Remote-facilitated mental simulation to bridge the theory-practice divide

Simulation design theory

Simulation education allows clinical environments to be replicated so participants can learn, train, rehearse and be assessed (Khan et al, 2011). Benishek et al (2015: 3) describe the three main aspects of simulation design as ‘who will be trained, what will they learn, and how will they learn it’. Constructive alignment ensures the intervention is in line with the programme learning outcomes and learner needs (Lioce et al, 2015).

There are several published models that can guide simulation implementation and ensure all the interrelated elements of simulation design are included (e.g. Khan et al, 2011; Sprick et al, 2012; Motola et al, 2013; INACSL Standards Committee, 2021). The simulation described here uses Sprick et al's (2012) framework: preparation, briefing, simulation activity, debriefing and reflection evaluation (Figure 2).

This framework was chosen above the others because of its ease of use and simple design flow, and as both authors had used it before when designing simulations.

Below, a brief discussion of similar remote simulation studies will be given, then each design stage will be addressed in turn and contextualised with relevant learning theory. As a learning format, remote simulation is increasing in use, and it is important to consider how it differs from in-person simulation.

What is remote-facilitated mental simulation?

Remote simulation, sometimes termed telesimulation, uses internet/telecommunication technology and simulation resources to connect distant learners to educators for the purpose of training, education or assessment (McCoy et al, 2017).

Remote simulation often involves a facilitator remotely viewing participants interacting with simulated patients in geographically distant settings (Duch Christensen et al, 2018; Ikeyama et al, 2012; Reece et al, 2021).

Mental simulation is a teaching modality where participants mentally rehearse the processes involved in a care episode without concentrating on psychomotor or procedural skills, often with only non-interactive visual cues to assist (Alinier et al, 2016; Dogan et al, 2021). As mental simulation occurs within participants' mind and they are encouraged to speak their thoughts aloud, it helps participants to reflect on their thought processes and decision-making (Dogan et al, 2021). If this thinking-aloud process happens within an organised group activity, it allows peer learning, teamworking and communication skills to be developed concurrently (Alinier et al, 2021).

The RFMS encompassed aspects of both remote and mental simulation modalities. It involved a facilitator interacting on site with a SimMan 3G simulator (Laerdal Medical), with participants interacting remotely from their homes via videoconferencing technology to mentally immerse themselves in the scenario and verbalise their decision-making and thought processes at key points (these are termed ‘stop:go’ points). These mental processes were augmented with real-time information shared with the participants from the SimMan 3G simulator.

During the COVID-19 pandemic, when in-person contact time has to be minimised and there are fewer opportunities for practice-based education, remote simulation can help minimise scheduling problems, remove concerns regarding commuting and allow students who cannot travel to campus an adjunct to asynchronous learning (Lang et al, 2021). This simulation approach is not without difficulties, and care must be taken to ensure participants engage effectively and are able to achieve the learning objectives. The advantages and disadvantages of RFMS are summarised in Table 1.

Remote simulation has been implemented successfully in other healthcare settings. Ikeyama et al (2012) described a remote-simulation implementation involving anaesthesia and intensive care medical staff. The participants evaluated the simulation positively. The authors discussed the benefits of reduced travel time, the ability to increase training frequency and the ability to take learning to a wider, potentially international, audience.

An insightful study by Duch Christensen et al (2018) reported a comparison of in-person and remote simulation involving nursing and medical professionals. The authors framed the study with a discussion of relevant learning theory, including cognitive load theory (Young et al, 2014), the technology acceptance model (Davis et al, 1989) and the social presence model (Kiliç Çakmak et al, 2014); all of which could be considered when designing remote simulation. Overall, the participants favoured in-person facilitation, perceiving the lack of human interaction and less effective debriefing as barriers.

