key: cord-0738560-a37zb2sj
authors: Nadir, Nur‐Ain; Kim, Jane; Cassara, Michael; Hrdy, Michael; Zaveri, Pavan; Wong, Ambrose H.; Ray, Jessica; Strother, Christopher; Falk, Michael
title: Simulation‐based emergency medicine education in the era of physical distancing
date: 2021-03-13
journal: AEM Educ Train
DOI: 10.1002/aet2.10586
sha: a72904e17ffec4741b7dec1382e7482b7261264a
doc_id: 738560
cord_uid: a37zb2sj

BACKGROUND: The COVID‐19 pandemic posed significant challenges to traditional simulation education. Because simulation is considered best practice for competency‐based education, emergency medicine (EM) residencies adapted and innovated to accommodate to the new pandemic normal. Our objectives were to identify the impact of the pandemic on EM residency simulation training, to identify unique simulation adaptations and innovations implemented during the pandemic, and to analyze successes and failures through existing educational frameworks to offer guidance on the use of simulation in the COVID‐19 era. METHODS: The Society for Academic Emergency Medicine (SAEM)’s Simulation Academy formed the SimCOVID task force to examine the impact of COVID‐19 on simulation didactics. A mixed‐methods approach was employed. A literature search was conducted on the subject and used to develop an exploratory survey that was distributed on the Simulation Academy Listserv. The results were subjected to thematic analysis and examined through existing educational frameworks to better understand successes and failures and then used to generate suggestions on the use of simulation in the COVID‐19 era. RESULTS: Thirty programs responded to the survey. Strategies reported included adaptations to virtual teleconferencing and small‐group in situ training with a focus on procedural training and COVID‐19 preparedness. Successful continuation or relaunching of simulation programs was predicated on several factors including willingness for curricular pivots through rapid iterative prototyping, embracing teleconferencing software, technical know‐how, and organizational and human capacity. In specific instances the use of in situ simulation for COVID‐19 preparedness established the view of simulation as a “value add” to the organization. CONCLUSIONS: Whereas simulation educator's responses to the COVID‐19 pandemic can be better appreciated through the lens of iterative curricular prototyping, their successes and failures depended on existing expertise in technological, pedagogical, and content knowledge. That knowledge needed to exist and synergize within a system that had the human and organizational capacity to prioritize and invest in strategies to respond to the rapidly evolving crisis in a proactive manner. Going forward, administrators and educators will need to advocate for continued investment in human and organizational capacity to support simulation‐based efforts for the evolving clinical and educational landscape.

Comprehensive integration of simulation with other instructional strategies is "best practice" in emergency medicine (EM) education. 1 The COVID-19 pandemic has imposed significant unanticipated challenges, threatening adherence to best practice.

During the initial phases of the pandemic response, face-to-face simulation as previously implemented was no longer possible.

"Brick-and-mortar" simulation learning environments, including simulation centers, classrooms, and conference venues, were closed and unavailable to stakeholders (learners, simulationists, simulation faculty, residency administrators) at many institutions for precautionary safety reasons. 2 Further, learner and educator availability to participate in simulation education was restricted due to the escalating need for qualified practitioners to support emergency and critical care patient-centered responsibilities.

Simulationists, when available, commonly faced limited or no access to simulation equipment and other instructional adjuncts and tools. When circumstances did afford access to them, simulationists were often unable to fully optimize their deployment due to concern for contamination.

Simulation educators reflecting on lessons learned in the wake of the COVID-19 pandemic understand that best practice must adapt to the "new normal" COVID-19 state of existence. To accommodate the social and physical limitations imposed by COVID-19, new approaches and innovations to learning, such as the incorporation of technological advances, are necessary. [3] [4] [5] We propose examining the success and failures of reported innovations through the lens of Koehler and Mishra's TPACK model. 6 TPACK is a theoretical framework originally developed to explore and understand reasons why educators have been successful when attempting to integrate newer learning technologies into existing educational programs. In the original Koehler and Mishra model, educator success or failure depends on four interdependent factors-pedagogical knowledge (PK), content knowledge (CK), technological knowledge (TK), and the contexts connecting them. Koehler and Mishra posit that educators with the best potential for instituting quick, contemporaneous curricular transformations meet minimum competency thresholds within the three aforementioned domains. The potential for change, however, is only effectively realized when educators are appropriately situated within contexts facilitating such transformations. Each stakeholder to whom the curriculum is beholden-educators, learners, administrators, programs, institutions, and organizations-must share common cultural beliefs (ethos, values, mental models, goals, etc.) and ensure adequate minimum standards of organizational infrastructure, along with attaining adequate individual competencies, for success to be likely.

