Telesimulation: An Innovative Tool for Health Professions Education

Abstract

Telesimulation is a new and innovative concept and process that has been used to provide education, training, and assessment in health‐related fields such as medicine. This new area of simulation, and its terminology, has its origins within the past decade. The face validity and ability to provide the benefits of simulation education to learners at off‐site locations has allowed the wide and rapid adoption of telesimulation in the field of medical education. Telesimulation has been implemented in areas such as pediatric resuscitation, surgery, emergency medicine, ultrasound‐guided regional anesthesia in anesthesiology, nursing, and neurosurgery. However, its rapid expansion and current use has outgrown its recent description less than a decade ago. To date, there is no unifying definition of telesimulation that encompasses all the areas where it has been used while simultaneously allowing for growth and expansion in this field of study. This article has two main objectives. The first objective is to provide a comprehensive and unifying definition of telesimulation that encompasses all the areas where it has been used while allowing for growth and expansion in the field of study. The secondary objective is to describe the utility of telesimulation for emergency medicine educators in the context of the current evidence to serve as a background and framework that educators may use when considering creating educational programs that incorporate telecommunication and simulation resources. This article is complementary to the large group presentation where this new comprehensive and unifying definition was introduced to the simulation community at the International Meeting on Simulation in Healthcare in January 2016.

Telesimulation, an innovative modality for education, training, and assessment in health‐related fields, has its origins within the past decade.1, 2, 3 University of Toronto surgeons recently described telesimulation as a novel concept that uses the Internet to link simulators between an instructor and a trainee in different locations.3 Since that time, telesimulation has seen rapid growth and has been implemented in areas such as pediatric resuscitation, surgery, anesthesia, nursing, and emergency medicine.4, 5, 6, 7, 8

Telesimulation's face validity and ability to reach learners at off‐site locations has allowed its wide and rapid adoption in medical education. However, its rapid expansion and current use has outgrown its recent description less than a decade ago. Much of the literature in the field of telesimulation expands beyond the early characterization that describes and requires redundant simulation resources at instructor and student locations. To date, there is no unifying definition of telesimulation that encompasses all the areas where it has been used while simultaneously allowing for growth and expansion in the field of study.

This article has two main objectives. The first objective is to provide a comprehensive and unifying definition of telesimulation that encompasses all the areas where it has been used while allowing for future growth. The secondary objective is to describe the utility of telesimulation for emergency medicine educators in the context of the current evidence, to serve as framework that educators may use to create educational programs that incorporate telecommunication and simulation resources.

Telesimulation Defined

Although this area of simulation has gained recent notoriety, the word telesimulation, as well as the overall concept of distance education, have been described prior to the recent characterization.9, 10, 11, 12, 13, 14, 15, 16 The description of telesimulation as linking instructor and learner simulators via the Internet3 is restrictive in that it primarily focuses on the psychomotor domain of learning and requires duplicate simulation resources at instructor and learner locations. The cognitive (thinking) and affective (feeling) domains of learning are also areas where telesimulation can provide value in the field of medical education. Through identifying the similarities among the varying definitions of telesimulation that exist in the literature, we propose a comprehensive and unifying definition. This definition was developed and submitted to the review committee at the Society for Simulation in Healthcare and has been presented to the simulation community at the Society for Simulation in Healthcare International Meeting on Simulation in Healthcare conference in 2016.17

We define telesimulation as a process by which telecommunication and simulation resources are utilized to provide education, training, and/or assessment to learners at an off‐site location. Off‐site location refers to a distant site that would preclude the education, training, and/or assessment without the use of telecommunication resources. This unifying definition encompasses all areas where telecommunication and simulation resources have been used in the past, while simultaneously allowing for its growth in the field of medical education, inclusive of all the domains of learning.

Apply Education Theory to Telesimulation in EM Education

Telesimulation allows the emergency medicine educator to reach learners at off‐site locations by leveraging telecommunications resources to implement the theoretical models underpinning effective simulation. Effective education of adults through simulation requires an understanding of both adult learning theory and experiential learning.

Adult learning theory is premised on several crucial assumptions about the characteristics of adult learners and proposes that they 1) are self‐directed and self‐regulated; 2) are intrinsically motivated to learn; 3) have prior knowledge and experience that can be built upon for learning; 4) form mental models which guide their behavior; and 5) use analogic reasoning in learning and practice.18, 19, 20 Self‐regulated learners require a student‐centered approach, which prioritizes those learning objectives most relevant to the learner.18 Simulation‐based education, because it allows hands‐on practice of skills and promotes community while increasing competency and autonomy, has the power to motivate adults to learn.21

Experiences, either real or simulated, serve as a catalyst for learning, which occurs during the reflection and debriefing that follows each experience. Experiences provide an opportunity for this reflection during which individuals can evaluate, refine, and enhance mental models that guided behavior. The process of having an experience (concrete experience), reflecting on that experience (reflective observation), developing mental models (abstract conceptualization), and then testing that mental model (active experimentation) is based on what is known as Kolb's experiential learning cycle (Figure 1).18, 20 Providing educational experiences to learners at off‐site locations can be accomplished with telecommunication and simulation resources, as the theoretical models that serve as the foundation for effective simulation training do not require the student and instructor to physically be in the same location. Telesimulation allows the benefits of simulation to extend beyond the walls of a simulation center and is particularly useful where there are distance limitations that preclude effective/efficient instruction, time constraints that make travel to learner or instructor site impractical, or a lack of available educators with specific content expertise.