A contemporary study regarding remote simulation (termed virtually facilitated simulation by the authors), using a cohort of various Canadian health professionals (including paramedics), was reported by Reece et al (2021). This simulation involved facilitators virtually (remotely) observing participants performing advanced airway procedures to prepare for care in the context of COVID-19. The participants in this study expressed comparable satisfaction levels with remote and in-person simulation. The authors discussed how participants may be becoming increasingly accepting of remote simulation because, in part, learners are becoming more accustomed to various online education approaches because of changes during the COVID-19 pandemic.

All the studies mentioned above implemented a form of remote simulation where the facilitator was a remote viewer and the participants interacted with the simulation equipment in geographically distant settings. In this article, the participants were remote observers, and the facilitator was interacting with the simulation equipment in a simulation centre. This study could therefore provide a useful comparison to the above-mentioned studies and build on the discussion of mental simulation by Dogan et al. (2021). Regardless of the approach, simulation interventions should be developed with adult education theory and experiential learning in mind (Motola et al, 2013).

As Reece et al (2021) discussed, remote simulation can deliver effective learning across long distances. It can be effectively implemented for international simulation interventions. However, there may be associated problems regarding language, cultural or health system differences (Shao et al, 2018).

Taking high-quality simulation to resource-scarce settings is a potential benefit of all forms of remote simulation. As discussed below, if you remove the requirement for simulation equipment and resources from the participant setting (by using a remote simulation model where the simulation resources are centrally located with the facilitator), this may increase access to simulation to learners who may not have simulators or simulation facilities nearby.

The RFMS in this study was designed to be incorporated into a BSc paramedic science programme to help link theoretical knowledge to its practical application. It was integrated into an anatomy and physiology module, where the learning objectives centred around applying anatomy and physiology knowledge to the pathophysiological presentations of prehospital patients.

These types of learning objectives are well suited to mental simulation, as the key thought processes in this context are those that link the presenting signs and symptoms to the underlying pathophysiological changes.

Asthma was chosen as the presenting condition as the cohort had recently been introduced to its pathophysiology and prehospital management. Furthermore, patients with asthma can rapidly deteriorate so this afforded realism and fidelity to the proposed simulation flow (Figure 1).

The model outlined here could readily be adapted to a variety of patient presentations.

Aims of the asthma RFMS

The asthma RFMS was designed so that participants (second-year BSc paramedic science students) experienced a deteriorating asthmatic patient, and linked their theoretical knowledge of asthma pathophysiology to a real-time patient simulation (Figure 1). Further aims included developing the clinical decision-making skills required to manage a deteriorating asthma patient, to mentally rehearse the processes involved, discuss these within a group and reflect on them during debriefing.

Preparation

The asthma simulation was developed using a purpose-built simulation centre, complete with an ambulance patient compartment (Figure 3). The simulation centre has proprietary audio-visual equipment, allowing live video streaming alongside the use of advanced manikins. The Echo360 (Echo360) video platform allowed participants to view both the facilitator within the ambulance patient compartment and real-time data output from the SimMan 3G manikin.

The simulation meant students could participate remotely in a simulated clinical scenario, facilitated by a faculty member on campus using SimMan 3G as the patient. A stop:go format allowed students to discuss the case at certain points and facilitated student-led formation of management plans. Zoom (Zoom Video Communications) videoconferencing software enabled small-group discussions and interaction with the facilitator. A simulation technician, located on site with the facilitator, ensured technical support was on hand if required.

Effective preparation, pre-briefing and briefing phases can help allay participants' anxieties and maximise the likelihood of the learning objectives being met (Eppich et al, 2013). Participants were pre-briefed so they could familiarise themselves with the technology, the logistics and the content of the session before progressing to the briefing.

Briefing

The briefing phase sets the scene for all participants, providing a platform for all subsequent phases. It should take place immediately before the simulation activity to help develop rapport and create a feeling of safety for the participants (Eppich et al, 2013). This can be achieved, for example, by inclusive ice-breaker activities or, if the simulation is in person, by arranging the room so people sit in a circle (Nestel and Bearman, 2015).

