Telesimulation Training for Endoscopic Mitral Valve Surgery: An Air-Pilot Training Concept for Distance Training

OBJECTIVE

The aim of this study was to validate and assess the feasibility and impact of telesimulation training on surgical skills using a portable mitral valve telesimulator.

METHODS

A telesimulation course composed of 3 online modules was designed based on backwards chaining, preassessment and postassessment, performance feedback, hands-on training on a telesimulator, and the theoretical content. A fully 3-dimensional-printed and transportable telesimulator was developed and sent out to the participants with instruments that were needed. Feedback about the platform was obtained from participants to validate its value as a training tool. Theoretical and technical assessments were carried out before and after the course. Technical assessments were based on the accuracy and time taken to place sutures at the anterior and posterior mitral annulus.

RESULTS

In total, 11 practicing cardiac surgeons from Oceania, Asia, Europe, and North America completed the course. Theoretical preassessment and postassessment showed that participants scored significantly higher on postassessment (mean 87.5% vs 68.1%, P < 0.004). The participant evaluation scores of the simulator as a tool for endoscopic mitral valve surgery was 4 to 5 out of 5. There was a significant improvement in the speed (median 14.5 vs 39.5 s, P < 0.005) and the accuracy to place sutures in the mitral valve annulus following course completion (P < 0.001).

CONCLUSIONS

Here we validated the educational value of a novel telesimulation platform and validated the feasibility to teach participants at a distance the knowledge and skills for endoscopic mitral valve surgery. Future studies will be required to validate the improvement in skills during surgery.

The dental microscope in endodontic education: A feasibility study of a distance learning course

This study aimed to evaluate the feasibility of preclinical training, specifically in root canal preparation, using a virtual educational system equipped with an operating microscope. Ten postgraduate general dentistry trainees and practitioners undergoing postgraduate training in endodontics participated. The telesimulation course included three steps: theory, demonstration of practical work by the teacher and lastly practical training by the participants. The digital environment including the dental microscope was presented, and the feedback was collected with a questionnaire. The majority of participants considered that the online video conference format allowed them to acquire theoretical content but also practical knowledge and skills, owing to the contribution of the operating microscope. The technical feasibility of endodontic telesimulation was demonstrated. The operating microscope has a potential role in distance education, enabling teaching to occur synchronously and collaboratively. This allows learners to interact with each other and demonstrators in real time.

Medical Students' Perception of Telesimulation Training: A Qualitative Analysis

OBJECTIVES

Over the past 2 decades, simulation-based learning has become an essential part of medical training. Simulated clinics have proven to be effective for training medical students. Even so, this learning method presents organizational and financial challenges that limit its dissemination to all medical students, especially since the COVID-19 pandemic. Simulated teleconsultation retains the advantages of interactive simulated clinics while offering concrete solutions to the challenges faced. The project aims to explore students' perspectives on simulated teleconsultation training compared to simulated clinics in person.

METHODS

Ten pre-clerkship students in the Faculty of Medicine at the University of Ottawa participated in interviews following in-person and teleconsultation simulated clinic sessions. The interview guide was developed based on previous work. The questions asked concerned experience with teleconsultation, interaction with the tutor and patient, practical or logistical obstacles, educational value and feasibility. The authors evaluated the results using a thematic analysis.

RESULTS

The interview analysis showed that the tutor feedback received during the simulated teleconsultation was comparable to that received after the in-person simulated clinic. Although most of the students enjoy teleconsultation, they raised the challenge of carrying out physical examinations and creating a personal connection with the tutor/patient.

CONCLUSION

Given the circumstances of the pandemic and students' comfort with technology, the new generation of medical students seems prepared to embrace teleconsultation. The themes identified in the analysis will enable the necessary adjustments to be made in order to optimize their teleconsultation training, an inextricable step in promoting the active offer of healthcare services.

Telehealth Competencies: Training Physicians for a New Reality?

In North America, telehealth increased by 40% between 2019 and 2020 and stabilized at 40% in 2021. As telehealth becomes more common, it is essential to ensure that healthcare providers have the required skills to overcome the challenges and barriers of this new modality of care. While the COVID-19 pandemic has accelerated the design and implementation of telehealth curricula in healthcare education programs, its general adoption is still a major gap and an important barrier to ensuring scaling up and sustainability of the telesshealth practice. Lack of experienced faculty and limited curricular time are two of the most common barriers to expanding telehealth education. Overcoming the barriers of telehealth curricula implementation may require moving away from the classic expert model of learning in which novices learn from experts. As the adoption of telehealth curricula is still in its early stages, institutions may need to plan for faculty development and trainee education at the same time. Questions regarding the timing and content of telehealth education, the interprofessional development of curricula, and the identification of optimal pedagogical methods remain open and crucial. This article reflects on these questions and presents telesimulation as an ideal instructional method for the training of telehealth competencies. Telesimulation can provide opportunities for practical training across a range of telehealth competencies, fostering not only technical proficiency but also communication skills and interprofessional collaboration.

Validation of telesimulation in the care of late preterm newborns with hypoglycemia for nursing students

OBJECTIVE

To develop and validate a telesimulation scenario for nursing students in the care of late preterm infants with hypoglycemia.

METHODS

A methodological study conducted between August 2021 and May 2022 in a virtual environment involved constructing and validating the scenario with 10 experts, and testing it with 10 students. The content validity index assessed validity, with a threshold of 80% or higher, and suggestions were analyzed using semantic approximation.