Figure 1.

Kolb's experiential learning cycle.

Demonstrated Applications of Telesimulation

Telesimulation helps develop crucial cognitive, kinesthetic, and psychomotor skills of learners by providing real‐time, hands‐on training that is facilitated by task trainer and/or instructor feedback. Telesimulation in procedural task training has been utilized in areas such as laparoscopic surgery, robotic surgery, ophthalmologic surgery, intraosseous needle insertion, regional anesthesia, and ultrasound.3, 4, 5, 10, 22, 23, 24 Many of these studies have been performed in regions of the world with limited resources that do not have access to costly simulation laboratories, supplies, or trained instructors. Telesimulation has also been used for instruction in critical care fields such as emergency medicine, pediatric anesthesia, and neonatal resuscitation, with some studies utilizing high‐fidelity simulators without the duplication of resources at student locations.9, 25, 26

Several studies have demonstrated the effectiveness of telesimulation in a variety of settings. A study using telesimulation to provide transatlantic medical education to trainees concluded that simulation‐based distance medical training proved to be a highly effective tool in improving emergency medical skills of junior physician trainees and that international simulation‐based training may ultimately provide the most realistic platform for large‐scale training of emergency medical personnel in less developed countries and in rural/remote regions of the globe.9 A military study designed to assess the efficacy and feasibility of training isolated emergency medical personnel at a Naval Hospital concluded that human patient simulation improves perceived preparedness and self‐efficacy in U.S. Navy emergency medical personnel and that simulation and distance education allows isolated medical personnel the opportunity to practice skills unconstrained by time or distance.27 In pediatric critical care and neonatal resuscitation, telesimulation has the Managing Emergencies in Paediatric Anaesthesia (MEPA) course to reach providers in areas previously limited by large distances between training sites.28, 29

Telesimulation has also been used for assessment of off‐site learners with observations of excellent interrater reliability between remote and onsite proctors.30 Assessment tool reliability when used remotely has been described as a key requirement in telesimulation programs allowing for structured feedback between the mentor and mentee.31

Telesimulation has also been used in ultrasound, with studies demonstrating the feasibility of using a long‐distance telerobotic arm to perform ultrasound accurately as well as in studies demonstrating its effectiveness in teaching ultrasound‐guided regional anesthesia to learners at off‐site loctions.24, 32 Telesimulation has also been described as a promising resource in other fields that do not particularly pertain to emergency medicine such as robotic surgery and ophthalmologic surgery.23, 33, 34

Telesimulation can also be used for debriefing, with work in this area describing teledebriefing as the use of videoconferencing capabilities to debrief learners at remote locations.35 This form of debriefing can be accomplished in a cost‐effective and straightforward manner using basic equipment: a Smartphone, television, and an audiovisual connection from the phone to the television.

Benefits of Telesimulation and Resources for Implementation

The aforementioned studies underpin the early foundation for telesimulation and provide the basis for the educational benefits provided to learners (Table 1). Implementing telesimulation into educational curriculum requires (at a minimum) resources that include, but are not limited to, simulation resources (ranging from simple procedural task trainers to high‐fidelity mannequins or standardized patients), telecommunication equipment that allows the capture and transmission of audio/visual data (can range from a simple smart phone, computer, or Web camera, to sophisticated audio/visual equipment within simulation centers), an Internet connection, and software that has teleconferencing capabilities. Although with virtually unlimited options, a few free/low‐cost options to consider include applications such as Skype, FaceTime, Google Hangouts, VSee, and Join.me. With these resources, which most educators are already in possession of or have (free/low‐cost) access to, a telesimulation course can be designed once learner objectives and educational content has been identified and created.

Table 1.

The Benefits of Telesimluluation for Healthcare Educators

Allows for education and training of learners at an off‐site location Allows assessment of learners at an off‐site location Eliminates distance barriers to educational content delivery Eliminates time barriers to educational content delivery Provides added convenience for educational content delivery Confers benefits of simulation beyond the walls of simulation centers Can provide significant cost savings to individuals, programs, and institutions Can provide revenue generation for simulation/education centers Allows for interinstitutional networking and collaboration Allows for the rapid dissemination of new content in medical education

The Future of Telesimulation

Telesimulation is a process by which telecommunication and simulation resources are utilized to provide education, training, and/or assessment to learners at an off‐site location. This comprehensive and unifying definition makes apparent the critical mass of educational research that has been conducted using telecommunication and simulation resources. Early studies have demonstrated the concept of bringing cost‐effective simulation training to learners at off‐site locations, including remote and resource‐restricted areas of the world that would otherwise not have been able to benefit from this innovative educational modality. Still in its infancy, this area of simulation provides the opportunity for innovative ways to provide education to learners of the 21st century and also has opened the door for new research with strong methodologic underpinnings to evaluate and establish its utility in the field of medical education.

AEM Education and Training 2017;1:132–136