Telesimulation: A Paradigm Shift for Simulation Education

Medical education has undergone several paradigm shifts over the past few decades. Specifically, there has been a shift toward educating physicians who can effectively work together as a team and practice patient‐centered care.1 Simulation‐mediated education has been a predominant vehicle for this shift and has been openly embraced by the medical community as a training tool that promotes active learning given its ability to approximate real conditions in controlled environments.2 Medical simulation has been proven to be an effective instructional tool that addresses both content‐ and process‐specific learning objectives, including the development of interpersonal, communication, and problem‐solving skills.1 Interestingly, simulation itself is now undergoing its very own paradigm shift.

In this issue of AEM Education and Training, the authors define telesimulation and describe its potential role as an innovative teaching tool for educators within emergency medicine. The term telesimulation, unfortunately, has not yet been defined in the Society for Simulation in Healthcare's Healthcare Simulation Dictionary.3 Although in its infancy, there is growing literature to suggest that telesimulation broadly falls under distance education and leverages technology to link learners with their respective instructors. To date, only studies that focus on the psychomotor domain of learning (i.e., intraosseous line placement,4 ultrasound‐guided regional anesthesia5) have been described. From an academic lens, however, a clear definition is essential to ensure that this training modality is appropriately advanced and developed. The authors present a cogent definition for the term and 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.”

Beyond simple definition, the authors relate several educational theories to scaffold the application of telesimulation into successful educational programming. David Kolb's widely quoted “experiential learning cycle” has been heavily applied to simulation instruction. In this framework, the learner is immersed in a concrete experience (i.e., simulated scenario); he/she then observes and reflects on himself/herself or others (i.e., the debriefing); the learner is then able to make inductive systematic conclusions or abstractions (i.e., refining frames for his/her clinical practice); which then allows the learner to empirically test the action plans that arise from the abstract concepts (i.e., applying this new practice to another simulation or future patient encounter).6 Kolb's cycle is most often used to describe the practice of reflection‐on‐action, which involves thinking through a situation after it has happened, where learners return “to experiences [they] have had, re‐evaluate these experiences, decide what [they] could do differently, and then try out whatever [they] decided to do differently.”7

Telesimulation demands moving beyond this educational framework, particularly during synchronous learner–instructor interactions. For several reasons, reflection‐in‐action may represent a more prudent framework during telesimulation education. Donald Schon's work suggests that reflection‐in‐action (or simply, “stop and think”) better allows learners to think and reshape what they are doing while they are doing it.8 Reflection‐in‐action is naturally more congruent with the practice of medicine. Crew resource management training would advise that an attending physician call for a time‐out during a patient resuscitation to reflect on actions executed by the team, arrive at a shared mental model, and then collectively decide on next steps. Similarly, a simulation educator may periodically pause a simulation to dissect the events taking place in the moment, asking the team to reflect on what the next intervention should be. Because the instructor may be off‐site during a simulation, it is difficult to defer the debriefing until the very end of the scenario, as vital information may not be captured. Pausing the simulation to debrief during the scenario would address this logistical shortcoming, and in the process allow for learners’ successful repertoire building.8

The authors highlight several advantages that telesimulation may offer, including the ability to deliver training in resource‐limited environments, the opportunity to assess learners remotely, and the potential to circumvent temporal and geographical obstacles to training. The latter is particularly true when one considers the landscape of academic medical centers: increasing mergers with a growing number of affiliate sites.9 With more and more undergraduate, graduate, and faculty learners to train, simulation centers at major academic medical centers will have to explore alternative approaches to offset resource utilization and instructor availability.

The one resource that cannot be overstated for quality simulation education training is well‐trained faculty. Among the list of barriers to advancing simulation in healthcare education is a lack of dedicated simulation specialists and educators.10 The National League for Nursing has identified skilled faculty as a major component to a sustainable simulation training program.11 Telesimulation potentially offers faculty and simulation champions the convenience of remote participation in the setting of increased instructional time, student load, and competing demands. Expanding on this point, with the integration of a telesimulation platform, it is feasible for faculty to provide feedback on learners’ skill synchronously (i.e., live, through the use of technological adjuncts, such as pan‐tilt‐zoom cameras and high‐speed Internet connectivity) or asynchronously (i.e., recorded videos of learners’ skills at the simulation center). There is mounting evidence to suggest that there is consistent interrater and intrarater reliability of delayed video review compared to live assessment of procedural skills.12 Unfortunately, there is a paucity of research of telesimulation in team‐based performance and communication skills; therefore, at this time, conclusions can only be limited to psychomotor skill acquisition.

Not discussed in the article is telesimulation's intrinsic ability to train providers on telehealth delivery. The anticipated shift from fee‐for‐service to value‐based care has created the need to develop new care delivery models that provide for chronic care, as well as acute unscheduled care. Healthcare organizations, practitioners, patients, families, policy makers, and legislators are increasingly recognizing the value added by the integrated use of telehealth. The benefits are threefold: this powerful means of healthcare delivery has the potential to significantly broaden access to healthcare; increase efficiency and reduce cost; and enhance patient safety, quality of care, and patient outcomes.13 Telehealth can potentially lead to a 40% reduction in unplanned hospital admissions.14 The introduction of telehealth and telemonitoring will require new skills, roles, and responsibilities.14 In the setting of this increased demand in telehealth services, telesimulation and its related training opportunities are well poised to bridge providers to adopting telehealth as a realistic medium for health delivery.

While telesimulation offers a vast array of educational advantages and opportunities, instructors need to proceed with caution and be mindful of learner audiences before any instructional design changes are made to educational programming. The Dreyfus Model of Skill Acquisition, which breaks down the process of practical skill acquisition into five distinct stages, may be helpful for educators as they consider using telesimulation as a training option.15 The Dreyfus model describes how learners acquire skills through formal instruction and practice, from a “primitive” form to a “sophisticated” form.15 Learners pass through five distinct stages: novice, competence, proficiency, expertise, and mastery. By developing sophisticated forms of recall, recognition, decision, and awareness, learners move from the rule‐based, analytical novice stage to the intuitive, experience‐driven mastery stage for a particular skill.

Based on the learning objectives of the simulation, combined with the logistic parameters and restrictions imposed by the nature of telesimulation, instructional designers will need to be cognizant of the specific learning needs of their trainees. In instances where novice learners will require handholding and guidance, telesimulation may not be a logical selection as an educational adjunct. There is a limitation to the scaffolding telesimulation can provide at this stage in their educational development. Conversely, telesimulation can appropriately challenge learners at the higher stages of mastery, where they are less reliant on rules and guidelines and can apply analytical approaches during new situations or simulations.

So long as educators are mindful of its nuances, telesimulation represents a new frontier in medical education, ripe with opportunities in innovative application and research. As telesimulation grows out of its infancy, educators and professional societies will need to develop best practices and competencies that will guide its meaningful integration into successful learning experiences in the health professions.

AEM Education and Training 2017;1:137–139