Evolution of Clinical Simulation Training and Pandemic-Led Acceleration: The International Medical University (IMU), Malaysia Journey

Abstract

In many universities, simulation-based learning has finally been inducted as a member of ‘the accepted teaching modality community’. This paper is to share the challenges and successes in the journey towards the inclusion of simulation-based learning in the medical curriculum at the authors’ university which saw a steep surge during the COVID-19 pandemic. Our teaching and learning that was heavily traditional based went through a dramatic change to adapt to the new norm when the actual environment and patients became out of reach. We followed five factors (5 Fs) that significantly influenced the successful change: fast, force, fellowship, flexibility, and favourable reception.

Introduction

Simulation-based learning has been gaining popularity over the last two decades and accomplished a steep rise, securing more recognition and momentum during the pandemic COVID-19. Traditional clinical teaching and learning of medical undergraduates at bedside, clinics, and operating theatres took a hard hit worldwide. Curriculum delivery had to be relooked and strategies were sought to ensure that the new norm was not going to get the better of continued clinical skills learning [1–4].

‘Simulation is a simulation, it is not real, and learning must take place in the actual environment’; there are and were many who believed this across the world [5]. While we accept that simulation is not real, we do emphasize the enhancement of clinical skills and the probability of transfer of these skills to the actual environment [6–8].

An impelling need to find ways to reduce mortality and morbidity caused by human errors ensued after the release of the landmark report; ‘To Err Is Human, Building a Safer Health System’ in November 1999, by the Institute of Medicine (IOM) Committee on Quality of Health Care [9]. The WHO’s work on patient safety began with the launch of the World Alliance for Patient Safety in 2004, and this work has continued to evolve towards increasing awareness regarding patient safety [10]. Increasing public awareness and hesitancy to be used as practice models have compelled healthcare organizations to turn to other ways to improve clinical competency among healthcare personnel to an appropriate level before being allowed to perform skills on patients. Simulation though has been around for a while now, began to be thought of as a novel way to improve clinical competency and prepare undergraduates for the actual work environment [11]. The pandemic COVID-19 has caused mayhem across the world forcing us to modify our practice.

This paper outlines the various stages of the development of simulation in the clinical phase of undergraduate medical education at International Medical University, Malaysia, sharing frameworks and ways challenges were surmounted.

Simulation Training and Practice in the Actual Environment

Simulation is a method of teaching and learning that incorporates all learning in the actual environment using manikins or simulated patients. It is not a technology but a technique to substitute or augment real experiences with guided experiences that induce or reproduce substantial aspects of the real world in a fully interactive manner [12]. Research shows that fidelity influences learning if applied appropriately and is something we aimed for when planning for the transition to online and simulated teaching [13]. One of the most important of the many advantages of simulation is that students can be exposed to all cases that they may not have been able to see and experience even without the pandemic, along with those common cases that they come across in the real wards in a more protected and safe environment. There is evidence that clinical skill is transferred from the simulated setting to the clinical setting; however, this process does not appear to be automatic and straightforward. There are many factors that have an impact on this transfer, and Masoomi et al. [14] in a review, categorize and relate them to (1) learners, (2) educational design, and (3) clinical environment.

From the beginning of 2020 when students lost all contact with real patients and the environment, simulated learning became the next best thing for clinical skills training to ensure quality and continuity. Using digital technology like virtual learning is an added enhancement to learning, lending diversity to the otherwise everyday online tutorials and lectures. As a result of the pandemic, the use of simulation began to be seen as a bridge to the real environment or even as a supplementary measure that would help to continue and maintain clinical skills among students. However, even prior to the pandemic for many other reasons like changes in student patient ratio, reduced varieties of cases due to more advanced clinical skills and technology, simulation was already being used to improve work performance in the actual environment. At our premise, we initially moved towards virtual medical clinics and ward sessions where a virtual platform using educational technology was created. A Virtual Medical Clinic (VMC) is a unique and effective education method that provides a positive learning experience. Clinical cases were prepared using the latest e-learning tools such as Articulate Storyline 360 or Vyond. Currently, there are 42 cases prepared by different departments, accessible by students at their own time and place. An example of an online virtual ward session was coined as Be(Side) Teaching (BeST) as a replacement for traditional bedside teaching (BST) [15].