Simulation training in a COVID-19 world is arguably even more crucial than before the pandemic. First, the COVID-19 pandemic represents a natural disaster for which there has already been a precedent set for the use of simulation training, such as during the 2009 SARS and 2013 Ebola epidemics. 7 Second, this pandemic represents exactly the kind of low-occurrence, high-acuity, high-stakes clinical situation that simulation training is most ideally suited to. 8, 9 Additionally, simulation training also identifies systemic issues and latent safety threats for both staff and patients that are particularly relevant now, perhaps more so recently, given the soaring numbers of health care providers contracting COVID-19. 10 Furthermore, rapidly changing clinical recommendations, such as use of intubation barrier devices and powered air-purifying respirator during intubations, represent new kinesthetic skill sets that must be practiced and honed through simulation, ideally before implementation in a realworld scenario. Finally, as a precautionary measure, several training programs are deliberately reserving the care of patients with COVID-19 requiring ventilatory support and cardiopulmonary resuscitation to senior residents or attending physicians, which could impact the development of these skill sets among junior learners. 11 Medical students have been impacted even more significantly; 12, 13 with limited or no exposure to patients with COVID-19 and other clinical conditions, they are likely to start residency training with persistent, unresolved knowledge and skill gaps. There are also some concerns that medical student's clinical skills may be somewhat less developed upon medical school graduation, relative to expected norm, as a good number of third-year clerkships are being offered virtually. 14 Simulation training, therefore, is vital both for successfully navigating this pandemic and ensuring that essential educational experiences for current and future trainees are maintained.

We therefore seize this moment and calling for thoughtful, disruptive innovation in simulation-based emergency medical education.

Accordingly, the main objectives of this paper are to (1) describe the impact of the COVID pandemic on EM residency simulation in the United States, (2) evaluate the responses by successful/unsuccessful simulation innovations and strategies implemented, and (3) analyze successes and failures through the TPACK educational-theoretical framework to obtain a better understanding of why they occurred. and content knowledge. That knowledge needed to exist and synergize within a system that had the human and organizational capacity to prioritize and invest in strategies to respond to the rapidly evolving crisis in a proactive manner. Going forward, administrators and educators will need to advocate for continued investment in human and organizational capacity to support simulation-based efforts for the evolving clinical and educational landscape.

We employed a mixed-methods approach 15 as depicted in Figure 1 .

This study was deemed "non-human subjects research" by a local institutional review board. Qualitative methods were utilized in addition to quantitative methods for this study to describe the interconnections of people, situations, events, and processes, 16 which allows for discovery, exploring a new area, and developing hypotheses. 17 Quantitative methods illustrated the impact of the pandemic on simulation training and the qualitative methods inductively built theory regarding the unique simulation adaptations and the determinants of their success or failure.

The Society for Academic Emergency Medicine (SAEM)'s Simulation Academy is one of the premier academies, sponsored by the SAEM with a broad membership of simulation faculty, directors, and researchers, collectively representing 130 academic centers across the United States. In May 2020 during the SAEM Sim Academy's annual executive meeting, a need for more guidance on simulation didactics in the COVID era was discussed by the Simulation Academy executive committee. As a direct result of the discussions a SimCOVID Task Force comprising various Simulation Academy members, including simulation researchers, faculty, and directors at various academic sites across the country, was convened. Participants were purposefully selected from the SAEM's Simulation Academy to study information-rich cases to yield insight and understanding. 18

The SimCOVID task force met in late May 2020 and after review- and inductively coded. Consensus agreement between the three coders was used to draft initial codes. Coded data were further organized into distinct themes. When new themes became apparent, survey data were reanalyzed and the codes were modified.

Through subsequent iterative discussions among all members of the SimCOVID task force, each theme thus identified was further refined, combined, or divided into the following specific categories:

in situ training, procedural training, physical or social modifications, and virtual simulations (Table 1) . Qualitative data were also analyzed by task force member (NN, PZ, JK) on the perceived impacts of the pandemic on simulation programs, which were further categorized into five categories: learner, simulation operations, innovation TA B L E 1 Simulation strategies deployed during the COVID-19 pandemic and associated successes and challenges

In situ training

In situ simulation example: "Essential Sims," that is ACLS/COVID surge preparation/ nursing competency/ COVID code blue simulations. and research, financial implications and organizational response ( Table 2) . Determination of the nature of impact (positive or negative) occurred through an iterative consensus-building process from all members of the SimCOVID task force. Data, thus generated, were evaluated through the lens of existing educational theoretical frameworks to gain an understanding of rationale behind successes and failures of various strategies and innovations.

We received a total of 30 responses from 130 represented institutions (response rate 23%). Multiple responses from the same intuitions were collated for the purposes of this study.

