Future directions for simulation in healthcare: A critical review

Abstract

There was a widespread discontinuation of simulation programs during and after the COVID-19 pandemic. The objective is to explore how to facilitate greater integration of simulation in healthcare organizations.

A literature review was conducted in PubMed, MEDES, IBECS and DOCUMED databases. Twenty-three articles published after the pandemic were selected, categorized in seven themes and critically reviewed.

In order to consistently and fully integrate simulation into the organizational culture it is recommended to prioritize the development of new strategies that enhance the efficiency and safety of healthcare delivery. And also strategies that enhance the satisfaction and well-being of all stakeholders.

Resumen

Durante y después de la pandemia de COVID-19 hubo una interrupción generalizada de los programas de simulación. El objetivo es explorar cómo facilitar una mayor integración de la simulación en las organizaciones sanitarias.

Se realizó una revisión crítica de la literatura en las bases de datos PubMed, MEDES, IBECS y DOCUMED. Se seleccionaron veintitrés artículos publicados después de la pandemia, categorizados en siete temas y revisados críticamente.

Para integrar de manera consistente y completa la simulación en la cultura organizacional, se recomienda priorizar el desarrollo de nuevas estrategias que mejoren la eficiencia y la seguridad de la prestación de atención sanitaria. Y también estrategias que potencien la satisfacción y el bienestar de todos los grupos de interés.

Introduction

Up until the 20th century, traditional apprenticeship was the most common method used in healthcare education. But after the last 25 years, patient simulation is now used as an adjunct to learning in real-life clinical settings.¹

This trend is supported by the fact that several systematic reviews and meta-analyses showed a positive correlation between simulation-based training (SBT) and improvements in technical skills, clinical decision-making, interprofessional teamwork, patient-related outcomes, and changes in organizational performance. Additionally, this positive correlation is stronger when compared to traditional learning methods and it remains consistent over time.²

As a result, there has been an exponential rise in the development, application, and general awareness of simulation use in the healthcare community over the last two decades. Four hundred eight simulation centers were identified in a recent study to characterize the current state of SBT in the health sciences in Latin America. Interestingly, most initiatives were university-linked (84%).³ Another study identified 80 centers in Spain, distributed among universities (54%), hospitals (34%), simulation centers (6%) and other entities (6%).⁴

SBT use in healthcare increased, its uptake was slow, and an often insufficient macro-level strategic focus limited healthcare system's ability to reap full benefits. Thereby, simulation centers with dedicated equipment and trained personnel have not yet become standard. A systematic review identified significant variations in the utilization of simulations, highlighted the underutilization of SBT by multiple health disciplines, and emphasized the need for more widespread and expedited use.⁵ Sim centers voluntarily registered in the Society for Simulation in Healthcare directory account for 15 in Africa, 54 in Asia, 12 in Australasia, 49 in Canada, 15 in Caribbean and Central America, 92 in Europe, 28 in the Middle East, 33 in South America, and 724 in the USA.

Although significant progress has been made in this century, there are gaps in the advancement and integration of simulation in healthcare institutions that were clearly identified during the COVID-19 pandemic. While simulation played a critical role in some institutions to refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers in unfamiliar roles, there was a widespread discontinuation of SBT for health professions, which limited the opportunities for providers to adapt to the new situation. As an example, thirty-eight (88.4%) simulation centers in Italy ceased their activities. Of these, 60.5% closed following the government's lockdown decree, while 39.5% closed even before that.⁶ There was also an interruption of courses for students in schools and/or hospital training rotations.⁵

Closures, especially during the height of restrictions, were intended to avoid the increased risk of infection that comes with close face-to-face interaction in routine training and practice, particularly in the early stages when gatherings of any size were not permitted. But later on, when the situation achieved some degree of stabilization or a steady state, and restrictions diminished and small classes and groups were allowed, most centers did not return to their normal activities at the same pace.⁶

The main lesson learned after the COVID-19 pandemic was the limited integration of SBT in the day-to-day activities of many healthcare institutions. Despite the need to provide adequate training in a short period to fill knowledge and practice gaps, which could have positively impacted patient care, SBT was not seen as a powerful tool to address the challenges emerging during the pandemic. Simulation programs and simulation centers were not considered as essential as other hospital services or departments that remained operational to ensure the highest quality of care.

Therefore, the objective of the present review was to explore how to promote and facilitate greater integration of simulation in healthcare organizations. This was addressed by reviewing the literature to understand the past and current situation, and laying the foundation for potential future directions.