RESULTS

Validation confirmed the appropriateness of all 14 scenario items, with an overall index of 97.8% and clarity and relevance indices of 98.5%. During testing, the overall index was 99.7%, with the "resources" item receiving the lowest score. Adjustments were made to objectives, technical terms, resources, and target audience based on feedback.

CONCLUSION

Telesimulation is a widely accepted educational technology for training nursing students, with potential to enhance teaching quality and neonatal care.

Ventilator Training through International Telesimulation in Sierra Leone

Background

The coronavirus disease (COVID-19) pandemic resulted in an increased need for medical professionals with expertise in managing patients with acute hypoxemic respiratory failure, overwhelming the existing critical care workforce in many low-resource countries.

Objective

To address this need in Sierra Leone, we developed, piloted, and evaluated a synchronous simulation-based tele-education workshop for healthcare providers on the fundamental principles of intensive care unit (ICU) management of the COVID-19 patient in a low-resource setting.

Methods

Thirteen 2-day virtual workshops were implemented between April and July 2020 with frontline Sierra Leone physicians and nurses for potential ICU patients in hospitals throughout Sierra Leone. Although all training sessions took place at the 34 Military Hospital (a national COVID-19 center) in Freetown, participants were drawn from hospitals in each of the provinces of Sierra Leone. The workshops included synchronous tele-education-directed medical simulation didactic sessions about COVID-19, hypoxemia management, and hands-on simulation training about mechanical ventilation. Measures included pre and postworkshop knowledge tests, simulation checklists, and a posttest survey. Test results were analyzed with a paired sample t test; Likert-scale survey responses were reported using descriptive statistics; and open-ended responses were analyzed using thematic analysis.

Results

Seventy-five participants enrolled in the program. On average, participants showed 20.8% improvement (a score difference of 4.00 out of a maximum total score of 20) in scores between pre and postworkshop knowledge tests (P = 0.004). Participants reported satisfaction with training (96%; n = 73), achieved 100% of simulation checklist objectives, and increased confidence with ventilator skills (96%; n = 73). Themes from the participants' feedback included increased readiness to train colleagues on critical care ventilators at their hospitals, the need for longer and more frequent training, and a need to have access to critical care ventilators at their hospitals.

Conclusion

This synchronous tele-education-directed medical simulation workshop implemented through partnerships between U.S. physicians and Sierra Leone healthcare providers was a feasible, acceptable, and effective means of providing training about COVID-19, hypoxemia management, and mechanical ventilation. Future ICU ventilator training opportunities may consider increasing the length of training beyond 2 days to allow more time for the hands-on simulation scenarios using the ICU ventilator and assessing knowledge application in long-term follow-up.

Telesimulation for the Training of Medical Students in Neonatal Resuscitation

Background: Telesimulation may be an alternative to face-to-face simulation-based training. Therefore, we investigated the effect of a single telesimulation training in inexperienced providers. Methods: First-year medical students were recruited for this prospective observational study. Participants received a low-fidelity mannequin and medical equipment for training purposes. The one-hour telesimulation session was delivered by an experienced trainer and broadcast via a video conference tool, covering all elements of the neonatal resuscitation algorithm. After the telesimulation training, each student underwent a standardized simulated scenario at our Clinical Skills Center. Performance was video-recorded and evaluated by a single neonatologist, using a composite score (maximum: 10 points). Pre- and post-training knowledge was assessed using a 20-question questionnaire. Results: Seven telesimulation sessions were held, with a total of 25 students participating. The median performance score was 6 (5-8). The median time until the first effective ventilation breath was 30.0 s (24.5-41.0) and the median number of effective ventilation breaths out of the first five ventilation attempts was 5 (4-5). Neonatal resuscitation knowledge scores increased significantly. Conclusions: Following a one-hour telesimulation session, students were able to perform most of the initial steps of the neonatal resuscitation algorithm effectively while demonstrating notable mask ventilation skills.

Effectiveness of an online program using telesimulation for academic-clinical collaboration in preparing nurse preceptors' roles

AIM

To evaluate the effectiveness of an online program on nurse preceptors' knowledge and self-efficacy in their roles to support students' clinical education, and to examine their online experience.

BACKGROUND

Professional development of nurse preceptors is paramount to fostering work readiness of future graduate nurses on entering the workforce. The support from academic institutions in developing preceptors' roles in clinical teaching and assessment is pivotal.

DESIGN

This study employed a mixed-methods design.

METHOD

A total of 59 nurse preceptors from six healthcare institutions participated in an online preceptor program by collaborating with academic educators in facilitating student clinical learning and assessment through telesimulation following web-based instruction. Pre-test and post-tests were administered to evaluate the preceptors' knowledge and self-efficacy in their roles. Survey questionnaires and focus group discussions were conducted to evaluate their online experience. SQUIRE 2.0 guidelines were applied.

RESULTS

The preceptors demonstrated significant improvements (p < .001) in knowledge and levels of self-efficacy in their preceptor roles immediately and 1 month after the program. The following four themes emerged from their learning experiences: 'interactive learning approach', 'academic-practice collaboration', 'better understanding of clinical assessment tool' and 'application of teaching strategies'. The preceptors reported positively on their motivation to learn using the web-based instruction and on their telesimulation experience.

CONCLUSION

The study findings demonstrated effectiveness and feasibility of an online preceptor program to enhance preceptors' roles in supporting nursing students' transition to clinical practice, using a mix of web-based technologies to provide preceptors with self-directed and experiential learning approaches.

RELEVANCE TO CLINICAL PRACTICE

This study contributed to the development of an innovative online preceptor program that provided opportunity for academic-clinical collaboration and has broad applicability. The telesimulation created robust remote simulation experiences for preceptors, allowing them to collaborate with academic educators in facilitating students' clinical practice amid the COVID-19 pandemic.

