These three are not competing versions of the same thing. Manikins buy psychomotor practice and team crisis work. VR and 360 scenarios buy repetitions, recognition and decision-making at a cost per learner that falls as the cohort grows. The recent meta-analytic evidence supports immersive methods on knowledge and self-efficacy, and does not support them on clinical skill performance, which is the claim most often made for them.
Key takeaway: Choose by what the learner has to do. If the assessed behaviour is in the hands, you need a manikin or a real patient. If it is in the noticing, the sequencing or the escalating, a scenario your own educators can author and update will reach more people, more often, for less.
This guide is part of our reference on immersive simulation training for the NHS, which covers governance, build and evidence in one place.
What they cost, honestly
No manikin vendor publishes UK list prices, so anyone quoting you a clean GBP comparison is estimating. The published figures that exist are American and secondary:
| Item | Published figure | Source |
|---|---|---|
| Flagship high-fidelity manikin | $65,000 to $85,000, wider range $55,000 to $250,000 | HealthySimulation, updated Mar 2026 |
| Annual service agreement | 5% to 15% of purchase price per year | Elevate Healthcare TCO guide, vendor source |
| Five-year total cost of ownership on a $50,000 unit | roughly $110,000 to $130,000 | as above |
We could find no published UK figures for running a simulation suite, covering technician time, room cost and consumables. That is a real gap in the literature rather than something we are withholding, and it matters, because staffing is the dominant recurring cost in most sim centres and the one that caps how often a cohort can repeat anything.
The cost-effectiveness research is thin and inconsistent by its own account: a targeted systematic review of 47 articles concluded that methods, definitions and estimates varied so much that comparison and generalisation are challenging (SAGE Open Medicine, 2020).
The one direct comparison worth citing is a cost-utility analysis in the Journal of Nursing Education (2024), which put cost per unit of utility at $0.15 for four hours of traditional clinical placement, $0.38 for two hours of screen-based virtual simulation and $0.62 for two hours of manikin-based simulation. Manikin simulation came out as the least cost-efficient of the three. It is a single US study with a US cost base, so treat the ordering as more informative than the figures.
What the evidence supports
The most recent relevant pooled analysis is a systematic review and meta-analysis of 21 randomised controlled trials covering 1,916 nursing students, published in the Journal of Korean Biological Nursing Science in 2025. Against mixed comparators including simulator-based education, lectures and video:
| Outcome | Effect (Hedges’ g) | Significant? |
|---|---|---|
| Knowledge | 0.32 (95% CI 0.08 to 0.57) | Yes, p = .010 |
| Self-efficacy | 0.46 (0.11 to 0.81) | Yes, p = .008 |
| Skill performance | 0.18 (-0.47 to 0.82) | No, p = .596 |
| Confidence | 0.12 (-0.20 to 0.43) | No, p = .460 |
Situation-based VR did better on knowledge, SMD 0.66, p < .001 (JKBNS, 2025). The authors flag substantial heterogeneity and English-only inclusion, and the comparators are pooled rather than manikin-specific.
Read that table the way a clinical educator would. Knowledge and self-efficacy move. Skill performance does not. Nobody selling you immersive simulation should claim it replaces hands-on practice, and we are not going to.
For 360° video specifically, a multi-site randomised trial across three Rome nursing schools (n = 96) compared 360° with standard video and found equivalent knowledge gain but significantly higher satisfaction and self-confidence in the 360° arm (Science Talks, 2023). That is the honest case for 360: context, engagement, standardisation and reach, not a learning-outcome advantage over good conventional media. Our longer review of the whole literature, including where it goes against us, is in is VR training effective.
Which to use for what
| Learning job | Best fit | Why |
|---|---|---|
| Psychomotor skills: cannulation, airway, compressions | Manikin or part-task trainer | Haptics and physical feedback, which no screen provides |
| Team crisis, human factors, closed-loop communication | High-fidelity manikin in situ | Needs a real team in a real room |
| Recognition and escalation: NEWS2, SBAR, sepsis | VR or 360 scenario | Repeatable, standardised, individually scored, runs weekly |
| Environment familiarisation before placement | 360 scenario | Whole cohort, before they arrive, on their own devices |
| Rare or unsafe events | VR or 360 scenario | You cannot schedule the deterioration you want to teach |
| Protocol and sequence rehearsal before an OSCE | VR or 360 scenario | Unlimited attempts without facilitator time |
| Assessed competence sign-off | Manikin, OSCE or practice | Regulatory expectation and skill evidence |
The practical reading is that these are complementary, and the scarce resource is almost always facilitator time rather than equipment. Scenario work absorbs the repetitions that would otherwise queue for the sim suite, which is how most of the trusts and universities we work with end up using it.
The regulatory frame, for nursing programmes
The NMC’s simulated practice learning guidance, last updated 1 October 2024, requires programmes to “provide 2,300 practice learning hours, of which a maximum of 600 hours can be simulated practice learning”. That ceiling is the planning constraint. Whether a given activity counts is a programme-level judgement about supervision, assessment and learning outcomes, not a property of the technology, so build with your practice learning lead rather than assuming.
The wider policy direction is supportive: Health Education England’s national strategic vision of simulation in health and care (November 2020) committed to equity of access to simulation resource across the system, which is precisely where cost per learner starts to matter.
A worked example from our own customers
Cardiff and Vale University Health Board built branching cardiac assessment scenarios in Node XR, authored by the health board’s own educators, and reports a 94% first-time pass rate on that programme. We quote it because it is real and because it shows what educator-authored content looks like at scale, but it is a single programme with no control group and should be read as a service evaluation rather than evidence. The full account is in the Cardiff and Vale case study, and the scenario design pattern is in deteriorating patient scenarios.
The short answer
Manikin simulation versus VR simulation is not a replacement decision. Manikins remain the right tool for psychomotor skills and team crisis work, and the recent meta-analytic evidence does not show VR improving clinical skill performance. VR and 360 scenarios earn their place on knowledge, self-efficacy, repeatability and cost per learner, especially for recognition, escalation and environment familiarisation, and the only published cost-utility comparison puts screen-based simulation ahead of manikin simulation on efficiency. Use the sim suite for the hands and scenarios for everything that happens before and after.
Talk to us about a clinical scenario, or see how this fits across a programme in our NHS immersive simulation reference.