Material and methods

This critical review goes beyond describing the strategic developments for patient simulation suggested in the literature. It also includes a degree of conceptual analysis and prioritization of the proposals to facilitate their integration into healthcare systems. In the first stage, the authors identified, categorized, and summarized the findings. In the second stage, they performed a critical analysis of those findings based on the authors’ collective expertise in using SBT to facilitate change in healthcare during the last 15 years in North and South America, as well as in Europe. They are regular contributors to the literature and are also expanding upon a recent conference keynote lecture on the topic.

The review was conducted in PubMed® to identify the majority of relevant studies at an international level. Additionally, the main databases in Spanish were searched to explore Spanish-speaking countries in Latin America and Spain. These included Medicina en Español (MEDES), Spanish Bibliographic Index in Health Sciences (IBECS) and Spanish Medical Documentation (DOCUMED).

Only articles written in English and Spanish published after the COVID-19 pandemic (2021–2023) were selected to capture the existing gaps and proposals, which may affect the way SBT will be used for future developments in healthcare.

MeSH headings (patient simulation[MeSH Terms]) AND (future[MeSH Terms]) and MeSH entry terms ((Simulation[Title]) AND (future[Title])) were used for PubMed®. Entries for MEDES and IBECS databases were (simulación[título] OR simulación[resumen] OR simulación[palabras_clave]) AND (futuro[título] OR futuro[resumen] OR futuro[palabras_clave]). Entries for DOCUMED included title/simulación or futuro; title/simulación and futuro; simulación and futuro; simulation and future.

Articles that reflect on the use of patient simulation for training and improving quality and safety in healthcare were selected for further review. Articles about the use of simulation for modeling to predict the future state of dynamic environments were excluded. Preference was given to review articles, and articles reflecting on the probable evolution of simulation in any specialty or discipline in healthcare. Books, thesis, conference abstracts and internet documents were not included.

Possible future developments and directions proposed by researchers were categorized into groups or themes to facilitate analysis.

Results

After the search was completed, following deduplication and exclusion, authors reviewed the titles and abstracts and 23 articles were included for review. Articles were classified into seven thematic categories, and are summarized and cited throughout the manuscript.

• 1.

  Improve SBT effectiveness.

Several authors focused on the need to train future simulation educators in an evidence-based way, just as patients are treated according to the best available evidence, to obtain effective and consistent learning outcomes.

They advocated for best practices for SBT in different domains, including (a) the definition of models for successful instructional designs⁷; (b) the alignment of the types of simulators to areas of application and the targeted groups; (c) the validation of assessment tools to provide participants with performance reviews⁸; and (d) the blending of simulation and learning in the clinical context, specially in the first part of the learning curve where SBT is superior to apprenticeship training, to ensure all trainees are competent before they perform their first supervised procedure on a patient.⁹

• 2.

  Develop new simulation technology.

Simple models using graft materials, suture boards, and basic instruments have largely failed to generate sustained interest among most mid-level and senior trainees. In response, some authors recommended combining software that enables segmentation and 3D reconstruction of medical imaging with emerging technologies, including dynamic three-dimensional visualization or printing, to provide both generic and patient-specific models for planning and practicing procedures.¹⁰ They include virtual reality applications and augmented reality platforms,¹¹ and 3D printing in combination with hydrogel models and pulsatile flow models.¹² Optimizing existing and future technologies to include airway haptics, olfactory stimuli, interactions in the metaverse,⁷ or multi-sensory augmentation may be another key enabling factor for the development of a new generation of simulators.¹³

A systematic review identified offline and online computer-based programs with virtual patient cases or practical skills simulations as the most likely prevalent clinical simulation teaching modality for the future. Visualization approaches included text, images, animations, videos, and 3D environments. However, there is no standard framework yet for assessing the value of these innovations.

Other researchers proposed using big data to automatically review electronic medical records and develop simulation programs that prioritize early error prevention and reduction. Artificial intelligence and machine learning may enhance data extraction and documentation.¹⁴

Another future use for artificial intelligence may be enhancing realism and interactivity and to provide automated personalized learning experiences. Advantages also include that trainees would be able to initiate self-study without the instructor directly managing the simulation. Additionally, they would receive personalized, intelligent, automated competency assessment and guidance during training.¹⁵

Novel simulation platforms that use artificial intelligence algorithms to measure participants’ cognitive load in real time (via electrocardiography and galvanic skin response) may modulate simulation difficulty through symptom severity changes in a patient.¹⁶

• 3.

  Adapt simulation modality to available resources.