Evaluating Emotional Outcomes of Medical Students in Pediatric Emergency Medicine Telesimulation

The coronavirus disease 2019 (COVID-19) pandemic has challenged the feasibility of traditional in-person simulation-based clinical training due to the public health recommendation on social distancing. During the pandemic, telesimulation training was implemented to avoid multiple students and faculties gathering in confined spaces. While medical trainees' perceived emotions have been acknowledged as a critical outcome of the in-person simulation-based training, the impact of telesimulation on trainees' emotions has been unexamined. We conducted an educational team-based simulation study with a pediatric case of septic shock. Seventeen and twenty-four medical students participated in the telesimulation training and in-person simulation training, respectively. The institutional pandemic social restrictions at the time of each training session determined the participant assignment to either the telesimulation training or in-person simulation training. All participants responded to the Japanese version of the Medical Emotion Scale, which includes 20 items rated on a five-point Likert-type scale before, during, and after the simulation sessions. The measured emotions were categized into four emotion groups according to two dimensions: positive or negative and activating or deactivating emotions. The one-way analysis of variance between the telesimulation and in-person simulation training revealed no significant differences in the emotions perceived by the participants before, during, and after the simulation training sessions. The perceived emotions of medical students were comparable between the telesimulation and in-person simulation training. Further longitudinal studies with larger samples and multiple variables are needed to generalize the effectiveness of telesimulation.

Medical Student Experiential Learning in Telesimulation

OBJECTIVES

Telesimulation utilizes telecommunication technology to engage learners in simulation while in different physical locations. Despite this potential advantage, understanding of the student experience and assessment of student learning in telesimulation activities is limited. This study evaluates medical student emotional experience and self-identified learning in telesimulation through the Kolb experiential learning framework and qualitative analysis.

METHODS

Fourth-year medical students enrolled in the Spencer Fox Eccles School of Medicine at the University of Utah participated in 3 telesimulation activities as part of a required internal medicine course. Students were surveyed regarding their satisfaction with the activity (N = 114) and responded to questions about their emotional experience and self-identified areas of learning. Free-text responses were analyzed using qualitative content analysis to identify themes until thematic saturation (N = 66).

RESULTS

Students were highly satisfied with telesimulation, with greater than 90% of students expressing a positive view of simulation realism, debrief quality, and group size. Themes of anxiety and uncertainty, confidence versus incompetence, team dynamics, fun, and difficult patient interaction were identified regarding the emotional experience. Themes of communication and teamwork, managing emotions, information gathering, differential diagnosis, resource reference, executing treatment, and medical knowledge were identified regarding student-identified learning.

CONCLUSION

In this analysis of medical student experiences with telesimulation, we found students have rich emotional, cognitive, and behavioral experiences and self-identify learning across a variety of domains. Our findings support further study of telesimulation for medical student learning and demonstrate how assessment of outcomes via Kolb framework, using the learner's reflective observation and self-identified learning, may help better define learning outcomes from simulation.

Development of Team Behavior Skills and Clinical Lactation Competence Among Medical Students Engaging in Telesimulations with Standardized Patients

Objective: The aims of this pilot feasibility study were to determine if telesimulations with standardized patients (SPs) wearing high-fidelity breast models impact students' team behavior and clinical competence in lactation support. Materials and Methods: Medical students (N = 19) completed five telesimulations: Cases 1, 2, 5 in a team, 3 as individual, and 4 randomized. SPs used the Formative Assessment Rubric (FAR) to evaluate interpersonal and clinical competence. Collaboration skills within team-based telesimulations (Cases 2 and 4) were rated using the Interprofessional Collaborator Assessment Rubric (ICAR). Satisfaction data were collected from a focus group and written evaluation. Descriptive statistics were calculated for FAR, ICAR, and written evaluations. Appropriate nonparametric tests were used to measure FAR and ICAR differences over time or between team and individual telesimulations and the relationship between FAR and ICAR scores. Content analysis was used to generate themes from focus group data. Results: Learners' interpersonal and lactation-specific competence improved over time (p = 0.003 and 0.009, respectively). Learners were able "to accept responsibility for their actions" more but spent less time "seeking perspectives from peers" in Case 4 compared with Case 2 (p = 0.01 and p < 0.001, respectively). Themes from the focus group related to the value of team telesimulations to learn clinical lactation skills and learn about one's role in a team. Learners agreed they developed clinical lactation skills (>4.5/5-pt). Conclusions: Opportunities to work collaboratively in telesimulations with a SP prepare learners for professional collaborations to effectively care for breast/chestfeeding dyads.

ECMO simulation training during a worldwide pandemic: The role of ECMO telesimulation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a supportive therapy used in the most severe forms of acute respiratory distress syndrome. Due to its intrinsic complexity and relatively low annual volume, simulation is essential for efficient and appropriate ECMO management. COVID-19 has limited the opportunities for high-fidelity in-person simulation training when many hospitals are looking to expand their ECMO services to battle the ongoing pandemic. To meet this demand, the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia, conducted a 3-day ECMO course entailing online didactic lectures (adult and paediatric stream), water drills and telesimulation.

PURPOSE

The purpose of the study is to report the evaluation result of this novel model of education during COVID-19 outbreak.

DATA COLLECTION

Participants were given an ECMO knowledge pre-course and post-course test and a telesimulation evaluation survey at the conclusion and these data were collected.

RESULTS

The course was attended by 104 physicians, critical care nurses and perfusionists. Pre-course and post-course assessments showed a significant improvement in ECMO knowledge (60.0% vs 73.3%, respectively). Overall, the participants rated the telesimulation positively, and most found it acceptable to in-person simulation training considering the pandemic restrictions.

