key: cord-0061080-vo977ib3 authors: Clark, Lou; Woll, Anne; Miller, Joseph M. title: SP Methodology Reimagined: Human Simulation Online date: 2020-10-16 journal: Comprehensive Healthcare Simulation: Implementing Best Practices in Standardized Patient Methodology DOI: 10.1007/978-3-030-43826-5_18 sha: f301df65c78bd28bf6ba6c0992c08175b832df2d doc_id: 61080 cord_uid: vo977ib3 On March 11, 2020, the Coronavirus also known as COVID-19 was declared a global pandemic. Citizens of countries around the world were directed to shelter-in-place as increasing numbers of people became infected and have died including frontline healthcare workers. At the time of the writing of this chapter nearly 180,000 Americans and more than 800,000 people worldwide have died. During this time employees who were fortunate to be able to work remotely were directed to do so from home, including many simulation professionals working for academic institutions. Most face-to-face educational activities stopped and SP Educators (SPEs) across the United States and the world needed to pivot and mobilize as quickly as possible to bring simulation activities with SPs online to keep learners progressing while safely implementing operations for all stakeholders, including SPs. Safety is a guiding principle in Domain 1 of the ASPE Standards of Best Practices and is paramount in discussing SP work during this pandemic. Given that SP activities are primarily face-to face encounters, prioritizing their on-the-job safety was of the utmost importance and the ethical choice. This chapter details how SPEs trained and implemented fully online SP activities for health sciences learners as part of the COVID-19 response. However, while COVID-19 was a stimulus, it has highlighted new potential and opportunities for SP based curriculums using online platforms as part of a collaborative educational design process. It is likely that online SP training and events will continue as innovation born from this crisis. Therefore, we offer and advance the definition of human simulation online as simulation designed to teach or assess learning objectives via any human simulation/SP learning activity that may be effectively planned and implemented synchronously (live) in online platforms. This chapter was not supposed to be the last chapter of this book. The original intention was to conclude the book with the previous chapter in which 14 SP Educators (SPEs) put forth their ideas to imagine what the future of our profession may entail. The tangible suggestions for professional growth in our field detailed in the previous chapter include: To think expansively, beyond individual SP encounters with learners to apply our best practices to systems-based problems; saying "yes!" to growth while being mindful of our well-being; ways to collaborate with our technical simulation counterparts to ensure that human simulation methodology is skillfully partnered with virtual modalities and augmented reality; to advance SP Methodology as a means of advocating for social justice; and to continue to promote socially sensitive human interaction, connection, and engagement to improve health and society. Little did we know how quickly these tangible suggestions would become key tenants of a new reality. We received the proofs of this book in March 2020 but knew our work was not done. On March 11, 2020 , the Coronavirus also known as COVID-19 was declared a global pandemic [1] . Citizens of countries around the world were directed to shelter-in-place as increasing numbers of people became infected and died including frontline healthcare workers. At the time of the writing of this chapter nearly 180,000 Americans and more than 800,000 people worldwide died [2] . During this time employees who were fortunate to be able to work remotely were directed to do so from home, including many simulation professionals working for academic institutions. Most face-to-face SP activities stopped and SPEs across the United States and the world needed to pivot and mobilize as quickly as possible to bring simulation activities with SPs online to keep learners progressing while safely implementing operations for all stakeholders including SPs. Safety is a guiding principle in Domain 1 of the ASPE Standards of Best Practices [3] and is paramount in discussing SP work during this pandemic. Given that SPs are typically on-call temporary workers-who are sometimes classified as employees though not always as many institutions classify SPs as independent contractors-prioritizing their on-the-job safety was of the utmost importance and the ethical choice. In the U.S. this is due to the fact that there is not a national healthcare plan for all and many institutions that hire SPs do not provide a guarantee of health coverage should they become injured or ill as a result of their work, so working with SPs online in the COVID-19 response was critical to their safety. Components in this chapter are intended to 1. Equip SPEs with the knowledge and practical tools necessary to train and implement events with SPs in fully online platforms. Doing this successfully requires both a philosophical as well as logistical shift from faculty and SPEs. Specifically, SPEs and their stakeholders must work collaboratively and intentionally to decide which events may best be implemented online and which, out of necessity such as a graduation or certification requirement, must remain as on-site events. 2. Discuss the necessity for the collaborative design of online SP curriculum, 3. Provide a brief review of the relevant existing literature on telehealth and telesimulation in which we situate our definition of human simulation online, 4. Share the transcription from the presentation "Zooming with SPs in COVID- We conclude with a call to action for further collaboration in support of our community of practice and continued profession-wide success. Partnering with SPs utilizing online platforms is not a new phenomenon. Some SPEs have, for well over a decade, been exploring the possibilities of training and implementing human simulation events online [5, 6] . Early efforts concluded that online training tools are useful for human simulation implementation but still an emerging field [7] . The concept of virtual (digital) patients has gained popularity over the past decade to further standardize clinical scenarios [8, 9] . For the purposes of this chapter we use the term virtual patient for digital avatars that represent patients in a computer-based and programed scenario. A virtual patient is distinctly different from the online SP. The online SP is a live-human interacting with learners and the computer is the conduit/platform/tool used to communicate. Therefore, we offer the following as a clarifying definition of human simulation online as simulation designed to teach or assess learning objectives via any human simulation/SP learning activity that may be effectively planned and implemented synchronously (live) in online platforms, (e.g. Zoom, Cisco WebEx or other video and audio conferencing software-based programs). A key part of this definition of human simulation online is that it is occurring synchronously versus virtual patients which are designed for asynchronous use. It is important to note that the Human Simulation Continuum Model and SP training methodology as discussed throughout this book may be applied in training and implementing human simulation online with SPs. At this point it is also essential to distinguish between the terms human simulation online, telemedicine and telehealth. Human simulation online is a modality that may be utilized to teach or assess learning objectives pertaining to telemedicine and/or telehealth. To clarify the difference between the latter two terms which may inadvertently be conflated or used synonymously we borrow these definitions: "Telemedicine (the use of technologies to remotely diagnose, monitor, and treat patients) and telehealth (the application of technologies to help patients manage their own illnesses through improved self-care and access to education and support systems) are being applied and combined to create new ways to deliver care. When properly imple-mented, the broad adoption of connected health has the potential to extend care across populations of both acute and chronically ill patients and help achieve the important policy goals of improving access to high-quality and efficient health care" [10] .Telemedicine holds potential to mitigate clinical shortages [11] and recent advances in working with SPs to meet telemedicine learning objectives include a project with nurse practitioners [12] . SPEs have skillfully worked with SPs advance telehealth training opportunities for interprofessional education in diabetes to nutrition and dietetics and exercise physiology students [13] , and in educating nurses in telehealth skills [14] [15] [16] [17] . As the terms telemedicine and telehealth are often conflated or inadvertently used synonymously, it is key to complete understanding of the remainder of this chapter to define each concept and to distinguish them from human simulation online. Additionally, and finally, the term telesimulation must be considered in relation to human simulation online. Telesimulation is defined "…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" [18] . While telesimulation may include human simulation-this modality does not need the presence of a live, human being in synchronous time interacting with learners to qualify as telesimulation. Human simulation online requires that a human participant be present interacting and connecting with learners synchronously. Therefore, human simulation online is the best term to use in describing the innovations outlined in the remainder of this chapter. On March 20, 2020 our M Simulation team at the University of Minnesota successfully held its first fully online simulation education event with 15 graduate nursing students who participated in standardized patient (SP) encounters. Since that time and at the time of this writing we have implemented more than 1000 contact hours with more than 700 learners operating at approximately 50% capacity for regularly scheduled programming from March 20, 2020 through May 25, 2020. We anticipate this capacity will grow and have not turned away stakeholders seeking to implement online simulation. In addition to supporting UMN learners and faculty, M Simulation hosted the live webinar "Zooming with SPs" [9] on March 27, 2020 with 300 participants in attendance to train other healthcare simulation professionals to implement these events in order to continue their operations [10] . To date this recorded presentation has been accessed more than 1000 times from over 35 countries around the world, (the recording is available on our M Simulation website) [4, 19] . We have nothing to disclose in relation to any products, including Zoom, which are mentioned in this chapter. There are many online platforms that may be used for this work (e.g. Cisco WebEx, GoTo Meeting, Google Hangouts Meet, join.me, BlueJeans, Cisco Jabber, TeamViewer, and Adobe Connect) but for the purposes of this chapter section we will refer to our work with Zoom as it is the platform utilized by our institution. As with all the SP training methods and knowledge that has come before this time, our work requires the ability to sensitively interact with our colleagues while incorporating new technology. Lou: I'm Lou Clark, Executive Director of M Simulation at the University of Minnesota. And today we welcome you to this presentation,: Zooming with SPs in COVID 19 Response: Using Zoom to train SP's and implement formative OSCE's with health science students. (Next slide.) Lou: We have nothing disclose. I think it is incredibly important to say, we have absolutely no stake in Zoom as a company. Like many of you we are just using it to try to make the events happen. None of us have a relationship with Zoom. Lou: Today, you the audience, it is so important you're here and we're so happy you're here. As I've mentioned, and if some of you are just signing on, please sign into the chat so we can provide resources and follow up with you. If you could please include your name, your institution, your email address. We'll get back to you and disseminate. Please keep your video and audio muted during this presentation. It will be easier because we have many people now. It will be easier for you all to focus and it'll keep the noise and the sound of distraction down. We ask you to please hold questions until the end and then type them into the chat function. (Next slide, please.) Lou: I wanted to share this is our entire M Simulation team, (referring to a slide with the team roster). For those of you who have smaller programs, I don't want you to get a lump in your throat and say, "Oh my gosh, how can we do that? We do not have this size of a team." I do want to share that it was important to put the whole team up here to acknowledge them because Joe and Anne and I are representing the work of many, many people today on our team who've done a wonderful job coming together and mobilizing this effort in less than two weeks. It's important for you to know that at least five of the people up here, are part-time, very, very