OXFORDMEDICALSIMULATION:2021 Simulation Survey

Healthcare simulation is used across all areas of health professional education. During the COVID-19 pandemic, simulation played a vital role in training new staff, reinforcing new processes, and providing opportunities to practice new techniques.

To shine a light on the dynamic simulation landscape, Oxford Medical Simulation (OMS) conducted a simulation community survey. This survey sought to discover the degree to which new methods were implemented and what educators learned in the process. Survey respondents indicated significant changes in their approach to simulation, and this report aims to share these learnings with the global simulation community as the healthcare education landscape continues to evolve.

2021 OMS SIM SURVEY

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THE CHANGING LANDSCAPE OF SIMULATION

Over time, the methods we use to deliver simulation and our ways of thinking about healthcare simulation have evolved. Previously described in terms of device (e.g. high-fidelity manikin) or place (e.g. in situ simulation), it has become increasingly apparent that it is the function that is the central component of simulation. In other words, “What impact should this simulation have?”

During the COVID-19 pandemic, educational institutions cancelled in-person classes and clinical placements. The urgency created by cancellations decreased the barriers

Simulation is an ever-increasing part of healthcare education, training, and assessment.

to adopting new approaches to simulation and allowed educators to focus on the impact they wanted to achieve. Educators no longer limited their thinking to choosing the best manikin for a given simulation; rather, the most important question became, “How do I scale my simulation delivery?”

With this impact-focused mindset, there was a case for employing new, scalable, distance simulation methodologies. Virtual and online approaches became mainstream alongside traditional physical simulation.

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THE STATE OF SIM DELIVERY IN 2020

From Laerdal & Safar’s foundational work building the earliest training manikins to the modern incorporation of virtual reality, simulation has come a long way in a brief period. Capital funds, grants, and private investment have brought dynamic new simulation centers to universities and hospitals worldwide.

Two broad categories commonly define simulation: physical simulation and virtual simulation. For our purposes, physical simulation refers to manikin-based scenarios and simulated patient (SP) scenarios, whether in an educational institution, simulation center, or in the clinical environment (in-situ).

Physical simulation is the traditional approach to experiential learning, with 91% of survey respondents utilising physical simulation.

Like physical simulation, virtual simulation provides clinically realistic scenarios through a variety of more flexible delivery models. Augmented reality (AR), screen-based simulation, and virtual reality (VR) are virtual simulation forms. Universities have been the early adopters leading the digital revolution through virtual simulation. In our survey, 82% of respondents reported AR or VR for simulation in educational institutions.

Healthcare simulation has been a continually evolving landscape fueled by innovation and collaboration.

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These various simulation delivery methods function like tools in a health educator’s tool belt, with specific methods better suited to meeting certain types of needs. Why spend the human or technological resources on a complex manikin-based scenario if your goal is to practice a specific clinical procedure? Learning outcomes should govern the choice of the simulation method. In this survey, 60% of respondents use more than one simulation method, and 72% of participants include at least one form of virtual simulation in their tool belt. This approach grants flexibility, greater specificity, and potential cost savings for institutions.

Our survey data reveals what many in simulation are already aware of: manikin-based simulation and simulated patient simulation are still the most prevalent clinical education and training modalities. However, the adoption of emerging technologies, like AR and VR, is rapidly growing. We can only expect this trend to continue as healthcare education continues to digitize.

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In our survey, 94% of respondents stopped or decreased capacity for clinical placements and, similarly, 95% of respondents experienced an impact on simulation activities.

Pre-pandemic, simulation-based education was delivered primarily via manikins, simulated patients, and task trainers. These methodologies require significant human and physical resources, including educators, technicians, debriefers, patients, and equipment. Because this type of simulation requires working in close proximity to one another, the need for social distancing caused the simulation landscape to quickly shift to include more virtual simulation.

Regardless of when or how COVID-19 closures began, the impact of classrooms, clinicals, offices and communities shutting down was severe.

THE IMPACT OF COVID-19 ON EDUCATION

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Over 80% of all institutions transitioned some or all of simulation activities to online learning; an impressive 15% of institutions made the complete transition to all digital resources. Of those who transitioned to an all-virtual or online program, 11% have not yet returned to any live simulation activities.

In addition to the pandemic’s profound impact, continued nursing shortages, educator shortages, and an evolving learning style for a new generation of learners all contributed to shifts in healthcare education.

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The trend towards virtual simulation modalities, already present before COVID-19, gave simulation experts the opportunity to reconfigure simulation delivery.

IMPLEMENTING VIRTUAL SIMULATION

Many who had long been mulling over the addition of simulation resources now had the opportunity to take action.

Many took action in a profound way — with one in three respondents transitioning 50% or more of their curriculum online.

One in three respondents transitioned 50% or more of

their curriculum online

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This period of change and opportunity did not come without challenges. As simulation instructors gathered information on resources and implemented various solutions, they naturally encountered other difficulties. Simulation was not the only resource transitioning online. Peripheral technologies, such as video conferences, learner management systems, calendar schedulers, and classroom discussion boards, also made the digital transition. Inevitably, learners encountered technical issues.

