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. 2026 Sep 26;17:622103. doi: 10.2147/AMEP.S622103

Video-Assisted Simulation with Audience Response (VASAR): An Educationally Efficient and Scalable Model for Medical Education Simulation

Adrian Gooi 1,2,3,✉, Kevin Fung 4, Lily H P Nguyen 5,6, Norbert Viallet 1
PMCID: PMC13625838  PMID: 42820027

Abstract

Purpose

High-fidelity simulation offers invaluable educational benefits in medical education. It provides the opportunity to develop critical communication and crisis resource management skills, but depends upon a high level of resources including technical equipment, a simulated environment, and instructors with expertise in simulation. This study aimed to develop an educational model that provided some of the benefits of simulation but with increased educational efficiency.

Methods

The intervention was implemented at a specialty continuing medical education conference. This study combined video scenarios, role-playing, team-based learning strategies, and audience response systems to create Video-Assisted Simulation with Audience Response (VASAR). Post-session questionnaire data was compared between traditional high-fidelity simulation and VASAR. Data was also compared to questionnaire responses from separate experiences with high-fidelity simulation.

Results

The study included 70 participants. The data suggest that participants found VASAR to be useful (96%) and realistic (92%). Both video and audience response systems were felt to be valuable (96% and 92%). Participants indicated the workshop would help them practice more safely (80%). In comparison of VASAR with traditional high-fidelity simulation, there were no statistical differences for usefulness of the course (p=0.53), feedback from debriefers (p=0.14), or recommending the course to colleagues (p=0.48).

Conclusion

This study suggests that Video-Assisted Simulation with Audience Response can provide an interactive simulated clinical experience which participants find useful to clinical practice, and that VASAR can provide a tool for future strategies in medical education.

Keywords: simulation learning, high-fidelity simulation, medical education, video, audience response system

Plain Language Summary

Traditional high‑fidelity simulation provides many educational benefits but requires heavy resources and instructor expertise. Video-Assisted Simulation with Audience Response (VASAR) utilizes videos, role-playing, team-based learning strategies, and audience response systems to provide some of the benefits of simulation, but with increased educational efficiency. Participants found VASAR to be interactive, to simulate real-life settings, and to provide useful feedback through debriefing. There were no statistically significant differences noted between VASAR and traditional simulation in this study. VASAR can provide a useful model for remote and distributed medical education with a scalable audience that can be used for the medical education of the future.

Introduction

Simulation technologies provide one of the highest levels of learning and skill acquisition in medical education. High-fidelity simulation allows medical students and residents to gain clinical management skills in a safe, realistic environment through a lifelike and repeatable experience.1,2 These models include technical trainers for procedural skills and surgical techniques.3–5 Similar to the airline industry, crisis resource management strategies promote the development of clinical decision making and communication during high-stress medical scenarios.6–8 These educational benefits are valuable not only for early medical trainees, but also for established physicians – especially in the management of rare or emergent clinical settings, such as airway management skills.9–11

However, despite the undeniable benefits of simulation, it remains an educational strategy that requires a heavy amount of resources and expertise.12 Fletcher and Wind discuss in their article costs of simulation including facilities, equipment and materials, personnel, other program inputs, and client inputs. Task trainers may require expensive mannequins and tools for the trainee to develop their skills. High-fidelity simulation requires not only expensive medical-type equipment and a simulation centre to run scenarios, but also instructor expertise in controlling medical equipment, acting as confederates in the scenario, and providing feedback in debriefing sessions.12–14 Thus, the aim of this study was to evaluate some of the benefits of simulation using a potentially more resource-efficient and scalable educational model. This study used a combination of multiple educational strategies. Video scenarios allowed for the deeper learning of multi-media learning theory compared to didactic learning. Role-playing facilitates the decision-making process of the simulation fidelity continuum. Team-based learning helps participants learn both from their small groups as well as the larger group as a whole. Audience response systems allow for real-time participant interaction that is scalable to large group learning. Our research question was to assess if a less resource intense and scalable teaching strategy could still provide some of the benefits of high-fidelity simulation. To the authors’ knowledge, this study is the first in the medical literature to report on an educational model using the strategies of Video-Assisted Simulation with Audience response.