Since the first simulator, Resusci-Anne, was created for resuscitation training in the early 1960s, medical simulation has grown significantly in the field of anaesthesia in the 1980s and in emergency medicine in the late 1990s [16, 17]. Simulation exercises are most successful when they become part of the standard curriculum and not an extra, additional component [18–20]. Simulation can be practiced as synchronous or asynchronous, synchronous allowing the learner to interact with the instructor and get instant feedback, being real time where students watch peers experiencing clinical simulation sessions and participate in the debriefing [21].

Chiniara et al. [22] categorize simulation modality into a computer-based simulation, procedural simulation, simulated patients, simulated clinical immersion, and hybrid simulation. Low technology with high fidelity alone will allow for learning outcomes to be achieved if pitched at the appropriate level.

Journey of Clinical Simulation Training at IMU (Fig. 1)

Fig. 1.

The progress of simulation and final integration into the curriculum

IMU clinical campus was first established in 1996 and equipped with a small clinical skills lab to improve communication, practical, and basic procedural skills, using simulated patients or task trainers (parts of manikins). The training then was simply conducted as supplementary to experiential learning in real clinical practice.

In 2011, the IMU medical program was revised to include competency-based training. This required ample opportunities for clinical learning in a safe environment which had started to become rarer in real clinical settings due to challenges from potential legal implications.

In 2015, IMU decided to transform the skills unit by changing its administration from school to the university to align with the university’s mission of promoting interprofessional learning and clinical skills; hence, a simulation centre was established. Training using high-fidelity manikins to simulate almost authentic clinical scenarios began a slow rise.

In 2020, COVID-19 pandemic took over the world and we had to turn to simulation and digitalization.

In 2021, seminar rooms were renovated into convertible wards, outpatient clinics, and treatment rooms. Though the use of various types of simulation had begun to increase by 2018, there was a notable surge in usability during and after the pandemic (Fig. 2). As the lockdown began to ease, students were allowed into the campus in small groups but with strict social distancing protocols. Initially, students and faculty played the roles of patients, and as the situation improved, standardized patients (SP) were allowed to participate in the teaching and learning using simulated ward and clinic environment.

Fig. 2.

Progress of the simulation activities from year 2018 to September 2022

To make up for the loss of learning from actual physical findings, we utilized real patients whose elective surgeries had been delayed because of the pandemic. Simulated clinical training was conducted with students clerking and managing patients within a controlled environment where strict universal precautionary measures were applied.

Committed to replacing the missing experience with opportunities using clinical simulation in a controlled environment, we formed a task force, the Clinical Simulation Training Committee (CST) in June 2020, the main goal being minimization of the impact of the COVID-19 pandemic on clinical training.

The Conception of the Clinical Simulation Training Committee

The committee included a representative from each medical discipline given the autonomy to decide the type of simulation to be utilized for instructional delivery. Both asynchronous and synchronous learning were employed to deliver all sessions. The goals of the committee were:

• To provide high-standard experiential learning to students

• Ensure improvement in the quality of clinical simulation, providing advice and guidelines for the use of available learning resources and facilities

• Identify weaknesses and tap on strengths

• Provide training for clinical faculty and support staff

• Make available opportunities for students to practice their clinical and decision-making skills through simulation

Challenges

A change from tradition always involves challenges. A few of the challenges we faced are listed here.

Challenges.

• Infrastructure

• Faculty support

• Support staff support

• Financial constraints

• Higher management

• Learner acceptance

• Lack of trained staff/faculty

• Resources- Equipment, consumables

Infrastructure

One major limitation we have is space for expansion. Hence, putting up a new structure to accommodate the sudden increase in the need for a simulated environment was off the table leaving us to re-think space-saving strategies that then led to the renovation of seminar rooms into wards usable as both ward/clinics and seminar rooms. Though the situation was not ideal, it worked to serve its purpose.

Faculty Support

Prior to the pandemic, simulated teaching was only conducted by a few disciplines. Personal beliefs, lack of experience, and exposure to simulation-based teaching were the reasons for this lack of support initially.

Support Staff

The number of experienced staff supporting the simulation sessions pre-pandemic was very small. It became a struggle made worse by having one simulation technician trying to support multiple concurrent sessions at times.

Financial Constraints

As with new projects which can be expensive considering the infrastructure change and purchase of new equipment, there were some hurdles to cross, but we managed to minimize cost, converting existing rooms, and allowing for multipurpose utilization.