part-time workers. But again, thank you to our team. Lou: We also want to acknowledge that we have had tremendous partners in leadership and our communication team, on our faculty, one of our wonderful doctoral students in the nursing practice program has agreed for you all to see her video today. We have a Simulation Oversight Committee that provides guidance for us representing the health professions across the University of Minnesota. And we want to thank them all. We could not be doing this and mobilizing this as quickly as possible without the support of so many people. And I think this speaks to the fact that each of you at your institution, please reach out to your leaders. Reach out to your constituents if you're not already and get them involved, let them help you with this effort. (Next slide, please.) Lou: With that, I want to introduce what we're up to. So, we are offering a session today about Zoom that the session is designed to be the first in a series. And the series is geared towards sharing information with our community about how to utilize online platforms to train and implement and keep our events going. Though it's in response to COVID 19, but the idea and the title of the series of healthcare simulation online-COVID 19 response in 2020 and beyond. I think the beyond part is so important because we will get beyond this, and when we do we know already, many of us, all of us probably know that what's happening now and how we're being called on to adapt our learning to educate our healthcare providers and workforce is so critical in this time, but it's going to change how we do it in the future. So, we need to mobilize. We need to see that those opportunities are there and they're going to be there when this time passes, and it will. One of the things that we decided to do was we also decided to record all of the SP training sessions because we had that functionality with Zoom. Our standard protocol is not to record all of our sessions. We needed to consent our standardized patients at the very beginning and make everyone aware, as well as the staff and faculty that were joining those training sessions. As a positive. we now have recorded all these training sessions moving forward, which is going to be really critical in helping with any one-off sessions or any retraining. We asked the standardized patients to minimize distractions. I think some of you might have just heard my dog bark. So, we asked them to try to make sure their pets were elsewhere and do the best that they could really have a focused environment that would be conducive to learning. And really partnering with us as well as thinking about that for the events with the students and making sure that the student really has their full focus. We kept it simple and consistent. We tried to make sure that we were following our typical protocol and our format that we did. Then really, we found that it was critical to use demonstration and role-play via technology. The use of video is something that was accessible to us. What we really wanted to make sure of, was that we demonstrated for the patients first and then also had them do roleplay with the technology. So, they got the flow and the cadence of speaking through technology and really not speaking over each other. Lou: So, I'm going to talk about SP training observations. I was fly on the wall for this training, enjoying it, seeing how it was going. But before I do that, we had a message come in over the wire and I'm going to reach out to my technical lead here, Joe. And this is happening in real time, we're going to see if we can work on an adjustment. We have heard from our Associate Vice President Carolyn Porta that we are capped at 300 participants. And is there any way to manage that, Joe, I'm going to throw that over to you. Joe: Just saw that. Lou: I'll keep going on these observations. If you have colleagues who are trying to get in, this is us trying to troubleshoot, Zoom in real time. I thought that be kind of fun to throw out there to the group and I'm going to keep going though SP training observa-tions…So, activity in an online format actually required four SPs rather than seven over two days. So, seven were originally scheduled but only four to do it online, were required. So, I'm going to come back around to that, but I was thinking about that right…in a Director role-as cost. I'm going to say more about that in a minute. The first hour of a two-hour training session wound up being spent on technology in relation to logistics. And this was our first time. So, I know this is going to get more streamlined as we go along, but it was something to consider. So, when I thought about the fact that four SPs were hired rather than seven. In your initial implementation, it would probably be a good idea to allow for a longer training time. Lou: I also observed the SPs and their feedback at the end of their training. So, all four had something to say. The first one talked about the opportunities that this new online training format presented, which I thought was terrific. And how they thought, wow, this is probably reflective of what's happening in health care and what's needed in healthcare. I thought that was so insightful from one of our SPs. Then another one mentioned the concern that online delivery of SP performance is authentic so that it's useful. She wanted to make sure her portrayal was authentic. We hear that in face-to-face settings, and we have evidence supporting that [the effective adaptation of this in the online setting] later in the presentation. We had another one [SP] talk about how narrating the physical exam findings is totally new. So, they wanted to make sure it didn't sound rehearsed or sort of scripted as opposed to handing a physical exam findings card. And I thought that was particularly interesting because I think we, you know, we all know it. You've got to suspend disbelief and break that fiction contract when you hand that card out anyway, so I thought that was something kind of interesting. And then finally, our last one [SP] discussed that she wasn't as challenged by the portrayal aspect of this, that she really was concerned that she wanted to be able to offer meaningful verbal feedback. And I thought that was interesting as well because that might come up in a face-to-face training. So that's what the SP's had to say. Anne: Thanks, Lou. I think it's important to re-emphasize the piece that you mentioned at the start, which is our staff had very limited experience with Zoom prior to a week before this project. And so we tackled this on-boarding experience as a team because we knew we needed to figure it out together very early on. In looking at Zoom, we had started to conceptualize using the breakout rooms as exam rooms, but we really didn't know how to do that. And so we tackled that by scheduling two 60 to 90 minutes Zoom meetings where seven of our staff members simply practiced with the settings and flow, worked closer to moving people through the Zoom space like we would for the actual project. And so, it was very much a collaborative discovery approach. Most of our energies were focused on understanding the nuances of breakout rooms and of the host controls because that's where we felt like we had the most to learn about making the flow work as we intended. What we quickly conceptualized in terms of a framework that would give us some of the same features in this virtual space as we had relied on in our physical space, was using the main session. Again, we're all in the main session right now in Zoom, that's where the learner pre-briefing would happen. And then we knew we needed to schedule four breakout rooms within the meeting. One for each of the SPs playing the abdominal pain case on that Friday. Another breakout room would be where we would move the learners to debriefing. And then Joe had a really great idea that we needed a space as a team to be able to talk openly, to troubleshoot on the spot. Because this was our first time doing this, we weren't sure what we were going to need to solve. And so, creating an additional breakout room for the M simulation staff-our team-to openly dialogue has served us really well. Additional things we discovered, we identified essential settings for learners to replicate. Essentially what would be a telehealth screen. Right now, we're seeing a lot of screens or we have the potential to see a lot of screens on Zoom. We felt like that could be a real distraction. And we wanted our staff to be able to be in these breakout rooms where the encounters were taking place without taking up real estate on the learner screen or distracting their attention or making them feel extra observed. We also figured out a waiting room, which you all got to experience as part of this. That gives the host of Zoom some control over who enters that meeting space, or in And we really approached this from the standpoint of let's over resource this from the beginning because this is new. We don't want to fail. We're a group that wants this to be perfect. We want this to be seamless. We want people to have a good experience. So, let's make sure we feel supported by each other and doing the best we can for this. So, the Zoom host is who we've been calling the driver, Joe is driving today. He's admitting people into the main session in our simulations, the driver also moves individuals into and in-between breakout rooms. They're managing the timing. So, we have a different strategy in our center for that. Host will manage timing. They can create broadcast banner messages that get sent out and appear as text in the breakout rooms. That's a helpful strategy in timing. And they're also providing technical assistance and troubleshooting. So, we put some of our most tech savvy people in this role to get started. We also had one individual facilitating the pre-briefing and debriefing, which freed up that individual to observe the encounters. Because we did a pre-briefing at the very, beginning of the simulation and at the very end, after all the cohorts had been through. We also felt like we wanted a staff member in each of the breakout rooms to help make audible those text banner messages. So, individuals heard the timing announcements. And we wanted them to be there to provide technical troubleshooting. So, we assigned them as a co-host role within Zoom which allowed them enhanced functionality. And then, as we always do with our simulations where we're working with standardized patients, we have somebody in the role of SP lead who's facilitating the SP prebriefing and debriefing, providing oversight for their performance. Generally making sure if there's something happening with SPs we have a point person who can communicate and support them. So those were our preliminary roles. We thought about the 30 minutes prior to the start of the learner prebriefing a little bit differently. We wanted to make sure everybody had established connectivity. So, all of our staff on the projects Zoomed in 30 minutes before. That also gave us an opportunity to use a huddle, much like we do on site when we're all moving quickly between many activities and are managing a lot of details. It's especially important in a new situation with all these new features to review, roles and flow make sure, everybody's clear on what we're doing. We had the SPs Zoom into that same session 15 minutes before the learners. That was our way to get them through in advance of the learners, make sure they had that connection. And we moved them almost directly into the breakout room where SP lead could work on prebriefing tending to any questions, reviewing case details with them. And then we worked on admitting the learners into the waiting room five minutes prior to the orientation, just as we did today, so that they had an opportunity to start getting their technology configured for their needs. You got to experience a Zoom poll. It's the same Zoom poll we used with learners when they entered the pre-briefing space, the main meeting in Zoom. That gave us a quick sense of where people were at with their perceived comfort. So, we could customize the prebriefing, use narrated slides for PowerPoint. It gave the facilitator a chance to think about going a little more slowly over some of the technical information or maybe going a little more quickly and waiting for questions to come via chat. We thought about many of our best practices in pre-briefing for simulation, but we wanted to make sure, particularly for this setting, that all staff members were visible in this pre-brief and that their video was on at the start so we could acknowledge them and introduce them. It felt particularly important so that learners knew that we were here to support them and that they didn't feel like they were being watched or observed in a way that had some other quality to it, and that it really felt more supportive to them. Our second slide in the pre-briefing actually focused on technical settings. We wanted to make sure everybody got their technology squared away in the beginning. We recommended specific features for their setting to best replicate the telehealth pieces. So, we had them choose speaker view. We asked them to disable the non-video participants. That allowed