The remote briefing followed a similar structure to an in-person briefing. The participants were given instructions, learning objectives and an outline of what to expect from the simulation. They were encouraged to ask questions, raise concerns and troubleshoot any technology issues. The facilitator emphasised that the simulation was not an assessment, that at times there would be time pressure to make decisions and how it would be important for all participants to communicate effectively within the breakout rooms.

Lave and Wenger (1991) suggest learning is an inherently social, situated and active process and proposed the concept of legitimate peripheral participation. This concerns the opportunities participants have to learn through observing others and gradually become active in discussions. Peripheral participants are able to view activities occurring within a learning community and, from their observations, they can learn important aspects of the situation such as communication strategies.

The RFMS allowed participants to observe and mentally rehearse a patient encounter, and participate in active discussions with their peers. In the RFMS, the students were essentially performing as themselves, and allowed to interact in a natural social learning experience and rehearse schema equivalent to Kolb's (1984) concrete experience phase of experiential learning. Avoiding role play in unfamiliar roles can prevent the discomfort associated with this. When the participants do not feel comfortable and safe, the simulation's effectiveness can be compromised (Turner and Harder, 2018).

Creating a safe environment where participants can explore their own professional identity and engage in meaningful reflection is described as creating psychological safety (Rudolph et al, 2014). While learners develop their own professional identity, they are sensitive to perceived criticism. Creating a safe educational space is an important safeguard against these negative experiences (Bearman et al, 2013), as participants could otherwise view engaging with a simulation as risky or intimidatory.

If participants are able to take the psychological risk and engage with the simulation while accepting they may make mistakes, facilitators can create excellent learning opportunities. Vygotsky's (1978) ‘zone of proximal development’ theory outlines how learners can achieve their potential by testing the limits of their expertise under guidance from skilled peers and facilitators. This can be achieved by fostering a safe space in the briefing phase, allowing participants to experiment without fear of failure and, importantly, to view any mistakes as learning points (Rudolph et al, 2014).

Simulation activity

The activity phase of the RFMS revolved around the participants observing a real-time, remote, simulated care episode. The facilitator played the role of a paramedic assessing a patient.

The obvious challenge in planning this phase was elucidating how students could best meet the learning objectives while observing remotely.

Structure was added to the group's discussions by setting key questions to be explored that related to patient care goals and participants' understanding, such as: what is happening now? What drugs are you going to use and why? This helped to align the learning with the objectives (Prince, 2004) and encouraged students to minimise digression.

This form of goal-directed group activity falls within Engeström's (1999) activity theory, where activity-based learning is viewed as a transformative learning experience as it allows division of labour within a group, thereby facilitating the sharing of and learning from multiple voices and points of view (Engeström, 1999).

Stopping the scenario at key points (the chosen stop:go points are shown in Figure 1) allowed students to discuss the information received, verbalise their own thought processes and formulate action plans in small groups. For example, they could ask themselves, ‘What is your working diagnosis and what are the main pathophysiological causes of the condition?’ This helps to frame the participants as active observers and stimulate mental rehearsal of the necessary clinical decision-making processes.

At the end of the stop:go breakout room sessions, the groups were asked for their opinion on what was happening with the patient and what the next actions should be. A consensus was sought from each group; the facilitator then applied the agreed actions to the simulation and moved on to the next stage.

A common hurdle in remote teaching is overcoming participants' reluctance to engage (Farrell and Brunton, 2020). Redinger et al (2020) suggest that using social, active engagement through group activities minimises the risk of students being distracted and promotes learning. Breaking the activity into stop:go discussions encouraged participants to contribute actively in their own learning; a key tenet of constructivist education theory (Lave and Wenger 1991).

Fidelity is another concept to reconcile within the limits of RFMS. Challenges include creating equipment, environmental and psychological fidelity, so participants can suspend disbelief and engage with the simulation (Tun at al, 2015). In the RFMS described here, a replica ambulance patient compartment provided high equipment and psychological fidelity.