States, with four from the New England region, six from New York State, three from the Mid-Atlantic region, one from the Midwest, five from the Great Plains, three from the Southeastern region, two from the South Central region, and five from the Western region (Table S2 ). There was significant variation in responses with respect to strategies deployed, resources available to centers during the pandemic and overall simulation operations. Likely these factors were affected by the size and resources of a center as well as the geographical location of the hospital during different phases of the pandemic. This survey was conducted in May, when Southeastern and some Western states were just beginning their peak and Northeastern/New York areas were decreasing in COVID-19 incidence.

Eighty-seven percent of respondents report mandatory cessation of all in-person training in their simulation centers (Figure 2A ).

Despite this, 33% of respondents report keeping their simulation centers open physically and 10% closed down physical operations but continued with previously established online activities ( Figure 2B ). Twenty-seven percent of centers reported having to furlough or reduce pay to simulation center staff ( Figure 2C ).

Reactions and changes to in situ programs were spread evenly across the options in the survey ( Figure 2D ). Approximately 64% of respondents maintained some level of in situ simulation during the pandemic, of whom 16.7% reported an increased practice in situ simulation compared with the prepandemic period. Twenty percent of respondents cancelled their in situ simulation. Approximately 17%

of respondents had never performed in situ simulations. Table 2 .

Simulation education programs, especially those located within America's early pandemic epicenters, were thrust into one of three The programmatic, procedural, and curricular transitions from conventional simulation practice which emerged (Table 1) Supportive contexts were also critical to success. EM simulationists with unwavering institutional will and organizational commitment to simulation, and recognition of its "value" in supporting the clinical service mission during the pandemic, were clearly more successful in maintaining or resuming their educational programs. The TPACK model explains the observation that the most successful simulationbased curricular pivots were possible when stakeholders (simulationists, learners, administrators); infrastructure; and organizations met minimum prerequisite knowledge, competencies, values, and cultural thresholds.

While the classic TPACK model offers adequate rationales for many of the successes and failures of the curricular transformations we analyzed, we believe that it omits a fifth dimension not originally described but clearly evident from our data: stakeholder cognitive load. We apply the phrase "human capacity" to this concept.

Our data reveal that, even when other criteria are met, curricular redirection attempts still failed when human capacity demands ex- Going forward, the feasibility of hosting traditional simulation programs will depend on local and institutional regulations.

Establishing simulation training as an "essential service," particularly for pandemic response preparation, is critical to the continuation or relaunch of simulation activities within an organization. Working with administrators to show that the value-add in this context is essential for maintaining or restarting simulation training, which might otherwise be seen as an unnecessary risk. Rather than proposing a complete return to simulation education as it was before COVID-19, 

One of the limitations of our study is that it represents only 30 programs/organizations, a response rate of 23%. The reported strategies, successes, and failures are therefore not all inclusive and there may be other innovations and strategies that were not captured by our survey. Although the responding programs are spread out across the United States there are more programs on the Eastern seaboard and more urban programs represented that

can potentially lead to a geographical or urban bias to the data retrieved. Furthermore, some of the innovative in-person strategies described in addition to the concept of value-add largely depended on the perceived role of the simulation program within the larger organization. This can be difficult to accomplish in smaller simulation operations, largely due to lack of staff and especially with ongoing staff furloughs. Finally, to date, reported innovations and adaptations lack formal evaluations; therefore, long-term impacts such as their utility for competency assessment remain unclear.

The evolution of the COVID-19 pandemic has seen a parallel evolution of various simulation strategies and innovations being deployed to meet the demands of the moment. Rapid curricular prototyping with frequent, timely feedback provides one framework for simulation curriculum innovation and adaptation. Successes and failures of various innovation can be explained through preexisting simulation faculty expertise in technological, pedagogical, and content knowledge. That knowledge needed to exist and synergize within a system that had the human and organizational capacity to prioritize and invest in strategies to respond to the rapidly evolving crisis in a proactive manner. In the future, administrators and educators will need to advocate for continued investment in human and organizational capacity to support simulation-based efforts for the evolving clinical and educational landscape.

Building on the lessons learned during this pandemic, there is a need for dedicated faculty development on the newer modalities that have developed such as the various video-conferencing platform-based simulations. In addition, there is a definite need for exploring augmented reality and immersive virtual reality as potential options for training. The role and utility of the latter has yet to be clarified and an in-depth review is needed. Whether these newer modalities are comparable to traditional simulations with respect to competency assessment also needs to be investigated. Finally,

given the success of in situ simulations and procedure training for COVID-19 preparedness, it is critical to reemphasize the scope and utility of simulation as "essential" to facilitate simulation program maintenance or relaunch, during the pandemic. Finally, the strategic alignment of simulation programs to organizational needs, mission, visions, and goals, especially as pertaining to disaster preparedness, need to be further explored and clarified.

Nur-Ain Nadir https://orcid.org/0000-0003-2538-3880

Ambrose H. Wong https://orcid.org/0000-0001-7471-1647

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