Several researchers proposed educators should explore alternative simulation environments and modalities to improve accessibility and to optimize learning effectiveness. Limited access to simulation programs may be due to (a) educators’ training and availability; (b) costs for complex simulation systems, especially for high fidelity simulation modalities and environments; (c) the time and commitment required for developing a high-quality scenario-based curriculum; (d) logistics and financial resources; (e) a large number of students; (f) continuation of training beyond the trainee years; and (g) limited networks for national courses.

Potentially less costly alternatives to a simulation center would include in situ programs, gamification, virtual reality or augmented reality scenarios.¹⁷ There is an increasing number of institutions choosing in situ simulation over in-lab or off-site simulation, depending on the available resources. However, little research was conducted to compare its effectiveness.¹⁸

As mentioned above, SBT is already the gold standard for healthcare education in most developed countries. The challenge for low- to middle-income countries is that most projects were initially conducted in collaboration with international organizations and reliant on external funding.¹³ Some researchers suggest they may benefit from direct collaboration with local experts, institutions and manufacturers.¹ Moreover, the availability of modern low-cost simulators and online or virtual simulation may help eliminate some of the costs related to designing programs and purchasing equipment, and are effective to improve patient outcomes.¹⁹

• 4.

  Utilize simulation for assessment and certification.

Some authors proposed setting standards for credentialing new providers in a controlled environment before practicing with real patients. Low frequency and high-risk clinical scenarios, such as resuscitation, robotic surgery, endovascular procedures or extracorporeal membrane oxygenation, may be practiced using simulation to decrease mistakes in care and improve patient safety.²⁰

Challenges that need to be addressed in the future include improving the fidelity, validity, and reliability of the scenarios, as well as developing valid and reliable assessment tools. Computer-based simulators and artificial intelligence-based algorithms may be valid to assess simulation training exercises and may have higher levels of agreement with the current gold standard.¹⁴

An increasing number of professional societies, such as the American College of Cardiology, the Society for Vascular Medicine and Biology, and the American and Spanish College of Surgeons strongly endorse the use of simulation-based training in high-risk procedures in a commitment to assist providers to reach a common benchmark of proficiency. The Joint Commission recently released new requirements for hospital to conduct multidisciplinary drills in order to test their systems in a safe simulated environment. Some malpractice insurers also joined this movement and are requiring the participation of native teams in simulation prior to insuring the organization. Along those lines, the maintenance of board certification for anesthesiologists now includes a simulation option.¹⁹

• 5.

  Develop patient-specific simulation.

Other researchers focused on developing patient-specific simulation as a strategy that may facilitate a distinct shift in the use of simulation from programs that allow practice of fundamental skills (e.g., fundamentals for laparoscopic surgery) to others that allow cognitive and/or physical rehearsal of specific events (i.e., a patient's operation). However, potential benefits are still limited by the feasibility to accurately define the anatomical/pathologic patient variability and translate them into viable models that demonstrate their effectiveness in improving outcomes.²¹

• 6.

  Use simulation as a research tool.

Most of the research on healthcare simulation focused on the simulation itself. Priorities included understanding the uses of simulation, determining the most effective research designs for comparing simulation effectiveness to traditional teaching methods, or exploring the dose–response relationship between simulation training and patient care outcomes.⁷

Several authors advocated doing research through simulation for supporting the improvement of quality and safety in healthcare systems and processes. Studies may be descriptive (to understand what happens in organizations and why), for theory-testing and generation (to evaluate theories relating to quality and safety) and evaluating interventions (to improve care).²²

In situ simulation may be used as a tool for proactively exposing latent safety threats in active care areas, testing any new or renovated patient care areas, and evaluating changes in policies and procedures.¹⁸ Simulation may also be used to test new equipment and support procurement processes.²³

• 7.

  Use simulation to improve organizational performance.

Finally, some researchers advocated using simulation for translational purposes, i.e., to accelerate the transfer of results from the laboratory to achieve measurable improvements in the health of individuals and society. It focuses on the purpose (safety and performance issues), irrespective of the location, modality, or content of the simulation activities.²⁴

In this regard, simulation may also be utilized in hospitals and primary care settings to train new employees, monitor and enhance performance, and improve efficiency.⁵ This was especially relevant to enhancing departmental preparedness for COVID-19. At universities, SBT may address learning gaps, like differences in pathophysiology and clinical presentations, or help prepare interns for clinical rotations.²⁵

Discussion

The use of patient simulation in healthcare organizations steadily increased over the past few decades internationally³ and most simulation programs are positive about its future, predicting a 55% growth in the next five years.⁵ It has been widely determined that SBT is significantly faster and safer in achieving proficiency, transferring to the clinical context, and improving patient-related outcomes compared to conventional training. E.g. for learning laparoscopic cholecystectomy and reducing catheter-related infections.² Nevertheless, the closure of many simulation programs after the COVID-19 pandemic revealed its limited integration into the day-to-day activities of many healthcare institutions and that there is still more work to be done to derive full benefits.⁶ This review aims to improve the understanding of how simulation can be more deeply integrated into healthcare organizations.