CONCLUSION

Despite the complexities of ECMO, our recent experience demonstrates ECMO education and simulation delivered online is feasible, welcomed and supportive of a change in ECMO training course format. As we incorporate more innovative digital technologies, telesimulation may further enhance the quality of future ECMO training.

Application of telesimulation in a medical undergraduate course during the SARS-CoV-2 pandemic: a quantitative and retrospective study

BACKGROUND

Because of the social isolation and distancing measures that were imposed to stop the spread of coronavirus disease 19 (COVID-19), new ways of teaching were implemented.

OBJECTIVES

To describe the implementation of telesimulation and seek to assess students' perceptions regarding telesimulation.

DESIGN AND SETTING

Retrospective quantitative study conducted within the hospital simulation at a private medical school in São Paulo, Brazil.

METHODS

After telesimulation training, students answered a questionnaire that provided an overall assessment of this activity, self-assessment and assessments of the facilitators and infrastructure provided by the University.

RESULTS

Among the students, 50% reported that the activity was below expectations and 45% reported that it was in line with their expectations. The strong points of the activity were the clinical cases, workload and teachers. The main challenge was students' difficulty in reflecting on their learning and the infrastructure.

CONCLUSIONS

Since students have less experience and fewer clinical encounters than residents or professionals, they also face more difficulty. Although telesimulation may have provided a valid alternative to replace simulation training during the COVID-19 pandemic, more face-to-face activities should be offered to students, when possible.

The Effect of a Sepsis Interprofessional Education Using Virtual Patient Telesimulation on Sepsis Team Care in Clinical Practice: Mixed Methods Study

BACKGROUND

Improving interprofessional communication and collaboration is necessary to facilitate the early identification and treatment of patients with sepsis. Preparing undergraduate medical and nursing students for the knowledge and skills required to assess, escalate, and manage patients with sepsis is crucial for their entry into clinical practice. However, the COVID-19 pandemic and social distancing measures have created the need for interactive distance learning to support collaborative learning.

OBJECTIVE

This study aimed to evaluate the effect of sepsis interprofessional education on medical and nursing students' sepsis knowledge, team communication skills, and skill use in clinical practice.

METHODS

A mixed methods design using a 1-group pretest-posttest design and focus group discussions was used. This study involved 415 undergraduate medical and nursing students from a university in Singapore. After a baseline evaluation of the participants' sepsis knowledge and team communication skills, they underwent didactic e-learning followed by virtual telesimulation on early recognition and management of sepsis and team communication strategies. The participants' sepsis knowledge and team communication skills were evaluated immediately and 2 months after the telesimulation. In total, 4 focus group discussions were conducted using a purposive sample of 18 medical and nursing students to explore their transfer of learning to clinical practice.

RESULTS

Compared with the baseline scores, both the medical and nursing students demonstrated a significant improvement in sepsis knowledge (P<.001) and team communication skills (P<.001) in immediate posttest scores. At the 2-month follow-up, the nursing students continued to have statistically significantly higher sepsis knowledge (P<.001) and communication scores (P<.001) than the pretest scores, whereas the medical students had no significant changes in test scores between the 2-month follow-up and pretest time points (P=.99). A total of three themes emerged from the qualitative findings: greater understanding of each other's roles, application of mental models in clinical practice, and theory-practice gaps. The sepsis interprofessional education-particularly the use of virtual telesimulation-fostered participants' understanding and appreciation of each other's interprofessional roles when caring for patients with sepsis. Despite noting some incongruities with the real-world clinical practice and not encountering many sepsis scenarios in clinical settings, participants shared the application of mental models using interprofessional communication strategies and the patient assessment framework in their daily clinical practice.

CONCLUSIONS

Although the study did not show long-term knowledge retention, the use of virtual telesimulation played a critical role in facilitating the application of mental models for learning transfer and therefore could serve as a promising education modality for sepsis training. For a greater clinical effect, future studies could complement virtual telesimulation with a mannequin-based simulation and provide more evidence on the long-term retention of sepsis knowledge and clinical skills performance.

Low-Cost "Telesimulation" Training Improves Real Patient Pediatric Shock Outcomes in India

INTRODUCTION

Pediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings.

MATERIALS AND METHODS

We conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom©). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room.

RESULTS

There was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; p < 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), p < 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (p < 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (p < 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (p < 0.001) and real patient care in post intervention (p < 0.05).

CONCLUSION

Telesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.

Telesimulation as a modality for neonatal resuscitation training

Introduction: Telesimulation may allow simulationists to continue with essential simulation-based training programs during the COVID-19 pandemic. Hence, we investigated the feasibility of telesimulation for neonatal resuscitation training, assessed participants' attitudes towards telesimulation as well as its effect on neonatal resuscitation knowledge, and compared results between medical students and neonatal nurses. Methods: For this prospective observational pilot study, medical students and neonatal nursing staff were recruited on a voluntary basis. Pre- and post-training knowledge was assessed using a 20-question questionnaire. Following the educational intervention, participants further answered a six-item questionnaire on their perception of telesimulation. For the telesimulation session, participants received a simulation package including a low-fidelity mannequin and medical equipment. The one-hour telesimulation session was delivered by an experienced instructor and broadcasted via Cisco Webex for groups of 2-3 participants, covering all elements of the neonatal resuscitation algorithm and including deliberate technical skills practice. Results: Nine medical students and nine neonatal nurses participated in a total of seven telesimulation sessions. In general, participants enjoyed the telesimulation session, acknowledged a positive learning effect and found telesimulation suitable for neonatal resuscitation training, but were critical of potential technical issues, training logistics, and the quality of supervision and feedback. Neonatal resuscitation knowledge scores increased significantly after the educational intervention both for medical students and nurses. Conclusions: Telesimulation is feasible for neonatal resuscitation training and associated with significant improvements in knowledge of current resuscitation guidelines, without differences between medical students and neonatal nurses.