Educators have long understood that implementing any new methodology, pedagogy, or technology will bring challenges. However, IT challenges were not as frequent or impactful as anticipated. Although nearly all respondents reported some technical difficulties encountered by their learners, less than 1% reported those challenges consistently. Approximately 20% of respondents reported little to no technological challenges for learners, and a surprising 2% reported no impact from technical difficulties at all.

In light of the massive shift for learners, the issues are not as dramatic as expected. As simulationists reconsider their simulation delivery into the future, these figures should provide confidence for those looking to add new or additional next-generation teaching resources.

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SIMULATION IN 2021

What will the future hold for simulation?

On the whole, our respondents anticipate a need for more simulation resources in 2021. The struggle to find, secure, or expand on clinical sites is a current issue for many healthcare programs. Additionally, many students have also expressed a desire for the continued safety of avoiding clinical placements. Simulation helps overcome these difficulties.

Programs are also seeing an increase in applicants since the pandemic began. Medical student applications increased by 18% in 2021 compared to 2020, and nursing schools are seeing as much as a 32% increase in applicants.

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As student demand increases, faculty resources are on the decline. In addition to a nursing shortage, there is a nursing faculty shortage, primarily due to nursing faculty retiring – with 1/3 of nursing faculty in baccalaureate and graduate programs expected to retire by 2025.

These contributing factors create a perfect storm for institutions and hospital education programs, requiring them to lean heavily on simulation to support learners and program development with fewer resources.

All combined, 73% of respondents expect an increase in simulation demand. The remaining respondents expected simulation demand to remain steady.

Many institutions are choosing virtual or virtual reality simulation to support the gaps discussed above. Investment in virtual reality simulation is poised to grow significantly, with 53% of respondents identifying VR as an area of planned investment. The only resource respondents plan to invest more in is faculty development.

To support the need for increased simulation, most participants anticipate spending up to $50,000 on simulation resources in the next 12 months. 20% are spending $50,000-$100,000, and 8.5% are investing heavily in simulation with a planned budget of over $500,000.

Although we can’t definitively say how institutions will invest their budgets, over 72% of the participants stated they would be using some combination of virtual simulation combined with live simulation.

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DEVELOPING SIMULATION EXPERTISE

From instructional design to simulation integration, success is only possible thanks to the people behind the manikin (or the VR headset). Our survey highlighted some of the challenges simulation experts faced due to COVID-19. Absenteeism due to isolation, COVID capacity restrictions and achieving smaller group sizes all drove an increased need for simulation and challenged simulation teams. This impacted in situ simulations, increasing demands on faculty time. Making the shift to fully online learning pushed faculty to develop or enhance their technical skills rapidly. And of course, providing funding for simulation’s digital transformation was an ever-present topic of discussion for leadership and administrators.

Faculty is at the heart of all simulation.

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Faculty development is our respondents’ highest priority for investment in the next 12 months. 65% of respondents ranked general faculty development as the most significant investment value for their institution. With so much learning transitioning to digital resources, 61% of respondents plan to invest in technical development for faculty to support the transformation.

What is the greatest challenge your simulation

program faced as a result of COVID-19?

"We actually increased

sims...we were the clinical replacements."

-Anonymous Respondent

How would you like to see simulation develop over the

next five years?

"...Greater collaboration across many disciplines [...]

better support for developing simulation faculty..."

-Anonymous Respondent

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THE FUTURE OF SIMULATIONThis survey set out to discover how the simulation community approached the pandemic and inform ongoing choices around delivering simulation in the post-pandemic world.

What Have We Learned?

COVID-19 has had a stark, global impact on all forms of healthcare training. Across the US, Canada, UK, Europe and Asia, approximately 94% of respondents said that clinical placements were affected by the pandemic, with a similar percentage having in-person simulation canceled. Meanwhile, the demand for simulation is increasing.

These two factors — decreased physical opportunity and increasing demand for simulation — led to over 80% of respondents implementing new online or virtual simulation over the pandemic. In the coming year, this proportion remains high: 75% of all respondents will be using online or virtual simulation for some or all of the clinical training in 2021.

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Adoption and Impact

Longevity and Continued Development

In healthcare systems, the pandemic’s urgency led to the adoption of an impact-focused mindset. Educators looked first at the intended impact of simulation and then at what scenarios and interactions were required to create that impact. The “how” — whether in-situ or in center, whether manikin or virtual — became a secondary consideration.

The pandemic also led to the removal of many traditional barriers to adoption in healthcare technology. Telehealth, wearables and virtual education were widely taken up, thanks to scalability, remote delivery and reduced cost.

While the pandemic’s urgency is receding, the issues that it highlighted are becoming even more apparent. In particular, the financial and workforce pressures that remain will compel us to provide evidence of all services’ efficiency and effectiveness long into the future. Virtual technologies’ ability to deliver simulation scalably, repeatedly, and at reduced cost makes virtual simulation an attractive alternative.

However, we must also focus on integrating simulation more broadly in our institutions to realize its true potential.