our staff in the breakout rooms to not appear on their screen. And then we gave them instructions when they got into the breakout room that they should pin the SP video. That makes the SP video appear across the full screen and gives a student a better view. We weren't sure what size devices people had, so we thought this was a particularly important piece. But just as we do on-site, we apply best practices around goals, describing the assessment, the ground rules, the fiction contract, the logistics. The one piece we don't normally reveal during the pre-brief are the learner instructions. And we're still working out how to do that in Zoom and would love to get feedback from all of you if you've got suggestions. We opted for revealing them on a slide in the final two minutes of the learner pre-brief. We ended up needing to truncate that a little bit for how much content we might normally put in learner instructions. Again, if somebody was using a smaller device, we were sensitive to how much text was on the screen and we also made sure to narrate them. So, if anybody was having any visual issue on reading the instructions, they were getting the verbal piece as well. And immediately after the first two minutes, the first round of students was sent into the encounter. A few tips or strategies we've learned about the pre-brief. I'm experiencing this now as the person sharing the screen. It's difficult to have other Zoom windows open. They tend to cover some of the content on the slides. And it's hard to be focusing on your slide content and monitoring chat and taking attendance. It's really helpful just as we've assigned roles among our team today, it's helpful to have other people support that. It's been very effective to have one person monitoring the chat, especially in some of our larger projects, and interrupting or interjecting those questions in a timely and appropriate manner so that the facilitator of the pre brief can respond to those. Also, we'd suggest preparing for the possibilities of connectivity issues as a facilitator, important to save any necessary files locally that just takes one variable out of the mix. We all have these slides up on our computers right now. Should something happen with my connection and other team members prepared to step in, has those files. And that's a strategy we use in the pre-brief as well. And you don't see it right now, but Joe as our host is doing what he's done in our simulations as well. He′s continuing to monitor the waiting room for late arrivals or anyone who needs to re-enter. That's particularly important in the simulations. If somebody loses their connection, they are going to need to rejoin the meetings, so somebody's got to be on the lookout for that. And that level of coordination is best handled by somebody who can be tuned into the technology features. I am going to turn it to Joe to talk more about our encounters. Joe: Thank you Anne. We have some great comments actually going on in the chat, so we'll get to those at the very end. A lot of good ideas are coming up as we're going through this presentation. So that's really, really helpful. So, at this point, we were ready for the encounters to begin. One of the things that I wanted to let everyone know is that before orientation was complete, the [Zoom] driver really does need to make sure that all necessary staff and team members and faculty have the particular privileges within Zoom that they need before we actually do this. So, you want to make sure that you create cohosts for this meeting. Anne and Lou are also cohosts. So again, it solves a little bit of that connectivity issue so that if for some reason someone drops out of the OSCE, the entire event or the entire meeting is not compromised. The other thing to think about with the breakout rooms, if you make someone a cohost, it allows them to move independently between the breakout rooms. You'll need to assign them first to their very first location. But then from there, faculty can jump between the four different exam rooms, go into the debriefing room, come back to the orientation and go back and forth kind of unobtrusively to the learner, but also independently for themselves. So, they can do what they need to do to really observe the experience and really get as much as they need to for that debrief. Once we're ready to do that, the driver opens the breakout rooms. All Zoom participants must be assigned to a breakout room or moved with the learners. We chose to not pre-build [the breakout rooms]. One of the features of Zoom is you can pre-build a schedule based on where the participants need to go. We chose to move the participants as opposed to build them. But we also made sure all faculty and our staff had the co-hosting privileges so they can move independently throughout the project. As we're ready to go, I let the learners know that we were ready to move them to their exam rooms. Excuse me, at the completion of orientations, we did that. (Next slide, please.) Once we had them all in their rooms, we broadcast a message across screens. One of the things that we noticed about the broadcasting messages was that the message is rather small on the screen and it disappears fairly quickly. So as Anne mentioned before, we chose to have a staff member assigned in the breakout room. To also manage those cues. If the learner missed that come across their screen because they were making a note or there was something that happened, one of our team members would unmute their audio and simply say "there's two minutes remaining" just to make sure that the learners were cued into every aspect of the simulation. You can see here that we did a beginning, two minutes remain to start the patient feedback and the end of the encounter. In our SP training session, we also queued the standardized patients to be essentially another mechanism that's in place to help safeguard against the learner going over time. And so, if needed, when it got to that feedback portion with the patient, the patient could have stopped and said, you know, I think they called time. We're going to go ahead and start feedback. So, a couple of different things there with the broadcast messaging as well as the verbal announcements. Once they were done with their encounters, we went ahead and moved them into the debrief room. We had three more rounds to get through before we did a final group debriefing of all 15 learners. So, the learners were instructed to wait in the debrief room and they could work on other things until we're ready to start that process at the very end. One thing to note is that the breakout rooms can be a lot to manage. And one of the things that we figured out was that depending on the number of learners per group or depending on the project, you'll want to be specific around how many breakout rooms you actually schedule or craft based on the planning meeting with your client. Joe: We're going to go ahead and show you a quick video of about three minutes of the experience with a learner that has agreed to let us show this. This is going to focus primarily on the physical exam portion, which is that narration that we talked about. And really why we thought this was helpful is that you get to see the standardized patient (SP) and the learner (LR) have a little bit of a negotiation, if you will, of how to make this work. And you can see, even though it's not verbally said between the two of them, you can see the give and take between them and how they manage this interaction. Joe: So, we're going to go ahead and stop there. So, you were you able to see a little bit of negotiation happening between the learner and the standardized patient. And really working through the trial or the first time with this narrated physical exam and this queuing sheet that the standardized patient used to help the learner get information they would normally get her elicit from their physical exam. Anne: So, as we moved into learner debriefing, we planned and did use the same debriefing strategy that we often use for larger group debriefings, which is based on modified plus delta strategy. And I was concerned I haven't facilitated a lot of debriefings in a large online group and wasn't sure how students were going to manage kind of talking over each other. And it's nice to have an organic conversation with the students. And so, I previewed for that. I said we're going to try to create an open dialogue here. If needed, I will step in if there's confusion over who can talk. But let's just see if we can co-facilitate this as a full group. And by and large, everybody was very successful doing that. As you can see, we covered a lot of the same types of content that we would have covered if this were a faceto-face interaction. There was an additional emphasis on the telehealth piece of how to navigate the online experience. But a lot of positive takeaways good contributions across the group. The first adjective that a student shared about their overall simulation experience was "smooth", which was really interesting. I was expecting to hear "awkward" or some other descriptor. And really what that told us was, despite that there might have been a few glitches behind the scenes that we were managing, that we knew about for the students, this really worked. And that was really exciting. I also want to point out that this is data that was captured in the whiteboard feature in Zoom. And so, I was facilitating debriefing and Joe was managing the whiteboard. And that allowed me to put the gallery view up so that I could see all of the 15 participants and their faculty members and could better have that exchange back and forth and still capture this content. So, it's available for the students to see and for us to have after the fact. We also routinely ask our students, and learners to evaluate their simulation experiences. We have some specific telehealth items, but these are items that we actually assess across all simulation projects [in which telehealth applies]. I think it was really encouraging to see how much agreement and how much strong agreement there is across these really important simulation categories. That it was realistic enough that it felt applicable to clinical practice, that they could work outside their comfort zone. That in the debriefing, even though we were in this gallery format in Zoom, they were able to learn from the experience and that they feel more prepared to manage these kinds of clinical situations in the future. And this global item, this was a useful experience-85.7% strongly agreed that it was useful. That erased any doubts we had about our ability to keep working to make this better, and that it is useful even if it's not perfect. We also asked for some comments from students, and these are verbatim off of their evaluation. We asked them to rate the three best things students said, still able to have the SP, even though at home. Seamless flow of experience. Being able to do it without having to come to campus. I think that speaks to the future. Getting to experience the role of the provider in a telemedicine environment. Really important. We didn't see that as an initial goal, the feeling of being back and clinical. And that certainly speaks to where students are out with their lack of access to clinicals and how we can play an important role in that and reaffirming my thought process with others through the debriefing. So, debriefing can still be really effective and important for students in this setting. We also asked students what to change. We wanted to know how we can continue to make our simulation experiences better. And this is some of what they had to say. I think there should have been a five-minute prep time before the first group had to go. As I mentioned that first group up after that two minutes of learner instruction got whisked into the encounter. They didn't have that walking time to get to exam room four or six. They had to go right in. So that's something to think about. Patient information should be shared at the beginning of the breakout room. We're still working on that and I think the chat will hopefully give us some good ideas and perhaps conversation after this as well. Longer visit times for a first-time…[online simulation]. We didn't think about that feature, but as we're continuing to work with faculty and adapting additional programming, that's something we're starting to discuss. Do we have an opportunity to increase time because this format is new and because this format might take a little bit longer where you can't talk over each other quite as easily or effectively? More clarity about physical exam instructions. So physical exam worked. They were able to have really positive evaluations and learn from the experience but just as you saw, there are some things we can do for training, for case development and instructions that can help that process as well. Debrief with the cohort instead of waiting until the very end. So, we waited for all four cohorts. That was very much a staffing choice. We had all of our staff deployed, or many of our staff deployed supporting the rooms. That's certainly something to be considering is what are students doing in their downtime? And my favorite opportunity to change is more frequent