Data analysis showed that the primary focus is still on promoting the acquisition and retention of clinical knowledge, attitudes, and skills by learners. Thus, most of the revised articles proposed future developments aimed at achieving consistent learning outcomes. These include effective instructional designs, new simulation technology, and customized simulation modalities based on the available resources. This will lead many initiatives in the simulation community toward the (a) assembly of human capital (simulation requires properly trained personnel); (b) integration of simulation into the standard curriculum (instead of ad hoc use); (c) development of software programs and devices for computer-based simulation with functionality and capability that correlate with current clinical practice^26,27; and (d) identification of standardized methods to assess procedural skills, and definition of best practices for skill maintenance.¹⁹ Other initiatives proposed to create simulations tailored to individual patient needs.

Although these developments are important and necessary endeavors to continue the advancement of simulation, especially in the academic field, the COVID pandemic signaled that the current and most pressing priority is to facilitate simulation programs running in parallel to other clinical activities in healthcare organizations. In other words, to use simulation as a routine part of the everyday work environment to foster teamwork, patient safety and design more efficient processes. In this regard, review findings summarized in themes number six (simulation as a research tool) and seven (organizational performance) are aligned with this priority and focus on organizational impact. They focus on how to make healthcare delivery safer and more efficient, and on how to improve all stakeholders’ satisfaction and well-being.

Our collective experience in using simulation as an organizational tool for change,²⁸ also supports the idea that simulation can and should be prioritized to understand organizational needs and improve organizational performance. It is essential that simulation contributes to building resilient health systems. It must benefit patients and all stakeholders. We apply the partnership pathway framework, as described by Christopher Roussin, to make an impact with simulation. This framework involves working from the identification of risks, gaps, and vision, to the establishment of key performance indicators, formation of a network of important individuals and engagement of learners, in order to facilitate organizational readiness and performance.

Other simulation programs adopt a similar approach for the future. Based on a critical review, a group of researchers also provided guidance on how practitioners and organizations may implement simulation in everyday practice to directly improve patient care and healthcare systems using the input-process-output framework.²⁴ Other groups recommend simulation programs that focus on systems to identify gaps and improve them before patients and staff are put at risk. They proposed a simulation framework which includes project and change management phases.²⁹

Practical implications for promoting and facilitating the integration of simulation in healthcare organizations include prioritizing its use to address organizational needs. As a practical illustration of this systems approach, it is important to highlight several seminal examples. On one hand, the use of SBT for central venous catheter insertion as a cost-effective intervention that resulted in fewer catheter-related bloodstream infections and decreased the length of intensive care unit and total hospital stays.³⁰ On the other hand, the utilization of SBT for shoulder dystocia that led to a four-fold decrease in brachial plexus injuries.¹⁹ In the university context, a new model was created to address deficiencies in the clinical year and to bridge the gap between students’ learning needs and the day-to-day challenges of clinical settings.

The main limitation of this review stems from the potential biases that may arise from the article selection process and the personal perspectives of the authors, which could influence the final conclusions. Future reviews can include experts from other fields and healthcare contexts who may offer disconfirming perspectives. Although the literature search was limited to the post-pandemic period in order to capture the unique changes that occurred in the healthcare system thereafter, data collection and thematic analysis reached saturation. This means that new incoming data may provide little or no additional information to address the research question in the analysis.

Conclusion

Although patient simulation is widely adopted in healthcare globally, it is necessary to consistently and fully integrate it into the organizational culture. It is suggested that future developments prioritize addressing organizational needs rather than focusing solely on technological and methodological advances. Simulation in healthcare may be a regular part of day-to-day activities as it enhances the efficiency and safety of healthcare delivery.

During the preparation of this work the authors used WORDVICE AI in order to improve vocabulary, grammar, spelling and punctuation. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that they do not have any financial relationships with companies that commercialize products or services related to simulation in healthcare. Valdecilla Virtual Hospital is an ambassador for the Center for Medical Simulation in Boston, USA. Both are nonprofit educational institutions that offer tuition-based programs for training simulation instructors and clinical teams.