Acceptability, technological feasibility and educational value of remotely facilitated simulation based training: A scoping review

Although remote teaching and learning is not new to medical education, the Covid-19 pandemic has heightened its importance as a mode of education delivery. This scoping review aims to provide a narrative/iterative summary of the current literature in assessing the acceptability, educational value and technological feasibility of remotely facilitated (RF) simulation-based training (SBT) - 'telesimulation', for medical students and facilitators. The review was conducted using the method described by Arksey and O'Malley. A systematic process was followed to search multiple electronic databases supplemented with a general internet search to identify any relevant grey literature. The search strategy was developed in collaboration with medical students and educators familiar with SBT. Nine articles were identified as fitting the review inclusion criteria. The results indicated that RF SBT was positively viewed by participants but may not be viewed as equivalent to locally facilitated SBT. Participants of RF SBT felt confident to deal with common acute scenarios, believed it could expand their knowledge and skills and in turn would improve patient care in the clinical setting. Facilitators found RF SBT to be technologically feasible, promoting the acquisition of desired learning outcomes. Future research should assess the reaction to, and learning acquired during RF SBT, particularly, the perception and attitudes of facilitators. A clear research gap was identified in literature assessing the role of RF SBT in behavioural change and improved clinical care outcomes. Addresing these gaps will clarify the role of RF SBT in medical education.

Telesimulation Innovation on the Teaching of SPIKES Model on Sharing Bad News

Coronavirus disease 2019 (COVID-19) brought to the world, an unprecedented emergency, which dramatically affected the face-to-face teaching in higher education academia. University faculty and students had to shift overnight to an online and remote course instruction. They were neither trained nor prepared and had limited resources and infrastructure. Palliative Care and Oncology Stream Faculty at Aga Khan University, School of Nursing and Midwifery, Pakistan, piloted an innovative academic project using telesimulation (TS). Trainee nurse interns were taught communication skills and the art of breaking bad news to palliative clients using the SPIKES model through TS. To incorporate best practices for simulation-based experiences, we used the International Nursing Association for Clinical Simulation and Learning to standardize and implement TS with 141 interns. This review article documents how the faculty planned and implemented the TS strategy during COVID-19. It outlines the challenges and the lessons learnt from implementation and feedback from faculty and students. This information could be useful in the future execution of TS, in any communication and counseling course, since COVID-19 has impacted the future educational course design and pedagogy worldwide.

Implementation Barriers in Telesimulation as an Educational Strategy: An Interpretative Description

Introduction Telesimulation is one of the different methodologies for distance learning to promote competency in medical trainees. This methodology needs to have professors, students, and standardized patients in one session to perform a teleconsultation. Telesimulation could lead to multiple implementation barriers. This study aims to describe the implementation barriers through the perspective of the professors, students, and standardized patients in a telesimulation scenario in undergraduate medical education. Method We designed and applied a telesimulation scenario in undergraduate medical students. Then we conducted an online questionnaire with the critical incidents technique. The study sample was 18 professors, 26 standardized patients, and 407 students Results We describe a taxonomy with five categories and each one with different subcategories: knowledge (clinical simulation, theoretical over the clinical case, and use of simulators), facilities (access, time of use, and functionality), financing (payment to staff and purchase of equipment), attitude (acceptance and emotion), and participants (communication, collaborative work, and debriefing). Conclusion The description of the implementation barriers through multiple perspectives generates a taxonomy that could improve the quality of the telesimulation. This taxonomy is a proposal to consider the design, implementation, and evaluation when a telesimulation is implemented. The taxonomy could generate a structured plan when the educators implement the telesimulations at their own institutions considering all the barriers proposed.

Use of Virtually Facilitated Simulation to Improve COVID-19 Preparedness in Rural and Remote Canada

Background

The Alberta Health Services' Provincial Simulation Program (eSIM) is Canada's largest simulation program. The eSIM mobile simulation program specializes in delivering simulation-based education (SBE) to rural and remote communities (RRC). During the COVID-19 pandemic, a quality improvement project involving rapid cycle in situ virtually facilitated simulation (VFS) for COVID-19 airway management and health systems preparedness in RRC was successfully implemented.

Methods

Between April 24 and July 31, 2020, a team of six rural simulationists (four nurses and two physicians) provided 24 VFS sessions with virtual debriefing to 200 health care providers distributed across 11 RRC in Alberta and the Northwest Territories, covering a geographic area of approximately 169,028 km².

Results

Video analysis of sequential VFS rapid cycle sessions using a standardized observational tool indicated decreased personal protective equipment (PPE) breaches by 36.6% between the first and third cycles. Teams demonstrated increased competency with airway management such as correct use of bag-valve-mask ventilation, and implementation of health system process improvements, such as incorporation of an intubation checklist. Improvements occurred on average over 2.2 rapid cycles completed within 1.3 weeks per RRC. Postsession self-reported participant electronic surveys indicated self-reported improvement in clinical management, teamwork behavior, and health systems issues outcome measures which were categorized based on the Crisis Resource Management and Systems Engineering Initiative for Patient Safety (SEIPS) frameworks. Of the 48 survey respondents, 86.1% reported that VFS was equivalent or superior to in-person simulation. The cost of VFS was 62.9% lower than comparable in-person SBE.