opportunity to do this, which is a great thing to change. Joe: And so, we also focused on the debriefing of the standardized patients. Our simulation team employed and is using the emerging standards of best practice. We have a high emotion and a low emotion debrief checkout form…We will sometimes choose to do that verbally and written. Lou: So again, my observations. I really want to reach out for a second to all of you, in particularly leadership roles, the most important thing you can do for your team is to say "it's okay not to be perfect". This is new. Give people the freedom, the lightness, the creativity that this community has-to work together and to make it happen. And as we're doing, you will find your way as you go. But it's still important because all of us take this very seriously to give that permission, to say it out loud, to say it is okay. You can see here it's a little bit hard to read, but I'll just give you the basics that we decided to go from four to six breakout rooms. And you can see that we have four learners per breakout room, they were put into pairs. There are two active participants and two observing participants. The observers had a role or a guide that they were filling out while they watched the encounter. This one also took a next step for us in that we moved the learners between two different cases, a large animal and a small animal case. So that was something that added another layer of complexity. And then they were also moved from there into the debrief and we had rolling debriefs for this one. So, you can see here we decided to take those next steps in certain key areas. Now, as the person who hosted or drove for this simulation, I can tell you that trying to move 24 or 48 participants at one time, to different breakout rooms can be particularly challenging. You're able to do it. And we were able to do it. I would really encourage you to be mindful about that and think about the time that you allow between encounters. Because we were able to make that happen, it just had to buffer a little bit of the time there. So that was a big consideration. We also were fortunate in that with us having created an SP lounge or a staff or a fac-ulty breakout room in the very first simulation. When we got to this one, we needed that extra room to actually move participants. So, I moved with participants from six into this empty room. And then you can move five to six and so on, so that you weren't moving learners into a room where other participants were already in there as we move through this process. So, as you're thinking about multiple encounters for learners, or multiple stations that they'll go through, definitely consider additional rooms so that you have that moving factor. And then, I think one thing that we mainly just want to make you aware of is that when you're thinking about scaling up or scaling down the project's really try to situate yourself within running the actual projects to see exactly how many participants are manageable and how that impacts your orientation and your debriefing as well. Joe: So, a few lessons learned here and another was that we figured out that it would be really helpful to use Zoom screenshots for orientation. Especially with the standardized patients, there were tech issues in terms of working through the different devices. And we didn't know that going in, that it's different on an iPad versus on an iPhone versus on a desktop, computer or laptop. So really taking screenshots of all those different platforms, so that you can have those at your ready to share with the patients or the learners are with faculty to really help navigate that. We thought it was really important to pair a tech person with an education person. Anne mentioned some of this in some of our staffing before. But we really made it a point so that to think about people not having too many things to do are extending themselves too far. We had someone helping with the debriefing whiteboard. We had someone driving. We had lots of different people behind the scenes navigating different aspects of this. We also realized that supporting faculty also needed to be thought about ahead of time, and really the orientation to Zoom and creating guides. And creating how-to's for making sure that faculty feel supported and that they're able to move through the simulation so that they can focus on the education. We did rolling orientations, as I said, for the veterinary medicine project, for larger projects that takes more support so really be mindful of that. And this seemed like a small thing, but a timer app became really, really critical when you're trying to manage all these different aspects of these announcements that are being broadcast to everyone without actually being able to verbally announce them to all rooms. And then we also made sure that if the students finished earlier at station, we had the standardized patient mute their microphone in their camera. So, there wasn't this awkward silence where they were staring at each other until our team could get around those rooms and actually in Zoom, moved them to the debrief. And then we're still thinking about better options for delivery of learner instructions. As Anne mentioned, we put those as one of the final slides in the orientation. We have thought about potentially putting those in the chat. And each of the breakout rooms the learner could click on them at that point which might be really beneficial when thinking about patient charts or any sort of other images or files that you want the learner to be exposed to lots of different ways to accomplish this. And we're still thinking about ways that would be successful sites. Lou: I do want to acknowledge we have about five minutes left officially together. We're going to go through the rest of what we have. We should be able to cover it in that time. We obviously had a lot to share with you today. We've had some incredible questions in the chat. I want to encourage you to keep putting your questions in the chat because we will get back to you. We plan to download the chat. We will answer the questions and we'll make it available in a script format for you along with the recording of this session. So, we're going to go ahead and do that, but a reminder to go ahead, keep those questions coming. And also, if you haven't already, please put your full name, institutional affiliation and don't forget to put your e-mail into the chat so we can get back to you. I will answer that we've had a lot of questions on how many staff did it take for us to do this? I will be very transparent. It took 7 full-time people working together to mount this first exploration-this first nursing event which is a great transition into sustainability. We can't keep doing that. 10 days into this, this poor team looked like, "Are you kidding, we can't keep doing this!" and they're right. So, we have support from leadership to explore how can we make this more sustainable. So here come do's and dont's: • Do be mindful of the health and wellness of the simulation team members, it's critical. That's number one. • Do not over schedule events, with multiple events on the same day; we're likely going to have to scale back, you know, and, and that can be a question of priority, but there are creative ways to do that. You might be able to combine And I think that just speaks to our future beyond COVID. And the title of this series ends with the word "beyond". We will get beyond this. I'm so happy to have you all with us today. We want to support you in that, and we are with you. We can't thank you enough for being with us today. Best wishes…and special thanks to our healthcare workers who are putting themselves on the line for us. Thank you all so much. (End of session) During the Zooming with SPs live presentation on March 27, 2020 the attendees had many questions for us that were posted in the chat function on Zoom. The questions are provided in italics with responses from our team below. The questions and responses provide specific details on managing technical aspects of Zoom to implement simulation events with SPs. We used this format so we could preserve the excellent questions our colleagues asked during the webinar and disseminate them for later use. Many thanks to each of our peers who posed a probing question that allowed us to further explain our processes as well as to help refine our processes for human simulation online. We hope their questions and our responses will be helpful to you as well. Is broadcast messaging a feature of Zoom or showed from your screen? Broadcast messages are sent out from the host controls. They are in the breakout rooms feature and you can send as many as you like. We chose to sync this with our timing announcements that we would typically do via a clinical skills software and overhead paging system in person. Were the encounters recorded and who does make the recording? Yes, anyone who is a host or co-host can record the encounters. Because we are part of the health sciences at our institution, we can only record locally on our devices. The full capabilities of Zoom include the ability to save to the Cloud. What number of rooms did you find manageable with how many staff? The answer to this question is somewhat dependent on the project, the number of learners, the formative or assessed nature of the project, and several other factors. As noted in this presentation, our first time implementing an event in Zoom we had seven staff members helping. Since that time, we have been able to scale back from this and, at times, have had one staff member running small events in Zoom. Also, we have trialed breakout rooms numbering from four up to 10. A key factor in the number of breakout rooms is how many learners you have in each of them. If it is 10 breakout rooms but one learner per room, that is more manageable than 10 breakout rooms with four learners per room. How did you, or how will you, address pronunciations during SP PE findings? The course directors provided the verbal findings in a format that more closely resembled written documentation in an EHR. For this event, the verbal findings were written in clinical language. For future events, we have asked course directors to provide findings in lay language, when possible. For necessary technical words, additional time will be spent in physical exam role play during training so that SPs can practice the flow of the verbal findings as well as the pronunciation of words that may be difficult. How were the SPs debriefed? The SPs were debriefed by a staff member who utilized our low emotion debriefing form which asks SPs to answer questions related to the things that learners brought up in the encounter that weren't exactly scripted or they felt unprepared to answer, the things they would change about the case/learners/setup/anything, what part of the simulation was the most challenging for them, and finally what part of the simulation did they think they did best or liked the most. We also specifically asked about comparisons to in person simulations vs. this online method. What were the total number of staff used and number of SPs involved? For both projects in this presentation, we used seven staff members. Four SPs worked on our nursing project on 3/20/20, and six SPs worked on our Vet Med project on 3/23/20. Where were the videos stored? On a computer? Hard drive? Where did you upload the videos to? Because of restrictions for health sciences regarding protected health information at our institution, we can only save Zoom files locally. We are only using University devices to store locally; staff are not using home computers. At our institution, you must also be designated as the host or a co-host to have recording capabilities. We are uploading the saved files to a Box site, which we are told has a higher level of security than other similar media management sites. How long was the SP debrief? SP debrief is typically scheduled for 15 minutes after the final encounter. This debrief took about 10 minutes. In the future, would you be able to share an encounter from the start? I am specifically interested in the use of the breakout rooms and the beginning of the encounter. We are open to sharing more about our implementation process and an encounter video and are considering the best way to do this so any presentation we provide would not be passive. Stay tuned! Did you have any concerns about the SPs not being able to distance from their role, as they simulate it in their own home? (Maybe more important for more emotionally challenging roles). Appreciate this question and for these events, we did not have undue concerns regarding the SPs working from home as these roles were not emotionally challenging or of a sensitive nature. We may choose to use our high emotion debriefing checkout form for sensitive or emotionally challenging cases in the future. This document helps SPs work through their emotions in the simulation, emotions they felt in other encounters that we prompt them with, and how they can leave them behind or strategies for this. No. In order to record each room to a local device, (a requirement with Zoom at our institution due to restricted use in health sciences and protected health information), an