Higher Management

As with many other institutions, we had to convince the higher management who were the authorizing party to approve resources. The pandemic made the process a little easier than usual as this change was global.

Learner Acceptance

As with any change from believed norms, students’ feedback was that it is not the same as the real thing but in time came to accept that this was the next best thing to the actual environment and patients. This fictional contract is important as the suspension of disbelief enhances immersive learning.

Lack of Trained Staff/Faculty

Faculty and staff with exposure and experience with the practice of simulation were not many. The committee had the responsibility to make available training and advise disciplines on areas where they could optimize clinical learning using simulation.

Resources—Equipment and Consumables

These were to cater to the current practice so there was a huge shortage that needed to be addressed when all disciplines began to change their style of teaching.

Evaluation of the Transformation of Clinical Simulation

An evaluation of the effectiveness of change was made, looking at the performance of students during the final examinations pre- and post-pandemic. Results from the clinical examination (OSCE) of 4 cohorts of students between the years 2018 and 2019, the pre-pandemic group (N = 405), were compared to 4 cohorts between years 2020 and 2021, the post-pandemic group (N = 339). The examination blueprint and question construct went through the same process of internal and external vetting. The format of OSCE remained the same. The passing rate for the pre-pandemic group was 95% and post-pandemic 92%.

Shapiro–Wilk test of normality indicated that data is normally distributed (p = 0.613). The independent t-test showed no significant difference in scores between the pre-COVID-19 and post-COVID-19 students, t (6) = −1.190, p = 0.279, despite post-COVID-19 student group (M = 68.2, SD = 2.1) attaining higher scores than pre-COVID-19 student group (M = 66.8, SD = 1.2). Levene’s test for variances was assumed to be equal (F = 2.59, p = 0.159) (Table 1).

Table 1.

Comparing mean OSCE scores of students before and after the COVID-19 pandemic

Time period	Pre-COVID-19		Post-COVID-19		t (6)	p	Cohen’s d
	M	SD	M	SD
Scores	66.8	1.2	68.2	2.1	−1.190	0.279	−0.84

It was heartening to note that there was no difference between the pre-pandemic and post-pandemic groups suggesting that the transformation has helped to maintain teaching and learning.

Strategies Following a Change Model

A 5-step change model was adopted to negotiate challenges and ensure relatively smooth implementation of changes that achieved expected outcomes [23]. Establishing and shifting the previous usual practice or ‘norm’ to an alternative learning mode and space requires several factors to ensure a good outcome. We base the concept from ADKAR (awareness, desire, knowledge, ability, reinforcement) model [24] to construct five fundamental ‘F’ factors: force, fast, flexibility, fellowship, and favourable reinforcement in ensuring the evolution is a success (Fig. 3).

1. Force

   When a change was needed during the unprecedented time of COVID-19 pandemic, IMU needed to sustain adequate clinical training of medical students and ensure that their quality meets the expectations of stakeholders. The academicians and academic support staff were ‘aware’ of the need for change and hence assembled to carry out an assessment of the external forces that were now influencing the organization’s practice [25]. The unavoidable event had become the most influential factor for the 360-degree turn in our clinical training modalities. The restricted access to healthcare premises played a major role in changing the views of many academicians who initially felt that clinical competencies are best obtained in actual clinical settings. Nevertheless, the change will not be sustained if there is no synergy between the staff’s perceived need and desire for improvement and the above extrinsic factors. The high demand from the stakeholders for continuous authentic clinical learning forced clinical academicians and administrators to work towards the utilization of 40–60% of clinical learning with standardized patients in a safe simulated environment. The effort will not be fruitful without a flow of trust within organizations that capitalize on positive peer pressure and suppress infectious negativity [25].

2. Fellowship

   A changemaker fellowship is a way to support the development of skills in changing behaviour, workplace culture, or systems when the change must satisfy various stakeholders with different backgrounds and expectations.