Conclusion

VFS provides a rapidly mobilizable and cost-effective way of delivering high-quality SBE to geographically isolated communities.

Telesimulation for remote simulation and assessment

Telesimulation (TS), the process of using the internet to link educators and trainees at locations remote from one another, harnesses the powers of technology to enable access to high-quality simulation-based education and assessment to learners across the globe. From its first uses in the teaching and assessment of laparoscopic skills to more recent interpretations during the current pandemic, TS has shown promise in helping educators to address pressing dilemmas in medical education.

Adaptive change in simulation education: Comparison of effectiveness of a communication skill curriculum on death notification using in person methods versus a digital communication platform

Background

Mandates to social distance and "shelter in place" during the COVID-19 pandemic necessitated the exploration of new academic content delivery methods. Digital communication platforms (DCP; e.g., Zoom) were widely used to facilitate content delivery, yet little is known about DCP's capacity or effectiveness, especially for simulation.

Objective

The objective was to compare the experience, outcomes, and resources required to implement a simulation-based communication skill curriculum on death notification to a cohort of learners using in-person versus DCP delivery of the same content.

Methods

We used the GRIEV_ING mnemonic to train students in death notification techniques either in person or utilizing a DCP. For all learners, three measures were collected: knowledge, confidence, and performance. Individual learners completed knowledge and confidence assessments pre- and postintervention. All performance assessments were completed by standardized patients (SPs) in real time. Wilcoxon rank-sum test was used to identify differences in individual and between-group performances.

Results

Thirty-four learners participated (N = 34), 22 in person and 12 via DCP. There was a statistically significant improvement in both groups for all three measures: knowledge, confidence, and performance. Between-group comparisons revealed a difference in pretest confidence but no differences between groups in knowledge or performance. More preparation and prior planning were required to set up the DCP environment than the in-person event.

Conclusions

The in-person and DCP delivery of death notification training were comparable in their ability to improve individual knowledge, confidence, and performance. Additional preparation time, training, and practice with DCPs may be required for SPs, faculty, and learners less familiar with this technology.

Resident Preparation for the American Board of Anesthesiology Objective Standardized Clinical Examination: A Comparison of Virtual Telesimulation With In-person Simulation

BACKGROUND

The Objective Structured Clinical Examination (OSCE) is part of the American Board of Anesthesiology (ABA) certification process. A simulated OSCE can aid examination preparation, but the COVID-19 pandemic prevented in-person simulation training. Therefore, we adapted our in-person simulated OSCE (SOSCE) as a Zoom-based telesimulation OSCE (ZOSCE), permitting examinees to participate remotely. Comparing this process with historical in-person SOSCE cohorts, we hypothesized that this telesimulation-based format would still be well received by the trainees as a substitute when it was not possible to provide in-person practice and formative assessment. Subsequently, the ABA proposed a virtual-format OSCE.

METHODS

We conducted our 7-station ZOSCE according to the ABA content outline for all graduating third-year clinical anesthesia residents (CA-3) in 2020. From a main meeting room, the facilitator paired each CA-3 with a faculty proctor, assigned them to their own breakout room for each station, and rotated standardized patients in. The faculty proctor observed the CA-3's performance in real time using an assessment tool with objectives graded on a 0-2 scale. At the conclusion of the ZOSCE, proctors reviewed the assessment tool with the CA-3 and provided personalized global feedback. Assessment tool scores were used to calculate performance data for the study group that were compared with a SOSCE historical cohort from 2017 and 2018. All parties completed a Likert-style evaluation specific to the ZOSCE.

RESULTS

A total of 22 CA-3 residents participated. Mean performance scores ranged from 82.2%-94.9% (minimum = 38%, maximum = 100%). Compared with the historical SOSCE cohort, ZOSCE scores for 5 of 7 stations were not different, but scores in communication with professionals (P = .007) and ultrasound (P < .001) stations were lower. Overall, CA-3 participants rated the learning experience positively and felt it was a reasonable substitution for in-person simulation, with responses similar to those of a historical in-person SOSCE cohort.

CONCLUSIONS

A telesimulation-based practice ZOSCE for formative examination preparation for the ABA OSCE resulted in similar institutional scoring for most stations compared with in-person SOSCE, but some stations may be better practiced in person or require modifications. The virtual format may permit flexible scheduling during nonclinical times or for learners in remote locations. These findings have implications for future formative exercises and the formal summative examination process.

How to Use TeleSimBox "Off the Shelf" to Connect Remote Content Experts With In-Person Simulation Participants

In this technical report, we describe how to use TeleSimBox to run a remotely facilitated simulation to connect the facilitator with learners at a distant site. This method was developed to comply with safety measures imposed during the coronavirus disease-19 (COVID-19) pandemic to reduce the risk of viral exposure and transmission. Here, we present one example where a telesimulation naïve facilitator was trained as an in-person facilitator to enable the in-situ medical student and resident learners to participate in a pediatric emergency simulation exercise remotely guided by an off-site content expert. The case of neonatal shock was run five times during a half-day emergency department (ED) educational program with one to four participants per session. 14/15 (93%) participants completed evaluations and felt that the simulation met the case learning objectives and that connecting with the remote facilitator was useful for their learning. Feedback from the one newly trained in-person facilitator was that the tool was easy to learn how to use quickly, and the process of connecting with a remote expert was worthwhile for learners. To grab this web-based toolkit off the proverbial shelf and successfully run a telesimulation session from start to finish took approximately one hour; 20 minutes were spent in preparation the day prior and 40 minutes to set up and run the simulations the day of. We believe that this is a low-cost, efficient, and perceived to be an effective method to connect remotely located content experts and learners to engage in a simulation-based education activity when access to in-person resources and personnel is limited.