individual must be designated as a host or co-host in the meeting. To record each of the four nursing rooms, we had one staff member assigned to be in each of those breakout rooms. That individual was responsible for recording that room. What is the MINIMUM number of staff necessary to run students through this kind of activity? Please describe the role of each staff member. Each project requires, at a minimum, a Host to oversee running Zoom. This individual admits participants into the meeting and can move them through the breakout rooms. From our knowledge, only one person can be assigned to be a Host with this full level of control. We also had the host manage timing and use the broadcast message feature in Zoom to display timing messages in the breakout rooms. As the number of learners and breakout rooms increases, this demand becomes challenging on the host. We had a separate staff member assigned to facilitate pre-briefing and debriefing, for much the same reasons that we typically have a control room operator onsite managing our digital asset management system and a separate staff supporting the prebriefing and debriefing. Beyond those two key roles, project complexity drives staffing needs. Because we can only save locally to University devices (a restriction from our institution due to our location in health sciences and needs concerning PHI), each breakout room must have a staff member if we are choosing to record. The other staffing consideration is providing general technical support. We have found it helpful, when not recording, to have one staff member assigned to two to three breakout rooms to circulate and provide more immediate technical support. This need may diminish as all users increase familiarity in Zoom. Depending on your monitor size and ability to display the learners' video and the whiteboard in debriefing, it can be helpful to bring in one staff member to use the whiteboard while another staff member facilitates the debriefing. Per our standard staffing, we typically assign one staff member to manage the SPs, facilitating their pre-briefing and debriefing and providing general QA. I would like more information about the white board option. The whiteboard is a feature you can utilize via the screen share option. It allows you to dictate the conversation that is happening during the debriefing. We chose to have one person dedicated to filing out the whiteboard. You could think about the feasibility of verbally facilitating the debrief and being the whiteboard scribe. How did you schedule the rooms and coordinate the SPs and students in each room? The host manually moved participants through the Zoom meeting and breakout rooms. SPs entered the meeting 15 minutes in advance of learners, and the host moved them immediately into the breakout rooms. The host admitted learners from the waiting room five minutes prior to the start of the pre-briefing into the main session, and then manually moved them into breakout rooms at the correct time. The SPs remained in their breakout room, just as they would remain in their exam room in our simulation center, and learners entered per the schedule. The host moved learners to the debriefing at the conclusion of their stations. The university provides us with the Zoom Enterprise feature. The Zoom Pro version has limited features including less participants (up to 100), a maximum meeting length of 24 hours before it times out, along with several other features. https://zoom.us/pricing has a comparison tab that speaks to features and pricing. We anticipate introducing checklists for SPs in the near future, using Qualtrics, which is an online tool supported at our institution. The SPs could access that tool during a postencounter period. We anticipate allowing more time for this than when onsite using our digital asset management system. Can you share the Zoom education videos? Please see tutorial videos created by zoom at this link (https://zoom.us/resources). What was the level of confidentiality of the case material? All of our case materials are standardly deemed confidential. SPs are given these materials in advance of training and are required to keep the contents confidential. In prebriefing, we requested that learners not disclose the case content to others. Would like to know what orientation materials/explanation you provided BEFORE the event (e.g. emails, etc. even before the live orientation in the main Zoom room) to learners. For the nursing project, learners had simple instructions from faculty regarding the Zoom meeting link and the general purpose. They were not advised of any content or process. These learners had previously participated in simulations onsite on several occasions. For our Vet Med learners, this was their very first simulation experience with us. When learners are new to simulation, we standardly create a broader overview of simulation that we disseminate to them in advance of the project to orient them to purpose, facilities and general processes; this is in addition to a more detailed pre-briefing onsite. For this Vet Med project, our simulation team adapted content for the broader overview in an effort to also minimize the time required to review Zoom features. Each virtual location in Zoom records as a separate video. You have additional control to break a room recording into multiple videos, or you can choose to create one long video (much like a security camera recording). Breakout rooms can be created within the event itself or created in the Zoom profile when you schedule the meeting. The breakout rooms are built according to your need. You can title them whatever you need, and you can have up to 50 breakout rooms in one meeting. You can run the entirety of a project from one account and the breakout rooms would need necessitate a need for more pro accounts unless you need over 50 rooms. We would encourage you to watch the how to videos on Zoom to begin with. That was very helpful in navigating the features on Zoom. Once we knew the features of Zoom, the system is fairly straight forward. We would also encourage you to look into the settings tab of your Zoom account so you can turn on and off the features you want or don't want (like a waiting room, breakout rooms, show controls, etc.). How is it possible to have four students per BR in one time block? Are they going at one time? We implement small group simulation onsite in our simulation facility as well, using a variety of formats to meet different learning objectives and to address different logistical parameters (e.g. group size and time allotment). Most often, we pair learners together, and one serves as the clinician while the other observes; learners can rotate between these roles across multiple stations. We also simulate teamwork but having two or more learners actively work together as clinicians in an encounter, in interprofessional and in single profession simulations. For this Vet Med project, we combined both strategies: two learners were active as the clinician working with the client and the other two were observers. The Vet Med simulation had two stations, so the two learners observing in one station became the active clinicians in the next station, and vice versa. How do you split the screen in the breakout room? The recording captures all participants in the breakout room who are sharing their screen. In the video we shared, the SP and the learner were visible because they both were sharing their screen. That room also had at least one staff member and potentially a faculty member, but they were not visible because they were not sharing their screen. Was the case for a formative OSCE? Were the materials confidential? All of our case materials are standardly deemed confidential. This was a very standard abdominal pain case written calibrated to the level of a second year Doctor of Nursing Practice (DNP) student focusing on adult and geriatric patient care. How do you share the Patient Door Chart? We have been sharing this in orientation on the final slide. This limits the amount of information that we can provide on one screen, as we are aware that learners' devices may have small screens. We are currently working to identify other strategies for doing this that better approximate the timing and format of information that we can provide. What are the steps to verbalize the timing announcements? There is no master verbal announcement. We can send uniform broadcast messages in text to all rooms including orientation room and debrief. We also chose to have a staff member assigned to each room to also say this announcement verbally if the learner didn't see it on their screen. You could also coach your SPs to keep track of broadcast messages and in some instances, they can say some of these. Can you please send the format of your learner instruction slide for the pre-brief? Reason Our institution considers our simulation center as part of health sciences. As such, we have a restricted use of Zoom to safeguard against many potentials policy violations. In our instance of Zoom, only the host and co-host have functionality to record encounters. We do not assign either of those roles to learners. Further, as a simulation team, we only record encounters on approved University devices. None of the projects contain protected health information; these cases are fully simulations. How will the timing change for you all after these two events? Would a full run-through be beneficial in your opinion? Pre-briefing took twice as long as we had anticipated. We are working on creating some screen captures of Zoom configurations and creating an online resource to distribute to learners in advance of the project to expedite the time required to get all learners properly configured. We did not do a full run to scale for any of these projects. Our team had spent the week using Zoom for meetings and three to four additional hours of discovering features, thereby practicing. Time permitting, some level of a full run could be beneficial and may minimize team stress. SP training might be an optimal time to engage in some level of piloting your project. How long did it take to do all 15 nursing students for this session with the breakout rooms? We planned for the same timing that we would have used for the onsite version of this project, using four SPs. Orientation ran long by 15 minutes, and we needed additional time to support learner movement between the breakout rooms. We had planned for three hours, but the project took three and a half hours in actuality. Were there any issues with downloading or accessing recordings after the fact? Downloading video onto our local devices took approximately 15 minutes for a couple hours of video. Staff reported slower operation of their devices until these videos were uploaded onto Box. Files need to be manually labeled for easy accessibility. How were course directors/faculty involved? Simulation development and implementation is a collaboration between course directors/faculty and our simulation team which is comprised of faculty and staff. Our team meets with course directors/faculty to develop the project. We cocreate case materials that meet required learning objectives, and we also consult on the development of any assessment tools. Our simulation team typically leads pre-briefing in the presence of faculty, who contribute by answering learner questions. Course directors/faculty observe simulations; in some projects, they also provide feedback to learners after an encounter. For the Nursing and Vet Med simulations we discussed, our simulation team co-facilitated the debriefing with course directors/faculty; the simulation team facilitates general discussion and faculty contribute clinical perspectives. This chapter section features perspectives from colleagues in the field who are also implementing human simulation online during the COVID-19 response. Our peers responded via email to six interview questions discussing their experience with implementing human simulation activities online before and during the pandemic. Each provides tips for this process. We knew there had to be something done for our students to complete their third year requirements. After attending the virtual presentation done by the University of Minnesota M Simulation team we learned the online OSCE process could run very smoothly. We patterned our OSCEs close to what was presented by UMN. UMN staff took the time on a separate occasion, to share additional information regarding the breakout feature in Zoom, which was extremely helpful. When M3-4 students were pulled from the wards, they were not getting any educational encounters. Also, the pandemic allowed people to see that telemedicine is something that is going to become commonplace in the future, so it makes sense to train the next generation. The Learner Instruction Guide and Technical Abilities Survey from New York Institute of Technology also helped us tremendously. Therefore, we did not need to create those documents, only tweak them to fit our institution. Our greatest challenges have been the need for additional support. We have a small team, and with Room Monitors needed to support the online encounters, we needed to reach out to additional staff. Although staff were very happy to support us, that process took the most time. The course and clerkship directors ensured us that we had their full support. With that support, we were able to provide a very positive experience for our students. Attend the webinars and use the resources provided by other members of ASPE. I would also advise SP Educators to continue to pay it forward, as was suggested to us. We were able to take what we learned, apply it, and help others get started. Education in the coming weeks, months, years? I believe this prepares students for future telemedicine and telehealth visits with actual patients. This situation has given them an opportunity to practice. Our SPs also provide feedback to the students after each online encounter. The student's response to the feedback has been very positive. 