   The initiative to transform IMU clinical campus into an almost fully functional ‘Simulated Hospital’ requires a highly committed team of clinical teachers with a vast range of expertise in clinical simulation facilitation, academic support staff, and encouraging managers. The transition from simple clinical skill teaching to more complex simulation learning using clinical vignettes and real patients was initially challenging but with time and collaborative practice, has rendered it successful. The medical students were made inclusive in this fellowship where their thoughts and grievances were heard, and views on the transformation process were considered. This is to ensure effective student engagement, motivate higher-level critical thinking skills practice, and promote meaningful learning experience [26]. The desire for change was made possible by the fellowship among academic staffs and medical students, motivating the higher management to fully support and approve the project.

3. Fast

   Reeves and Deimler [27] wrote in The Harvard Business Review, about adaptability to a rapidly changing market, indicating that those who are responsive to signals of change, would be able to quickly act, experiment, and further strategize to remain competitive. They also implied continual episodic planning processes should be employed in a fast-moving environment.

   During the pandemic, the change has been even more drastic, especially since clinical placement has become limited in some regions due to fear of transmission of infection among students, healthcare personnel, and patients. Our response to this situation is guided by prioritization, feasibility, and meeting the urgent needs of our stakeholders. The knowledge of innovative approaches to increase meaningful students’ learning experience was the key for us to employ an enhanced clinical simulation learning with standardized patients in a controlled environment. The steps took into consideration the immediate obtainability of facilitating expertise, manpower, and resources to support the activities. We intervened and executed the change in modality (simulation learning) quite instantaneously, as the main replacement for the missing real hospital/clinic-based learning. The example is explained in our journey especially in 2020 where the transformation of the campus into a simulated hospital took place within 2 months.

4. Flexibility

   The process of change includes our ‘ability’ to design, plan, and execute, made to suit the availability of time and space within the packed teaching–learning schedule. The affordability of the support system and agreement between teachers and learners are pivotal to ensure acceptable outcomes in this hypercompetitive environment [28].

   It has been said that three types of flexibility are required to adapt to fast-evolving changes [28].

   1. Cognitive flexibility: divergent thinking that allows changemakers to incorporate multiple strategies and mental frameworks in planning or making a decision.
   2. Emotional flexibility: allows changemakers to deal with transition and resistance without compromising the potential outcomes. The managers must constantly be prepared to make dynamic changes.
   3. Dispositional flexibility: the ability to embrace change as a positive opportunity but with realism and openness.

   Many, including our team, have attempted various approaches to improve the authenticity of learning which include conducting first-person ‘Point of View’ filming or live telecast but the issues of privacy, patient confidentiality, and feasibility can be major obstacles. Flexibility allowed us to respond and adapt to many challenges during the transformation.

5. Favourable Reinforcement

   In facilitating acceptance of any significant change, we believe that the three factors: force, flexibility, and fellowship are the major elements. These have also been shown to be the means to achieve autonomy support which is proposed in the ‘self-determination theory’ for better internalization [29]. Research has shown that the recipients of change would usually evaluate a reform negatively especially if it would have an impact on the ‘norm’ or if they are given minimal control during the process [30]. Furthermore, it is equally important that the stakeholders are made to understand the institution’s strategic direction and transformational practices to enable recognition of work, value, and importance [30].

   All faculty from various disciplines came together to prepare lesson plans following Gagne’s model [31] of instructional design, for simulated clinical sessions to standardize teaching plans and reinforce the changes made in the clinical training even after they were allowed presence on the campus.

Fig. 3.

A ‘5F (factors)’ in sustaining change for adequate clinical training

Conclusion

We realize that to succeed in changing ‘what is the norm’ in traditional practices requires a high level of ‘buy in’. Opportunities presented in various forms require responsive and innovative practitioners and administrators to realize and turn them into more fruitful outcomes. Support from stakeholders, especially in trust and faith for good outcomes, financial aid, quick mobilization of manpower and resources, and willingness to participate, was crucial to the success. We have reached a consensus that simulation training in an undergraduate medical curriculum is valuable and worthwhile to be formally practiced as part of clinical experiential learning. It is feasible and manageable in any situation where the safety of patients and practitioners is questioned, further supported by the advanced technology of the twenty-first century.

Author Contribution

TS, SSA, and MAI were involved in the concept and design of the study as well as in the writing of the script.

Declarations

Ethical Approval

This manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work if that information is not provided in another form.

Consent for Publication

International Medical University Joint-Committee on Research and Ethics approved this commentary for publication.

Conflict of Interest

The authors declare no competing interests.

Disclaimer

Manuscript not presented in any conference or published in any journal before.