Materials and Methods

Our simulation education group ran annual simulation sessions at an annual medical conference. Initial courses were offered using traditional high-fidelity simulation models. These sessions, however, required heavy use of resources including costly simulation and medical equipment and a simulation facility in which to hold the course. We also required faculty with experience in simulation and debriefing, as well as other support staff to run the simulation equipment and act as confederates/actors during the simulation experiences. As this model became increasingly challenging to run each year, we aimed to devise an educational model that was less resource-intense and more educationally efficient. Our group used its experience with audience responses systems, team-based learning strategies, and medical education videos to design VASAR: Video-Assisted Simulation with Audience Response.9,15–19

Attendees of the Canadian Society of Otolaryngology – Head and Neck Surgery Annual General Meeting (CSO-HNS AGM) were invited to participate in the simulation sessions. The data for the study were collected over three years, including one high-fidelity simulation course (HFS) and two sessions of Video-Assisted Simulation with Audience Response (VASAR). This comparison involved non-randomised, non-equivalent cohorts drawn from different conference years. Recruitment was done for all participants of the conference sessions. Response rates were 100% of the high-fidelity simulation session and estimated 60–65% of the VASAR sessions. Ethics approval was granted by the Health Research Ethics Board.

The high-fidelity simulation course included course faculty with a diverse international team of practicing Otolaryngologists, Emergency Medicine and Anesthesiology physicians, nurses, residents, and students. The course was held in a technologically equipped simulation centre. Over 15 instructors and support staff were involved to train 19 participants. The simulations used adult and infant high-fidelity mannequins that could replicate basic life functions. Participants would run through an airway management scenario with simulation and content experts present, programmers operating the mannequins from a mirrored control room, and confederates/actors to enrich the simulated environment. Debriefing sessions were held afterwards, led by otolaryngologists with experience in simulation.

The VASAR sessions were led by 2–4 people from our simulation group. These sessions were run in a standard lecture hall with a standard projector and screen. The sessions were approved for Continuing Medical Education (CME) credits. The Tophat audience response system (www.tophat.com) provided audience interactivity through the simple use of texting on their mobile phones. Each time we used the audience response system, we displayed a slide with the phone number for texting and method for participants to text their responses. In our sessions, 2–4 instructors ran sessions for 50–80 participants. These sessions were focused on acute airway management, with segments of an educational video from the creative commons. The session proceeded with a background pre-session slide to prepare the audience for interactivity, asking them to assemble in groups of 2–4 people, and with information on CME credits. We then followed with session-readiness activities for participants to practice using the audience response system (ARS) and to assign themselves the role of either surgeon or anesthesiologist for role-playing in the upcoming scenario. To practice, we had participants introduce themselves to their small groups, choose a team name, and then text us their team name using the audience response system. We prepared the audience by informing them of the following simulation cycle procedures: short video, 2 minutes of role-play, 2 minutes of discussion within small groups, then use the audience response system to text their group response. The participants would then watch a short 5-minute video of an operating room scenario, followed by 2 minutes of role-play in their group to pretend what they would do as surgeon or as anesthesiologist. After stopping the role-play, participants had 2 minutes to discuss within their small groups what they felt should have been done next in the scenario. They then texted their group-decided responses using the ARS, but review of the responses and discussion was withheld until the very end of the session. The simulation cycle of short video, 2 minutes of role-play, 2 minutes of discussion in small groups, and texting of responses was then repeated one more time. Following the simulation cycles, the simulation experience was completed and we proceed with debriefing. The debriefers reviewed what happened during the scenario, then used the ARS to review what the participants felt should have been done in that setting. Participants were then given the opportunity for further feedback on the case and on the educational session. Please refer to Figure 1 for an overview of the session.

Figure 1.

Slide detailing a simulation session structure.

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Video-Assisted Simulation with Audience Response (VASAR): Procedures and Methods.

Following both the high-fidelity simulation course and VASAR session, participants were given the opportunity to consent and complete a questionnaire for the study. As this is a new teaching modality, the survey was developed by the research group. A power calculation with alpha of 0.5 and power of 80% noted sample size of 12 for HFS group and 24 for the VASAR group. Statistical analysis was performed including ANOVA and independent samples t-tests. The study compiles with the Declaration of Helsinki.