6 . What else would you like to add on this topic that I have not asked you about? Don't be afraid to reach out to your colleagues. Partnering up with other schools has helped us to provide timely OSCEs to our students. We have received feedback from the students, sharing their appreciation for a very educational experience, in their efforts to become great College Park, MD Our only online experience was doing makeup case training and feedback modules for our SPs. We had very little experience with online video conferencing platforms except for rare meetings with distant faculty and offsite clients or vendors. Our occasional virtual SP trainings were a mix of conference calls and the training component within our simulation AV enterprise system, CAE Learningspace. We actually had been exploring the use of online video conferencing to extend the reach of a simulation-based preceptor training project we'd partnered on for several years, but that was in the infancy stage when the pandemic hit. 2. What helped you implement SP activities online during the COVID-19 pandemic? Grit, need, a great SP simulation team, and the bravery instilled by watching the early adapters in our fabulous international simulation community. We knew we needed to take the leap to support graduating students in need of clinical hours, provide necessary high stakes exams, to support student learning and overwhelmed faculty, and to prove that online simulation could be stimulating and effective. Diving in without adequate planning created a series of lessons learned. Confused SPs and learners, while grateful for the work and experiential learning, caused a bit of frustration in the beginning. We quickly realized the detail, extra effort and resources required for online simulation. At this juncture, I would say the three things that continue to provide the greatest challenge are: a) test security for summative simulation encounters, b) an easy method for video capture in a confidential, FERPA compliant environment, c) teaching and assessing physical exam skills. Those things are driving the discussions around making simulation an onsite essential function within our university for the fall semester. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? Of course, everyone will say… just do it. Access all the wonderful resources within our professional associations and talk to a few experienced early online adaptors, (everyone is so eager and willing to share, bless them), process the formulas that worked and take a leap. Plan like hell and plan again. Prepare your learners and SPs on formats and procedures -there is big payoff in a simple one-hour tech session. Have written procedures and guidelines. Have faith in your SPs and learners to get it and do it. Just this week we rolled out a videotaped, four station OSCE for 160 medical students and were amazed at how smoothly and effectively it ran. A few unavoidable connectivity glitches, but otherwise remarkably uneventful. The high stakes virtual simulation maiden voyage, a three station OSCE for 140 pharmacy students, we'd run a few weeks prior gave us confidence and a template for planning. It is daunting, but with good prep it can be done! 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? The realization that we can do online SP simulation effectively and relatively easily is a game changer from my point of view. Given the state of the unknown with our current pandemic situation, online simulation will continue to play an important role in safely educating and assessing our students for the months and perhaps years ahead. With the current reliance on telemedicine, SP simulation can provide an ideal modality for training providers. Telemedicine OSCEs can assess these skills. Further, I believe that even if we return to in person simulation in the near future, we will conduct all of our case trainings and many of our formative simulation events online. In addition, the online world expands our ability to schedule large and remote groups of learners, extending opportunities for events that would be otherwise impossible to do live in our limited capacity simulation space. 6 . What else would you like to add on this topic that we have not asked you about? I would add that tapping into the talents and strengths of your team and providing recognition for success is key. It is also critical to realize that online simulation often takes more resources, not less, than in person simulation. SPs can be a great administrative asset in that regard. University of Alabama at Birmingham Birmingham, AL We had no previous experience in conducting online or remote SP encounters before the COVID pandemic began. Our institution had prioritized hands-on clinical skills learning and assessment up to this point. Although the importance of preparing our health professional learners for telemedicine has been an ongoing discussion point, no measures implementing such curriculum had yet occurred. The COVID-19 pandemic has created the large spark needed for curricular change around telehealth as we move forward. We are extremely grateful to the M Simulation group at the University of Minnesota for their global effort to share a rapid and effective approach to moving SP-based training online. Dr. Clark and her team provided, to my knowledge, the first open access webinar addressing the logistical requirements to conduct remote SP encounters back in March 2020. This webinar entitled "Using Zoom to train Standardized Patients (SPs) and implement formative Objective Structured Clinical Examination (OSCEs) with health science students" remains as the go-to resource for information on training and executing web-based SP encounters with learners. The efforts by the M Simulation group was quickly reinforced by webinars from other institutions, such as the University of Michigan, and other organizations, such as the Association of Standardized Patient Educators and the American Association of Medical Colleges. Since Dr. Clark's M Simulation team's initial report, the use of remote SPs for online encounters has allowed us to move forward and transition the majority, if not all, of all our center's prescheduled activities and programming into an online format. Inherent vulnerabilities to online SP encounters are internet access and internet stability. We have encountered issues with either student, faculty, SP, or staff losing internet access during an online event. We quickly learned to need to always have back-up SPs and staff ready in the event someone loses internet connection. We recommend to always plan on recording an SP-learner encounter if faculty cannot be present for observation. I remember preparing for an online OSCE when a severe thunderstorm hit my area. I woke up with no power and a large OSCE beginning at 8:00am! Fortunately, there were enough staff with internet to begin without me. I recommend always preparing for such issues. Another issue is staffing. Although, once the technology becomes familiar, it does not take an army to execute an online OSCE, never put the sole responsibility on one person to oversee the event. That individual could lose internet, get sick, or have some other issue making it difficult to successfully run the online event. Finally, we have a number of SPs who are eager and willing to be trained to participate in online encounters but do not have the technologic capabilities to do so. This is a very unfortunate situation and, depending on the anticipated need for and amount of telehealth encounters to occur as our centers move forward, this will be something that needs to be discussed and addressed. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? My recommendation is to take the plunge and have fun! We initially tested the waters with practice sessions using staff and SPs before we ever scheduled an actual event. We reached out to colleagues with questions and issues and were always supported. We have a wonderful SP Educator community who has your back during challenging times. The high level of support from the SP community gave us the confidence to be in the position we are in now, running online events and OSCEs for multiple schools within our university. It is an exciting time even as we continue to face a high degree of uncertainty of returning to "normal". 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? We are currently witnessing an exciting time in SP work. The need to expand our efforts and think "outside the box" in order to respond to the COVD-19 crisis, has placed new potential and opportunity for SP-based curriculum into the hands of our stakeholders. As the COVID-19 pandemic continues, health care providers are increasingly relying on telehealth technology to provide for their patients. The use of telemedicine has underscored the importance of training health professional students on efficient and effective use of it. We are now seeing SP Centers readied and able to conduct online patient encounters. This provides a wide range of opportunity for all health professional schools and health systems in the training and reinforcement around telehealth visits. This opens the door to a new wave of SP-based programming and highlights the ongoing educational value of SP Methodology globally. 6 . What else would you like to add on this topic that we have not asked you about? Over the past two months, we have been training and employing SPs for online encounters. During this time, I have been truly impacted by something I've observed. When the COVID-19 pandemic first hit, there was a high degree of uncertainty among SPs. They were, understandably, concerned how this would impact their employment and ability to work during the time that the university would remain closed. Once we began messaging our efforts to move to online and remote educational programming, there was such a spark of excitement and enthusiasm from our SPs. By engaging them directly in our positive approach to dealing with the crisis, we helped reinforce their value and worth in educating our learners. Based on comments by our SPs, this reminded them how important they are to our institution and gave them a sense of hope and optimism for the future. NEOMED had begun to explore implementation of SP activities online prior to the pandemic. As part of the buildout of our new simulation center, we had planned to be able to offer tele-SP training, albeit with SPs on-site at the new center. 2. What helped you implement SP activities online during the COVID-19 pandemic? NEOMED is a small community-based medical & health professions university in the Midwest. Honestly, what comes to mind is a quote by Margaret Mead "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has." Flipping an on-site model to a remote platform in two weeks to implement SP Methodology online and continue to deliver medical, pharmacy, and interprofessional education curriculum, required a collaborative dedicated small group of SP Educators, center staff, and faculty. This group worked tirelessly around the clock to provide this just-in-time training to students & faculty. The greatest challenge has been the greatest reward. The "flying the plane while building it" model only worked through the collaboration of a diverse international community of SP Educators & simulationists that we're able share knowledge, lessons learned, and support one another despite the global turmoil and individual and collective emotional toll. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? Reach out to your colleagues and invest in professional associations. Identify mentors through organizations such ASPE that promote and provide professional development opportunities and encourage collaboration. In the coming weeks, months, and years, the SP Educator will play a key role in leading and guiding the application of best practice SP Methodology & the transformational power of human interaction to promote safe and ethical healthcare and human services. None. 2. What helped you implement SP activities online during the COVID-19 pandemic? I was being asked to create telemedicine cases online with video recording for the first time and felt very overwhelmed before I attended your webinar. After hearing how Joe, Anne and Lou did their simulations with Zoom, I not only knew it could be done on the fly but also had a wonderful blueprint to follow. Luckily I had invited a faculty member from one of our off site clients who felt the same way and who needed to find a way to complete a canceled behavior health program (which lent itself easily to a transfer online). In addition, the client had the faculty support to have an observer in each room recording student sessions. We started small and gave ourselves time between sessions so even when we ran into issues, we stayed on time and the students say only a well-run program. • Discovering the roles needed to run a successful program in Zoom. Finding out where backup is needed and how to keep SPs and facilitators engaged. • Learning my own limitations as a Host (in Zoom), delegating tasks, keeping back channel communications going while hosting and finding tricks and tips to help me more easily manage SPs and learners. • Supporting my staff and SPs in Zoom, who are all on different hardware / software / operating systems. • Educating faculty members on the limitations of Zoom recordings and possible FERPA, (Family Educational Rights and Privacy Act) issues when recording to staff or learner or faculty home computers. • Encouraging faculty to adapt simulations and change them from their in-person versions to a way that allows us to easily transition to either Zoom or CAEs adaptation to Zoom. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? • Managing Zoom simulations can be more challenging than the in-person versions of the same events so schedule your program and yourself accordingly. • Create detailed workflows and update them as you go. Define and redefine roles and responsibilities as you go to make sure you create a system that works for you. • I do believe more history taking workshops will be done via tele-sims • Unless we come up with better exam security, I don't believe exam activities will continue • I think it has emphasized the difference between telesim vs. telehealth (which we can simulate…). I do think we will be simulating more tele-health in the coming years. • We will start to use more online training sessionsespecially for first trainings of in-person sims and telehealth encounters. • More collaboration opportunities. We can now start using SPs in different parts of the world for learners to see different demographics. • Personally, now we need to start doing more interprofessional tele-sims. 6 As institutions reeled from the announcement of stay at home orders and the immediate implementation of online delivery of simulation programming in response to COVID-19, there was an almost immediate rise to action within the Standardized Patient Educator community. Leading the charge, at least from my perspective, was Lou Clark who originated the Facebook discussion group, Simulation Online 2020. This open forum provided immediate access to discourse with colleagues around the world exploring delivery options for SP programming. Soon after the University of Minnesota M Simulation team presented one of the first online presentations on how to utilize teleconferencing modalities to structure and deliver SP encounters. The Association of Standardized Patient Educators (ASPE) has continually provided a sense of connected community by providing webinars, town hall discussions and online resources throughout the pandemic. Having guidance and leadership from these individuals and institutions helped propel our institution from "How do we do this?" into the realm of "It's possible and here's how". There is a significant amount of time that was needed to bring SPs up to speed in the utilization of teleconferencing technology. Extra time to initially survey each SP for technology accessibility, comfort level of usage, equipment performance, bandwidth, and connectivity requirements. This also meant certain SPs were not eligible for hiring due to limitations in technological access. Even with best laid plans and testing procedures in place, technology failings and potential user error without the ability to provide immediate hands on troubleshooting continues to provide challenges with each and every ongoing project. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? Allow plenty of time for testing your activity prior to going "live". After completing SP and student technology training prior to your live date, schedule time to run a "mock event" with the SPs and any staff you may have involved with the event. Having a dry run alleviates a tremendous amount of stress and provides opportunities for SPs and staff to ask questions and troubleshoot prior to having students present. 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? I believe the implementation of online SP activities is just beginning and will continue to expand and inform the future landscape of SP Methodology. The efforts of so many, under great pressure, to deliver quality programming is merely the tip of the iceberg. From rapidly adjusting previously tried and true delivery practices to exploring and sharing new innovations and expanding solutions is exciting to ponder as we move forward. To quote Olympian Michael Johnson, "Pressure is nothing more than the shadow of great opportunity." 6. What else would you like to add on this topic that we have not asked you about? The astounding sense of community and support found within the SP Educator community is second to none. Our strength and pride is not only in the excellence of upholding best practices and providing the highest quality of human simulation to our learners, but it is also in our ability to communicate, to collaborate and hold each other aloft in times of pandemic or otherwise. Tamara First, I would advise the SP Educator at this juncture to meet with an SP Educator who has implemented online SP activities. This meeting will provide insight as to how to design and execute as well as identify potential institutional challenges. Second, I would advise the SP Educator to meet with their team to share the vision and to discuss team member roles and responsibilities. There are similarities in roles but there are differences that will require staff to think about. Third, document all new policies and procedures for the online SP activities. 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? SP Education will forever be executed online. Curriculum implications are identified clinical skills optimal for teaching and assessing online. Research implications are increased studies on online SP activities. Communication skills studies specifically nonverbal communication will increase. 6 We surveyed SPs about their comfort level with different technology platforms and access to different devices. This information helped us plan for what might be possible. We needed a baseline idea about how many SPs had a device, and internet access bandwidth that would allow them to serve as an SP online. We knew we could teach them to use a video conferencing platform if they just had the equipment and internet access. We offered a couple optional low stakes online social events first (an SP Lunch and then a Happy Hour) to help us get an idea of how many folks could really do it. We wanted to backup the survey data by seeing it with our own eyes. This gave us the confidence cautiously to move forward with online SP events. Internet access and access to technology is a privilege that not all our SPs have, especially in a city where the digital divide runs along poverty lines. A big ongoing challenge is how to offer online work in a fair way to SPs who do not have access to a device or internet access. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? You must give yourself, staff, SPs, Faculty and Learners the grace to fail -things will probably not go exactly as planned. Acknowledge that we cannot control so many aspects of this situation, if something goes wrong it's okay. We can do it over again if need be. If something that we didn't expect occurs, we'll learn from it. Yes, we are all anxious about doing this for the first time, and we prepared to death, but it had to become our mantra and answer for everything: this is okay -we're all figuring this out together. 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? I'm excited about the future possibility of having a global pool of SPs to hire from! Even after things return to face to face, we will make training SPs to use an online platform a regular part of SP orientation and continue to have SP training sessions that were once in person online instead. Now that we see that it is possible, it only makes sense to continue. Why have SPs commute and pay for parking to achieve the same results in a more efficient and cost-effective way. 6 . What else would you like to add on this topic that we have not asked you about? I'm curious about how this experience will (or should) impact the SOBPs from ASPE and INACSL, for example the domains on safety, or do there need to be additions for telehealth in case writing… Ryanne Noel-Luttrell, BS, OTA/L Simulation Laboratory Technician Bellarmine University Louisville, KY MD learners in the US, (I am interested to hear how other countries are managing testing)-it has expanded who we work with, the focus on communication-based simulations, and how learners' train. The think out loud model of learning is not a way medicine has been taught, trained, or performed. When learners are performing physical exams with SPs in a remote environment, they will need to be more clear on each step through speaking it out loud. 6 . What else would you like to add on this topic that we have not asked you about? How quickly SP Educators moved to action speaks to how agile the field is and can be. In two weeks, we had all the staff trained on how to train and run remote SP encounters, all our SPs trained on Zoom, and two remote SP encounters executed. I know we are not alone. This not only speaks to how agile we can be, but how creative, innovative, and team driven we are. We quickly figured out that none of this could happen without everyone on board and working. Amber Snyder, M.S. Note The experience provided from these responses are coming from the social work field. To give context to the responses, the learning provided by my organization occurs under the umbrella of a University, however our learners are working professionals in the area of child welfare. Funded by an inter-governmental agreement between the University of Pittsburgh, Office of Children, Youth, and Families, and Pennsylvania Children and Youth Administrators, the Child Welfare Resource center is mandated to provide the certification series for caseworkers which was challenged by the pandemic. The individuals we work with to provide simulation activities are called Standardized Clients (SC), so that term will be used in lieu of SP. Very minimal. The SCs who work for our organization are located statewide, so we have hosted online SC training and team meetings, but no events with stakeholders. The support of the SP community has been integral to our success. Learning how to navigate Zoom, considerations for making SCs comfortable in their space and online roles, and using technology has all been supported through webinars, resources, and connections with the SP community. Internally, we have had the support of our technology department and our leadership team to make decisions and strategize how to implement without interference-opening up the ability to be creative. implemented SP activities online in the COVID-19 pandemic? One of the biggest challenges has been training all SCs to be comfortable with the technology associated with Zoom and ensuring all SCs had the devices needed to be able to simulate online. We were concerned that we would not be able to provide opportunity equitably if not all SCs had the devices to do the work. I advocated and was provided the opportunity to order Chromebooks for all SCs so that they were on an equal playing field to be able to receive opportunities. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? I think patience and grace with yourself and others as you learn the ropes. Knowing that there are going to be mistakes and technology glitches is important throughout. I also highly recommend a lot of practice sessions with all players involved. We have only 27 SCs, but contract with over 150 instructors and work with 67 different counties, who all come to the table with differences in style and need in an online environment. Additionally, seek out support from others in the SP field. Watch what they are doing and learn from them. Observe their process, write them down, and adjust for your needs. Finally, document everything so you have processes in place. 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? We have already begun to create new curriculum that will always be held online, providing stakeholders with the opportunity to access simulation modules outside of the certification series. We anticipate simulations to continue to be held online as needed for the health and safety of stakeholders. The organization has also considered the possibility of running simulations online as needed for inclement weather, which often challenges our trainings. We are also considering how we can utilize the online environment to provide more training and professional development opportunities for SCs to support role portrayal, standardization, and feedback. I strongly believe much of our work will remain online and we will continue to explore the expansion of opportunities. 