Traditionally seen purely as a method of education, simulation is increasingly in use more broadly across healthcare. This is particularly true in workforce development. Simulation can be instrumental in recruiting and selecting staff, developing and assessing clinical competencies, ensuring lifelong learning, adopting new procedures, and remediation and support.

As simulation becomes instrumental in recruiting and training our expert workforce, it becomes an integral and indispensable component of the system.

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Summary

As demand for simulation increases, virtual simulation integration alongside traditional live simulation makes the best of each simulation’s strengths, and this is where the future of simulation lies.

This will allow simulation to do what it does best: support efficient and effective care, improve patient safety, and enhance the patient experience in our rapidly changing healthcare environment.

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STUDY OVERVIEW

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This was a brief, general survey and not a rigorous study. Survey respondents provided insight into questions created to gain an overview of medical simulation’s changing landscape.

The survey deliberately focused on brevity to give an overview of the space, and questions were not designed to delve into in detail. While this survey was distributed widely across the healthcare education community, note that it is likely a partly self-selecting sample of those interested in simulation.

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Survey respondents were from fourteen countries around the globe, with the majority of respondents from the United States (49%), the United Kingdom (24%), and Canada (10%). The remaining respondents were from countries in Europe (10%) and the rest of the world (7%).

Respondents self-identified professional roles, which included Educators (75.2%), Administrators (11.7%), Sim Technicians (8.3%) and C-Suite or other Executive roles (4.8%).

Respondents self-identified professional institutions as Educational Institution (66%), Hospital Organisation (11%), Simulation Centre (3.3%), or a combination of the available options (14.4%).

A total of 153 respondents completed the survey. The survey was composed of 23 questions, including four demographic questions, 13 simulation-focused multiple-choice questions, and two open-response qualitative simulation questions. The survey was open publicly to respondents from 2 January 2021- 17 February 2021.

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Over 100 institutions leveraged Oxford Medical Simulation’s (OMS) virtual simulation platform to provide learners with remote, high-fidelity simulation during COVID-19.

One such institution is Johns Hopkins University, one of the world’s top nursing programs, leading advancements in education, research, and practice.

Recently, JHU implemented OMS Virtual Reality scenarios to train both pre-licensure and advanced practice students across the nursing school. JHU’s Virtual Reality lab provides fully immersive virtual placements for multiple nursing programs, and helped JHU maintain training momentum during the COVID-19 pandemic.

"We rolled out the [OMS] virtual simulation platform over the summer, during COVID, and were able to train about 400 students in a short time frame," says Kristen Brown, advanced practice simulation coordinator at the School of Nursing.

COVID SIMULATION SUCCESS: Johns Hopkins University

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Maximizing experiential learning opportunities, JHU learners begin with the scenarios on-screen. Students who score 80% and above can visit the school’s brand-new Virtual Reality Lab, where COVID-19 safety protocols enable them to use the VR headsets for a fully immersive experience.

Following VR sessions, students gather with their instructors at a safe distance to participate in a group debrief session. Together with their instructors, students discuss the case, review their performance, ask questions, learn as a team, and become better prepared for clinical practice.

Students then repeat scenarios to help improve their performance and reduce the emotional stressors that can derail procedures. "And they don’t run the risk of hurting anyone," Brown says. "They learn critical thinking skills while being exposed to high-risk situations not seen very often. It’s great preparation."

The JHU simulation team is now expanding OMS use in their virtual simulation program, continuing to provide world-leading simulation opportunities to their students.

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Dr. Jack Pottle BSc, BMBCh, MRCP

Molly Schleicher MSN, RN, CHSE

Dr. Jack Pottle is Founder and Chief Medical Officer of Oxford Medical Simulation. In his career as a physician, clinical entrepreneur and medical simulation instructor he saw first-hand the errors made by clinicians, and the lives that are lost because of it. His passion to improve patient safety through enhanced healthcare training led to the foundation of Oxford Medical Simulation (OMS) to deliver quality healthcare training through fully-immersive virtual reality.

Molly is a Nursing Educator and Certified Healthcare Simulation Educator. As an inpatient and outpatient nurse with a love for learning, she fell into simulation education five years ago and transitioned her career to simulation education. In addition to running simulations, Molly is Harvard-trained debriefing specialist with a passion for curriculum development, implementation planning and outcomes analysis.

CONTRIBUTORS

Nathan Costiuc MSN, APRN, FNP-BC

Ryan Eling CHSOS

Nathan is a Nurse Practitioner and Simulation Educator. He began his career delivering clinical simulation to nursing students, quickly realizing the industry’s potential to impact modern training for all healthcare professionals. His passion is in using innovative methods and emerging technologies to reduce medical error, solve practical problems, and improve patient care.

Ryan is a Certified Healthcare Simulation Operations Specialist. He has been working in the world of healthcare simulation for over a decade. As a lifelong jack of all trades, he has served as technician, debriefing specialist, scenario designer, event director, and more for nonprofits and schools. VR Healthcare simulation brings together many of his passions: technology, collaboration, theater, creativity, and learning.

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