Results

During the study, 19 of 19 participants from the high-fidelity simulation (HFS) course and 51 of an estimated 80 participants from VASAR conference sessions responded to the questionnaire. Forty-two percent of the HFS group and 46% of the VASAR group had previous experience in simulation. The questionnaire employed a 5-point Likert scale from 1-Strongly Disagree to 5-Strongly Agree.

The VASAR data suggest that participants found the session to be useful (96% of respondents) and realistic (92%). Both the use of Video and Audience response systems were felt to be valuable to the session (96%, 92%) and feedback from both faculty debriefers and fellow participants were felt to be useful and non-judgemental (98%, 98%) (Figure 2). Participants reported that they overall would behave similarly in a real-life situation (78%) and that the workshop would help them practice more safely (80%) (Figure 3). Respondents felt an increased confidence for encountering similar situations in practice (80%) and would recommend the course to colleagues (94%).

Figure 2.

A stacked horizontal bar graph showing five point Likert ratings for VASAR interactivity and debriefing items. A stacked horizontal bar graph illustrates VASAR interactivity and debriefing across seven statements. The X-axis ranges from 0% to 100%, with tick marks at 20% intervals. The Y-axis lists: 1) Instructions were sufficient (Ave 4.27), 2) Video use was valuable (4.63), 3) Audience Response was valuable (Ave 4.40), 4) Debriefers′ feedback was useful and non-judgmental (4.53), 5) Participants′ feedback was useful and non-judgmental (4.51), 6) Overall debriefing quality was excellent (4.44), 7) Simulated scenarios were realistic (4.31). Likert categories 1-5 are shown in the legend. Bar labels indicate: Instructions were sufficient, 51% category 4, 41% category 5; Video use, 25% category 4, 71% category 5; Audience Response, 40% category 4, 52% category 5; Debriefers′ feedback, 39% category 4, 59% category 5; Participants′ feedback, 41% category 4, 57% category 5; Overall quality, 44% category 4, 52% category 5; Simulated scenarios, 45% category 4, 47% category 5.

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VASAR Interactivity and debriefing. 5-point Likert scale.

Figure 3.

A stacked horizontal bar graph showing VASAR Program Evaluation responses on a 5-point Likert scale. A stacked horizontal bar graph with five bars and a legend labeled 1-5. X-axis: percent, with ticks at 0, 20, 40, 60, 80, 100. Y-axis lists five statements with averages: Overall, the course was useful (Ave 4.49); I behaved as I would in real-life (4.06); Workshop helps practice safely (4.10); I feel more confident after session (4.12); Recommend course to colleagues (4.49). Bar labels: useful shows 33% category 4 and 63% category 5; behaved similarly shows 18% category 3, 43% category 4, 35% category 5; practice safely shows 16% category 3, 45% category 4, 35% category 5; more confident shows 18% category 3, 45% category 4, 35% category 5; recommend shows 33% category 4 and 61% category 5.

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VASAR Program Evaluation. 5-point Likert scale.

Survey items were compared when available from both HFS and VASAR surveys. In comparison between the VASAR data and the high-fidelity simulation data, there were no statistical differences between responses regarding the usefulness of feedback from debriefers (4.79 vs 4.53, p=0.14, 95% CI: −0.08, 0.60) or of feedback from participants (4.63 vs 4.51, p=0.51, 95% CI: −0.24, 0.48) (Figure 4). The data also demonstrated no significant difference between participants finding the course useful (4.67 HFS vs 4.55 VASAR, p=0.53, 95% CI: −0.25, 0.49), or recommending the course to colleagues (4.63 vs 4.49, p=0.48, 95% CI: −0.26, 0.54).

Figure 4.

A grouped horizontal bar graph showing VASAR and Simulation Likert ratings for four survey items.

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VASAR vs Traditional high-fidelity simulation. 5-point Likert scale.