6 . What else would you like to add on this topic that we have not asked you about? One additional area we have really focused on since going online is the idea of de-rolling and what I have been calling de-spacing. All of the cases we run are higher in emotional state and effect because of the sensitive nature of our work, our SCs are portraying in roles involving intimate partner violence, grief and child abuse and neglect. De-rolling has always been important to ensure that SCs can walk away and safely be back to themselves. Asking SCs to portray these roles within their own homes has provided a need to consider how SCs remove themselves from the simulation space and make sure their home is theirs, not that of the character. As we move into the statewide launch of all of our simulations online, we are going to be continuously strategizing with SCs to ensure that support is there. Our team got on Zoom, experimented, used the tools, practiced with each other first, then hired some SPs/ coaches and had training sessions to see how it worked. We sent out a survey to see who needed some equipment from our lab and provided some laptops/headphones/etc. to those that wanted to work and needed more up to date equipment. We then ran some trainings/practice for students in groups. About this time U of Minnesota M Simulation put on their webinars and we realized we were about 80% ready. We learned a lot of tips/resources, best practices from those webinars-especially the first one, (Zooming with SPs). To Our school is doing everything virtual through at least Sept 8th-so we will be starting the new school year with events for first through fourth year students through remote events/and coordinated lecture/demos, etc. with faculty and are in the planning stages now. A. Instability of some SPs and some students with their internet connections/and delay in communications. B. Variety of tech abilities and comfort in utilizing Zoom/online resources of both SPs and students (we have some SPs who were not comfortable using Zoom and/or did not have a quiet/dedicated place in their home to be able to work with us. They are on hold for now until we get back on campus). C. Limitations in doing the Physical Exams-researching more options now. Mostly we have just been giving the students the findings and having them narrate that they would do a physical and document on SOAP note what tests/things they would do for the physical. D. Due to "the Driver" being the only one that can move people around-we have limited our student/SP groups to between 12-15 of each, where in the lab we usually would have groups of 20-22. Therefore, the events take longer and Zoom fatigue can set in for staff. We try to break the SP's into am/pm groups. E. Lacked knowledge in the beginning that the one who originates the Zoom set up cannot have two Zoom lines/meetings at the same time. We did this for a debriefing room and kicked EVERYONE off the event in one of the first practices we did. DISASTER! 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? • Practice in Zoom with your staff/SP's first so you really understand and know it • Have as many staff as you can work and divide up roles • Zoom Driver/Host-assign one person who is good/fast at assigning rooms and moving people • Assign SPEs or staff as floaters who can move into the rooms if SP/learner connection fails • Make sure to have an emergency phone number to call for students • Provide directions on using/achieving best connection possibilities for Internet and Zoom/other online platforms. • Be mindful of appearance, (e.g. dress professionally and clean up background) • Talk a little more slowly than usual and pause to account for lag time 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? I believe we will have some form of remote SP events included in the curriculum from now on, (as opposed to pre-COVID-19). This is so much a part of how medicine is operating now-and will continue to, especially for very sick people so as not to infect others on in-person visits to doctor's and other healthcare provider offices. 6 . What else would you like to add on this topic that we have not asked you about? A big thank you to Lou for initiating the Simulation Online 2020 Facebook page, (on March 13, 2020). I have yet to read all of it and gather all the knowledge and resources but plan on doing more reading in the next few weeks. Thank you also to the amazing M Simulation staff at the University of Minnesota for the wonderful webinars! Amelia Wallace Senior Standardized Patient Educator Sentara Center for Simulation and Immersive Learning: Professional Skills Center Eastern Virginia Medical School Norfolk, VA My experience implementing SP activities online prior to the COVID-19 pandemic was limited. We had small bursts of creating online modules within Blackboard or on other platforms, but no efforts really got off the ground. On reflection, this was most probably because we were focused on (and preferred) face-to-face interaction. 2. What helped you implement SP activities online during the COVID-19 pandemic? Three things seemed to help implement online SP activities: Leadership at our center, maintaining the SP community (as best as we could), the SP Educator and simulation community in general. Leadership. I work in a center with a large leadership team (Jenn Styron, Alicia Wolters, Bob Armstrong, Catherine Neighbors & Pam Cobb) who quickly identified which online platform would work best for the most amount of people and who devised a strategy that consisted of smallscale implementation (e.g. the first weeks our online sessions were done with the SPs coming on-site to ensure consistency of implementation followed by a transition to fully online sessions). Additionally, they reimagined the logistical flow of an event utilizing additional full-time staff as room administrators and identified auxiliary support resources to help maintain close communication within events (e.g. Slack). I cannot say enough how this leadership maximized the quality of what the SP Educator team was able to focus on regarding maintaining quality of simulation and assessment. The SPE team could still focus on the QA part of our jobs because our center's leadership took on the logistical work, (including being the last people at the center to transition to work from home status). Maintaining the SP community. Individual connection with the SP community by way of phone calls to check-in at the beginning and end of stay at home status (the SP Educator team-four individuals-called each SP to identify support deficits). We also had hour-long weekly online "lounge" sessions to maintain a sense of community. This also allowed us to continue informal interactions that were helpful to maintain morale with full time staff and SPs. The SPE/simulation community. Webinars have been very helpful as a support resource-especially, for people to know that they are not alone. I am thinking specifically about the first meeting on transitioning to Zoom by the University of Minnesota. It was empowering! 3. What have your greatest challenges been as you have implemented SP activities online in the COVID-19 pandemic? The biggest challenges I have experienced are related to the inconsistent comfort levels and access individuals have to online platforms. This has been of specific concern related to some SPs who have challenges navigating online platforms, (unfortunately, some aren't able to work and have been impacted financially) as well as those who don't have access to high speed internet and are unable to work. Our center has shared resources (e.g. laptops) but this has not been a solution for everyone. It begs the question: Can we afford to lose the narrative and perspective of those individuals most impacted by this pandemic? We strive to be diverse and inclusive as a center. This has limited that pool. Resources. It takes more to do less. Specifically, more people. This has limited what we are able to provide to faculty. Summative assessment is also more challenging because we have no baseline for online interactions. 4. What is one or a few tips you have for SP Educators who are seeking to implement online SP activities but who have not done so yet? • Contact your SPs and survey them to truly get a read on comfort level. Be prepared to reassess and adapt to changing needs. • Have multiple people booked as back-up (back-up SPs, back-up administrators) to account for connectivity challenges. • Have mandatory sessions for learners to orient themselves with the online platform prior to the event. 5. How do you think this work will change the scope of SP Education in the coming weeks, months, years? I believe we have discovered that the adaptation to online sessions is more manageable than we thought. I anticipate we will train SPs online, (at least in part) in the future even for face-to-face events. We will be positioned in such a way as to leverage the best aspects of online and face-to-face sessions to maximize the learning potential within the simulation. 6 . What else would you like to add on this topic that I have not asked you about? I am concerned about maintaining the importance of feedback from the individual SP and maintaining their voice within simulation. One big strength of SP methodology is the potential for true inclusivity of the patient's perspective within medical and health professions education; this includes the SP's opinion of the interaction. I have been to many sessions and asked, "What did the SP think?" only to hear, "Oh, we did not collect data from them." With a focus on high-stakes, summative assessment, this message can be lost when filtered through a postpositivist paradigmatic lens that prioritizes numerical consistency over the subjective impressions of an individual. I am concerned that a move to online sessions, left unchecked, could favor leaving the actual patient out of the conversation. Looking ahead, while we hope and anticipate a future in which we can work safely on-site at our simulation facilities, we know that our industry will never be the same again. The expansion, innovation, and prevalence of human simulation online during this time will forever change our profession. So, it is imperative that we look to this phenomenon as one filled with opportunity rather than with regret and yearning for pre-COVID times. Those times are gone. We must continue reimagining our processes, SP-based curricula and our community of practice as it necessarily evolves-even more collaboratively. We know, up to this point in time, that the SP Methodology has succeeded because of its flexibility and ability to be situationally responsive in addressing evolving curricular challenges with innovative means. In addition, at this point in time, SP Educators must further collaborate with stakeholders by cultivating our leadership skills-namely leading from an assertive, proactive place. This necessitates an approach that emphasizes anticipating and identifying needs in addition to being situationally responsive to curricular challenges brought forth by our stakeholders, or from outside challenges-in this case-a global pandemic. As we are experiencing now, in this time of expanding human simulation online, assertive proactive action on our part as a profession is not only meeting curricular challenges with innovation but also ensuring increased safety for our SP Educators and SPs who are working remotely [20] . This highly collaborative model is succeeding as the needs of all parties are met-the educational needs of our stakeholders including our leaners and the safety needs of our human simulation professionals including and especially our SPs. This time of online simulation expansion not only gives us a new set of paintbrushes to work with, but also a different set of choices to make regarding how we paint authenticity in our simulations. How and what do we choose to emphasize? For fidelity we make choices routinely about what to include. This must be done as part of a collaborative educational design process in which we, SP Educators, share our expertise in full partnership with our stakeholders while advocating for our methodology which includes prioritizing our safety [3] . SPEs must also advocate, lead, and innovate from a collaborative place which will best support our profession in creatively meeting emerging needs in healthcare education and improve the quality of our contributions and ultimately the SP Methodology (Human Simulation). Advancing the future of our human simulation profession depends on it. We must all do our part and we leave you with this question, which is really a call to action: How will we continue moving forward to collaboratively advocate for and to advance human simulation and our profession, and where will this journey take us in partnership with healthcare industries and beyond? Gayle, further thanks to you for making your vision the reality that is this book. You are a trailblazing educator doing the job with grace, style, and kindness-thank you for all you have taught us, have passed on here and through the years, and for your contributions yet to come! 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