Leveraging Videoconferencing Technology to Augment Surgical Training During a Pandemic

Our objective was to review the use of videoconferencing as a practical tool for remote surgical education and to propose a model to overcome the impact of a pandemic on resident training.

Summary Background Data

In response to the coronavirus disease 2019 pandemic, most institutions and residency programs have been restructured to minimize the number of residents in the hospital as well as their interactions with patients and to promote physical distancing measures. This has resulted in decreased resident operative exposure, responsibility, and autonomy, hindering their educational goals and ability to achieve surgical expertise necessary for independent practice.

Methods

We conducted a narrative review to explore the use of videoconferencing for remote broadcasting of surgical procedures, telecoaching using surgical videos, telesimulation for surgical skills training, and establishing a didactic lecture series.

Results and Conclusions

We present a multimodal approach for using practical videoconferencing tools that provide the means for audiovisual communication to help augment residents' operative experience and limit the impact of self-isolation, redeployment, and limited operative exposure on surgical training.

Telesimulation-based education during COVID-19

Simulation is a valuable, immersive educational tool for both health professional trainees and experienced clinicians. By promoting a realistic, collaborative, safe, hands-on, learning environment, simulation allows interprofessional teams to come together and practise both routine and high stakes, low-frequency events. The COVID-19 pandemic and the need for social distancing have shifted traditional simulation-based medical education towards a virtual platform: telesimulation. Telesimulation is an evolving field and the speed at which clinical educators need to adapt to use this platform is unprecedented. Educators must quickly navigate and leverage the differences between traditional simulation and telesimulation to create robust remote educational experiences. Telesimulation has unique goals and objectives, technology needs, and participant roles that need to be understood and properly operationalized to maximize opportunities for learning. This article reviews the authors' recommendations for developing and delivering successful telesimulations.

TeleSimBox: A perceived effective alternative for experiential learning for medical student education with social distancing requirements

INTRODUCTION

During the COVID-19 pandemic the Association of American Medical Colleges recommended that medical students not be involved with in-person patient care or teaching, necessitating alternative learning opportunities. Subsequently we developed the telesimulation education platform: TeleSimBox. We hypothesized that this remote simulation platform would be feasible and acceptable for faculty use and a perceived effective method for medical student education.

METHODS

Twenty-one telesimulations were conducted with students and educators at four U.S. medical schools. Sessions were run by cofacilitator dyads with four to 10 clerkship-level students per session. Facilitators were provided training materials. User-perceived effectiveness and acceptability were evaluated via descriptive analysis of survey responses to the Modified Simulation Effectiveness Tool (SET-M), Net Promoter Score (NPS), and Likert-scale questions.

RESULTS

Approximately one-quarter of students and all facilitators completed surveys. Users perceived that the sessions were effective in teaching medical knowledge and teamwork, though less effective for family communication and skills. Users perceived that the telesimulations were comparable to other distance learning and to in-person simulation. The tool was overall positively promoted.

CONCLUSION

Users overall positively scored our medical student telesimulation tool on the SET-M objectives and promoted the experience to colleagues on the NPS. The next steps are to further optimize the tool.

The Efficacy of Hybrid Telesimulation with Standardized Patients in Teaching Medical Students Clinical Lactation Skills: A Pilot Study

Introduction: Medical students lack competencies in clinical lactation. We determined the effect of hybrid telesimulation with a standardized patient (SP) on medical students' clinical performance in lactation support. We assessed students' engagement and satisfaction with the experience. Materials and Methods: Undergraduate medical students (n = 13) completed (1) preparatory case scenarios with multiple-choice questions and (2) three telesimulations with SPs wearing a high-fidelity breast model. Students had the option to complete the Encounter Documentation. SPs used the Formative Assessment Rubric (FAR) to evaluate students' interpersonal skills and clinical lactation experts used the Summative Assessment Rubric to evaluate documentation skills. Investigators collected satisfaction data from a focus group and written evaluation. Dunn's multiple comparison and Freidman tests were used to measure differences in FAR scores between cases and telesimulations. Qualitative data were analyzed using thematic analysis. Results: Most students (70%) attempted case questions multiple times and scores improved (p < 0.0001) between attempts. FAR scores suggest students were prepared for telesimulations (5.5/6-pt Likert) and interpersonal skills were appropriate (5.4/6), with no differences by case (p = 0.11). FAR scores increased between telesimulation 1-2 (+24.5/114, p = 0.002) and 2-3 (+17.5/114, p = 0.014). Students were satisfied with the experience and would recommend it to classmates (both 4.6/6). Thematic analysis revealed feedback regarding interpersonal skills was helpful. Conclusions: Medical students must develop skills to support breastfeeding in virtual settings. Telesimulation can be incorporated into existing curricula to support clinical lactation competencies.

A Telesimulation Elective to Provide Medical Students With Pediatric Patient Care Experiences During the COVID Pandemic

OBJECTIVES/INTRODUCTION

The Association of American Medical Colleges suggested that medical students not be involved in direct patient care activities in the United States because of the COVID pandemic. Our objectives are to (1) describe the rapid creation and implementation of a fully online simulation-based pediatric emergency medicine training intervention for medical student learners using existing simulation center staff (faculty, technicians, actors) and resources (simulation technology, scenario files) and (2) report student and faculty feedback on the intervention.

