information that cannot be represented graphically, also interpreting the patient’s voice or impersonating external consultants, if required.

A tradition that is being renewed

VEMS is part of a well-established tradition: that of tabletop simulations, which have been used for decades, especially in disaster and emergency management exercises (e.g., with the Emergo Train system). What sets it apart is its clear focus on explicating cognitive processes and using simple but powerful visual materials to stimulate the imagination.

Connecting Narrative Medicine and Patient Simulation

Evidence from the literature

In recent years, VEMS has begun to appear more and more frequently in scientific literature, with results confirming its validity as an educational tool.

I found the study by Brazil and colleagues (2025) particularly interesting. At Gold Coast Hospital in Australia, VEMS was introduced in a wide variety of clinical settings, from emergency rooms to geriatrics to home care, and was subsequently the subject of a qualitative survey of participants and facilitators. Five key themes emerged from the interviews:

• the flexibility of the methodology, which allows the scenario to be adapted to different training needs;

• the ability to be unexpectedly engaging, despite the absence of mannequins or sophisticated equipment;

• the focus on teamwork, made clearer by the absence of technical distractions;

• the impact on training programs, which have begun to integrate VEMS alongside more complex simulations; and finally

• essentiality, a curious observation, namely that for many learners, mannequins are sometimes more “confusing” than the simplicity of a cardboard cutout.

In other words, the clarity of the instructions and the need to verbalize decision-making processes have made VEMS not only more accessible but also more effective than expected.

VEMS even at a distance

The experiment conducted by Demir et al. (2023) in Turkey is also interesting. Here, VEMS is tested in an online version, with students from a paramedic course engaged in mass emergency scenarios. Using a quasi-experimental design with pre- and post-tests, the authors observed a significant increase in triage and multiple casualty management skills. Students who participated in simulated scenarios using a virtual whiteboard and shared visual materials reported that the experience felt realistic and safe, helping to reduce anxiety and strengthen confidence in clinical decisions. Feedback was mostly enthusiastic: many emphasized the opportunity to “see their mistakes” in a protected environment and to acquire knowledge that they felt was more stable and transferable to practice.

Considerations on VEMS

VEMS therefore presents itself as a particularly interesting methodology for those involved in healthcare training, and some considerations deserve further exploration:

• Low cost and flexibility: its greatest strength is undoubtedly its affordability. Only a few easily available materials (a whiteboard, laminated images, and a few markers) are needed to create a training scenario. This not only drastically reduces costs compared to high-tech, high-fidelity simulations, but also reduces preparation time. VEMS can therefore be integrated into the daily work routine, perhaps by organizing a last-minute exercise during a shift with a low workload, with the staff actually present in the ward. The speed of set-up makes it an agile and easily replicable option, even in contexts with limited resources.
• Pre-scenario familiarization: the simplicity of VEMS should not be misleading. To ensure a good level of engagement, a thorough pre-briefing phase is essential. Participants need to understand how the methodology works, be familiar with the materials that will be used, and feel comfortable with the fact that this is a “very low fidelity” simulation. Clarifying how clinical information will be provided and how facilitators will intervene during the scenario is essential to create psychological immersion and avoid confusion.
• Facilitator competence: the role of facilitators is crucial. It is not enough to know the VEMS technique: it is necessary to know how to guide participants’ critical thinking, stimulate their reflection, and above all, conduct an effective debriefing. In fact, much of the educational value of VEMS lies in the debriefing. For this reason, facilitators must be proficient not only in the methodology, but also in conversational and critical thinking techniques, so as to transform the experience into a true moment of transformative learning and behavioral change.
• Focus on NTS: VEMS does not allow for the training of strictly technical skills, such as manual dexterity in performing invasive procedures. However, this limitation can become a strength. Freed from the operational burden, participants focus more on relational, communicative, and decision-making aspects. It is true that this condition can lead to a slight underestimation of the ‘noise’ present in real scenarios (where practical execution and distractions affect teamwork), but it remains an ideal context for developing cross-cutting skills such as leadership, priority management, and coordination.
• Online VEMS: an additional advantage is the possibility of conducting VEMS remotely. Simply share the screen with visual materials (patient posters, equipment sheets, etc.) and use a videoconferencing platform to enable remote teams and facilitators to collaborate. This method, which has also been successfully tested during the pandemic, expands training opportunities, allowing professionals in different locations to be reached while maintaining a high level of group interaction.

Conclusions

Overall, these experiences suggest that VEMS is not simply a cost-effective solution to be adopted in the absence of alternatives, but a method with intrinsic training value. It is versatile, easily scalable, applicable both in person and remotely, and above all, it proves to be powerful in training non-technical skills: decision making, communication, and team coordination. In other words, what may initially appear to be a ‘poor’ exercise in terms of materials often proves to be rich in terms of learning.

The literature on VEMS is still evolving, but in the meantime, giving it a chance requires little effort and could prove to be an effective complementary option for integrating simulation into our work routine.

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