Open-ended response on VASAR indicated that participants overall felt the session to be interactive (13 mentions) and valuable (19 mentions). Comments include: “very good learning experience”, “Great! Will do this again. Residents should attend!”, and “FUN + USEFUL”. Negative comments were rare, with only a few participants having difficulty with the instructions or wanting a more didactic style lecture or feeling the scenario was not realistic. The overwhelming response from the data, however, is that participants were pleasantly surprised by the level of interaction and simulation possible from the session, with responses indicating the participants were surprised by “the amount of audience participation/candid responses”, “the emotional involvement while watching the video”, and noted it to be “surprisingly nerve wracking”. One participant’s comment that “Video was very high quality and realistic. Interactive texting was smooth and effective. Program organizers were well prepared” seemed to effectively summarize the overall positive response to Video-Assisted Simulation with Audience Response.

Discussion

The study findings indicate that Video-Assisted Simulation with Audience Response can be an effective model for medical education by combining the use of video scenarios, role-playing, team-based learning, and audience response systems. Participants overall found VASAR to be engaging and interactive, with similarity to real-life medical management and an impact on future practice.

However, VASAR cannot replace the full benefits of high-fidelity simulation. The tactile aspect of using medical equipment, realistic environment of a simulation centre, and full crisis resource management concepts used in HFS are not reproducible through VASAR.20–22 However, this study suggests that VASAR can employ some of the benefits from HFS, including role-playing, team communication and decision making, and some level of a simulated clinical experience. Additionally, VASAR requires much fewer resources. At its core, VASAR can be carried out with one instructor, a video scenario, and a pen and paper for each small group to record responses that can be collected and later shared with the large whole group. Audience response systems requiring technology are not required for VASAR, but more easily allows the session to be scalable to larger groups of 100s or even 1000s of participants, and with a potential future benefit: the opportunity for real-time distributed remote VASAR sessions.23–26 VASAR strategies have been employed during a 1-hour grand-rounds session, where a single instructor used their computer from home to interact with participants online. Video scenarios were shown online, participants interacted with each other using small group or “think-pair-share” strategies, and then reported their decision using the Tophat mobile audience response system.27–29 Responses were collected in real-time online by the instructor and used as a focal point for large group discussions. Feedback to this session was also overwhelmingly positive, with interaction between participants in different hospitals and different cities. This suggests a potential future application of the VASAR framework on a larger scale, with formal data that can be collected in future research.

The scalability of VASAR is such that a session could potentially be run with participants in different countries all over the world. This could be examined in future studies. During the writing of this paper, medical education and the world were struggling with the COVID-19 pandemic. Much of medical education and education in general has moved towards increasingly online strategies.30–32 VASAR provides the ability for interactive and simulation education even during challenging academic and societal circumstances.

To the authors’ knowledge, this study is the first in the medical literature to report on an educational model using the strategies of Video-Assisted Simulation with Audience Response. As an initial report on VASAR, there are of course limitations. The empirical findings of this study suggest some benefit of VASAR for medical education, but broader educational implications could be explored through further investigation. VASAR cannot replicate the non-verbal communication and real-time team dynamics of HFS. Future research could include a randomized controlled trial of VASAR vs HFS, or examine longer term educational impacts of VASAR on clinical practice. Additional studies could include larger sample sizes, equivalent comparison groups, validation of questionnaire items, evaluation of behavioural transfer, knowledge retention, clinic performance, and resource utilization. Educational efficiency could be formally assessed with specific analysis of course cost and resource utilization. However, the data indicate the early response to the VASAR model is overall very positive and could provide a framework for medical education in the future.

Conclusion

The study findings suggest that Video-Assisted Simulation with Audience Response can provide an interactive simulated clinical experience which participants find useful to clinical practice. VASAR has the potential to be more educationally efficient with much less resources required compared to traditional high-fidelity simulation. The combination of video scenarios, team-based learning, and audience response systems has the potential to allow for VASAR to be scalable to large numbers of participants and to be distributed in real-time across different institutions and cities all over the world. Future larger, controlled studies could further determine the education benefits and potential applications of VASAR. As our models for teaching and learning evolve at all levels of academia, VASAR may help provide a framework for future strategies to be used in medical education.

Ethics Approval and Informed Consent

The Health Research Ethics Board (University of Manitoba) approved the study with the ID Number H2015:144. All authors demonstrate that they have adhered to the accepted ethical standards of a research study and that all study is conducted with integrity, fidelity, and honesty. All participants provided informed consent prior to participation. The study complies with the Declaration of Helsinki.

Disclosure

The authors report no conflicts of interest in this work.

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