METHODS

The sessions involved the use of our existing simulation center faculty, staff, and resources. Feedbacks on the sessions were collected via a survey from faculty and students at the end of each session.

RESULTS

Sixteen simulation sessions were conducted (8 febrile infant, 8 anaphylactic toddler). Forty-eight students, 2 technicians, 2 actors, and 10 faculty participated. Ninety percent of the students agreed with the statements, "I am more comfortable with pediatrics after this session," "participating improved my pediatric knowledge/skills," "this session was more useful than other learning activities I am involved in at this time." Seventy percent of the students agreed with the statement, "I learned as much from observing as when I was actively involved." All faculty agreed with the statement, "this was an effective educational strategy compared to other distance learning." Most faculty (60%) disagreed with the statement, "virtual simulation was equal to or superior to in-person simulation." All students and faculty strongly agreed with the statement, "I would highly recommend this to others."

CONCLUSIONS

A telesimulation intervention involving all medical students, staff, and facilitators interacting remotely for pediatric emergency training during COVID was associated with high levels of satisfaction by the majority of learners and faculty.

Tips for Conducting Telesimulation-Based Medical Education

Telesimulation utilizes communications technology, such as video conferencing platforms, to provide simulation-based medical education when participants and facilitators are geographically separated. Learners interact with each other, embedded participants, and a simulated patient and/or vital sign display on the computer screen. Facilitators observe the learners in real-time and provide immediate feedback during a remote debrief. Telesimulation obviates the need to have instructors, learners, and high fidelity patient simulators (HPS) in the same place, allowing simulation-based educational sessions to occur in institutions located remotely from simulation centers or when other barriers limit in-person education and/or training. For example, due to the novel coronavirus (COVID-19) pandemic, many medical education programs temporarily discontinued in-person simulations to adhere to physical distancing guidelines. The authors have reflected upon their experiences executing telesimulation sessions since the start of the pandemic and provide these 12 tips as practical suggestions on how to successfully implement telesimulations with medical trainees. These tips are intended to guide implementation and facilitation by staff and faculty trained in simulation.

A Randomized Study Using Telepresence Robots for Behavioral Health in Interprofessional Practice and Education

Background: The events of the coronavirus disease 2019 (COVID-19) pandemic forced the world to adopt telemedicine frameworks to comply with isolation and stay-at-home regulations. Telemedicine, in various forms, has been used by patients and medical professionals for quite some time, especially telepsychiatry. To examine the efficacy and role of telesimulation as a method to educate health sciences students via telepresence robots. The study recruited students from the above health science disciplines. All participants were trained to administer a contextual interview to a standardized patient (SP) for mental health concerns. Methods: The completion of the contextual interview observation form adult (CIOF-A), National Aeronautics and Space Administration Task Load Index, self-efficacy in patient centeredness questionnaire (SEPCQ), and communication skills attitude scale with or without a telepresence robot. All participants completed baseline metrics and were trained to conduct a contextual interview to an SP. Researchers block-randomized the participants to either the telepresence robot group (TP) or in-person (IP) group. Results: The study recruited n = 43 participants to the IP group (n = 21) or TP group (n = 22). Mean participant demographics of age were 25.3 (±1.9) years in the IP group and 24.3 (±2.1) years for the TP group. Mean and standard deviation scores with effect sizes in CIOF-A scores IP: 0.05 (±1.91) and TP: -0.45 (±1.71), Cohen's d = 0.28; SEPCQ-Patient Domain scores IP: 0.42 (±4.69) and TP: 0.50 (±7.18), Cohen's d = 0.01; change in SEPCQ-Sharing Domain scores IP: 0.53 (±5.10) and TP: 0.91 (±9.98), Cohen's d = 0.05. These effect sizes will inform future studies and appropriate sample sizes. Conclusion: These data indicate that health sciences students utilizing a telepresence robot in an SP scenario to perform a behavioral health screening felt as comfortable and competent as those health sciences students performing the same behavioral health screening in person. ClinicalTrials.gov Identifier: NCT03661372.

Telesimulation-based education during COVID-19

Simulation is a valuable, immersive educational tool for both health professional trainees and experienced clinicians. By promoting a realistic, collaborative, safe, hands‐on, learning environment, simulation allows interprofessional teams to come together and practise both routine and high stakes, low‐frequency events. The COVID‐19 pandemic and the need for social distancing have shifted traditional simulation‐based medical education towards a virtual platform: telesimulation. Telesimulation is an evolving field and the speed at which clinical educators need to adapt to use this platform is unprecedented. Educators must quickly navigate and leverage the differences between traditional simulation and telesimulation to create robust remote educational experiences. Telesimulation has unique goals and objectives, technology needs, and participant roles that need to be understood and properly operationalized to maximize opportunities for learning. This article reviews the authors’ recommendations for developing and delivering successful telesimulations.

Use of Telemedicine to Improve Neonatal Resuscitation

Most newborn infants do well at birth; however, some require immediate attention by a team with advanced resuscitation skills. Providers at rural or community hospitals do not have as much opportunity for practice of their resuscitation skills as providers at larger centers and are, therefore, often unable to provide the high level of care needed in an emergency. Education through telemedicine can bring additional training opportunities to these rural sites in a low-resource model in order to better prepare them for advanced neonatal resuscitation. Telemedicine also offers the opportunity to immediately bring a more experienced team to newborns to provide support or even lead the resuscitation. Telemedicine can also be used to train and assist in the performance of emergent procedures occasionally required during a neonatal resuscitation including airway management, needle thoracentesis, and umbilical line placement. Telemedicine can provide unique opportunities to significantly increase the quality of neonatal resuscitation and stabilization in rural or community hospitals.