However, remote teaching necessitates that concessions are made regarding environmental fidelity, as remote participants lack non-visual cues such as the feel, sound and cramped conditions of an ambulance patient compartment (Tun et al, 2015). Balmaks et al (2021) highlight the difficulties of preserving fidelity within remote simulation. They suggest fidelity can be maintained by using cues from realistic manikin changes and conceptual prompts at important points.

Realism and fidelity are connected, but the link between fidelity and learning is non-linear (Norman et al, 2012). In the RFMS, psychological fidelity was maintained by providing real-time streaming of patient observations. By removing the psychomotor domain of learning entirely, this approach could reduce extraneous loading and minimise cognitive overload (Reedy, 2015).

Cognitive overload is a psychological concept concerning how learners have a limit to the amount of information they can process and store successfully at any one time (Reedy, 2015). Learning occurs when memories are ordered and processed in a meaningful way. If a task or situation is too complex, this can lead to cognitive overload, where memories are not stored effectively, which negatively affects learning (Reedy, 2015).

Mental simulation must make concessions over the inclusion of certain domains of learning, most commonly the psychomotor domain (Dogan et al, 2021). This may reduce the likelihood of cognitive overload and allow the learning to focus on cognitive and affective domains.

The RFMS was designed to emphasise decision-making and information interpretation. It is equally important to ensure participants are challenged appropriately within the remaining domains to create meaningful learning experiences. This concept is described as the germane load of a learning activity (Reedy, 2015).

Debriefing/feedback

The debriefing phase is widely said to be the most influential part of simulation (Jaye et al, 2015). Debriefing encourages learners to reflect on their actions, compare the outcomes to existing or novel schema and, ultimately, use this knowledge to inform their practice, thereby improving patient outcomes (Cheng et al, 2020).

Debriefing remote simulations has advantages and disadvantages, and consideration of these aspects helped shaped the debriefing in the RFMS. Cheng et al (2020) provide a contemporary view of remote simulation, framed by the changes brought to the entire education sector because of the COVID-19 pandemic. The authors build on the communities of practice model (Lave and Wenger, 1991) to describe three factors influencing successful online debriefing: cognitive presence; educator presence; and social presence.

Cheng et al (2020) describe cognitive presence as how students learn and think together through reflective discourse. In our simulation, the group debriefing sessions were facilitated then followed by a whole-group discussion. The participants stayed in the same groups for the debriefing, allowing the continued development of cognitive presence. The stop:go breakout rooms started this process and the debriefing phase allowed the groups to identify problems and apply new concepts collaboratively.

Educator presence within remote debriefing shares the same goals as in-person debriefing: a facilitator should provide a supportive, inclusive space (Cheng et al, 2020). The facilitator should shape discourse, provide structure and carefully consider the level of intervention, while noting that the level of facilitation will vary according to the levels of participant engagement and previous experience (Gordon, 2017).

Developing social presence while remotely debriefing may be the greatest challenge; how students project themselves and their emotions could differ between in-person and remote simulation (McCoy et al, 2017). The question of how remote debriefing allows the students time and space to vent, reflect and share their emotions remains (Gordon, 2017).

In this intervention, the intention was to allow participants time to discuss the simulation without immediate facilitator presence to allow space and time for emotional venting. The disadvantage of remote debriefing in this format is the facilitator would not be present to provide support for any emotional issues shared by the participants. Therefore, it was considered imperative to the RFMS that psychological safety and openness was promoted within the earlier phases. These emotional states have been described as crucial to effective remote debriefing (Cheng et al, 2020).

Reflection

Reflection is a means of gaining understanding through questioning and investigation (Loughran, 2002). It is vital to reflect on the learning experience with a view to improving practice (Box 1). It is equally important to ensure any reflection considers problems from an honest, unbiased viewpoint.

Author reflections on remote-facilitated mental simulation